British Journal of Anaesthesia 99 (5): 713–16 (2007)

doi:10.1093/bja/aem257 Advance Access publication on September 14, 2007

Case report

Sciatica and the sacroiliac joint: a forgotten concept

E. Buijs1*, L. Visser2 and G. Groen3
1
Department of Anaesthesia and Pain Management, Gelre Hospital Apeldoorn, PO Box 9014, 7300DS
Apeldoorn, The Netherlands. 2Department of Neurology, St Elisabeth Hospital, The Netherlands.
3
Centre for Perioperative Medicine, Anesthesiology and Pain Clinic, University Medical Centre Utrecht,
Utrecht, The Netherlands
*Corresponding author: Department of Anaesthesia and Pain Management, Gelre Hospital Apeldoorn, PO Box 9014,
7300DS Apeldoorn, The Netherlands. E-mail: e.buijs@gelre.nl
The definition of sciatica is restricted to the pattern and localization of pain, although much
emphasis is given to root compression as causative factor. Other sources of similar pain pat-

Downloaded from http://bja.oxfordjournals.org/ by guest on April 8, 2015

terns are generally neglected. Despite absence of obligatory neurological signs in radicular syn-
dromes, a number of patients are subjected to extensive, but redundant screenings. In this
report, three patients are presented with presumed radicular pain syndromes, whose symp-
toms finally could be linked to the sacroiliac (SI) joint either via CT and MRI scans or via pain
relief by intra-articular injection with local anaesthetics. Possible mechanisms of SI joint-related
pain and difficulties in diagnostic specificity of signs and symptoms are discussed.
Br J Anaesth 2007; 99: 713–16
Keywords: anaesthetics local, mepivacaine; analgesic techniques, intra-articular; analgesic
techniques, neurolysis
Accepted for publication: July 3, 2007

Sciatica is generally defined as ‘pain in the lower back and
hip radiating in the distribution of the sciatic nerve’.1 In
the 20s, the sacroiliac (SI) joint was considered to be an
important cause for sciatica.2 By the 1930s, it became
apparent that the lumbar disc could create sciatica and
interest in the SI joint faded.3 Recently, there has been a
resurgence of interest in the SI joint as a potential source
of low back pain, however, not as a cause of sciatica.4 – 8
We present three patients who were referred with a clinical
diagnosis of lumbar disc herniation, but in whom the diag-
nosis referred pain from the SI joint was made.
Case reports
Case 1
A 41-yr-old woman was operated for a herniated disc L4 –
5 in 1995. After operation, the pain did not subside. CT
scanning of the lumbar spine ruled out a herniated disc,
scar tissue, or root compression. Because of the chronicity
of her pain, she was seen by a psychologist. Signs of psy-
chopathology were absent. Manual and chiropractic thera-
pies were ineffective. She was referred to our pain clinic
with complaints of pain in the right buttock radiating to
the dorsal side of the right upper leg, the lateral side of
the calf, and into the great toe. Her pain score on the VAS
score was 9.2 (on 0 – 10 scale; 0¼no pain, 10¼unbearable
pain maximum score). The straight leg raising test (SLR)
was negative, but painful at 908 with pain in the back.
There were no abnormalities on neurological examination.
The SI provocation tests used were the thigh thrust, iliac
compression test, and Patrick test (the subject’s SI joint is
stressed when the leg is flexed, abducted, and exorotated
with overpressure, while the heel rests against the knee)9
and these tests were positive. After fluoroscopic-controlled
infiltration of the right SI joint with a local anaesthetic
(mepivacaine 2%, 2 ml, Astra-Zeneca, London, UK), her
pain was completely relieved for a few hours, the SI provo-
cation tests were negative, and the diagnosis ‘sacroiliac
joint related pain’ was made. A radiofrequency (RF) dener-
vation of the right SI joint was successfully performed
afterwards. Six months later, she was still pain free.
Case 2
A 48-yr-old woman was operated 24 yr earlier for a her-
niated disc syndrome at L4– 5. After a period of many
years without symptoms, she experienced pain in the back
and left leg. She complained of a radiating pain starting

# The Board of Management and Trustees of the British Journal of Anaesthesia 2007. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
 Buijs et al.
from the left SI region into the dorsal side of the left
upper leg, the lateral side of the calf, and into the lateral
side of the foot. Her pain score on the VAS score was 6.7.
The SLR was positive at 608. Neurological screening
revealed hypaesthesia in the affected leg. A MRI scan
ruled out a herniated disc and scar tissue. She was treated
with manual therapy and RF procedures at the facet joints
L4 –5 and L5 –S1 and at the left-sided dorsal root ganglion
L5, without success. The patient was referred to our pain
clinic. The following SI provocation tests were positive:
thigh thrust, iliac compression test, and Patrick test.9
Intra-articular injection, performed under fluoroscopic
control, with local anaesthetics (mepivacaine 2%, 2 ml,
Astra-Zeneca) relieved her pain for a few hours, the SI test
became negative, and the diagnosis ‘sacroiliac joint related
pain’ was made. A RF SI joint denervation was success-
fully performed afterwards. Three months later, the pain
had not recurred. She cancelled her 6 month appointment.
Case 3
A woman was first referred to the neurology outpatient
clinic at the age of 27 yr because of pain radiating from
the buttock into the lower left leg and the great toe. On
examination a positive SLR was found at 608. There were
no signs of muscle weakness, decreased reflexes, or
sensory loss. A CT scan of the lumbar spine did not reveal
abnormalities. Physiotherapy was ineffective. One year
later she developed sciatica at the right side, which per-
sisted in varying degrees of severity during the next 10 yr.
The neurologist repeatedly suspected a compression of the
L5 root, because she had a typically radiating pain into the
great toe and the SLR was positive at 608. During this 10
yr period, she had four CT scans of the lumbar spine, four
myelographies, and one MRI of the lumbar spine. All
investigations showed no abnormalities. Finally, the SI
joints were evaluated. SI provocation tests (thigh thrust,
iliac compression test, and Patrick test)9 were positive.
Plain X-rays showed extensive sclerosis. Subsequent CT
and MRI of the SI joints demonstrated chronic sacroiliitis.
Because of the chronic sacroiliitis, the SI joint was not
intra-articularly injected. The final diagnosis in this patient
was seronegative spondylarthropathy. She was treated by
the rheumatologist with anti-inflammatory drugs.
Discussion
Sciatica is a common syndrome in clinical practice and, in
general, is considered to be caused by root compression
due to disc herniation, lateral or foraminal stenosis, spon-
dylolisthesis, or tumour. However, the presented cases
clearly demonstrate that other mechanisms may prevail
and that sciatica-like symptoms can be mimicked expli-
citly by referred pain derived from the SI joints. For that
reason, the diagnosis sciatica should be considered as non-
specific. In the first two cases, the involvement of the SI
714
joint in the sciatica-like symptoms was confirmed by an
intra-articular injection.
After the RF SI, the pain reduction as measured by VAS
was .50% and the two patients (cases 1 and 2) were satis-
fied with the result and needed no additional treatment.
A decision to perform a RF SI is only made in those cases
when injection with a local anaesthetic gives a pain
reduction of at least 50%. Functional impairment was not
measured by questionnaires, but mentioned by the patients.
Follow-up was up to 6 months, in which period the effect
of the RF SI remained the same. This suggests that it is
very unlikely that the effects can be attributed to purely
placebo.
These procedures, however, were not indicated in the
third case since the SI joint abnormalities on the MRI
were evident by which it is very likely that the SI joint
was the source of her pain.
Root compression itself is not always a conditio sine
Downloaded from http://bja.oxfordjournals.org/ by guest on April 8, 2015
qua non for the diagnosis sciatica. The definition empha-
sizes the pain and its radiation,1 but root compression with
or without inflammation is just one of the causes of pain.
Consistency of history taking and physical examination in
patients with suspected lumbar nerve root involvement is
low. History should be emphasized on increased pain on
coughing–straining–sneezing and urine incontinence. Root
compression is probable when on physical examination,
paresis, sensory loss, reflex changes, or a positive SLR or
Bragard test are found.10 However, in 30% of the patients
with a strong presumptive diagnosis of a lumbar disc hernia-
tion, the diagnosis could not be confirmed by radiological
imaging studies or even during operation.11 12 This is in
accordance with our clinical experience: in many patients
with sciatica, referred to a pain clinic or to a specialized
neurological clinic, often no underlying lumbar disc
abnormality can be found. If there are no neurological signs
or symptoms in patients with radicular pain syndromes other
sources of pain, that is, SI joints, should be taken into
account, especially when the pain radiates into the lower leg
in an area similar to the dermatomes L5 and S1.
SI joint-related pain shows similar patterns. It can refer to the
buttocks, thigh, upper and lower leg to the lateral ankle5 13
(Fig. 1). These patients frequently complain of pain in the
SI area. SLR testing can then be positive. Establishing an
accurate diagnosis for SI joint-related pain on physical
examination is difficult. The diagnosis is based on a
pattern of findings, no single SI joint test is validated and
a large variation in reliability is reported.14 – 17 In 20% of
asymptomatic patients, these tests can be positive.18
Although Fortin5 15 described a specific area in patients
with SI joint-related pain, pain referral maps are of limited
value. There are no specific radiological abnormalities for
this syndrome, although CT scan and MRI can be helpful
in diagnosing sacroiliitis and joint space narrowing.19 With
clinical suspicion of a SI origin of pain, intra-articular
injection is currently the only means to confirm that diagno-
sis,20 although its validity is questioned.21 If SI joint pain is
 Sciatica and the sacroiliac joint
Fig 1 Schematic representation of radiating pain due to root compression L5 or S1 or due to diseases of the SI joint, according to the mentioned
authors.4 5 13 35
confirmed, it can be treated by injection with corticosteroids
or by RF denervation.22
Besides root compression with or without inflammation
and the SI joint, diseases of the lumbar facet joints23 and
spinal tumours24 may cause radiating pain into the leg. If
imaging techniques do not reveal a possible cause of the
pain, differentiation between these possible sources should
be performed by blockades with local anaesthetics,25
although false positive findings and low specificity and
sensitivity have been reported.26 27
Two of our patients responded positively to intra-
articular injection of the SI joints with local anaesthetics.
This is considered as the gold standard for diagnosing SI
joint-related pain6 7 and should be performed under fluoro-
scopy or CT guidance.6 28
Explanations for the radiating pattern of pain into the leg
due to the SI joint are several. First, it can be interpreted as
referred pain from this joint, since pain from deep somatic
structures is referred just like visceral pain.29 The radiating
pattern depends upon the segmental nerve supply of the SI
joint, which is described as primarily deriving from branches
from L5 to S4 spinal nerves.30 The character of deep somatic
pain is rather diffuse and is described as dull, with a deep
aching quality, although, at times, it tends to be more superfi-
cially projected.13 31 Secondly, it has been reported that
radiating SI joint-related pain may also be considered as seg-
mental nerve-related pain because of the close relationship
between the ventral capsule of the SI joint and the
715
Downloaded from http://bja.oxfordjournals.org/ by guest on April 8, 2015
spinal nerves L5 and S1, just before where these nerves join
to form part of the sciatic nerve.8 Arthrograms of patients
with SI joint-related pain sometimes show tears of this
ventral capsule.6 It has been suggested that SI capsular irri-
tation and cytokine release may cause adjacent neural insult
by these communications.8
Although this latest study demonstrates communication
between the dorsal and ventral aspects of the SI joints, the
amount of contrast medium injected is not mentioned.8
Finally, one should take into account that radiating pain
into the leg can also derive from other structures in the
lower back other than the SI joint, particularly when they
are supplied by branches from the same spinal nerves, that
is, L5 – S4.32 33
We conclude that sciatica is a common syndrome,
which is not defined specifically. Sciatica generally is
related to root compression with or without inflammation,
but in the absence of neurological signs, other sources
should be ruled out. In a number of cases, sciatica may
originate from the SI joint. Single SI joints tests on phys-
ical examination are not reliable. Multiple SI provocation
tests are helpful, but the gold standard for establishing the
diagnosis SI joint-related pain is an intra-articular block-
ade with low volume local anaesthetics. Recognizing that
sciatica can be referred pain from the SI joint is important,
since it may prevent unnecessary investigations and oper-
ations. Moreover, patients can successfully be treated for
this condition.22 34
 Buijs et al.

References 19 Ryan LM, Carrera GF, Lightfoot RW, Jr, Hoffman RG, Kozin F. The
radiographic diagnosis of sacroiliitis. A comparison of different
1 Dirckx JH, ed. Stedeman’s Concise Medical & Allied Health
views with computed tomograms of the sacroiliac joint. Arthritis
Dictionary. Baltimore: Williams & Wilkins, 1997
Rheum 1983; 26: 760 – 3
2 Yeoman W. The relation of arthritis of the sacro-iliac joint to
20 Elgafy H, Semaan HB, Ebraheim NA, Coombs RJ. Computed
sciatica, with an analysis of 100 cases. Lancet 1928; 2: 1119– 22
tomography findings in patients with sacroiliac pain. Clin Orthop
3 Mixter WJ, Barr JS. Rupture of the intervertebral disc with invol-
2001; 382: 112 – 8
vement of the spinal canal. N Engl J Med 1934; 211: 210– 5
21 Berthelot JM, Labat JJ, Le Goff B, Gouin F, Maugars Y. Provocative
4 Fortin JD, Aprill CN, Ponthieux B, Pier J. Sacroiliac joint: pain
sacroiliac joint maneuvers and sacroiliac joint block are unreliable
referral maps upon applying a new injection/arthrography tech-
for diagnosing sacroiliac joint pain. Joint Bone Spine 2006; 73:
nique. Part II: clinical evaluation. Spine 1994; 19: 1483 – 9
17– 23
5 Fortin JD, Dwyer AP, West S, Pier J. Sacroiliac joint: pain referral
22 Cohen SP. Sacroiliac joint pain: a comprehensive review of
maps upon applying a new injection/arthrography technique. Part
anatomy, diagnosis, and treatment. Anesth Analg 2005; 101:
I: asymptomatic volunteers. Spine 1994; 19: 1475– 82
1440– 53
6 Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in
23 Schellinger D, Wener L, Ragsdale BD, Patronas NJ. Facet joint dis-
chronic low back pain. Spine 1995; 20: 31 – 7
orders and their role in the production of back pain and sciatica.
7 Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double
Radiographics 1987; 7: 923 – 44
block and value of sacroiliac pain provocation tests in 54 patients
24 Copeman MC. Presenting symptoms of neoplastic spinal cord
with low back pain. Spine 1996; 21: 1889– 92
compression. J Surg Oncol 1988; 37: 24– 5
8 Fortin JD, Washington WJ, Falco FJ. Three pathways between the
25 Stolker RJ, Vervest AC, Groen GJ. The management of chronic
sacroiliac joint and neural structures. Am J Neuroradiol 1999; 20:
spinal pain by blockades: a review. Pain 1994; 58: 1 – 20

Downloaded from http://bja.oxfordjournals.org/ by guest on April 8, 2015

1429– 34
26 North RB, Kidd DH, Zahurak M, Piantadosi S. Specificity of diag-
9 Kokmeyer DJ, Van der Wurff P, Aufdemkampe G, Fickenscher
nostic nerve blocks: a prospective, randomized study of sciatica
TC. The reliability of multitest regimens with sacroiliac pain pro-
due to lumbosacral spine disease. Pain 1996; 65: 77 – 85
vocation tests. J Manipulative Physiol Ther 2002; 25: 42 – 8
27 Wolff AP, Groen GJ, Wilder-Smith OH. Influence of needle pos-
10 Vroomen PCAJ, Krom de MCTFM, Knottnerus JA. Consistency of
ition on lumbar segmental nerve root block selectivity. Reg
history taking and physical examination in patients with suspected
Anesth Pain Med 2006; 31: 523 – 30
lumbar nerve root involvement. Spine 2000; 25: 91–7
28 Pulisetti D, Ebraheim NA. CT-guided sacroiliac joint injections.
11 Modic MT, Ross JS, Obuchowski NA, et al. Contrast-enhanced
J Spinal Disord 1999; 12: 310 – 2
MR imaging in acute lumbar radiculopathy: a pilot study of the
29 Kellgren JH. On the distribution of pain arising from deep
natural history. Radiology 1995; 195: 429 – 35
somatic structures with charts of segmental pain areas. Clin Sci
12 Ohnmeiss DD, VanHaranta H, Ekholm J. Degree of disk disrup-
1939; 4: 35– 46
tion and lower extremity pain. Spine 1997; 22: 1600 – 5
30 Grob KR, Neuhuber WL, Kissling RO. Innervation of the sacro-
13 Bernard RN, Cassidy JD. The sacroiliac joint syndrome. In:
iliac joint of the human. Z Rheumatol 1995; 54: 117 –22
Frymoyer JW, ed. The Adult Spine: Principles and Practice.
31 Ropper AH, Brown RH, eds. Adams and Victor’s Principles of
New York: Raven Press Ltd, 1991; 2107
Neurology. New York: McGraw-Hill Education, 2005
14 Wurff van der P, Buijs EJ, Groen GJ. A multitest regimen of pain pro-
32 Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low
vocation tests as an aid to reduce unnecessary minimally invasive
back pain and sciatica: a report of pain response to tissue stimu-
sacroiliac joint procedures. Arch Phys Med Rehabil 2006; 87: 10–4
lation during operations on the lumbar spine using local anesthe-
15 Wurff van der P, Buijs EJ, Groen GJ. Intensity mapping of pain
sia. Orthop Clin North Am 1991; 22: 181– 7
referral areas in sacroiliac joint pain patients. J Manipulative Physiol
33 Groen GJ, Baljet B, Drukker J. Nerves and nerve plexuses of the
Ther 2006; 29: 190 – 5
human vertebral column. Am J Anat 1990; 188: 282 – 96
16 Wurff van der P, Hagemeijer RHM, Meyne W. Clinical tests of the
34 Buijs E, Kamphuis ET, Groen GJ. Radiofrequency treatment
sacroiliac joint. A systematic methodological review. Part 1:
of sacroiliac joint-related pain aimed at the first three
reliability. Man Ther 2000; 5: 30– 6
sacral dorsal rami: a minimal approach. The Pain Clinic 2004; 16:
17 Wurff van der P, Meyne W, Hagemeijer RHM. Clinical tests of the
139– 46
sacroiliac joint. A systematic methodological review. Part 2: val-
35 Dubuisson D. Nerve root disorders and arachnoiditis. In: Wall P,
idity. Man Ther 2000; 5: 89 – 96
Melzack R, eds. Textbook of Pain. Edinburgh: Churchill Livingstone,
18 Dreyfuss P, Dryer S, Griffin J, Hoffman J, Walsh N. Positive sacroiliac
1999; 851 – 78
screening tests in asymptomatic adults. Spine 1994; 19: 1138–43

716