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LETTERS: Andrew N Bamji Low back pain: Sacroiliac joint pain may be myth BMJ 2004; 329: 232 [Full text]

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And curst be he that moves my bones

Dr. Herbert H. Nehrlich   (23 July 2004)

Evidence for sacroiliac joint pain exists

Robin C Chakraverty   (25 July 2004)

Sacroiliac joint pain: is it a myth?

Munier Hossain   (25 July 2004)

Evidence pertaining to the clinical significance of the sacroiliac joints

Adrian B Wenban   (27 July 2004)

And curst be he that moves my bones 23 July 2004
Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507 Send response to journal: Re: And curst be he that moves my bones	"....joint is so rigid that mechanical disruption is almost impossible.The pelvis will fracture first." These words by Dr. Bamji and his explanation why injections into the SI joint sometimes work make interesting, if disturbing reading. Dr. B. states that injection works because the injected material goes into the muscle (here gluteals) and he mentions a colleague who, many years ago, injected ink into corpses and subsequently found all the ink in the muscle tissue. I assume that no pain relief was experienced by the subjects. About 75 years ago, a Swiss chiropractor conducted very similar experiments but came to quite different conclusions. He was, of course Dr. Fred Illi and you could not have convinced him nor many thousands of chiropractors that Dr. Bamji's assessment is correct. It is said that cranial bones are practically immoveable yet there are techniques both in Osteopathy and Chiropractic to accomplish near miracles through cranial manipulation. The sacroiliac joint can undergo 'fixation' and various forms of misalignment -commonly known as 'subluxation'- and these conditions can cause considerable symptoms. They are successfully treated every day in all parts of the world by the skilful application of manipulation. While many so-called sacroiliac strains or subluxations are probably lumbar disc problems in real life, and many sacroiliac complaints are mechanical fixations (jamming)due to various pathologies,the gluteal muscle is not a major player. The gluteals do not mechanically 'lock' the sacroiliac joint with resultant symptoms nor does any other muscle accomplish this. This is for the simple reason that Nature has not provided a muscle to actually lock the SI joint, and for very good reasons. I have observed a lay bonesetter get instant pain relief from severe 'sacroiliac pain' by forcefully tugging on the leg. Competing interests: None declared
Evidence for sacroiliac joint pain exists 25 July 2004
Robin C Chakraverty, Musculoskeletal and Sports Physician Royal Orthopaedic Hospital, Birmingham. B31 2AP. Send response to journal: Re: Evidence for sacroiliac joint pain exists	Bamji suggests that in the absence of inflammatory joint disease or infection, the sacroiliac joint is an unlikely source of low back pain but this assumption ignores a decade of scientific evidence 1. Well designed studies using intra-articular sacroiliac joint block injections with local anaesthetic (with exact placement confirmed with radiographic contrast) followed by repeat confirmatory blocks to exclude placebo responses, have estimated that in between 13 and 19% of chronic low back pain, the source of the pain could be traced to the sacroiliac joint 2,3. Injectate may escape from the joint in a significant proportion of cases but the volumes injected are so small (2.5mls or less) that it is hardly likely that any pain relief during the local anaesthetic phase is from buttock muscle anaesthesia 4. Bamji suggests that joint rigidity makes it an unlikely pain source but movement of the sacroiliac joints in normal volunteers and the asymmetry of movement between paired sacroiliac joints in patients with pelvic pain have been observed 5-7. Although there is no proven treatment for sacroiliac joint pain; if you dismiss it as a clinical entity, then you will never find it and research into specific treatments will flounder. 1. Bamji AN. Low Back Pain: Sacroiliac joint pain may be a myth. BMJ 2004;329:232.(24 July) 2. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995;20(1):31-7. 3. Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996;21(16):1889-92. 4. Fortin JD, Washington WJ, Falco JE. Three pathways between the sacroiliac joint and neural structures. Am J Neuroradiol 199;20:1429-1434. 5. Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine 1989;14(2):162-5. 6. Buyruk HM, Snijders CJ, Vleeming A et al. The measurement of sacro -iliac stiffness with colour Doppler imaging: a study on healthy subjects. European J of Radiology 1995;21:117-121. 7. Buyruk HM, Stam HJ, Snijders CJ et al. Measurement of sacroiliac stiffness in peripartum pelvic pain patients with Doppler imaging of vibrations (DIV). European J Obstetric And Gynaecological Reproductive Biology 1999;83:159-63. Competing interests: None declared
Sacroiliac joint pain: is it a myth? 25 July 2004
Munier Hossain, Orthopaedic Registrar Bangor Hospital , Gwynedd LL57 2PW Send response to journal: Re: Sacroiliac joint pain: is it a myth?	I read with interest the review article by by Speed on Low back pain and the subsequent response from Bamji 1. I find Bamji’s statement not supported by evidence. His assertion is based on some observations-none of them supported by reference. Injections into the sacroiliac joint (SIJ) under fluoroscopic control have proved that the joint is a source of low back pain 2. SIJ is an important link in weight transmission to the lower limb. The SIJ surface is oriented parallel to the line of weight transmission. So, weight bearing results in significant amount of shear stress. The SIJ may be a very rigid joint, but there is movement on physiological loading, increased under larger loading, in both symptomatic and asymptomatic joints 3. Sacroiliac pain have so far been attributed to joint hypermobility. It appears increasingly clear that we should think in terms of joint dysfunction due to instability from abnormal motor unit recruitment. There is growing evidence that patients presenting with low back pain of “sacroiliac origin” have altered pattern of motor unit recruitment4. The causative relationship is still unclear. Exercise related stress reaction of SIJ is a known cause of low back pain 5. I find no evidence to support his observation that most cases of sacroiliac strain are injuries of the gluteal region. Our understanding of the role of SIJ in low back pain is still evolving. There are many aspects where we need more research until we have definitive knowledge. Contributing unsubstantiated statements may help to increase the myth rather than dispel it. References 1. Bamji AN. Sacroiliac joint pain may be myth. BMJ 2004;329:232. 2. Maigne J, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996;21:1889-92. 3. Struesson B, Selvik G, Uden ALF. Movements of the sacroiliac joints: a roentgen stereophotogrammetric analysis.Spine.1989;14(2):162-5. 4. Hungerford B, Gilleard W, Hodges P. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine. 2003;28(14): 1593-1600. 5. Marymont JV, Lynch MA, Henning CE. Exercise related stress reaction of the sacroiliac joint. An unusual cause of low back pain in athletes. American Journal of Sports Medicine. 1986;14(4):320-3. Competing interests: None declared
Evidence pertaining to the clinical significance of the sacroiliac joints 27 July 2004
Adrian B Wenban, Associate Governor, Australian Spinal Research Foundation Barcelona, 08001,Spain. Send response to journal: Re: Evidence pertaining to the clinical significance of the sacroiliac joints	To the editor: I offer the following information to better inform the discussion that has arisen out of Bamji's non-evidence based suggestion that, in the absence of inflammatory joint disease or infection, the sacroiliac joint (SIJ) is an unlikely source of low back pain. The possibility that the SIJ was a potential source of low back pain was discussed as early as 1905 (1). More recently the prevalence of SIJ syndrome in persons with back pain has become a topic of interest. The prevelance has been reported to vary widely (2,3). For example Schwarzer et al. found that the prevalence of SIJ pain appears to be at least 13% and perhaps as high a 30% in patients with low back and buttock pain (2). Bernard and Kirkaldy-Willis reported the prevalence to be 22.5% in 1293 patients with back pain (3). Recent histological studies suggest that the SIJ should be classified anatomically as a symphysis with some characteristics of a synovial joint being confined to the distal cartilaginous portion at the iliac side. (4) Animal model studies suggest that the SIJ is a pain- and proprio-sensitive structure richly innervated by sensory neurons in dorsal root ganglions ipsilateral to the joint from L1 to S2 (5). The presence of nerve fibers and mechanoreceptors in the SIJ capsule and ligaments demonstrate that the central nervous system receives proprioceptive and pain information from the SIJ (6). One of the major functions of the SIJ appears to be to dissipate loads of the torso to the lower extremity and vice versa. During recent years a number of studies have shown that despite the stability of the joint (not just a product of the ridges present in the joint, but also due to the presence of many generously sized ligaments) small degrees of movement, mostly rotation and translation, do occur within the SIJ (7-9). Variablility in patterns of pain referral from the SIJ have been documented. It has been proposed that the variablility in patterns of pain referral from the SIJ may arise for several reasons, including the joint's complex innervation, sclerotomal pain referral, irritation of adjacent structures, and varying locations of injury with the SIJ. A statistically significant relationship has been identified between pain location and age, with younger patients more likely to describe pain distal to the knee. Pain referral from the SIJ does not appear to be limited to the lumbar region and buttock (10). References: 1.) Goldwaith JH, Osgood RB: A consideration of the pelvic articulations from an anatomical pathological and clinical standpoint. Boston Med Surg J 1905; 152:593-601. 2.) Schwarzer AC, Aprill CN, Bogduk N: The sacroiliac joint in chronic low back pain. Spine 1995;20:31-7. 3.) Bernard TN, Kirkaldy-Willis WH: Recognizing specific characteristics of nonspecific low back pain. Clin Orthop 1987;(217):266- 80. 4.) Puhakka KB, Melsen F, Jurik AG, Boel LW, Vesterby A, Egund N. MR imaging of the normal sacroiliac joint with correlation to histology. Skeletal Radiol. 2004;33:15-28. 5.) Murata Y, Takahashi K, Yamagata M, Takahashi Y, Shimada Y, Moriya H. Sensory innervation of the sacroiliac joint in rats. Spine. 2000;25:2015-9. 6.) Vilensky JA, O'Connor BL, Fortin JD, Merkel GJ, Jimenez AM; Scofield BA, Kleiner JB. Histologic analysis of neural elements in the human sacroiliac joint. Spine. 2002;27:1202-7. 7.) Jacob HA, Kissling RO. The mobility of the sacroiliac joints in healthy volunteers between 20 and 50 years of age. Clin Biomech. 1995;10:352-361. 8.) Kissling RO, Jacob HA. The mobility of the sacroiliac joint in healthy subjects. Bull Hosp Jt Dis. 1996;54:158-64. 9.) Wang M, Dumas GA. Mechanical behavior of the female sacroiliac joint and influence of the anterior and posterior sacroiliac ligaments under sagittal loads. Clin Biomech. 1998;13:293-299. 10.) Slipman CW, Jackson HB, Lipetz JS, Chan KT, Lenrow D, Vresilovic EJ. Sacroiliac joint pain referral zones. Arch Phys Med Rehabil. 2000;81:334-8. Competing interests: None declared