1. 2015;18;E781-E786Value of Examination Under Fluoroscopy for the Assessment of Sacroiliac Joint Dysfunction
   Prospective Review
   P. Jonathan Eskander, MD, Juan G Ripoll, MD, Frank Calixto, MD, Burton D. Beakley, MD, Jeffrey T Baker, MD, Patrick J. Healy, MD, O H Gunduz, MD, Lizheng Shi, PhD, Jamie A Clodfelter, DO, Jinan Liu, MHA, Alan D. Kaye, MD, PhD, and Sanjay sharma, MD.

BACKGROUND: Pain emanating from the sacroiliac (SI) joint can have variable radiation patterns. Single physical examination tests for SI joint pain are inconsistent with multiple tests increasing both sensitivity and specificity.
OBJECTIVE: To evaluate the use of fluoroscopy in the diagnosis of SI joint pain.
STUDY DESIGN: Prospective double blind comparison study
SETTING: Pain clinic and radiology setting in urban Veterans Administration (VA) in New Orleans, Louisiana.
METHODS: Twenty-two adult men, patients at a southeastern United States VA interventional pain clinic, presented with unilateral low back pain of more than 2 months’ duration. Patients with previous back surgery were excluded from the study. Each patient was given a Gapping test, Patrick (FABERE) test, and Gaenslen test.  A second blinded physician placed each patient prone under fluoroscopic guidance, asking each patient to point to the most painful area. Pain was provoked by applying pressure with the heel of the palm in that area to determine the point of maximum tenderness. The area was marked with a radio-opaque object and was placed on the mark with a fluoroscopic imgage. A site within 1 cm of the SI joint was considered as a positive test. This was followed by a diagnostic injection under fluoroscopy with 1 mL 2% lidocaine. A positive result was considered as more than 2 hours of greater than 75% reduction in pain. Then, in 2-3 days this was followed by a therapeutic injection under fluoroscopy with 1 mL 0.5% bupivacaine and 40 mg methylprednisolone.
RESULTS: Each patient was reassessed after 6 weeks. The sensitivity and specificity in addition to the positive and negative predictive values were determined for both the conventional examinations, as well as the examination under fluoroscopy. Finally, a receiver operating characteristic (ROC) curve was constructed to evaluate test performance. The sensitivity and specificity of the fluoroscopic examination were 0.82 and 0.80 respectively; Positive predictive value and negative predictive value were 0.93 and 0.57 respectively. The area under ROC curve was 0.812 which is considered a “good” test; however the area under ROC for the conventional examination were between 0.52 -0.58 which is considered “poor to fail”.
LIMITATIONS: Variation in anatomy of the SI joint, small sample size.
CONCLUSIONS: Multiple structures of the SI joint complex can result in clinical symptoms of pain. These include intra-articular structures (degenerative arthritis, and inflammatory conditions) as well as extra-articular structures (ligaments, muscles, etc.).