Consensus practice guidelines on sacroiliac joint complex pain from a multispecialty, international working group
Issued Date
2025-01-01
Resource Type
ISSN
10987339
eISSN
15328651
Scopus ID
2-s2.0-105023649670
Pubmed ID
41318932
Journal Title
Regional Anesthesia and Pain Medicine
Rights Holder(s)
SCOPUS
Bibliographic Citation
Regional Anesthesia and Pain Medicine (2025)
Suggested Citation
McCormick Z.L., Hurley R.W., Anitescu M., Bhaskar A., Bhatia A., Cassidy R.C., Chen A.S., Dawson T.C., Ares J.D.A., De Campos J.L., Hayek S.M., Hernández-Porras B.C., Kissoon N.R., Kohan L.R., Beuffe M.F.E.L., Moon J.Y., Provenzano D.A., Reece L.D.E., Schuster N.M., Smith C.C., Stout A., Szadek K., Thomas D.A., Tontisirin N., Vagg M.F., Van Zundert J., Woodbury A., Cohen S.P. Consensus practice guidelines on sacroiliac joint complex pain from a multispecialty, international working group. Regional Anesthesia and Pain Medicine (2025). doi:10.1136/rapm-2025-107387 Retrieved from: https://repository.li.mahidol.ac.th/handle/123456789/113454
Title
Consensus practice guidelines on sacroiliac joint complex pain from a multispecialty, international working group
Author(s)
McCormick Z.L.
Hurley R.W.
Anitescu M.
Bhaskar A.
Bhatia A.
Cassidy R.C.
Chen A.S.
Dawson T.C.
Ares J.D.A.
De Campos J.L.
Hayek S.M.
Hernández-Porras B.C.
Kissoon N.R.
Kohan L.R.
Beuffe M.F.E.L.
Moon J.Y.
Provenzano D.A.
Reece L.D.E.
Schuster N.M.
Smith C.C.
Stout A.
Szadek K.
Thomas D.A.
Tontisirin N.
Vagg M.F.
Van Zundert J.
Woodbury A.
Cohen S.P.
Hurley R.W.
Anitescu M.
Bhaskar A.
Bhatia A.
Cassidy R.C.
Chen A.S.
Dawson T.C.
Ares J.D.A.
De Campos J.L.
Hayek S.M.
Hernández-Porras B.C.
Kissoon N.R.
Kohan L.R.
Beuffe M.F.E.L.
Moon J.Y.
Provenzano D.A.
Reece L.D.E.
Schuster N.M.
Smith C.C.
Stout A.
Szadek K.
Thomas D.A.
Tontisirin N.
Vagg M.F.
Van Zundert J.
Woodbury A.
Cohen S.P.
Author's Affiliation
Columbia University
Mayo Clinic
Yale School of Medicine
David Geffen School of Medicine at UCLA
Northwestern University Feinberg School of Medicine
University of Washington School of Medicine
Vrije Universiteit Amsterdam
Emory University School of Medicine
Universiteit Maastricht
University of Utah School of Medicine
Deakin University
CASE School of Medicine
Pontificia Universidad Católica de Chile
Wake Forest University School of Medicine
Seoul National University College of Medicine
Maastricht Universitair Medisch Centrum+
Uniformed Services University of the Health Sciences
University of Kentucky College of Medicine
Hospital Universitario La Paz
University of Virginia Health System
The University of Chicago Medicine
Toronto Western Hospital
Institute of Health Policy, Management and Evaluation
Charing Cross Hospital
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
Faculty of Medicine Ramathibodi Hospital, Mahidol University
UC San Diego Health
Ziekenhuis Oost-Limburg
Pain Diagnostics and Interventional Care
Hospital Vera Cruz
Asociación Mexicana para el Estudio Y Tratamiento del Dolor
Mayo Clinic
Yale School of Medicine
David Geffen School of Medicine at UCLA
Northwestern University Feinberg School of Medicine
University of Washington School of Medicine
Vrije Universiteit Amsterdam
Emory University School of Medicine
Universiteit Maastricht
University of Utah School of Medicine
Deakin University
CASE School of Medicine
Pontificia Universidad Católica de Chile
Wake Forest University School of Medicine
Seoul National University College of Medicine
Maastricht Universitair Medisch Centrum+
Uniformed Services University of the Health Sciences
University of Kentucky College of Medicine
Hospital Universitario La Paz
University of Virginia Health System
The University of Chicago Medicine
Toronto Western Hospital
Institute of Health Policy, Management and Evaluation
Charing Cross Hospital
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
Faculty of Medicine Ramathibodi Hospital, Mahidol University
UC San Diego Health
Ziekenhuis Oost-Limburg
Pain Diagnostics and Interventional Care
Hospital Vera Cruz
Asociación Mexicana para el Estudio Y Tratamiento del Dolor
Corresponding Author(s)
Other Contributor(s)
Abstract
Background The past two decades have witnessed tremendous growth in the appreciation and treatment of sacroiliac joint (SIJ) complex pain, including anatomical dissections that shed light on innervation, an appreciation for the contribution of extra-articular components to SIJ complex pain, the advent of radiofrequency ablation (RFA) and a host of minimally-invasive surgical techniques. Yet, there is no standardization of diagnosis and treatment paradigms. Methods In February 2023, the Boards of Directors for the American Academy of Pain Medicine (AAPM) and American Society of Regional Anesthesia & Pain Medicine (ASRA-PM) approved the development of multispecialty guidelines on SIJ complex pain. Thirty partner organizations with clinical and scientific interests in SIJ complex pain were identified, and formal letters of request-for-participation were sent to each, along with a request for nominees to serve on the committee. Twenty five organizations agreed to participate in addition to the Departments of Defense and Veterans Affairs. A steering committee developed 21 questions, which spanned criteria for diagnosis, non-interventional and interventional treatments including surgery, technical parameters on how to optimize results, and what constitutes positive outcomes. Questions were methodically assigned to specialized modules comprising 4–5 members with complementary expertise, who collaborated with the Subcommittee Lead and one of three Committee Chairs to develop preliminary drafts. Following thorough revisions, these drafts were subsequently submitted to the full committee for comprehensive review. A modified Delphi method was used in which the answers to questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was achieved. During a committee meeting before commencement, it was agreed that recommendations would be noted when there was >50% agreement among committee members, but that a formal recommendation would require ≥75% consensus. Results Twenty-one organizations formally endorsed the guidelines. The American Society of Anesthesiologists, and American Academy of Physical Medicine & Rehabilitation, and the North American Spine Society affirmed the benefit of the guidelines but did not officially endorse them. The American Academy of Neurology declined to affirm the benefit of the guidelines citing ‘lack of relevance to their membership.’ Per policies, while the Departments of Defense and Veterans Affairs did not formally review the guidelines for endorsement, their representatives approved them. In addition to being endorsed or the benefit affirmed by all voting organizations, complete consensus from committee members was obtained on all 21 questions. On two recommendations, there were dissensions from three societies who thought that selecting patients for sacral lateral branch RFA and minimally-invasive fusion should be based on ≥75% relief from two blocks instead of at least 50% relief from a single block before RFA, and greater than 50% pain relief with documented functional improvement after a single block before fusion. One additional society (Latin American Society of Regional Anesthesia) abstained on the statement that the evidence is stronger for extra-articular than intra-articular injections. The committee found that a battery of physical exam tests has reasonable sensitivity, but lower specificity, for identifying intra-articular but not extra-articular pain, with negative tests having greater predictive value than positive ones. Intra-articular injections have diagnostic validity for SIJ intra-articular, but not extra-articular, pain. There is unclear or negative evidence for imaging. The prevalence rates of intra-articular and extra-articular pathology are comparable, with both intra- and extra-articular steroid injections providing at least 4 weeks of relief in well-selected patients. However, the evidence is slightly stronger for extra-articular corticosteroid injections to provide short-term relief. The evidence base for non-interventional therapies is indirect, extrapolated mostly from low back pain studies. There is weak evidence supporting dextrose-based prolotherapy and platelet-rich plasma to provide at least 3 months of pain relief. There is strong evidence for sacral lateral branch RFA to provide relief for at least 6 months in individuals with extra-articular pathology, with face validity and indirect evidence from randomized trials supporting sacral lateral branch blocks as a prognostic tool. There is stronger evidence for larger lesions or more aggressive lesioning strategies than for less stringent techniques. There is weak evidence to support non-steroidal anti-inflammatory drugs to prevent neuritis after RFA, and in most cases anticoagulation does not require cessation in the periprocedural period. With an aggressive lesioning strategy, sensory stimulation provides minimal therapeutic benefit, with weak, extrapolated evidence that motor stimulation can provide safety benefit. The cut-off to designate diagnostic or prognostic blocks as positive is most commonly set at 50%, with higher values not shown to improve outcomes for more definitive procedures; for therapeutic treatment outcomes, the evidence supports a lower threshold of ≥30% pain relief or meaningful benefit on non-pain outcomes (eg, opioid cessation) for designation of a positive response. For carefully selected patients with intra-articular SIJ complex pain based on controlled blocks who have failed conservative therapies, there is weak or very weak evidence that minimally invasive SIJ fusion can provide benefit for at least one year. Conclusions SIJ complex pain remains an underappreciated source of chronic low back pain, affecting between 15% and 30% of patients with axial pain predominantly below L5. Answers to many questions were limited by low-quality evidence, indicating the need for better research. SIJ complex pain is a multifarious condition (ie, pain can be from different portions of both the intra- and extra-articular components of the joint) for which an interdisciplinary, multimodal treatment plan can optimize treatment outcomes.