Authors: McCormick ZL et al.
BMJ Journals Regional Anesthesia & Pain Medicine
Summary
This multispecialty international working group developed comprehensive consensus practice guidelines for the diagnosis and treatment of sacroiliac joint (SIJ) complex pain. The effort involved 25 professional organizations plus the U.S. Departments of Defense and Veterans Affairs. The committee addressed 21 structured questions covering diagnostic criteria, interventional and non-interventional treatments, technical considerations, and definitions of successful outcomes. Consensus (≥75%) was achieved for every question.
The group concluded that SIJ complex pain is multifactorial, involving both intra-articular and extra-articular components, with prevalence estimates of 15–30% in patients presenting with axial low back pain below L5. Physical examination tests show reasonable sensitivity but poor specificity, with negative tests more clinically useful than positive ones. Intra-articular injections have diagnostic validity for intra-articular pathology only; imaging adds little value for diagnosis.
Both intra-articular and extra-articular steroid injections can provide at least four weeks of relief in well-selected patients, though evidence is slightly stronger for extra-articular injections. Evidence supporting non-interventional therapies is indirect, largely extrapolated from generalized low back pain research. Prolotherapy and platelet-rich plasma have weak evidence for ≥3-month relief.
For interventional treatments, sacral lateral branch radiofrequency ablation (RFA) has strong evidence for ≥6 months of benefit in patients with extra-articular pathology. Larger or more aggressive lesioning strategies demonstrate superior outcomes. Prognostic sacral lateral branch blocks are supported by indirect and face-valid evidence. Non-steroidal anti-inflammatory drugs may have weak benefit in reducing post-RFA neuritis, and anticoagulation generally does not need to be discontinued.
The committee discussed threshold requirements for positive diagnostic or prognostic blocks. A ≥50% pain relief threshold is most common, with higher thresholds not shown to improve outcomes for subsequent definitive procedures. For treatment outcomes, ≥30% pain relief or a meaningful functional improvement (e.g., opioid cessation) is considered clinically significant. For carefully selected patients with intra-articular disease confirmed by controlled blocks and who fail conservative management, minimally invasive SIJ fusion has weak or very weak evidence for at least one year of benefit.
Key Points
• SIJ complex pain accounts for 15–30% of chronic axial low back pain below L5.
• Physical exam tests are more useful when negative than positive.
• Intra-articular injections diagnose intra-articular—but not extra-articular—pathology.
• Evidence for steroid injections supports short-term relief; extra-articular injections have slightly stronger support.
• Sacral lateral branch RFA has strong evidence for ≥6 months of benefit in extra-articular pathology.
• A ≥50% relief threshold is standard for diagnostic/prognostic blocks; ≥30% improvement is meaningful for therapeutic outcomes.
• Minimally invasive fusion provides weak evidence of benefit for selected intra-articular cases.
• Many recommendations remain limited by low-quality data, highlighting the need for improved research.
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