Original articleDiagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests
Introduction
The sacroiliac joint (SIJ) can be a nociceptive source of low back pain (Fortin et al., 1994, Fortin et al., 1994; Bogduk, 1995). SIJ pain has no special distribution or features and is similar to symptoms arising from other lumbosacral structures. There are no provoking or relieving movements or positions that are unique or especially common to SIJ pain (Dreyfuss et al., 1996; Fortin et al., 1994, Fortin et al., 1994; Schwarzer et al., 1995; Maigne et al., 1996; Fortin and Falco, 1997). The clinical diagnosis of symptomatic SIJ remains problematical, but the ability to make the diagnosis is an important objective. It may be presumed that treatment strategies for SIJ lesions should differ from strategies intended to relieve and treat pathologies of other structures such as disk, nerve root or facet joint pain. Without a readily accessible means of differentiating between these possible sources of pain, treatment strategies are perforce non-specific, and likely to have at best, modest efficacy.
At present, a current acceptable method of confirming or excluding the diagnosis of a symptomatic SIJ is fluoroscopically guided, contrast enhanced intra-articular anaesthetic block (Fortin et al., 1994, Fortin et al., 1994; Grieve, 1988; Merskey and Bogduk, 1994; Schwarzer et al., 1995; Sakamoto et al., 2001; Adams et al., 2002). While certain SIJ tests have been shown to have acceptable inter-rater reliability (Laslett and Williams, 1994; Kokmeyer et al., 2002), current evidence suggests that these tests alone cannot predict the results of a criterion standard such as diagnostic injection (Dreyfuss et al., 1996; Maigne et al., 1996; Slipman et al., 1998). These reports have not reported the sensitivity, specificity or likelihood ratios or provided data on the diagnostic power of individual or composites of provocation SIJ tests (Slipman et al., 1998). However, in a previous publication, the current authors have identified a composite of three provocation SIJ tests in the absence of centralization during repeated movement testing has clinically useful sensitivity, specificity and positive likelihood ratio (93%, 89% and 6.97%, respectively) (Laslett et al., 2003).
Conceptually, it seems reasonable to propose that stress testing of the SIJ should provoke pain of SIJ origin. However, clinical stress tests are unlikely to load the targeted structure alone. Herein lies the problem. When a test provokes familiar pain, the question arises if this is evidence of pathology within the targeted structure, or evidence of pathology in a different but nearby structure that is also stressed at the same time. However, if different stress tests of a structure provoke pain, greater diagnostic confidence may result. The use of composites of tests is common in musculoskeletal medicine. When a straight leg raise test provokes familiar leg pain, nerve root irritation from a herniated lumbar disc may be suspected. However, pain, paraesthesiae or skin anaesthesiae in a known segmental distribution, weakness of key muscles or reflexes must also be present before the diagnosis of a herniated lumbar disc can be made with any degree of confidence. Confirmation with computed tomography or magnetic resonance imaging completes the composite of tests for this diagnosis. The need for diagnostic research to investigate the added value of composites of tests within the diagnostic process has been emphasized (Deville et al., 2000; Grieve, 1988). This current study explored the utility of utilizing composites of SIJ provocation tests to predict the results of fluoroscopically guided, contrast enhanced SIJ blocks (diagnostic injection).
Section snippets
Material and methods
The diagnosis of symptomatic SIJ pathology may mean that either SIJ structures contain the pain generating tissues, or that the SIJ functions or malfunctions in such a way as to cause pain. Throughout this report, references to symptomatic SIJ, SIJ pain or pathology are confined to meaning that the pain originates from the SIJ structures.
The study design is presented graphically in Fig. 1. Physiotherapists (ML and SBY) visited a private radiology practice in New Orleans specializing in the
Results
Sixty-two patients agreed to participate and were examined by both radiologist and physical therapist. Of these patients, three were unable to tolerate the physical examination, two were pain free on the day of the clinical assessment, seven had no SIJ injection, and two had a bony obstruction causing a technical failure to inject the SIJ. These patients were excluded from the study. Forty-eight patients satisfied all inclusion criteria. Twenty-seven patients received the clinical assessment at
Discussion
All patients with SIJ pathology identified by injection had at least one positive test. Only one patient out of 16 with SIJ pain had a single positive test with 15 having two or more positive SIJ tests. Consequently, one reasonable clinical rule is that when all provocation SIJ tests are negative, symptomatic SIJ pathology can be ruled out. The thigh thrust test is the most sensitive test and the distraction test is most specific.
Three or more of the six tests produce the highest likelihood
Conclusion
Provocation SIJ tests have significant diagnostic utility. Six provocation tests were selected on the basis of previously demonstrated acceptable inter-examiner reliability. Two of four positive tests (distraction, compression, thigh thrust or sacral thrust) or three or more of the full set of six tests are the best predictors of a positive intra-articular SIJ block. When all six SIJ provocation tests are negative, painful SIJ pathology may be ruled out.
Acknowledgements
Thanks to Duncan Reid, Wayne Hing, and the Auckland University of Technology Multimedia Unit for assistance with photographs.
Travel and Louisiana licensing costs for Mrs. Young were funded by The McKenzie Institute International.
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