PRP and sacroiliac joint injection cover

prp and sacroiliac pain

case presentation

A healthy, 30-year-old recreational runner presents with low back discomfort that has been ongoing for about 2 months.  She describes pain that worsens through her runs and seems somewhat progressive.  On examination, she localizes pain to the SI joint with FABER testing.  She also has a positive Gaenslen test and thigh thrust test.  What is the first line treatment for this condition

A. Corticosteroid injection
B. Platelet rich plasma
C. Stem cell treatment
D. Physiotherapy

introduction

Sacroiliac joint (SIJ) pain has been broadly defined as pain located in the area of the SIJ that can be elicited by various pain provocation tests.  Sacroiliac joint pain can also be called sacroiliac complex pain and can affect both younger and older individuals.  The prevalence of SIJ pain has been reported to range from 10% to 62% based on the clinical setting, with a point prevalence around 25% [1].

The anatomy of the SIJ is complex. The anterior third of the sacrum and ilium serve as the true synovial portion of the joint and, without a true posterior capsule, many ligamentous connections extend over the dorsal aspect of the joint. There remains a lack of consensus regarding the innervation of the SIJ but some experts agree that L4-S3 dorsal rami are major contributors . Due to its complexity, it has been reported that neither history, physical examination or radiologic studies, reliably exhibit strong sensitivity nor inter-rater reliability for diagnosis of SIJ-mediated pain [2].

The treatment of SIJ pain remains a therapeutic challenge. Besides physiotherapy and systemic therapies including nonsteroidal anti-inflammatory drugs (NSAIDs) and biological agents, intra-articular and periarticular injections of SIJ, radiofrequency neurotomy, and surgical fusion are often performed for pain relief [3-6].

However, those patients who fail to improve with conservative measures, oftentimes undergo SIJ intra-articular corticosteroid injections [16] or radiofrequency (RF) neurotomy [7]. Evidence of SIJ corticosteroid injections have varied with systematic reviews finding both limited [8-9] and moderate [10] evidence to support their use. 

One study reported a relatively low yield with a reduction in the visual analog scale (VAS) score of >50% in 12.5 and 31.25% of patients after intra-articular and periarticular SIJ steroid injection, respectively [11]. Additionally, chronic use of corticosteroids may lead to increased degenerative changes [12], and may lead to decreased bone mineral density and increase risk of fracture [13].

Image 1: Ultrasound image of the sacroiliac joint and approach.  Adopted from [28].

Platelet-rich plasma (PRP) is autologous blood that contains platelet concentrations above normal physiological levels, and the injectable solution is obtained by using centrifugation to separate solid and liquid blood components [14-15]. PRP is believed to stimulate regeneration through the release of growth factors and proteins that may be involved in repairing the matrices of degenerative discs [16]. There are a few systematic reviews and meta-analyses in the literature assessing the efficacy of PRP for treatment in lumbar spondylosis and sacroiliac arthropathy [17-18].

A recent systematic review by Rothenberg et al. has shown very positive results after evaluating  seven studies [2].   These studies evaluated the effects of these regenerative treatments on the intra-articular SI joint or periligamentous SI structures (FIG) with various different pain scales and measurements.  There were improvements in the primary end point of all seven studies, however, only (5/7) 71% of articles had outcome measures that were considered responders, a greater than 50% improvement in pain and functional scores [2].

All seven studies within this review used image-guidance [19-25]. However, there were slight variations in the SIJ target of the PRP interventions and imaging modalities used (Figure 2). Three studies directed the treatments to the sacroiliac intra-articular joint alone [21–23].   Ko et al. directed the treatment at the Hackett points A–C of the enthesis and Saunders et al. directed treatment toward the dorsal sacroiliac ligament, without injecting directly into the joint [20-21]. Broadhead and Wallace et al. directed PRP into the combined intra-articular joint and adjacent soft tissues and posterior sacroiliac ligaments [23-26]. A study by Dreyfuss et al. demonstrated multi-site multi-depth lateral branch blocks were physiologically effective in blocking nociception from the interosseous and dorsal sacroiliac ligaments in 70% of subjects [27].

Figure 2.  Summary of studies in the systematic review looking at responders versus non-responders.  Adopted from [2].

In this review, there were only two studies with a control group [22-23]. Singla et al. compared PRP with a steroid injection, and demonstrated 18/20 (90%) in the PRP group and only 5/20 (25%) had a reduction in VAS of at least 50% [22]. Notably, Mohi Eldin et al. studied the delivery methods of PRP in a larger sample size, comparing 124 patients treated with liquid injectable platelet rich fibrin to 62 patients treated with PRP and found that, at 6 months follow-up, patients receiving platelet rich fibrin injections had statistically significant improvement in VAS pain score when compared with the PRP injection group [23]. 

Most recently, Mohamed et al. reported relief showed similar results between corticosteroid injection and PRP in 50 patients at six weeks.  However, at eight weeks and four months, PRP was shown to have better pain relief and function scores [28].  Similarly, Dev at al. had a similar study showing superiority of a single PRP injection at one, three and six months for pain relief in fifty patients when compared to a single steroid injection [29].

Figure 3.  Image of an SI joint depicting differences in location of recent studies evaluating effectiveness of PRP.  Adopted from [2].

Summary

In conclusion, PRP is a regenerative strategy that is gaining traction as a treatment option for sacroiliac pain.  The existing literature suggests that there may be favorable pain and functional primary outcomes, with no major adverse events. However, standardization of these outcome measures in future studies, with appropriately designed studies would offer more consistent and comparable data to evaluate treatment effectiveness. There is a need for adequately powered well-designed, standardized, double-blinded randomized clinical trials in order to determine the effectiveness of PRP in sacroiliac pain.

CASE CONCLUSION

D. Though studies show short term effectiveness of both corticosteroid injections and PRP for sacroiliac pain, physiotherapy remains the first line treatment of sacroiliac pain. There is limited power with the studies evaluating PRP as a treatment option and even more limited evidence supporting stem cell treatment.   Corticosteroid injections are likely used as a second line option if the patient fails physical therapy. 

Kohler’s disease is another term for avascular necrosis of the navicular bone and is seen almost exclusively in pediatric patients.  It would also present with pain over the midfoot most likely.

– Read More Back Pain: https://www.sportsmedreview.com/by-joint/back/

SI Joint Injection @ Wiki Sports Medicinehttps://wikism.org/Sacroiliac_Joint_Injection

References

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Dev, Priyanka, et al. “Comparison of the Efficacy of Intra-articular Platelet-rich Plasma with Intra-articular Steroid in the Management of Pain due to Sacroiliac Joint Dysfunction.” Indian Journal of Pain 37.3 (2023): 173-177.