I am delighted to have the opportunity to respond to the comments on our article “Accuracy of the Diagnostic Tests of Sacroiliac Joint Dysfunction.” In responding to the author's critique, I should first say that in spite of the multitude of studies performed on diagnostic accuracy, the inconsistencies, coupled with a paucity of high-quality, replicative, and consistent literature, have made the sacroiliac joint (SIJ) a mysterious joint with difficult examination and diagnosis.
It is also important to note that the term sacroiliac joint dysfunction (SIJD) is used to mean a non-inflammatory condition of the SIJ that is characterized by a reversible decreased mobility, resulting from articular causes.1 Therefore, only the patients who had SIJD were included in our study for the purpose of evaluating the accuracy of physical tests in comparison with the gold standard diagnostic test: SIJ block.
Moreover, despite the obscurity of diagnostic studies, the evidence for diagnostic accuracy is level II for dual-diagnostic blocks, with at least 70% pain relief as the criterion standard, and level III for single-diagnostic blocks, with a minimum of 75% pain relief as the criterion standard.2
Although the SIJ block is considered a definitive diagnostic method in SIJ disorders, both the fluoroscopy or computed tomography (CT) in double blocking the joint and the experience required for blocking make it less feasible.
According to the coverage recommendations of the North American Spine Society, intra-articular SIJ injections are indicated to aid in the diagnostic workup of lower back pain when all of the listed criteria are met: (1) patient's report of non-radicular pain; (2) a physical examination typically demonstrating localized tenderness with palpation over the sacral sulcus; and (3) positive response to a cluster of at least 3 provocative tests. Thus, our study only included patients who were highly suspected to have SIJD based on their clinical symptoms in addition to at least 2 positive provocation tests and 1 positive motion palpation test.
As for the differential diagnosis pointed out in the letter, I would say that all the patients underwent lumbosacral and sacroiliac joint magnetic resonance imaging before enrollment. The other causes of lower back and buttock pain, such as ankylosing spondylitis, lumbar radicular pain, and lumbar facetogenic pain, were ruled out through magnetic resonance imaging scanning.
Unlike the authors of the letter, we deem it is unnecessary to block the SIJ in all patients with sacroiliac pain. Regarding the high predictive value of the physical tests3 when used in combination and also considering the results of our study, a multitest regimen of such tests can satisfactorily diagnose SIJD and can be used before the invasive procedure of SIJ block.4,5 Logically, clinical judgment based on medical history, clinical symptoms, and combined physical tests and imaging to rule out other causes might obviate the need for more procedures before treatment. Hence, there is good evidence for exercise therapy and manipulative methods for SIJD that can be implemented in patients who are suspected of SIJD.6, 7, 8
References
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