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Mark Laslett* Peter van der Wurff Evert Buijs Charles N. Aprill Moorhouse Medical Centre, PhysioSouth, Level 2, 3 Pilgrim Place, Christchurch, Canterbury, New Zealand *Corresponding author. Tel.: þ64 3 385 5446; fax: þ64 3 377 0614. E-mail address: [email protected] (M. Laslett) 19 August 2006 Available online 7 March 2007 DOI of original article: 10.1016/j.jbspin.2004.08.003 129 7-3 19X/$ - see fron t matt er 200 7 Els evie r Mass on SAS . Allrightsreserve d. doi:10.1016/j.jbspin.2006.11.006 Reply to the letter by Mark Laslett on the review entitled: ‘‘Prov ocativ e sacroiliac joint maneu vers and sacroi liac joint block are unreliable for diagnosing sacroiliac joint pain’’ Keywords: Sacroiliac joint; Diagnosis; Reference standard; Controlled blocks; Clinical tests We thank Dr Laslett et al. for their enthusiastic comments, and do apologize for not including their recent works in our for- me r rev ie w (wh ich had bee n submitted more tha n two yea rs ago ) [1]. Our main goal was to stress the possibility of false positive res ult s of sac roi liac blocks, rel ate d either to pla cebo/Hawthorne effects and/or communications between sacroiliac joints and surrounding tissues (including ligaments and nerves) [2]. In ouropi nion , thisshouldstill pre clud e the ir use as a gol d sta nda rd (although they might deserve a ‘silver standard’ label). Indeed, too much confidence in those tests/blocks might lead to circular reasoning, and unnecessary fusion of sacroiliac joints for many patients with chronic back or buttock pain. In this respect, it should be kept in mind that the results of those fusions can be rather poor, even in patients with highly probable sacroiliac pain [3] . In other words, we think that the specificity of either clinical tests or a single diagnosis block should be even better than 0.80, to be considered reliable enough to prompt sacroiliac surgery and discard other explanations for chronic back pain. Althou gh they recogn ized in their recent works that perfe ct gold standards did not exist for the diagnosis of discogenic, fac- etogenic pain, or pain arising from the SIJ [4], Laslett et al. seemingly did not check whether a leakage of the contrast me- dium out of the sacroiliac joint had occurred before considering their (single) sacroiliac block as positive [5,6]. Hence, it cannot be ruled out that some pain ascribed to the sacroiliac joint in- deed arose from neighbouring tissues. The same holds true for the report by van der Wurff et al. [7] , who performed two blo cks (with a short and a long las ting anaest het ic) usi ng 3 ml (1 cm 3 of contrast medium and 2 cm 3 of anaesthetic fluid), and did observe some lea kag es, even lea ding to tempor ary sciatic palsy in five patients. We quite agree with the useful ad- vice of Dr Laslett et al. to use no more than 0.5 cm 3 of contrast media and 1 cm 3 of anaesthetic fluid, although it should be checked whether when using such volume no leakage can still occur, and whether the relief of pain is equal to what has been observed with larger volumes [7] . The studies by Laslett et al. [4e6] have high scientific con- tent, and are probably the most valuable breakthroughs on this frustrating topic. However, they would be even more convinc- ing if it can be definitively proven that the phenomenon of cen- tralization is so specific for pain of disc origin that no other diagnosis should be considered [8]. Indeed, the increased spec- ificity of sacroiliac tests observed by Laslett et al. (up to 0.87) [5,6], compared with previous papers, has been favoured by the elimination from the control group of patients with a cen- tralization phenomenon. This is an important point, as pain arising from the discs is probably the most frequent differen- tial diagnosis to consider in patients with back/buttock pain. Simil arly , the specificity of a test for diagn osing back/but tock pain should ideally be calculated using a control group repre- sentative of the whole population of patients with back/buttock pain. In another nice study by Laslett et al. [4] the authors ob- served in a sample of 216 chronic lumbar pain patients that only 67% could receive a patho-anatomic diagnosis based on available reference standards, 10% had more than one tissue origin of pain identified, and only 51% were given the same diagnosis by two physiotherapists. This underlines the diffi- culty of conducting such studies without rather strong selec- tion bias of the control group, as also stressed by van der Wurff et al. in a previous response [9]. The sec ond explan ati on for the dis cre pancie s bet ween recen t results [5e7] and those summar ized in our rev ie w [1], might be the threshold of pain relief required to consider a sacroiliac block as positive. For instance van der Wurff et al. [7] considered that a 50% reduction of pain was enough (com- pared with the threshold of 75% selected by Maigne et al. [10], and 80% by Laslett et al. [5]), which did offer a very clear split of patients between two groups of 27 responders and 33 non- responders [7]. However, this should lead to the conclusion that 45% of chronic low-back pain originates from the sacro- iliac joint stricto sensu, which appears rather improbable, and might cast doubt on the validity of the control group in this study too [7]. Indeed, figures from past works using a dou- ble-block paradigm, ranged from 10% to 19% [11]. To reconcile those observations, we proposed that many pa- tients relieved by a sacroiliac block could indeed suffer from sacroiliac lato sensu, i.e. from surrounding ligaments, includ- ing ilio-lu mbar ligaments, and sugge sted that expla nation s other than the sacroiliac joint itself should still be considered, even when several ‘sacroiliac’ provocation tests (which also stress lumbar structures) are positive [1]. This would be in agree ment with the impro veme nt induc ed in 13/18 patients with pain arising from the sacroiliac joint, by blocks of the L4e5 dorsal rami and S1e3 lateral branches [12] which inner- vate the ligaments surrounding the sacroiliac joint probably as much as the sacroiliac joint stricto sensu. Hence, we would quite agree with Dr Laslett that clinical tests (and perhaps 307 Correspondences / Joint Bone Spine 74 (2007) 306 e 308
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Mark Laslett*Peter van der Wurff
Evert BuijsCharles N. Aprill
Moorhouse Medical Centre, PhysioSouth, Level 2, 3 PilgrimPlace, Christchurch, Canterbury, New Zealand*Corresponding author. Tel.: 64 3 385 5446;
fax: 64 3 377 0614.E-mail address: [email protected] (M. Laslett)
19 August 2006
Available online 7 March 2007
DOI of original article: 10.1016/j.jbspin.2004.08.003
1297-319X/$ - see front matter 2007 Elsevier Masson SAS. All rights reserved.doi:10.1016/j.jbspin.2006.11.006
Reply to the letter by Mark Laslett on the review entitled:Provocative sacroiliac joint maneuvers and sacroiliac jointblock are unreliable for diagnosing sacroiliac joint pain
Keywords: Sacroiliac joint; Diagnosis; Reference standard; Controlled blocks;Clinical tests
We thank Dr Laslett et al. for their enthusiastic comments,and do apologize for not including their recent works in our for-mer review (which had been submitted more than two years ago)[1]. Our main goal was to stress the possibility of false positiveresults of sacroiliac blocks, related either to placebo/Hawthorneeffects and/or communications between sacroiliac joints andsurrounding tissues (including ligaments and nerves) [2]. Inour opinion, this should still preclude their use as a gold standard(although they might deserve a silver standard label). Indeed,too much confidence in those tests/blocks might lead to circular
Correspondences / Joint Bonreasoning, and unnecessary fusion of sacroiliac joints for manypatients with chronic back or buttock pain. In this respect, itshould be kept in mind that the results of those fusions can berather poor, even in patients with highly probable sacroiliacpain [3]. In other words, we think that the specificity of eitherclinical tests or a single diagnosis block should be even betterthan 0.80, to be considered reliable enough to prompt sacroiliacsurgery and discard other explanations for chronic back pain.
Although they recognized in their recent works that perfectgold standards did not exist for the diagnosis of discogenic, fac-etogenic pain, or pain arising from the SIJ [4], Laslett et al.seemingly did not check whether a leakage of the contrast me-dium out of the sacroiliac joint had occurred before consideringtheir (single) sacroiliac block as positive [5,6]. Hence, it cannotbe ruled out that some pain ascribed to the sacroiliac joint in-deed arose from neighbouring tissues. The same holds truefor the report by van der Wurff et al. [7], who performed twoblocks (with a short and a long lasting anaesthetic) using3 ml (1 cm3 of contrast medium and 2 cm3 of anaesthetic fluid),and did observe some leakages, even leading to temporarysciatic palsy in five patients. We quite agree with the useful ad-vice of Dr Laslett et al. to use no more than 0.5 cm3 of contrastmedia and 1 cm3 of anaesthetic fluid, although it should bechecked whether when using such volume no leakage can stilloccur, and whether the relief of pain is equal to what has beenobserved with larger volumes [7].
The studies by Laslett et al. [4e6] have high scientific con-tent, and are probably the most valuable breakthroughs on thisfrustrating topic. However, they would be even more convinc-ing if it can be definitively proven that the phenomenon of cen-tralization is so specific for pain of disc origin that no otherdiagnosis should be considered [8]. Indeed, the increased spec-ificity of sacroiliac tests observed by Laslett et al. (up to 0.87)[5,6], compared with previous papers, has been favoured bythe elimination from the control group of patients with a cen-tralization phenomenon. This is an important point, as painarising from the discs is probably the most frequent differen-tial diagnosis to consider in patients with back/buttock pain.Similarly, the specificity of a test for diagnosing back/buttockpain should ideally be calculated using a control group repre-sentative of the whole population of patients with back/buttockpain. In another nice study by Laslett et al. [4] the authors ob-served in a sample of 216 chronic lumbar pain patients thatonly 67% could receive a patho-anatomic diagnosis based onavailable reference standards, 10% had more than one tissueorigin of pain identified, and only 51% were given the samediagnosis by two physiotherapists. This underlines the diffi-culty of conducting such studies without rather strong selec-tion bias of the control group, as also stressed by van derWurff et al. in a previous response [9].
The second explanation for the discrepancies betweenrecent results [5e7] and those summarized in our review[1], might be the threshold of pain relief required to considera sacroiliac block as positive. For instance van der Wurff et al.[7] considered that a 50% reduction of pain was enough (com-pared with the threshold of 75% selected by Maigne et al. [10],and 80% by Laslett et al. [5]), which did offer a very clear splitof patients between two groups of 27 responders and 33 non-responders [7]. However, this should lead to the conclusionthat 45% of chronic low-back pain originates from the sacro-iliac joint stricto sensu, which appears rather improbable, andmight cast doubt on the validity of the control group in thisstudy too [7]. Indeed, figures from past works using a dou-ble-block paradigm, ranged from 10% to 19% [11].
To reconcile those observations, we proposed that many pa-tients relieved by a sacroiliac block could indeed suffer fromsacroiliac lato sensu, i.e. from surrounding ligaments, includ-ing ilio-lumbar ligaments, and suggested that explanationsother than the sacroiliac joint itself should still be considered,even when several sacroiliac provocation tests (which alsostress lumbar structures) are positive [1]. This would be inagreement with the improvement induced in 13/18 patientswith pain arising from the sacroiliac joint, by blocks of theL4e5 dorsal rami and S1e3 lateral branches [12] which inner-vate the ligaments surrounding the sacroiliac joint probably as
307e Spine 74 (2007) 306e308much as the sacroiliac joint stricto sensu. Hence, we wouldquite agree with Dr Laslett that clinical tests (and perhaps
-
sacroiliac blocks) should be more specific for sacroiliac syn-drome than for sacroiliac joint pain.
References
[1] Berthelot JM, Labat JJ, Le Goff B, Gouin F, Maugars Y. Provocative
sacroiliac joint maneuvers and sacroiliac joint block are unreliable for
diagnosing sacroiliac joint pain. Joint Bone Spine 2006;73:17e23.
[2] Fortin JD, Washington WJ, Falco FJ. Three pathways between the sacro-
iliac joint and neural structures. AJNR Am J Neuroradiol 1999;
20:1388e9.
[3] Schutz U, Grob D. Poor outcome following bilateral sacroiliac joint
fusion for degenerative sacroiliac joint syndrome. Acta Orthop Belg
2006;72:296e308.
[4] Laslett M, McDonald B, Tropp H, Aprill CN, Oberg B. Agreement
between diagnoses reached by clinical examination and available refer-
ence standards: a prospective study of 216 patients with lumbopelvic
pain. BMC Musculoskeletal Disord 2005;6:28.
[5] Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful
sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac
provocation tests. Aust J Physiother 2003;49:89e97.
[6] Laslett M, Aprill CN, McDonald B. Provocation sacroiliac joint tests
have validity in the diagnosis of sacroiliac joint pain. Arch Phys Med
Rehab 2006;6:874e5.[7] Laslett M, Oberg B, Aprill CN, McDonald B. Centralization as a predictor
of provocation discography results in chronic low back pain, and the influ-
ence of disability and distress on diagnostic power. Spine J 2005;5:370e80.
[8] Van der Wurff P, Buijs EJ, Groen GJ. A multitest regiment of pain prov-
ocation tests as an aid to reduce unnecessary minimally invasive sacroil-
iac joint procedures. Arch Phys Med Rehabil 2006;87:10e4.
[9] van der Wurff P, Buijs EJ, Gerbrand J, Groen GJ. The authors respond.
Arch Phys Med Rehabil 2006;87:874e5.
[10] Maigne JY, Planchon CA. Sacroiliac joint pain after lumbar fusion. A
study with anesthetic blocks. Eur Spine J 2006;15:8e15.
[11] McKenzie-Brown AM, Shah RV, Sehgal N, Everett CR. A systematic
review of sacroiliac joint interventions. Pain Physician 2005;8:
115e25.
[12] Cohen SP, Abdi S. Lateral branch blocks as a treatment for sacroiliac
joint pain: a pilot study. Reg Anesth Pain Med 2003;28:113e9.
Jean-Marie Berthelot*Hotel-Dieu-CHU Nantes,
1, Place Alexis Ricordeau,Nantes Cedex 01, France
*Correspondence author. Rheumatology Unit,Nantes University Hospital (CHU Nantes), 44093,Nantes, France. Tel.: 33 02 40 08 48 22/25/01;
fax: 33 02 40 08 48 30.E-mail address: [email protected]
19 September 2006
Available online 5 March 2007
DOI of original article: 10.1016/j.jbspin.2004.08.003
1297-319X/$ - see front matter 2007 Elsevier Masson SAS. All rights reserved.doi:10.1016/j.jbspin.2006.11.007
308 Correspondences / Joint Bone Spine 74 (2007) 306e308
Reply to the letter by Mark Laslett on the review entitled: Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint painReferences
