1. 2012;15;E305-E344A Systematic Evaluation of Prevalence and Diagnostic Accuracy of Sacroiliac Joint Interventions
   Systematic Review
   Steven P. Cohen, MD, Sudhir Diwan, MD, Haroon Hameed, MD, Thomas T. Simopoulos, MD, Sanjeeva Gupta, MD, Vijay Singh, MD, and Laxmaiah Manchikanti, MD.

BACKGROUND: The contributions of the sacroiliac joint to low back and lower extremity pain have been a subject of considerable debate and research. It is generally accepted that 10% to 25% of patients with persistent mechanical low back pain below L5 have pain secondary to sacroiliac joint pathology. However, no single historical, physical exam, or radiological feature can definitively establish a diagnosis of sacroiliac joint pain. Based on present knowledge, a proper diagnosis can only be made using controlled diagnostic blocks. The diagnosis and treatment of sacroiliac joint pain continue to be characterized by wide variability and a paucity of the literature.

OBJECTIVE: To evaluate the accuracy of diagnostic sacroiliac joint interventions.

STUDY DESIGN: A systematic review of diagnostic sacroiliac joint interventions.

METHODS: Methodological quality assessment of included studies was performed using Quality Appraisal of Reliability Studies (QAREL). Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were utilized for analysis. Studies scoring less than 50% are presented descriptively and analyzed critically.

The level of evidence was classified as good, fair, or poor based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF).

Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to December 2011, and manual searches of the bibliographies of known primary and review articles.

OUTCOME MEASURES: In this evaluation we utilized controlled local anesthetic blocks using at least 50% pain relief as the reference standard.

RESULTS: The evidence is good for the diagnosis of sacroiliac joint pain utilizing controlled comparative local anesthetic blocks. The prevalence of sacroiliac joint pain is estimated to range between 10% and 62% based on the setting; however, the majority of analyzed studies suggest a point prevalence of around 25%, with a false-positive rate for uncontrolled blocks of approximately 20%. The evidence for provocative testing to diagnose sacroiliac joint pain was fair. The evidence for the diagnostic accuracy of imaging is limited.

LIMITATIONS: The limitations of this systematic review include a paucity of literature, variations in technique, and variable criterion standards for the diagnosis of sacroiliac joint pain.

CONCLUSIONS: Based on this systematic review, the evidence for the diagnostic accuracy of sacroiliac joint injections is good, the evidence for provocation maneuvers is fair, and evidence for imaging is limited.