{
  "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.",
  "authors": [
    {
      "affiliations": [
        "Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake, UT, USA"
      ],
      "name": "Zachary L McCormick"
    },
    {
      "affiliations": [
        "Departments of Anesthesiology, Translational Neuroscience, and Public Health Sciences, and Pain Outcomes Lab, Wake Forest University School of Medicine, Winston-Salem, NC, USA"
      ],
      "name": "Robert W Hurley"
    },
    {
      "affiliations": [
        "Department of Anesthesia and Critical Care Medicine, University of Chicago Medicine, Chicago, IL, USA"
      ],
      "name": "Magdalena Anitescu"
    },
    {
      "affiliations": [
        "Pain Management Centre, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK"
      ],
      "name": "Arun Bhaskar"
    },
    {
      "affiliations": [
        "Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada",
        "Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada"
      ],
      "name": "Anuj Bhatia"
    },
    {
      "affiliations": [
        "University of Kentucky College of Medicine/UK Healthcare, Lexington, KY, USA"
      ],
      "name": "Ryan Carter Cassidy"
    },
    {
      "affiliations": [
        "Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA"
      ],
      "name": "Allen S Chen"
    },
    {
      "affiliations": [
        "Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA"
      ],
      "name": "Timothy C Dawson"
    },
    {
      "affiliations": [
        "Department of Anesthesiology, Hospital Universitario La Paz, Madrid, Spain"
      ],
      "name": "Javier De Andrés Ares"
    },
    {
      "affiliations": [
        "Department of Anesthesiology, Hospital Vera Cruz, Brazil"
      ],
      "name": "José Luiz de Campos"
    },
    {
      "affiliations": [
        "Department of Anesthesiology and Perioperative Medicine, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA"
      ],
      "name": "Salim M Hayek"
    },
    {
      "affiliations": [
        "Asociación Mexicana para el Estudio y Tratamiento del Dolor, Mexico, Mexico"
      ],
      "name": "Berenice Carolina Hernández-Porras"
    },
    {
      "affiliations": [
        "Division of Pain Medicine, Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN, USA"
      ],
      "name": "Narayan R Kissoon"
    },
    {
      "affiliations": [
        "Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA"
      ],
      "name": "Lynn R Kohan"
    },
    {
      "affiliations": [
        "Departament of Anesthesiology, Pontificia Universidad Catolicade Chile, Santiago, Chile"
      ],
      "name": "María Francisca Elgueta Le Beuffe"
    },
    {
      "affiliations": [
        "Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Bethesda, Republic of Korea"
      ],
      "name": "Jee Youn Moon"
    },
    {
      "affiliations": [
        "Pain Diagnostic and Interventional Care, Sewickley, PA, USA"
      ],
      "name": "David A Provenzano"
    },
    {
      "affiliations": [
        "Department of Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, USA"
      ],
      "name": "LTC David E Reece"
    },
    {
      "affiliations": [
        "UC San Diego Center for Pain Management, Department of Anesthesiology, UC San Diego Health System, La Jolla, CA, USA"
      ],
      "name": "Nathaniel M Schuster"
    },
    {
      "affiliations": [
        "Department of Physical Medicine & Rehabilitation, Columbia University, New York, NY, USA"
      ],
      "name": "Clark C Smith"
    },
    {
      "affiliations": [
        "Center for Spine Health, Neurological Institute, Cleveland Clinic, Case Western Reserve Lerner College of Medicine, Cleveland, OH, USA"
      ],
      "name": "Alison Stout"
    },
    {
      "affiliations": [
        "Anesthesiology and Pain Treatment, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands"
      ],
      "name": "Karolina Szadek"
    },
    {
      "affiliations": [
        "Department of Anesthesiology, Yale School of Medicine, New Haven, CT, USA"
      ],
      "name": "Donna-Ann Thomas"
    },
    {
      "affiliations": [
        "Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand"
      ],
      "name": "Nuj Tontisirin"
    },
    {
      "affiliations": [
        "Deakin University Medical School, VIC, Victoria, Australia"
      ],
      "name": "Michael F Vagg"
    },
    {
      "affiliations": [
        "Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium",
        "Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands",
        "Mental Health and Neuroscience Research Institute, Division Translational Neuroscience, Maastricht University, Maastricht, The Netherlands"
      ],
      "name": "Jan Van Zundert"
    },
    {
      "affiliations": [
        "Emory University School of Medicine, Atlanta VA Healthcare System, Atlanta, GA, USA"
      ],
      "name": "Anna Woodbury"
    },
    {
      "affiliations": [
        "Departments of Anesthesiology, Neurology, Physical Medicine & Rehabilitation, Psychiatry, and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA",
        "Departments of Physical Medicine & Rehabilitation and Anesthesiology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, USA"
      ],
      "name": "Steven P Cohen"
    }
  ],
  "title": "Consensus practice guidelines on sacroiliac joint complex pain from a multispecialty, international working group",
  "uid": "d1c3d0e3-cc75-5b52-9b64-e48057e41bd8"
}