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Chapter 22 Anatomy, Nonoperative Results, Preoperative Injections, and Prescriptions 393
radiofrequency treatment of the nerves supplying the joint.
e injection of steroids and local anesthetics for treatment of
SI joint pain has oen been assumed to require the intraarticular injection of the medication. However, the periarticular
muscular and ligamentous connections are complex, and may
also be a source of pain.96 A retrospective study of 120 patients
found that the combination of intraarticular and extraarticular
injection provided better pain relief than intraarticular alone.97
In randomized controlled studies, the periarticular injection
of local anesthetic and steroids has provided short-term relief.
ere have been several studies of intraarticular injection of
steroids, most of which have found at least short-term benet.91
However, two separate systematic reviews of SI joint pain
found that the quality of these studies was too poor to grade
the evidence or assessed the evidence to be limited.
96,98
A more
recent systematic review of SI joint diagnosis and treatment
graded the evidence as moderate.
99
e treatment of SI joint pain with radiofrequency ablation
has limited evidence through mostly observational studies,
with pain improvement lasting up to a year.
96,98
In a small
randomized, placebo-controlled trial of cooled-radiofrequency
(cooled-RF) ablation versus sham ablation, the treatment
group had signicant relief compared to baseline at 1, 3, and
6 months.
100
Additionally, 11 of those who received the sham
treatment crossed over to cooled-RF treatment and exhibited
similar pain relief results to the initial treatment group. An
additional sham-controlled study of cooled-RF found similar
101
results.
Studies for conventional radiofrequency have been
more limited and mostly observational, with a couple of randomized studies comparing cooled-RF to conventional RF. In one
of those studies, Cheng et al. found that both provided greater
than 50% pain relief for 3 to 6 months, with no signicant
dierence between the treatments.
102
Last, there is one study of
pulsed-radiofrequency neuromodulation of the lateral branch
nerves for SI joint pain. In this study by Vallejo et al., 22 patients
with SI joint pain conrmed with diagnostic blocks underwent
pulsed-radiofrequency of the L4 medial branch, L5 posterior
rami, and S1 and S2 lateral branch nerves; 73% achieved at
least 50% pain relief at 6 to 9 weeks.
103
e percentage with
signicant improvement dropped to 32% at 17 to 32 weeks.
Procedure: Sacroiliac Joint Injection
e patient is placed in a prone position, and prepped and
draped in the usual sterile fashion. e C-arm is positioned in
the AP direction, and the posterior inferior SI joint is identied. At this point, the practitioner may use a combination of
either cephalad versus caudal or ipsilateral versus contralateral
oblique to increase the lucency of the target, which is located
about 1 to 2 cm superior to the inferior aspect to the joint,
at the medial side of the joint. e skin is then anesthetized
with lidocaine 1%; a spinal needle is then directly coaxial to
target. e needle is then walked into the joint, with a medial
to lateral trajectory. Iohexol (Omnipaque 240) is injected to
conrm proper spread of the contrast medium within the joint
space, also conrming that there is no intravascular runo. A
lateral view should be checked to conrm that needle placement is ventral to the posterior sacrum but is not advanced too
far ventrally through the joint into the viscera. No more than
1.5 to 2 mL of injectate mix of steroid and local anesthetic is
then performed.
15,98,104
(Fig. 22.9).
Summary
is chapter has discussed the etiology of joint, disc, ligamentous, and nerve root pain and how each contributes to
the complexity of the pain experience. In general, evidence
for spinal injections is rather limited and high-quality gold
standard studies are few. Diagnostic and therapeutic spinal
injections must be performed in conjunction with a good
history, physical examination, and appropriate diagnostic
workup. ere are complications with any procedure, and the
risks and benets must be weighed before proceeding. Given
reports of serious complications in the cervical spine with
spinal cord injury and vascular infarcts, cervical TFESI should
be avoided, and cervical interlaminar epidurals performed
instead. ere is also an increased risk from transforaminal
epidural steroid injections in the lumbar spine, but signicantly lower than seen in the cervical spine. erefore, TFESI,
lumbar interlaminar epidural steroid injection, and CESI
SECTION
III
A
FIG. 22.9 Sacroiliac joint injection. (A) Anteroposterior radiograph showing the left sacroiliac joint.
(B) Anteroposterior radiograph showing contrast spread in the left sacroiliac joint with superior and lateral ow,
highlighting the joint space.
B
394 SURGICAL ANATOMY AND APPROACHES
are routinely performed to help treat radicular symptoms
or symptoms of central stenosis. For axial pain, diagnostic
medial branch blocks must be performed before treating with
RFA. In the lumbar spine, there is also the option of direct
zygapophyseal joint or facet joint injections. Finally, the SI
joint should also be considered as a common reason for low
back pain, and SI joint injections or RFA may be considered.
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Sacroiliac Joint Pain: Pathophysiology
SECTION
23
CHAPTER
Introduction
Low back pain remains a signicant burden on the health
care system, representing a source of approximately 12 million
physician oce visits per year in the United States. It is among
the leading causes of disability, accounting for expenditures
in excess of $80 billion every year.
of low back pain is known to result in variable success rates,
suggesting that the etiology of back pain is complex, oen
multifactorial, and frequently not clearly known or that treatments provided (or their execution) inadequately address pain
generators.
Sacroiliac joint (SIJ) pain is a dicult problem with marked
impact on quality of life4 that is becoming increasingly
recognized for its contribution to low back pain. In certain
circumstances, SIJ pain may present as an isolated condition.
However, in many scenarios, the SIJ represents one of many
factors contributing to axial back pain and its various referral
patterns. Studies have shown that sacroiliac pathology may
either present in association with, or contribute directly to, the
etiology of back pain in 15% to 30% of cases.
overlooked as a contributing source of back pain. Maintaining
an index of suspicion—and a thorough understanding of the
relevant anatomy, biomechanics, and clinical presentation
involved in SIJ-mediated pain—are required for accurate
diagnosis. is chapter presents a comprehensive review of
SIJ pathology and diagnostic algorithms as well as current
surgical and nonsurgical treatment options and techniques.
Background
Successful management of low back pain requires recognition
and appropriate management of the pain source. Studies have
shown that the cause of low back pain may not only have variable lumbar origins but may also be a manifestation of hip or
SIJ etiology. In a review of over 1200 cases, 44% of individuals
*Dr. Reckling and Dr. Cher are employees of SI-Bone, a medical device company.
1–3
Surgical management
5–9
e SIJ is oen
and Diagnosis
Alexandra Schwartz
Vinko Zlomislic
W. Carlton Reckling*
Daniel Cher*
presenting with low back pain had ndings consistent with
lesser-recognized diagnoses such as SIJ and posterior facet
syndromes.6 An additional 33% of patients in their cohort
had concordant SIJ symptoms in addition to lumbar stenosis
or spondylolisthesis. Further work has shown that of patients
presenting to spine clinics for back pain, only 65% have a
singular pain generator localized to the spine and 15% to 30%
have pain that involves the SIJ to some degree.
Adjacent-segment degeneration in instrumented lumbar
or lumbosacral fusion is well documented. Not surprisingly,
adjacent-segment degeneration of the SIJ also occurs. In a prospective cohort, the rate of radiographic ndings consistent
with SIJ degeneration was nearly double in patients who had
undergone posterior spinal fusion compared to age-matched
nonfusion controls followed over a 5-year period.10 Finite
element analysis simulating the eects of lumbar fusion has
demonstrated increased forces transmitted across the SIJ that
could precipitate degeneration11; angular motion and stress
were increased along the articular surface following a lumbosacral fusion. A three-level lumbar fusion may result in up to
30% incidence of SIJ degeneration over about 4 years.
Anatomy
e SIJ is the largest axial joint in the human body, with an
average surface area of approximately 17.5 cm2.
tion of the complex anatomy is critical to making a diagnosis
of SIJ dysfunction. As rst described in 1864, the SIJ is char-
acterized as a true synovial joint16 despite the fact that over
70% of its surface area is comprised of capsular and ligamentous structures. A thick layer of hyaline cartilage covers the
sacral side of the SIJ. e thinner covering of the iliac surface,
though commonly described as brocartilage, contains chondrocytes with type II collagen, making this surface a variant
of hyaline cartilage.17 ese surface dierences may increase
the likelihood of SIJ degeneration.
e SIJ undergoes signicant morphologic changes
throughout life. Development is complete by early adulthood,
with formation of an auricular or C-shaped articular joint
18
5–9
13–15
Apprecia-
12
III
397
398 SURGICAL ANATOMY AND APPROACHES
Anterior
sacroiliac ligament
Iliac tuberosity
Groove for internal
Sacrotuberous
CBA
Inguinal
ligament
Sacrospinous
ligament
ligament
Lumbosacral ligament
Iliolumbar
ligament
FIG. 23.1 Anatomy of the sacroiliac joint. (A) Anterior ligamentous and capsular structures. (B) Posterior
ligamentous and capsular structures. (C) En face view of ilium depicting auricular nature of sacral articulation.
Anterior
longitudinal
ligament
Interpubic
fibrocartilage
Short posterior
sacroiliac ligament
Supraspinal
ligament
Superficial posterior
sacrococcygeal ligament
whose nal anatomic orientation varies substantially across
individuals (Fig. 23.1). Degenerative changes are common
over the course of adulthood and have a predilection for the
iliac side of the joint rst, followed by sacral involvement. It
should be stressed, however, that nonspecic degeneration is
common, with more than two-thirds of asymptomatic older
adults showing radiographic changes consistent with SIJ
degeneration.
19
e SIJ capsule is primarily located in the anterior third
of the joint and has a distinct synovial membrane, lined by
a thin capsule and overlying ligament that are conuent with
the iliolumbar ligament. ere is no synovial membrane
posteriorly. e interosseous ligament and the dorsal ligaments, which function as a tension band, form a functional
dorsal capsule of the SIJ. e sacrospinous and sacrotuberous
ligaments contribute to this dorsal capsule (see Fig. 23.1).
Additional stabilization is provided by the dynamic function
of the gluteus maximus and gluteus medius, erector spinae,
biceps femoris, psoas, and piriformis muscles, as well as the
lumbodorsal fascia.14 ese structures allow indirect transfer
of regional muscle forces to the SIJ and, in many cases, have
expansions that invest with the posterior sacroiliac ligament structures. e structural integrity of the capsular and
ligamentous structures is at least partly gender specic, with
hormonally induced increased laxity in females, allowing for
additional necessary motion during parturition.
20–22
e sacrum is considered the keystone of the pelvis. It
is the most caudal component of the vertebral column and
provides the transition from the spinal axis to the pelvis. It
is critical in the transfer of load from the lower extremities
and pelvis to the lumbar spine. e SIJ is six times stronger
in lateral compression than the lumbar spine, but fails at
one-twentieth the axial load and one-half the shear force.23
A common misconception is that the SIJ is static. However,
current research has shown an average of 2 to 4 degrees of
motion in the sagittal plane and smaller amounts of motion
in the other planes.
24–26
e primary joint motion is nutation,
Iliolumbar
ligament
Long posterior
sacroiliac ligament
Sacrospinous
ligament
Sacrotuberous
ligament
Transversus
abdominis
Rectus
Arcuate line
Groove for
obturator vessels
and nerve
Symphysis
pubis
Articulate with
Constrictor
urethrae
Transversus
abdominis
Iliac fossa
for iliacus
Psoas
minor
Crus
penis
Quadratus lumborum
Sacrospinalis
Obturator internus
Levator ani
pudendal vessels
and nerve
Transversus perinei
superficialis
Ischiocavernosus
which refers to a rocking forward of the sacrum relative to
the ilium, and counternutation (rocking backward). With
nutation of the sacrum, there is concurrent lateral translation
of the ilium. Interestingly, the degree of SIJ motion does not
correlate with the presence of SIJ pain.
20
In a series of lectures from 1860 through 1862, John Hilton
observed that a nerve that both crosses a joint and innervates
the muscles crossing and acting on a joint also innervates the
joint.27 e complexity and ambiguity of SIJ innervation is in
part based on Hilton’s law. Various macroscopic, histologic,
and immunohistochemical studies have demonstrated that the
SIJ is highly innervated, with multiple nociceptors and mechanoreceptors present.28 e synovium and capsule contain
unmyelinated nerve endings for pain and temperature. e
nerve supply to the posterior joint originates from either L4
to S3 root dorsal rami branches or independent contributions
from the L3 and S4 nerve roots.
29,30
e anterior joint similarly
has signicant variability, with innervation supplied by the
ventral rami from L2 to S2 roots.13 Additional animal studies
have evaluated the various pain thresholds of the nociceptive
elds involving innervations of the lumbar facet articulations,
SIJs, and lumbar disc. Pain sensitivity measured as mechanical threshold was 70 g for the SIJ, which was signicantly
greater than the lumbar facet (6 g), and less than the lumbar
disc (241 g).
31,32
Relevant surrounding neurologic anatomy consists of
the L5 ventral ramus and lumbosacral plexus, which cross the
cephalad portion of the SIJ approximately 2 cm distal to
the pelvic brim.33 e L5 root then courses along the anterior
aspect of the sacral ala. e S1 ventral ramus crosses the SIJ
more caudally, near the inferior aspect of the joint.
Pathology
SIJ dysfunction, a term commonly used to describe pain and
disability related to poor functioning of the SIJ, has multiple
for sacroiliac
ligament
Articular
surface
for articulate
with sacrum
Chapter 23 Sacroiliac Joint Pain: Pathophysiology and Diagnosis 399
ABC
FIG. 23.2 (A) Degenerative changes within the sacroiliac joint (SIJ) with dense sclerosis and osteophytes.
(B) Inammatory changes in the SIJ with bilateral erosive sacroiliitis. (C) Complete fusion of the SIJ.
SECTION
III
etiologies. SIJ dysfunction may result from capsular or synovial disruption, ligamentous tension, altered joint mobility
and stress, microfracture, or disruption in the myofascial
kinetic chain. Pathology may be categorized as either intra- or
extraarticular. Common causes of intraarticular pathology
include infection, inammation, and degenerative or inam-
matory arthritis. e most common infectious organisms
include Staphylococcus, Pseudomonas, Cryptococcus, and
Mycobacterium and should be suspected in intravenous drug
use, endocarditis, or posttraumatic situations.14 Degenerative
changes occur over the course of decades and are related to
repeated microtrauma, ultimately presenting as a progression
of joint sclerosis on imaging studies (Fig. 23.2). Far more
rarely, unilateral or bilateral sacroiliitis can be an early
symptom in the seronegative and HLA-B27–associated spondyloarthropathies, occurring in individuals diagnosed with
ankylosing spondylitis. ere is a strong male predilection for
the inammatory spondyloarthropathies and the association
with HLA-B27 supports an immune-mediated etiology that is
characterized by more erosive changes on radiographs (see
Fig. 23.2). ese cases must be identied and distinguished
from degenerative changes so that they can be referred for the
appropriate nonsurgical management.
34
Extraarticular pathology, oen posttraumatic, may be
attributable to ligamentous injury, myofascial pain, and fractures. e underlying causes are myriad, including leg-length
discrepancy, gait abnormalities, prolonged exercise, athletic
injuries, and prolonged liing and bending.13 In a retrospective
study of 54 patients with injection-conrmed SIJ pain, trauma
was the cause in 44% of cases, 35% were idiopathic, and 21%
were due to repeated stress.35 e most common traumatic
events were categorized as motor vehicle accidents followed by
falls. In young adults, major trauma resulting in SIJ disruption
is most common, with lateral compression injuries more likely
to result in later development of SIJ dysfunction.36 Cumulative
microtrauma from overzealous activity and repetitive loading,
microfracture, and ligamentous or capsular injuries may also
commonly cause insidious onset of SIJ pain.
Additional common causes of SIJ pathology may arise from
iatrogenic injury due to overaggressive iliac crest gra harvest
that inadvertently violates the SIJ or damages the iliolumbar
ligament.37 Increasingly recognized in females, hormonal
changes during the nal trimester of pregnancy may induce
hypermobility of the SIJ that predisposes it and surrounding
ligaments to additional injury, resulting in chronic pain and
instability. ere is evidence that a prior history of lumbar
fusion contributes to biomechanical and anatomic alteration
of the SIJ.
10,11
Metabolic diseases such as calcium pyrophosphate crystal deposition disease, gout, hyperparathyroidism,
and renal osteodystrophy may potentiate early inammation
and degeneration.14 Although primary sacroiliac tumors are
rare, bony metastasis to the pelvis ranks second only behind
spinal metastasis and must be ruled out.
Diagnosis
Although oen perceived as challenging, diagnosis of the SIJ
as a pain generator is possible through a combination of
history, physical examination, and diagnostic SIJ block. e
importance of the clinical examination may be a “paradigm
shi” for surgeons who rely primarily on imaging for ortho-
pedic diagnoses, as imaging plays little role in the diagnosis of
SIJ pain. Because SIJ pain referral patterns vary and can
overlap with those of other pathologic conditions, the SIJ
should be kept in mind when evaluating patients with chronic
low back, buttocks, and hip pain.
Clinical History
Patients with SIJ complaints may present with a constellation
of variable, and sometimes inconsistent, pain complaints in
the lumbosacral region. Pain is usually o-center below L5 in
the area of the posterior superior iliac spine (PSIS), with radiation into the buttocks, or, less commonly, into the groin. Pain
in the legs above the knee is relatively common; pain below
the knee is less commonly reported. Patients with SIJ dysfunction commonly point to an area just medial to and inferior to
the PSIS (the insertion of the long dorsal ligament), which is
deemed a positive Fortin nger test.
Patients frequently report pseudoradicular pain, numbness, tingling, and weakness in the distribution of the L5 and
S1 nerve roots. However, physical examination typically
demonstrates no true neurologic decit. SIJ arthrography has
38
400 SURGICAL ANATOMY AND APPROACHES
shown a high proportion of patients with anatomic connections along the dorsum of the SIJ underneath the ligaments
between the SIJ and the S1 neuroforamen or S1 nerve root.39
Likewise, an anatomic connection is frequently demonstrated
between the anterior SIJ capsule and the L5 nerve root/lumbar
plexus. Finally, the same segmental spinal nerves innervate a
variety of structures in the low back, pelvis, and proximal legs,
and potentially can cause pain referral patterns from these
structures due to convergent sensory pathways. Together,
these anatomic ndings may explain pseudoradicular pain in
patients with SIJ dysfunction.
Typical complaints include pain with activities that preferentially load the involved SIJ, most commonly sitting for
prolonged periods, rolling over in bed, sleeping on the aected
side, passing over road bumps while driving, or getting in and
out of a car or chair. Activities that ooad the aected SIJ
typically lessen SIJ pain. In prospective studies of patients
undergoing surgical intervention, subjects reported the
common occurrence of radiating leg pain, groin pain, pain
worse with sitting (especially on the aected side), rising,
walking, and climbing stairs. Pain occurs during the stance
phase of gait. However, no specic aspect of the patient history
is considered diagnostic of SIJ pain.
Physical Examination
Physical examination of the SIJ focuses on provocative maneuvers (Table 23.1) that stress the SIJ. A maneuver is considered
positive if the test reproduces the patient’s pain. Interrater
reliability of physical examination maneuvers is high for most
tests.40 No single test is perfectly correlated with results from
diagnostic SIJ block (considered the reference standard);
however, meta-analysis has shown that the occurrence of three
or more positive physical examination tests has a high predictive value for a positive diagnostic SIJ block.41 Another test,
used more commonly in Europe, is the active straight-leg raise
test. In this test, the supine patient is asked to rate the diculty
of actively raising the leg 20 cm o the examining table. is
test is commonly positive in women with peripartum pelvic
pain attributed to the SIJ.42 In one study of minimally invasive
SIJ fusion (SIJF), the active straight-leg raise test improved in
patients undergoing fusion but remained at baseline levels in
patients undergoing nonsurgical treatment.
43
Role of Imaging
Imaging is considered an important part of diagnosis of
autoimmune sacroiliitis, being part of the New York Criteria
for this condition.44 Whether MRI is best for detecting early
autoimmune disease is still being debated.45 However, in the
more common setting of suspected SIJ dysfunction due to
osteoarthritis or joint disruption, imaging—including plain
radiography and scintigraphic scans—has not been found
to be useful.46 Signs of osteoarthritis degeneration (sclerosis,
osteophytes, vacuum phenomenon, subchondral cysts) on CT
scan are common in patients without suspected SIJ pain.19
While ndings suggestive of osteoarthritis have been reported
as somewhat more common in patients with suspected SIJ
pain than an age-matched cohort, sensitivity and specicity of CT ndings were low.47 In summary, no nding on
radiography or CT scan has been shown to be diagnostic
of SIJ pain. Imaging, especially plain radiographs and crosssectional imaging, is therefore primarily used during diagnosis to rule out inammatory SIJ arthropathy or other hip or
spine conditions.
Diagnostic Injection
As in most pain conditions, there is no gold standard for
diagnosis of SIJ pain. e accepted reference standard for
diagnosis of SIJ pain is an acute reduction in typical pain
in response to a uoroscopically or CT-guided diagnostic
intraarticular joint injection with a combination of radiographic contrast and local anesthetic, that is, an SIJ block (Fig.
23.3). Several aspects of SIJ block remain to be optimized:
Are one or two blocks required? Which anesthetic should be
used? Should nonresponse to a control injection (e.g., saline)
be required? What threshold for acute decrease in pain is
most appropriate? While steroids are commonly used in
combination with local anesthetic, does subacute response
to steroids aid in diagnosis? Despite these questions, it is well
accepted that blind SIJ injections are unacceptable; SIJ injections must be performed under imaging guidance in order to
conrm intraarticular entry and spread in the anterior and
lower two-thirds of the SIJ.15 Extravasation outside the joint
suggests the potential for nonspecic responses, though this
has not been proven. Injection volumes are typically about 1 to
2 mL; larger volumes may promote leakage and nonspecicity.
Even with image guidance, various studies have demonstrated
a signicant number of false-positive and false-negative
results,48 though one study suggests that SIJ block is more
accurate than previously reported.49 False-positives may result
from placebo eect, extravasation of local anesthetic to sur-
rounding structures, or convergence of pain referral patterns.
Conversely, false-negative results may be attributed to failure
of local anesthetic to reach symptomatic regions of the SIJ,
particularly the most anterior and cephalad areas or in the
presence of extraarticular pain sources. In the absence of a
gold standard for diagnosis, all such injection studies remain
of questionable validity.
Extraarticular SIJ blocks, which focus on anesthetizing
lateral branches of sacral nerve roots, are oen used to screen
for SIJ-mediated pain potentially responsive to radiofrequency
ablation. In one study, extraarticular blocks at multiple depths
were able to mask pain due to probing the interosseous and
posterior sacroiliac ligaments but not pain elicited by distending the joint itself.50 e study suggests not only dual
innervation of the SIJ complex but also the probability of
extraarticular pain generators.
Summary
SIJ pain is a common but oen overlooked cause of low back
pain. Diagnosis is based on a combination of history, physical
examination tests that stress the SIJ and reproduce typical pain,
Chapter 23 Sacroiliac Joint Pain: Pathophysiology and Diagnosis 401
TABLE 23.1 Physical Examination Tests for Sacroiliac Joint Pain
Test Description Example
Distraction The patient lies supine and is asked to place the forearm behind the lumbar spine to
support the natural lordosis. A pillow is placed under the patient’s knees. The
examiner places his or her hands on the anterior and medial aspects of both of the
patient’s anterior superior iliac spines (ASISs) with arms crossed. A slow and steady
increasing pressure is placed through the arms and held.
Compression The patient is placed in a side-lying position, facing away from the examiner, with a
pillow between the knees. The examiner places a downward pressure through the
lateral aspect of the patient’s top-side ASIS and pelvis, anterior to the greater
trochanter.
FABER
(Patrick test)
The patient lies supine as the examiner crosses the same-side foot over the opposite-
side thigh. A force is steadily increased through the knee of the patient, exaggerating
the motion of hip flexion, abduction, and external rotation (FABER). The pelvis is
stabilized at the opposite ASIS with the hand of the examiner.
SECTION
III
Thigh thrust The patient lies supine, with one hip exed to 90 degrees. The examiner stands on the
same side as the exed leg. The examiner provides either a quick thrust or a steady
increasing pressure through the line of the femur. The pelvis is stabilized at the
opposite ASIS with the hand of the examiner.
Gaenslen’s The patient lies supine with the near-side leg hanging o the table. The patient is
asked to hold the opposite-side knee into exion. The examiner applies an extension
force to the near-side thigh and a exion force to the opposite knee. The patient
assists with opposite-side hip exion. This is performed bilaterally.
A combination of three positive tests has a high predictive value for a positive sacroiliac joint block.
402 SURGICAL ANATOMY AND APPROACHES
AB
FIG. 23.3 (A) Inferior pole of sacroiliac joint (SIJ), entry point for an intraarticular SIJ injection. (B) Fluoroscopic
view of SIJ injection with contrast in joint.
SIJ anesthetic block, and imaging to rule out other conditions.
Understanding the anatomy and function of the SIJ and its
surrounding structures aids in the diagnosis of the condition.
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