Deconstructing Chronic Low Back Pain in the Older Adult—Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: <em>Part X: Sacroiliac Joint Syndrome</em>

Algorithm component

Comments

References

30% pain reduction as significant

Data on 2724 subjects from 10 placebo controlled trials of pregabalin in diabetic neuropathy, postherpetic neuralgia, CLBP, fibromyalgia, and OA.

[ 23 ]

SIJ pain was not one of the conditions specifically studied; in older adults with CLBP it is often one of several contributors.

[ 28 ]

SIJ injection with local anesthetic and steroid

While no single aspect of the history or physical examination can reliably identify pain originating from the SIJ, a battery of three or more provocation tests can predict response to diagnostic blocks. Evidence supports both intra- and extra-articular causes for SIJ pain, and clinical studies demonstrate intermediate-term benefit for both intra- and extra-articular steroid injections.

[ 29 ]

SIJ denervation

In those who fail to experience sustained relief from SIJ injections, radiofrequency (RF) denervation may provide significant relief lasting up to 1 year. Conventional RF denervation has been compared to a cooled RF technique that results in a wider ablation diameter. The results do not demonstrate a clear advantage of one technique over the other.

[ 30–32 ]

Pain self-management program

High quality evidence is lacking specifically in older adults. Arthritis pain self-management programs that contain some CBT elements demonstrate efficacy.

[ 21 ]

Non-acetylated salicylates

Non-cyclooxygenase selective NSAIDs (e.g., ibuprofen, naproxen) should not be used chronically in older adults because of the potential for multiple adverse effects including but not limited to gastrointestinal bleeding, renal insufficiency, and exacerbation of hypertension and congestive heart failure.

[ 25 ]

Opioids as part of stepped-care management

American Geriatrics Society pain guidelines recommend opioids over non-selective NSAIDs.There are no data specifically for the treatment of SIJ pain.

[ 25 ]

Table 1

Sacroiliac joint syndrome: Theoretical and pragmatic underpinnings of algorithm recommendations

Algorithm component	Comments	References
30% pain reduction as significant	Data on 2724 subjects from 10 placebo controlled trials of pregabalin in diabetic neuropathy, postherpetic neuralgia, CLBP, fibromyalgia, and OA.	[ 23 ]
30% pain reduction as significant	SIJ pain was not one of the conditions specifically studied; in older adults with CLBP it is often one of several contributors.	[ 28 ]
SIJ injection with local anesthetic and steroid	While no single aspect of the history or physical examination can reliably identify pain originating from the SIJ, a battery of three or more provocation tests can predict response to diagnostic blocks. Evidence supports both intra- and extra-articular causes for SIJ pain, and clinical studies demonstrate intermediate-term benefit for both intra- and extra-articular steroid injections.	[ 29 ]
SIJ denervation	In those who fail to experience sustained relief from SIJ injections, radiofrequency (RF) denervation may provide significant relief lasting up to 1 year. Conventional RF denervation has been compared to a cooled RF technique that results in a wider ablation diameter. The results do not demonstrate a clear advantage of one technique over the other.	[ 30–32 ]
Pain self-management program	High quality evidence is lacking specifically in older adults. Arthritis pain self-management programs that contain some CBT elements demonstrate efficacy.	[ 21 ]
Non-acetylated salicylates	Non-cyclooxygenase selective NSAIDs (e.g., ibuprofen, naproxen) should not be used chronically in older adults because of the potential for multiple adverse effects including but not limited to gastrointestinal bleeding, renal insufficiency, and exacerbation of hypertension and congestive heart failure.	[ 25 ]
Opioids as part of stepped-care management	American Geriatrics Society pain guidelines recommend opioids over non-selective NSAIDs.There are no data specifically for the treatment of SIJ pain.	[ 25 ]

Algorithm component	Comments	References
30% pain reduction as significant	Data on 2724 subjects from 10 placebo controlled trials of pregabalin in diabetic neuropathy, postherpetic neuralgia, CLBP, fibromyalgia, and OA.	[ 23 ]
30% pain reduction as significant	SIJ pain was not one of the conditions specifically studied; in older adults with CLBP it is often one of several contributors.	[ 28 ]
SIJ injection with local anesthetic and steroid	While no single aspect of the history or physical examination can reliably identify pain originating from the SIJ, a battery of three or more provocation tests can predict response to diagnostic blocks. Evidence supports both intra- and extra-articular causes for SIJ pain, and clinical studies demonstrate intermediate-term benefit for both intra- and extra-articular steroid injections.	[ 29 ]
SIJ denervation	In those who fail to experience sustained relief from SIJ injections, radiofrequency (RF) denervation may provide significant relief lasting up to 1 year. Conventional RF denervation has been compared to a cooled RF technique that results in a wider ablation diameter. The results do not demonstrate a clear advantage of one technique over the other.	[ 30–32 ]
Pain self-management program	High quality evidence is lacking specifically in older adults. Arthritis pain self-management programs that contain some CBT elements demonstrate efficacy.	[ 21 ]
Non-acetylated salicylates	Non-cyclooxygenase selective NSAIDs (e.g., ibuprofen, naproxen) should not be used chronically in older adults because of the potential for multiple adverse effects including but not limited to gastrointestinal bleeding, renal insufficiency, and exacerbation of hypertension and congestive heart failure.	[ 25 ]
Opioids as part of stepped-care management	American Geriatrics Society pain guidelines recommend opioids over non-selective NSAIDs.There are no data specifically for the treatment of SIJ pain.	[ 25 ]

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