Dr. Dadian - Sacroiliac joint dysfunction in patients with herniated lumbar disc

To determine the relative frequency of sacroiliac joint dysfunction in a sample of patients with image
proven lumbar disc herniation.

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Journal of Back and Musculoskeletal Rehabilitation 00 (2013) 1–7 1
DOI 10.3233/BMR-130376
IOS Press
Sacroiliac joint dysfunction in patients with
herniated lumbar disc: A cross-sectional study
Seyed PezhmanMadania,∗, Mohammad Dadianb, Keykavous Firouzniac and Salah Alalawid
aDepartment of Physical Medicine and Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
bDepartment of Physical Therapy, University of Welfare and Rehabilitation, Tehran, Iran
cDepartment of Radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran
University of Medical Sciences, Tehran, Iran
dPhysical Medicine and Rehabilitation Specialist, Royal National Hospital for Rheumatic Diseases, London, UK
Abstract. OBJECTIVES: To determine the relative frequency of sacroiliac joint dysfunction in a sample of patients with image
proven lumbar disc herniation.
METHODS: A single group cross-sectional study was conducted in a three year period from 2007 in an outpatient clinic at a
university hospital. Overall, 202 patients aged more than or equal to 18 years with image proven herniated lumbar disc and with
physical findings suggestive of lumbosacral root irritation were included.
RESULTS: Overall, 146 (72.3%) participants had sacroiliac joint dysfunction. The dysfunction was significantly more prevalent
in females (p <0.001, adjusted OR = 2.46, 95% CI = 1.00 to 6.03), patients with recurrent pain (p <0.005, adjusted OR = 2.33
with 95% CI = 1.10 to 4.89) and patients with positive straight leg raising provocative test (p < 0.0001, adjusted OR = 5.07,
95% CI = 2.37 to 10.85). There was no significant relationship between the prevalence of SIJD, and working hours, duration of
low back pain, or body mass index.
CONCLUSIONS: Sacroiliac joint dysfunction is a significant pathogenic factor with high possibility of occurrence in low
back pain. Thus, regardless of intervertebral disc pathology, sacroiliac joint dysfunction must be considered in clinical decision
making.
Keywords: Sacroiliac joint, low back pain, lumbar disc herniation
1 1. Introduction
2 About 70–85% of adults experience low back pain
3 (LBP) at some point during their life [1,2]. The disc,
4 facet joint and sacroiliac joint (SIJ) are potential
5 sources of LBP [3]. Disc-related diseases of the lumbar
6 spine are common causes of pain, and frequently lead
7 to reduced productivity and lost to work [4,5]. Lum8
bar disc herniation frequently affects the spine [6], and
∗Corresponding author: Seyed Pezhman Madani, M.D., Assistant
Professor, Department of Physical Medicine and Rehabilitation,
Shafayahyaian Rehabilitation Hospital, Tehran University of Medical
Sciences, Baharestan Square, Mojahedin-E-Islam Ave, Tehran
1157637131, Iran. Tel.: +98 21 33542001; Fax: +98 21 33542020;
E-mail: p-madani@sina.tums.ac.ir.
if the symptoms are attributable to lumbar disc pathol- 9
ogy, magnetic resonance imaging (MRI) or computer- 10
ized tomography (CT) are indicated to confirm [7]. 11
Diseases with the manifestations similar to those of 12
herniated intervertebral disc pose a challenging prob- 13
lem in the diagnostic workup, and in decision mak- 14
ing for the best treatment modality in patients with 15
LBP. In addition, one should be aware that dual pathol- 16
ogy may exist, otherwise patients may undergo clinical 17
and imaging investigations and the etiology may still 18
remain unclear. Treatment of low back pain resistant 19
to conservative management is still a problem. Open 20
surgery has disadvantages such as intraoperative tissue 21
damage, epidural fibrosis, and scar formation [5,8]. 22
SIJ is a poorly defined subset of several recognized 23
causes of LBP. Researchers identified the SIJ as one of 24
ISSN 1053-8127/13/$27.50 c 2013 – IOS Press and the authors. All rights reserved
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2 S.P. Madani et al. / Sacroiliac joint dysfunction in herniated lumbar disc
the possible starting 25 points of pain via injection of lo26
cal anesthetic [9]. Depending on the studied population
27 and diagnostic measures, the prevalence of the sacroil28
iac joint as a source of low back pain is reported 13%
29 to 48% in different studies [9,21,23]. In a study [24], it
30 has been reported that, of 1293 patients with low back
31 pain the SIJ dysfunction was thought to be the source
32 of pain in 22.5%, based on history and physical exam33
ination. Relative hypomobility of SIJ and the result34
ing pelvic asymmetry has been described as sacroil35
iac joint dysfunction (SIJD) [10,11]. The underlying
36 processes leading to pain production or the responsi37
ble tissues are still debated. It has been suggested that
38 LBP may arise from pelvic tissues or low back region
39 because of pelvic asymmetry and excessive or limited
40 spinal or SIJ motion [9,11].
41 It has been suggested that chronic LBP (more than
42 4 weeks of duration) is related to discopathies evi43
dent on MRI or CT, even in the absence of neuro44
logical manifestation. But the findings on these imag45
ing techniques are not highly correlated with those of
46 clinical examinations. Low diagnostic accuracy of rou47
tine clinical tests for exact detection of involved tissue
48 and presence of referred lower extremity symptoms are
49 other obstacles in the workup of LBP. Any pathology
50 in the SIJ that causes spasm of piriformis muscle may
51 lead to sciatic irritation and to a broad spectrum of
52 symptoms and a variety of pain radiation patterns [12].
53 A study showed that in 22.5%of patients, the radiation
54 was towards the calf and foot; the symptoms which
55 could be marked as radicular or discogenic pain [12].
56 Positional and functional clinical tests have been
57 developed to investigate whether SIJ is the source of
58 LBP. Several studies have been performed to investi59
gate the accuracy of the clinical tests [13]. Fluoroscop60
ically guided, contrast enhanced intra-articular anes61
thetic block is used as a valid test [13], but the proce62
dure is invasive, and not widely available.
63 Deep location, limited movement and irregular ana64
tomy are major limitations in SIJ evaluation. There65
fore, there is no single and suitable test for routine
66 clinical use [14] and physician should rely on a com67
bination of examinations in this regard. Treatment
68 strategies for SIJ lesions differ from those intended to
69 the pathologies of intervertebral disc, and non-specific
70 treatments may be inefficient [13].Moreover, there are
71 still some questions about the prevalence of simultane72
ous SIJD in patients with lumbar disc herniation.
73 The aimof conducting this cross-sectional study was
74 to determine the relative frequency of SIJD in a sample
75 of patients with image proven lumbar disc herniation.
We hypothesized that SIJ dysfunction could be a fre- 76
quent concomitant pathology,with a potentially signif- 77
icant effect on pain and functional disability in patients 78
with sub acute radicular back pain and discopathy. The 79
rationale of the study was to decrease the possibility 80
of missed diagnosis of SIJD when herniation is evident 81
on MRI. 82
2. Patients and methods 83
2.1. Design and setting 84
We performed a single group cross-sectional study. 85
The study was conducted in a three year period from 86
2007 in an outpatient clinic of physical medicine and 87
rehabilitation at the university hospital, Shafa Yahya- 88
ian; a large referral orthopedic and rehabilitation prac- 89
tice and research center in Tehran. 90
2.2. Recruitment 91
Participants were referees from university pain, or- 92
thopedics and neurosurgery clinics to our referral reha- 93
bilitation center for diagnostic and rehabilitation con- 94
siderations. A board-certified radiologist read MRI 95
views. Demographic data, medical history and a de- 96
tailed history of low back pain and its possible causes 97
were taken at the first visit. The recruitment question- 98
naire asked about various lifestyle and personal char- 99
acteristics. A board-certified physiatrist visited the par- 100
ticipants, completed a detailed medical history, per- 101
formed physical examinations and conducted further 102
investigations. All patients were Farsi speaking, and 103
there was no linguistic confusion between participants 104
and the assessors. 105
2.3. Inclusion criteria 106
Patients with image proven herniated lumbar disc 107
and physical findings suggestive of lumbosacral root 108
irritation were identified and invited to participate in 109
the study. Briefly, patients aged more than or equal to 110
18 years were enrolled if they had paracentral or in- 111
traforaminal lumbar disc herniation on MRI. We con- 112
sidered “herniation” as a posterior focal extension of 113
the disc with sagittal image showing a narrow and dis- 114
tinguishable pedicle of the nucleus. Then, all patients 115
were assessed for positive physical signs of SIJD. 116
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S.P. Madani et al. / Sacroiliac joint dysfunction in herniated lumbar disc 3
117 2.4. Exclusion criteria
118 Patients were excluded if they were unwilling or un119
able to complete the extensive physical examination.
120 Pregnant women and patients with prior lumbar spine
121 surgery, osteoporosis, spinal or hip fractures, sever hip
122 joint degenerative disorders, polyneuropathy, diabetes
123 mellitus and patients with disc herniation producing
124 progressive neurological deficit signs, were excluded
125 from the study.
126 2.5. Protocols and clinical tests
127 At the beginning of the study all research staff were
128 qualified and briefed according to their tasks. Partici129
pants had been evaluated with MRI 1.5 T, Signa, GE,
130 USA, and had positive findings for lumbar disc her131
niation. They completed neurological, and a variety
132 of clinical tests for detection of SIJD including: mo133
tion, palpation, and provocation tests with some short
134 breaks between the examinations. Neurologic exami135
nation and the assessment of SIJD were performed by
136 the research physiatrist, and physiotherapist, respec137
tively.
138 In order to determine the side of dysfunction, an
139 examiner seated behind each patient and performed
140 sitting posterior superior iliac spines (PSIS) palpa141
tion test, with forward bending of the patient’s trunk.
142 The test was considered positive if a PSIS seemed to
143 be higher than the other, in fully flexed position. For
144 standing flexion test, relative heights of the PSIS were
145 assessed in standing position. Then the patient was re146
quested to flex forward as far as possible. A change
147 in the relative relationship of the PSIS in fully flexed
148 position was considered positive [13,15].
149 In Patrick-Faber test, patients were requested to lay
150 supine on a table, and to flex, abduct, and externally
151 rotate the hip of the tested leg, and the examiner placed
152 the lateral malleolus on the knee of the opposite leg.
153 ASIS was stabilized and a light overpressure was ap154
plied to the medial aspect of the knee. The range of
155 motion in the tested extremity was compared with the
156 opposite side. Aggravated pain on buttock, low back
157 or groin area was considered for differentiating be158
tween hip and sacroiliac joints as the origin of pain.
159 In addition, the evaluator checked if a difference in the
160 range of motion existed between the two sides [13,16,
161 17]. For long-sitting test, each participant was placed
162 in supine position with extended hips and knees. The
163 lengths of the inferior aspects of both medial malleoli
164 were compared for the assessment of levelness. Then,
while the evaluator held the medial border of the me- 165
dial malleoli with the thumbs, the patients were as- 166
sisted to a long-sitting position and the relative leg 167
lengths were evaluated again. The test was considered 168
to be positive, if there was any observable difference 169
in the relative position of medial malleoli between the 170
supine and long-sitting position, suggesting a posteri- 171
orly or anteriorly rotated innominate [15]. Gillet test 172
was performed with the patient standing, and facing 173
away from the examiner. The examiner placed one 174
thumb under the PSIS on the side being tested, with 175
the other thumb over the S2 spinous process. The pa- 176
tient was instructed to stand on one leg while flexing 177
the contralateral hip and flexing his knee toward the 178
chest. The test result was recorded as positive, when 179
the PSIS failed to move posterior and inferior with re- 180
spect to S2 [13,16,18]. For each participant Sphinx test 181
was performed in which the patient was in prone po- 182
sition with backward bending. Then, the assessor pal- 183
pated sacral sulci and inferior lateral angles. Sacral 184
base asymmetry was considered as positive [13]. 185
With provocative examinations the irritation points 186
were assessed. The examiner applied antero-posterior 187
pressure on sacral base and apex; and observed for 188
sacral flexion and extension, respectively. Pain or 189
movement abnormality was evaluated with cephalic 190
pressure on sacrum, near the base and apex. Also, tor- 191
tional movement around the oblique axis was exam- 192
ined with pressure on the contralateral ilia of the deep 193
sulcus. Pressure was applied on long dorsal sacroil- 194
iac ligament, the anterior ligament, the sacroiliac joint 195
capsule, and the lumbosacral junction [19]. For the 196
provocative tests, elicited ipsilateral pain in the gluteal 197
region or below the level of L5 was considered as posi- 198
tive. Pain caused by pressure from the examiner’s hand 199
or an uncomfortable position was not recorded as pos- 200
itive. 201
Sacroiliac joint dysfunction was diagnosed if the pa- 202
tient had a cluster of at least four positive anatomical, 203
and two positive provocative tests. Range of motion 204
and pain on pressure were recorded, according to the 205
specific clinical test. 206
2.6. Ethical considerations 207
The study was conducted in accordance with the 208
Declaration of Helsinki, and the research protocol was 209
approved by the institutional review board of Tehran 210
University of medical sciences. The research inves- 211
tigators explained the aims, rationale, and safety of 212
the study to eligible patients. A study nurse accom- 213
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4 S.P. Madani et al. / Sacroiliac joint dysfunction in herniated lumbar disc
panied patients and 214 provided them with verbal infor215
mation, and a leaflet on lumbar disc herniation and
216 SIJD. All patients regardless of participation in this re217
search were referred for appropriate treatment. Patients
218 were informed that they were free to withdraw from
219 the study at any time.
220 2.7. Sample size
221 Sample size calculations were based on the formula:
N = 4 pq
ω2 z2
1−α/2222 , where p is the anticipation of the
223 prevalence of SIJD; q = 1 − p; ω is the planned width
224 of 95% CI for the estimation of the prevalence, α =
225 0.05, and z0.975 = 1.9600. For the anticipated preva226
lence of 70%, the numbers of participants required
227 with ω = 0.1, and 0.2 are 323 and 81, respectively.
228 We were able to enroll 202 participants to provide the
229 planned width ω ≈ 0.12 of 95% CI for the estimation
230 of the prevalence.
231 2.8. Statistical analysis
232 Data were presented as mean and standard devia233
tion (STD) for continuous variables, and as numbers
234 and proportions for categorical variables. Chi-squared
235 test was used for the analysis of categorical data and
236 a p-value of less than 0.05 was considered significant.
237 Odds ratios with 95% confidence intervals were re238
ported for each contributing factor.Multivariable anal239
ysis was performed using logistic regression model to
240 estimate the adjusted effect of risk factors on SIJD.
241 Data was analyzed with SPSS forWindows, version 10
242 (SPSS, Inc., Chicago, IL, USA).
243 3. Results
244 We identified 202 patients who met our inclusion
245 criteria. They ranged in age from 19 to 70 years with
246 a mean (STD) age of 42 (12) years. The range of
247 weight was from 42 to 105 with the mean (STD) of
248 71 (11.4) kg weight, and the range of height was from
249 148 to 190 with the mean (STD) of 166.2 (9) cm. Sev250
enteen (8.4%) participants had abnormal pinprick test,
251 and 93 (47.2%) had diminished or absent knee and (or)
252 ankle reflexes. In 59 (29.2%) patients, one grade di253
minished power of ankle dorsi-flexion or plantar flex254
ion was evident in manual muscle test, and in 149
255 (73.8%) straight leg raising test was positive (i.e., from
256 30 to 60 degrees). Disc herniation was reported in 54
257 (26.7%), 73 (36.1%), and in 8 (4%) patients at the levn=
173
n=130
n=166
n=184
n=172
n=147
n=185 n=185
n=62
n=36
n=100
Percent
Fig. 1. Percent and frequency of positive clinical tests for SIJD in
202 patients with image-proven herniated lumbar disc.
els of L5/S1, L4/L5, and L3/L4, respectively. Besides, 258
in 67 (33.2%) participants, both L4/L5 and L5/S1 were 259
affected. 260
In our sample, 146 (72.3%) participants had SIJD, 261
of which 113 (55.9%)were female. Figure 1 shows fre- 262
quency, and percent of positive clinical tests, respec- 263
tively. In addition, 139 (95.2%) participants had the left 264
on left type of SIJD. Only in 3 (2.1), and 4 (2.7) pa- 265
tients with SIJD, right on left, and right on right types 266
were recorded, respectively. 267
The prevalence of SIJD was significantly higher in 268
women [Chi squared χ2 (1) = 10.7, p = 0.001]; crude 269
odds ratio (OR) = 2.84, with 95% CI = 1.5 to 5.37, 270
adjusted OR = 2.46 and 95% CI = 1.00 to 6.03. In 271
addition, SIJD was more prevalent in patients with an 272
abnormal straight leg raise test [Chi squared χ2 (1) = 273
16.3, p < 0.0001]; crude OR = 3.82, with 95% CI = 274
1.95 to 7.47, adjusted OR = 5.07 and 95% CI = 2.37 to 275
10.85. A positive history of recurrent back pain within 276
the last year was associated with the possibility of SIJD 277
by 2.4 folds [Chi squared χ2 (1) = 7.3, p = 0.005]; 278
crude OR = 2.4 with 95% CI = 1.26 to 4.58, adjusted 279
OR = 2.33 with 95% CI = 1.10 to 4.89. Heavy work 280
load assessed subjectively by the participantswas asso- 281
ciated with SIJD [Chi squared χ2 (1) = 6.2, p = 0.01], 282
crude OR = 2.27 with 95% CI = 1.18 to 4.38, but in 283
multivariable analysis with adjusting appropriate vari- 284
ables, the effect diminished in magnitude (adjusted OR 285
= 1.46 with 95% CI = 0.58 to 3.68). However, there 286
was no significant relationship between the prevalence 287
of SIJD, and working hours, duration of low back pain, 288
and body mass index (p > 0.05). 289
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S.P. Madani et al. / Sacroiliac joint dysfunction in herniated lumbar disc 5
290 4. Discussion
291 The present study was conducted to detect sacroil292
iac joint dysfunction and its prevalence as a coexisting
293 pathology among patients with discopathy. The results
294 indicated that a large number of patients with image295
proven herniated lumbar disc had SIJD. Female sex
296 and a positive history of recurrent back pain were im297
portant risk factors. Heavy work load was a risk fac298
tor too; the finding that may be of public health impor299
tance.
300 The epidemiology of the SIJ lesions has been poorly
301 described in previous studies. The reported prevalence
302 is between 13–48% [9,21,23,24]. Limited sacroiliac
303 joint mobility with age-induced decrement and the ab304
sence of a specific historical point or clinical exam305
ination technique have made the diagnosis of SIJD
306 a challenging problem. Inflammatory mediators from
307 disrupted capsule and multilevel innervations from an308
terior and posterior rami of L2 to S3 explain the re309
ferral pain of SIJD with variable distribution [20]. Be310
sides, there is no gold standard for the clinical diagno311
sis of SIJD, and the dysfunction is not detectable with
312 imaging procedures such as MRI or CT scan. Imag313
ing evaluation of SIJ is routinely done to rule out in314
fections,metabolic disorders, fractures, or tumors. But,
315 commonly the results are normal in patients with SIJ
316 pain [21].
317 Sacroiliac joint block has been reported as the
318 valid diagnostic means [19]. The controlled diagnos319
tic blocks utilizing the international association for the
320 study of pain (IASP) criteria demonstrated the preva321
lence of pain with sacroiliac origin in 19% to 30% of
322 the patients suspected to have sacroiliac joint pain [11,
323 20,22]. However, anesthetic block is not aimed at
324 extra-articular structures, the fact thatmay explainwhy
325 in our study the prevalence of SIJD was higher than
326 previously measured [20]. To our knowledge, there is
327 no recent study on the prevalence of SIJD in patients
328 with image-proven lumbar disc herniation using clin329
ical diagnostic tests. Our study was sufficiently large
330 and the study sample was representative of patients
331 with herniated lumbar disc. Combination of palpation
332 and provocative tests which evaluate articular, periar333
ticular and biomechanical pathologies were used for
334 detection of concomitant SIJD in the studied popula335
tion.
336 There are several studies on validity of clinical tests
337 with especial attention to composites of pain provo338
cation and motion - palpation tests [13,25]. It was re339
ported that the use of the manual tests of SIJD in combination,
had been informative with positive likelihood 340
ratio of 3.2 (95% CI 2.3–4.4) and negative likelihood 341
ratio of 0.29 (95% CI 0.12–0.35) [3]. All the studies 342
have suggested the application of multiple tests as a 343
reliable strategy for the diagnosis of SIJD [22,26]. In 344
a recent study [27], researchers highlighted inter- and 345
intra-examiner reliability of single and composites of 346
selected motion palpation and pain provocation tests 347
for SIJD on twenty five participants. The best reliabil- 348
ity was for three or more palpation together with two 349
or more provocation tests. 350
In a study [9], the frequency and significance of 351
SIJD in patients with low back pain and sciatica and 352
imaging-proven disc herniation was evaluated. They 353
examined 150 patients with herniated lumbar discs 354
of which 46 had SIJD. All patients received inten- 355
sive physiotherapy. The researchers concluded that in 356
the presence of lumbar and ischiadic symptoms SIJD 357
should be considered, and that in the presence of SIJD 358
appropriate therapy regardless of intervertebral disc 359
pathomorphology should be pondered. They empha- 360
sized that such an approach could avoid wrong in- 361
dications for nucleotomy [9]. Due to the absence of 362
newly developed reliable diagnostic clinical criteria at 363
the time of study, their conclusion was mostly based on 364
patients’ response to physical therapy for SIJ.While in 365
our study the more recent concept of “cluster of clini- 366
cal tests” has been followed. 367
In our study, the estimated prevalence of SIJ dys- 368
function was significantly higher than previous studies 369
(72.3%) [9,21,23,24]. This could be explained by the 370
importance of extraarticular factors which are not de- 371
tected by diagnostic blocks. However, body stress in- 372
duced by heavy work and poor ergonomic standards at 373
work place could be considered as the secondary in- 374
teracting factors affecting the studied population. The 375
other influencing factor was the examined population. 376
This study was conducted on patients with definite 377
MRI findings of discopathy. 378
It was found that females were more prone to the SIJ 379
dysfunction. Higher frequency of the SIJ dysfunction 380
in female patients (p = 0.001) could be due to child- 381
bearing effects on the sacroiliac joint [28] or other fac- 382
tors such as lifestyle or low exercise activities. 383
Past history of recurrence of same back pain within 384
previous year increases the possibility of SIJ dysfunc- 385
tion. This could mean that the recurrent back pain was 386
due to chronic biomechanical abnormalities which had 387
not been corrected, but the symptoms were transiently 388
subsided by adaptation [28]. Positive straight leg rais- 389
ing test significantly increased the suspicion of SIJD, 390
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6 S.P. Madani et al. / Sacroiliac joint dysfunction in herniated lumbar disc
but the test 391 could not be considered as differentiating
392 physical finding.
393 Our findings implied that SIJD is a prevalent con394
comitant pathology in patients with herniated lumbar
395 disc, and that SIJD can be evaluated by combinations
396 of easily performable palpation and pain provocative
397 tests. Sacroiliac joint dysfunction has been discussed
398 properly in manual medicine references. But, in med399
ical books on back pain the subject has not described
400 with sufficient details. Therefore, some physicians do
401 not consider SIJD as a differential diagnosis in the
402 work-up of low back pain [12]. According to our re403
sults, any practitioner should be aware of coincident
404 SIJD during evaluation of patients who apparently suf405
fer from lumbar disc herniation.
406 It is worth investigating whether disc herniation and
407 SIJ dysfunction develop independently or the patholo408
gies are interrelated. The pathogeneses are associated
409 with complex and asymmetrical motions and with ex410
ternal loads. Having a successful gentle manual ther411
apy to correct biomechanical defects of sacroiliac joint
412 and surrounding structures without any significant ef413
fect on concomitant discopathy can be considered as
414 a basis for future clinical trials to determine the main
415 pathology.
416 5. Conclusion
417 This study found the sacroiliac joint dysfunction to
418 be a prevalent concomitant pathology in patients with
419 herniated lumbar discs. Thus it recommends that SIJ
420 dysfunction must be considered during examination
421 and planning of each conservative management proto422
col in LBP patients.
423 Conflicts of interest
424 The authors declare that they have no competing in425
terests.
426 Source of support
427 The study has been supported financially by the
428 Tehran University of Medical Sciences.
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[20] S.L. Forst, M.T. Wheeler, J.D. Fortin, J.A. Vilensky, The 495
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Journal of Back and Musculoskeletal Rehabilitation 00 (2013) 1–7 1
DOI 10.3233/BMR-130376
IOS Press
Sacroiliac joint dysfunction in patients with
herniated lumbar disc: A cross-sectional study
Seyed PezhmanMadania,∗, Mohammad Dadianb, Keykavous Firouzniac and Salah Alalawid
aDepartment of Physical Medicine and Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
bDepartment of Physical Therapy, University of Welfare and Rehabilitation, Tehran, Iran
cDepartment of Radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran
University of Medical Sciences, Tehran, Iran
dPhysical Medicine and Rehabilitation Specialist, Royal National Hospital for Rheumatic Diseases, London, UK
Abstract. OBJECTIVES: To determine the relative frequency of sacroiliac joint dysfunction in a sample of patients with image
proven lumbar disc herniation.
METHODS: A single group cross-sectional study was conducted in a three year period from 2007 in an outpatient clinic at a
university hospital. Overall, 202 patients aged more than or equal to 18 years with image proven herniated lumbar disc and with
physical findings suggestive of lumbosacral root irritation were included.
RESULTS: Overall, 146 (72.3%) participants had sacroiliac joint dysfunction. The dysfunction was significantly more prevalent
in females (p <0.001, adjusted OR = 2.46, 95% CI = 1.00 to 6.03), patients with recurrent pain (p <0.005, adjusted OR = 2.33
with 95% CI = 1.10 to 4.89) and patients with positive straight leg raising provocative test (p < 0.0001, adjusted OR = 5.07,
95% CI = 2.37 to 10.85). There was no significant relationship between the prevalence of SIJD, and working hours, duration of
low back pain, or body mass index.
CONCLUSIONS: Sacroiliac joint dysfunction is a significant pathogenic factor with high possibility of occurrence in low
back pain. Thus, regardless of intervertebral disc pathology, sacroiliac joint dysfunction must be considered in clinical decision
making.
Keywords: Sacroiliac joint, low back pain, lumbar disc herniation
1 1. Introduction
2 About 70–85% of adults experience low back pain
3 (LBP) at some point during their life [1,2]. The disc,
4 facet joint and sacroiliac joint (SIJ) are potential
5 sources of LBP [3]. Disc-related diseases of the lumbar
6 spine are common causes of pain, and frequently lead
7 to reduced productivity and lost to work [4,5]. Lum8
bar disc herniation frequently affects the spine [6], and
∗Corresponding author: Seyed Pezhman Madani, M.D., Assistant
Professor, Department of Physical Medicine and Rehabilitation,
Shafayahyaian Rehabilitation Hospital, Tehran University of Medical
Sciences, Baharestan Square, Mojahedin-E-Islam Ave, Tehran
1157637131, Iran. Tel.: +98 21 33542001; Fax: +98 21 33542020;
E-mail: p-madani@sina.tums.ac.ir.
if the symptoms are attributable to lumbar disc pathol- 9
ogy, magnetic resonance imaging (MRI) or computer- 10
ized tomography (CT) are indicated to confirm [7]. 11
Diseases with the manifestations similar to those of 12
herniated intervertebral disc pose a challenging prob- 13
lem in the diagnostic workup, and in decision mak- 14
ing for the best treatment modality in patients with 15
LBP. In addition, one should be aware that dual pathol- 16
ogy may exist, otherwise patients may undergo clinical 17
and imaging investigations and the etiology may still 18
remain unclear. Treatment of low back pain resistant 19
to conservative management is still a problem. Open 20
surgery has disadvantages such as intraoperative tissue 21
damage, epidural fibrosis, and scar formation [5,8]. 22
SIJ is a poorly defined subset of several recognized 23
causes of LBP. Researchers identified the SIJ as one of 24
ISSN 1053-8127/13/$27.50 c 2013 – IOS Press and the authors. All rights reserved
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2 S.P. Madani et al. / Sacroiliac joint dysfunction in herniated lumbar disc
the possible starting 25 points of pain via injection of lo26
cal anesthetic [9]. Depending on the studied population
27 and diagnostic measures, the prevalence of the sacroil28
iac joint as a source of low back pain is reported 13%
29 to 48% in different studies [9,21,23]. In a study [24], it
30 has been reported that, of 1293 patients with low back
31 pain the SIJ dysfunction was thought to be the source
32 of pain in 22.5%, based on history and physical exam33
ination. Relative hypomobility of SIJ and the result34
ing pelvic asymmetry has been described as sacroil35
iac joint dysfunction (SIJD) [10,11]. The underlying
36 processes leading to pain production or the responsi37
ble tissues are still debated. It has been suggested that
38 LBP may arise from pelvic tissues or low back region
39 because of pelvic asymmetry and excessive or limited
40 spinal or SIJ motion [9,11].
41 It has been suggested that chronic LBP (more than
42 4 weeks of duration) is related to discopathies evi43
dent on MRI or CT, even in the absence of neuro44
logical manifestation. But the findings on these imag45
ing techniques are not highly correlated with those of
46 clinical examinations. Low diagnostic accuracy of rou47
tine clinical tests for exact detection of involved tissue
48 and presence of referred lower extremity symptoms are
49 other obstacles in the workup of LBP. Any pathology
50 in the SIJ that causes spasm of piriformis muscle may
51 lead to sciatic irritation and to a broad spectrum of
52 symptoms and a variety of pain radiation patterns [12].
53 A study showed that in 22.5%of patients, the radiation
54 was towards the calf and foot; the symptoms which
55 could be marked as radicular or discogenic pain [12].
56 Positional and functional clinical tests have been
57 developed to investigate whether SIJ is the source of
58 LBP. Several studies have been performed to investi59
gate the accuracy of the clinical tests [13]. Fluoroscop60
ically guided, contrast enhanced intra-articular anes61
thetic block is used as a valid test [13], but the proce62
dure is invasive, and not widely available.
63 Deep location, limited movement and irregular ana64
tomy are major limitations in SIJ evaluation. There65
fore, there is no single and suitable test for routine
66 clinical use [14] and physician should rely on a com67
bination of examinations in this regard. Treatment
68 strategies for SIJ lesions differ from those intended to
69 the pathologies of intervertebral disc, and non-specific
70 treatments may be inefficient [13].Moreover, there are
71 still some questions about the prevalence of simultane72
ous SIJD in patients with lumbar disc herniation.
73 The aimof conducting this cross-sectional study was
74 to determine the relative frequency of SIJD in a sample
75 of patients with image proven lumbar disc herniation.
We hypothesized that SIJ dysfunction could be a fre- 76
quent concomitant pathology,with a potentially signif- 77
icant effect on pain and functional disability in patients 78
with sub acute radicular back pain and discopathy. The 79
rationale of the study was to decrease the possibility 80
of missed diagnosis of SIJD when herniation is evident 81
on MRI. 82
2. Patients and methods 83
2.1. Design and setting 84
We performed a single group cross-sectional study. 85
The study was conducted in a three year period from 86
2007 in an outpatient clinic of physical medicine and 87
rehabilitation at the university hospital, Shafa Yahya- 88
ian; a large referral orthopedic and rehabilitation prac- 89
tice and research center in Tehran. 90
2.2. Recruitment 91
Participants were referees from university pain, or- 92
thopedics and neurosurgery clinics to our referral reha- 93
bilitation center for diagnostic and rehabilitation con- 94
siderations. A board-certified radiologist read MRI 95
views. Demographic data, medical history and a de- 96
tailed history of low back pain and its possible causes 97
were taken at the first visit. The recruitment question- 98
naire asked about various lifestyle and personal char- 99
acteristics. A board-certified physiatrist visited the par- 100
ticipants, completed a detailed medical history, per- 101
formed physical examinations and conducted further 102
investigations. All patients were Farsi speaking, and 103
there was no linguistic confusion between participants 104
and the assessors. 105
2.3. Inclusion criteria 106
Patients with image proven herniated lumbar disc 107
and physical findings suggestive of lumbosacral root 108
irritation were identified and invited to participate in 109
the study. Briefly, patients aged more than or equal to 110
18 years were enrolled if they had paracentral or in- 111
traforaminal lumbar disc herniation on MRI. We con- 112
sidered “herniation” as a posterior focal extension of 113
the disc with sagittal image showing a narrow and dis- 114
tinguishable pedicle of the nucleus. Then, all patients 115
were assessed for positive physical signs of SIJD. 116
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S.P. Madani et al. / Sacroiliac joint dysfunction in herniated lumbar disc 3
117 2.4. Exclusion criteria
118 Patients were excluded if they were unwilling or un119
able to complete the extensive physical examination.
120 Pregnant women and patients with prior lumbar spine
121 surgery, osteoporosis, spinal or hip fractures, sever hip
122 joint degenerative disorders, polyneuropathy, diabetes
123 mellitus and patients with disc herniation producing
124 progressive neurological deficit signs, were excluded
125 from the study.
126 2.5. Protocols and clinical tests
127 At the beginning of the study all research staff were
128 qualified and briefed according to their tasks. Partici129
pants had been evaluated with MRI 1.5 T, Signa, GE,
130 USA, and had positive findings for lumbar disc her131
niation. They completed neurological, and a variety
132 of clinical tests for detection of SIJD including: mo133
tion, palpation, and provocation tests with some short
134 breaks between the examinations. Neurologic exami135
nation and the assessment of SIJD were performed by
136 the research physiatrist, and physiotherapist, respec137
tively.
138 In order to determine the side of dysfunction, an
139 examiner seated behind each patient and performed
140 sitting posterior superior iliac spines (PSIS) palpa141
tion test, with forward bending of the patient’s trunk.
142 The test was considered positive if a PSIS seemed to
143 be higher than the other, in fully flexed position. For
144 standing flexion test, relative heights of the PSIS were
145 assessed in standing position. Then the patient was re146
quested to flex forward as far as possible. A change
147 in the relative relationship of the PSIS in fully flexed
148 position was considered positive [13,15].
149 In Patrick-Faber test, patients were requested to lay
150 supine on a table, and to flex, abduct, and externally
151 rotate the hip of the tested leg, and the examiner placed
152 the lateral malleolus on the knee of the opposite leg.
153 ASIS was stabilized and a light overpressure was ap154
plied to the medial aspect of the knee. The range of
155 motion in the tested extremity was compared with the
156 opposite side. Aggravated pain on buttock, low back
157 or groin area was considered for differentiating be158
tween hip and sacroiliac joints as the origin of pain.
159 In addition, the evaluator checked if a difference in the
160 range of motion existed between the two sides [13,16,
161 17]. For long-sitting test, each participant was placed
162 in supine position with extended hips and knees. The
163 lengths of the inferior aspects of both medial malleoli
164 were compared for the assessment of levelness. Then,
while the evaluator held the medial border of the me- 165
dial malleoli with the thumbs, the patients were as- 166
sisted to a long-sitting position and the relative leg 167
lengths were evaluated again. The test was considered 168
to be positive, if there was any observable difference 169
in the relative position of medial malleoli between the 170
supine and long-sitting position, suggesting a posteri- 171
orly or anteriorly rotated innominate [15]. Gillet test 172
was performed with the patient standing, and facing 173
away from the examiner. The examiner placed one 174
thumb under the PSIS on the side being tested, with 175
the other thumb over the S2 spinous process. The pa- 176
tient was instructed to stand on one leg while flexing 177
the contralateral hip and flexing his knee toward the 178
chest. The test result was recorded as positive, when 179
the PSIS failed to move posterior and inferior with re- 180
spect to S2 [13,16,18]. For each participant Sphinx test 181
was performed in which the patient was in prone po- 182
sition with backward bending. Then, the assessor pal- 183
pated sacral sulci and inferior lateral angles. Sacral 184
base asymmetry was considered as positive [13]. 185
With provocative examinations the irritation points 186
were assessed. The examiner applied antero-posterior 187
pressure on sacral base and apex; and observed for 188
sacral flexion and extension, respectively. Pain or 189
movement abnormality was evaluated with cephalic 190
pressure on sacrum, near the base and apex. Also, tor- 191
tional movement around the oblique axis was exam- 192
ined with pressure on the contralateral ilia of the deep 193
sulcus. Pressure was applied on long dorsal sacroil- 194
iac ligament, the anterior ligament, the sacroiliac joint 195
capsule, and the lumbosacral junction [19]. For the 196
provocative tests, elicited ipsilateral pain in the gluteal 197
region or below the level of L5 was considered as posi- 198
tive. Pain caused by pressure from the examiner’s hand 199
or an uncomfortable position was not recorded as pos- 200
itive. 201
Sacroiliac joint dysfunction was diagnosed if the pa- 202
tient had a cluster of at least four positive anatomical, 203
and two positive provocative tests. Range of motion 204
and pain on pressure were recorded, according to the 205
specific clinical test. 206
2.6. Ethical considerations 207
The study was conducted in accordance with the 208
Declaration of Helsinki, and the research protocol was 209
approved by the institutional review board of Tehran 210
University of medical sciences. The research inves- 211
tigators explained the aims, rationale, and safety of 212
the study to eligible patients. A study nurse accom- 213
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4 S.P. Madani et al. / Sacroiliac joint dysfunction in herniated lumbar disc
panied patients and 214 provided them with verbal infor215
mation, and a leaflet on lumbar disc herniation and
216 SIJD. All patients regardless of participation in this re217
search were referred for appropriate treatment. Patients
218 were informed that they were free to withdraw from
219 the study at any time.
220 2.7. Sample size
221 Sample size calculations were based on the formula:
N = 4 pq
ω2 z2
1−α/2222 , where p is the anticipation of the
223 prevalence of SIJD; q = 1 − p; ω is the planned width
224 of 95% CI for the estimation of the prevalence, α =
225 0.05, and z0.975 = 1.9600. For the anticipated preva226
lence of 70%, the numbers of participants required
227 with ω = 0.1, and 0.2 are 323 and 81, respectively.
228 We were able to enroll 202 participants to provide the
229 planned width ω ≈ 0.12 of 95% CI for the estimation
230 of the prevalence.
231 2.8. Statistical analysis
232 Data were presented as mean and standard devia233
tion (STD) for continuous variables, and as numbers
234 and proportions for categorical variables. Chi-squared
235 test was used for the analysis of categorical data and
236 a p-value of less than 0.05 was considered significant.
237 Odds ratios with 95% confidence intervals were re238
ported for each contributing factor.Multivariable anal239
ysis was performed using logistic regression model to
240 estimate the adjusted effect of risk factors on SIJD.
241 Data was analyzed with SPSS forWindows, version 10
242 (SPSS, Inc., Chicago, IL, USA).
243 3. Results
244 We identified 202 patients who met our inclusion
245 criteria. They ranged in age from 19 to 70 years with
246 a mean (STD) age of 42 (12) years. The range of
247 weight was from 42 to 105 with the mean (STD) of
248 71 (11.4) kg weight, and the range of height was from
249 148 to 190 with the mean (STD) of 166.2 (9) cm. Sev250
enteen (8.4%) participants had abnormal pinprick test,
251 and 93 (47.2%) had diminished or absent knee and (or)
252 ankle reflexes. In 59 (29.2%) patients, one grade di253
minished power of ankle dorsi-flexion or plantar flex254
ion was evident in manual muscle test, and in 149
255 (73.8%) straight leg raising test was positive (i.e., from
256 30 to 60 degrees). Disc herniation was reported in 54
257 (26.7%), 73 (36.1%), and in 8 (4%) patients at the levn=
173
n=130
n=166
n=184
n=172
n=147
n=185 n=185
n=62
n=36
n=100
Percent
Fig. 1. Percent and frequency of positive clinical tests for SIJD in
202 patients with image-proven herniated lumbar disc.
els of L5/S1, L4/L5, and L3/L4, respectively. Besides, 258
in 67 (33.2%) participants, both L4/L5 and L5/S1 were 259
affected. 260
In our sample, 146 (72.3%) participants had SIJD, 261
of which 113 (55.9%)were female. Figure 1 shows fre- 262
quency, and percent of positive clinical tests, respec- 263
tively. In addition, 139 (95.2%) participants had the left 264
on left type of SIJD. Only in 3 (2.1), and 4 (2.7) pa- 265
tients with SIJD, right on left, and right on right types 266
were recorded, respectively. 267
The prevalence of SIJD was significantly higher in 268
women [Chi squared χ2 (1) = 10.7, p = 0.001]; crude 269
odds ratio (OR) = 2.84, with 95% CI = 1.5 to 5.37, 270
adjusted OR = 2.46 and 95% CI = 1.00 to 6.03. In 271
addition, SIJD was more prevalent in patients with an 272
abnormal straight leg raise test [Chi squared χ2 (1) = 273
16.3, p < 0.0001]; crude OR = 3.82, with 95% CI = 274
1.95 to 7.47, adjusted OR = 5.07 and 95% CI = 2.37 to 275
10.85. A positive history of recurrent back pain within 276
the last year was associated with the possibility of SIJD 277
by 2.4 folds [Chi squared χ2 (1) = 7.3, p = 0.005]; 278
crude OR = 2.4 with 95% CI = 1.26 to 4.58, adjusted 279
OR = 2.33 with 95% CI = 1.10 to 4.89. Heavy work 280
load assessed subjectively by the participantswas asso- 281
ciated with SIJD [Chi squared χ2 (1) = 6.2, p = 0.01], 282
crude OR = 2.27 with 95% CI = 1.18 to 4.38, but in 283
multivariable analysis with adjusting appropriate vari- 284
ables, the effect diminished in magnitude (adjusted OR 285
= 1.46 with 95% CI = 0.58 to 3.68). However, there 286
was no significant relationship between the prevalence 287
of SIJD, and working hours, duration of low back pain, 288
and body mass index (p > 0.05). 289
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S.P. Madani et al. / Sacroiliac joint dysfunction in herniated lumbar disc 5
290 4. Discussion
291 The present study was conducted to detect sacroil292
iac joint dysfunction and its prevalence as a coexisting
293 pathology among patients with discopathy. The results
294 indicated that a large number of patients with image295
proven herniated lumbar disc had SIJD. Female sex
296 and a positive history of recurrent back pain were im297
portant risk factors. Heavy work load was a risk fac298
tor too; the finding that may be of public health impor299
tance.
300 The epidemiology of the SIJ lesions has been poorly
301 described in previous studies. The reported prevalence
302 is between 13–48% [9,21,23,24]. Limited sacroiliac
303 joint mobility with age-induced decrement and the ab304
sence of a specific historical point or clinical exam305
ination technique have made the diagnosis of SIJD
306 a challenging problem. Inflammatory mediators from
307 disrupted capsule and multilevel innervations from an308
terior and posterior rami of L2 to S3 explain the re309
ferral pain of SIJD with variable distribution [20]. Be310
sides, there is no gold standard for the clinical diagno311
sis of SIJD, and the dysfunction is not detectable with
312 imaging procedures such as MRI or CT scan. Imag313
ing evaluation of SIJ is routinely done to rule out in314
fections,metabolic disorders, fractures, or tumors. But,
315 commonly the results are normal in patients with SIJ
316 pain [21].
317 Sacroiliac joint block has been reported as the
318 valid diagnostic means [19]. The controlled diagnos319
tic blocks utilizing the international association for the
320 study of pain (IASP) criteria demonstrated the preva321
lence of pain with sacroiliac origin in 19% to 30% of
322 the patients suspected to have sacroiliac joint pain [11,
323 20,22]. However, anesthetic block is not aimed at
324 extra-articular structures, the fact thatmay explainwhy
325 in our study the prevalence of SIJD was higher than
326 previously measured [20]. To our knowledge, there is
327 no recent study on the prevalence of SIJD in patients
328 with image-proven lumbar disc herniation using clin329
ical diagnostic tests. Our study was sufficiently large
330 and the study sample was representative of patients
331 with herniated lumbar disc. Combination of palpation
332 and provocative tests which evaluate articular, periar333
ticular and biomechanical pathologies were used for
334 detection of concomitant SIJD in the studied popula335
tion.
336 There are several studies on validity of clinical tests
337 with especial attention to composites of pain provo338
cation and motion - palpation tests [13,25]. It was re339
ported that the use of the manual tests of SIJD in combination,
had been informative with positive likelihood 340
ratio of 3.2 (95% CI 2.3–4.4) and negative likelihood 341
ratio of 0.29 (95% CI 0.12–0.35) [3]. All the studies 342
have suggested the application of multiple tests as a 343
reliable strategy for the diagnosis of SIJD [22,26]. In 344
a recent study [27], researchers highlighted inter- and 345
intra-examiner reliability of single and composites of 346
selected motion palpation and pain provocation tests 347
for SIJD on twenty five participants. The best reliabil- 348
ity was for three or more palpation together with two 349
or more provocation tests. 350
In a study [9], the frequency and significance of 351
SIJD in patients with low back pain and sciatica and 352
imaging-proven disc herniation was evaluated. They 353
examined 150 patients with herniated lumbar discs 354
of which 46 had SIJD. All patients received inten- 355
sive physiotherapy. The researchers concluded that in 356
the presence of lumbar and ischiadic symptoms SIJD 357
should be considered, and that in the presence of SIJD 358
appropriate therapy regardless of intervertebral disc 359
pathomorphology should be pondered. They empha- 360
sized that such an approach could avoid wrong in- 361
dications for nucleotomy [9]. Due to the absence of 362
newly developed reliable diagnostic clinical criteria at 363
the time of study, their conclusion was mostly based on 364
patients’ response to physical therapy for SIJ.While in 365
our study the more recent concept of “cluster of clini- 366
cal tests” has been followed. 367
In our study, the estimated prevalence of SIJ dys- 368
function was significantly higher than previous studies 369
(72.3%) [9,21,23,24]. This could be explained by the 370
importance of extraarticular factors which are not de- 371
tected by diagnostic blocks. However, body stress in- 372
duced by heavy work and poor ergonomic standards at 373
work place could be considered as the secondary in- 374
teracting factors affecting the studied population. The 375
other influencing factor was the examined population. 376
This study was conducted on patients with definite 377
MRI findings of discopathy. 378
It was found that females were more prone to the SIJ 379
dysfunction. Higher frequency of the SIJ dysfunction 380
in female patients (p = 0.001) could be due to child- 381
bearing effects on the sacroiliac joint [28] or other fac- 382
tors such as lifestyle or low exercise activities. 383
Past history of recurrence of same back pain within 384
previous year increases the possibility of SIJ dysfunc- 385
tion. This could mean that the recurrent back pain was 386
due to chronic biomechanical abnormalities which had 387
not been corrected, but the symptoms were transiently 388
subsided by adaptation [28]. Positive straight leg rais- 389
ing test significantly increased the suspicion of SIJD, 390
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6 S.P. Madani et al. / Sacroiliac joint dysfunction in herniated lumbar disc
but the test 391 could not be considered as differentiating
392 physical finding.
393 Our findings implied that SIJD is a prevalent con394
comitant pathology in patients with herniated lumbar
395 disc, and that SIJD can be evaluated by combinations
396 of easily performable palpation and pain provocative
397 tests. Sacroiliac joint dysfunction has been discussed
398 properly in manual medicine references. But, in med399
ical books on back pain the subject has not described
400 with sufficient details. Therefore, some physicians do
401 not consider SIJD as a differential diagnosis in the
402 work-up of low back pain [12]. According to our re403
sults, any practitioner should be aware of coincident
404 SIJD during evaluation of patients who apparently suf405
fer from lumbar disc herniation.
406 It is worth investigating whether disc herniation and
407 SIJ dysfunction develop independently or the patholo408
gies are interrelated. The pathogeneses are associated
409 with complex and asymmetrical motions and with ex410
ternal loads. Having a successful gentle manual ther411
apy to correct biomechanical defects of sacroiliac joint
412 and surrounding structures without any significant ef413
fect on concomitant discopathy can be considered as
414 a basis for future clinical trials to determine the main
415 pathology.
416 5. Conclusion
417 This study found the sacroiliac joint dysfunction to
418 be a prevalent concomitant pathology in patients with
419 herniated lumbar discs. Thus it recommends that SIJ
420 dysfunction must be considered during examination
421 and planning of each conservative management proto422
col in LBP patients.
423 Conflicts of interest
424 The authors declare that they have no competing in425
terests.
426 Source of support
427 The study has been supported financially by the
428 Tehran University of Medical Sciences.
429 References
430 [1] C. Schizas, G. Kulik, V. Kosmopoulos, Disc degeneration:
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