Ablation of Si Joint Under Spinal Endoscopy

  • Javier Quillo-Olvera
  • Jin-Sung Kim


The diagnosis of chronic low back pain secondary to dysfunction of the sacroiliac joint is a challenge for the spine surgeon and interventional pain specialist. The sacroiliac joint is an anatomical structure with an important function in the distribution of loads from the spine to the legs and vice versa. It also has a complex nerve network that gives it sensitivity and which is formed mainly by the lateral branches of the dorsal sacral ramus from S1 to S3 with the inconstant participation of L5 and S4. The treatment of the pain syndrome caused by this joint is equally complicated. Within the current options, there are intra-articular and periarticular injections, radiofrequency ablation, and, in selected cases, the fusion of the joint. This chapter presents the endoscopic-assisted radiofrequency ablation technique for sacroiliac joint pain. Also, the topographic anatomy, diagnosis of articular dysfunction, and current treatments are discussed for the correct understanding of the endoscopic technique.


Chronic low back pain Sacroiliac joint Ablation Endoscopy Pain management Radiofrequency 





Body mass index


Computerized tomography


Flexion abduction external rotation


Korean Oswestry disability index


Lateral branch


Lateral branches block


Low back pain


Medial branch


Magnetic resonance imaging


Numeric rating pain scale


Nonsteroidal anti-inflammatory drugs


Oswestry disability index


Positron emission tomography


Pulsed radiofrequency


Posterior superior iliac spine


Posterior sacral network




Radiostereometric analysis


Superior articular process


Sacroiliac joint


Single-photon emission computed tomography


Short-tau inversion recovery


T1-weighted contrast-enhanced


T2-weighted fat-saturated


Visual analogue scale


  1. 1.
    Sembrano JN, Reiley MA, Polly DW Jr, Garfin SR. Diagnosis and treatment of sacroiliac joint pain. Curr Orthop Pract. 2011;22:344–50. Scholar
  2. 2.
    Bernard TN Jr, Kirkaldy-Willis WH. Recognizing specific characteristics of nonspecific low back pain. Clin Orthop Relat Res. 1987;(217):266–80.Google Scholar
  3. 3.
    Stelzer W, Stelzer V, Stelzer D, Braune M, Duller C. Influence of BMI, gender, and sports on pain decrease and medication usage after facet-medial branch neurotomy or SI joint lateral branch cooled RF-neurotomy in case of low back pain: original research in the Austrian population. J Pain Res. 2017;10:183–90. Scholar
  4. 4.
    Sembrano JN, Polly DW Jr. How often is low back pain not coming from the back? Spine (Phila Pa 1976). 2009;34:E27–32. Scholar
  5. 5.
    Ha KY, Lee JS, Kim KW. Degeneration of sacroiliac joint after instrumented lumbar or lumbosacral fusion: a prospective cohort study over five-year follow-up. Spine (Phila Pa 1976). 2008;33:1192–8. Scholar
  6. 6.
    Katz V, Schofferman J, Reynolds J. The sacroiliac joint: a potential cause of pain after lumbar fusion to the sacrum. J Spinal Disord Tech. 2003;16:96–9.PubMedCrossRefGoogle Scholar
  7. 7.
    DePalma MJ, Ketchum JM, Saullo TR. Etiology of chronic low back pain in patients having undergone lumbar fusion. Pain Med. 2011;12:732–9. Scholar
  8. 8.
    Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat. 2012;221:537–67. Scholar
  9. 9.
    Cohen SP, Chen Y, Neufeld NJ. Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment. Expert Rev Neurother. 2013;13:99–116. Scholar
  10. 10.
    Foley BS, Buschbacher RM. Sacroiliac joint pain: anatomy, biomechanics, diagnosis, and treatment. Am J Phys Med Rehabil. 2006;85:997–1006.PubMedCrossRefGoogle Scholar
  11. 11.
    Polly DW Jr. The Sacroiliac Joint. Neurosurg Clin N Am. 2017;28:301–12. Scholar
  12. 12.
    Sturesson B, Selvik G, Udén A. Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine (Phila Pa 1976). 1989;14:162–5.CrossRefGoogle Scholar
  13. 13.
    Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine (Phila Pa 1976). 2000;25:364–8.CrossRefGoogle Scholar
  14. 14.
    Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of the movements of the sacroiliac joints in the reciprocal straddle position. Spine (Phila Pa 1976). 2000;25:214–7.CrossRefGoogle Scholar
  15. 15.
    Lee D, Vleeming A. An integrated therapeutic approach to the treatment of the pelvic girdle. In: Vleeming A, Mooney V, Stoeckart R, editors. Movement, stability and lumbopelvic pain: integration and research. Edinburgh: Churchill Livingstone; 2007. p. 621–38.Google Scholar
  16. 16.
    Kiapour A, Abdelgawad AA, Goel VK, Souccar A, Terai T, Ebraheim NA. Relationship between limb length discrepancy and load distribution across the sacroiliac joint—a finite element study. J Orthop Res. 2012;30:1577–80. Scholar
  17. 17.
    Bakland O, Hansen JH. The "axial sacroiliac joint". Anat Clin. 1984;6:29–36.PubMedCrossRefGoogle Scholar
  18. 18.
    Fortin JD, Dwyer AP, West S, Pier J. Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part I: asymptomatic volunteers. Spine (Phila Pa 1976). 1994;19:1475–82.CrossRefGoogle Scholar
  19. 19.
    Fortin JD, Aprill CN, Ponthieux B, Pier J. Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part II: Clinical evaluation. Spine (Phila Pa 1976). 1994;19:1483–9.CrossRefGoogle Scholar
  20. 20.
    Fortin JD, Kissling RO, O'Connor BL, Vilensky JA. Sacroiliac joint innervation and pain. Am J Orthop (Belle Mead NJ). 1999;28:687–90.Google Scholar
  21. 21.
    Vilensky JA, O'Connor BL, Fortin JD, Merkel GJ, Jimenez AM, Scofield BA, et al. Histologic analysis of neural elements in the human sacroiliac joint. Spine. Spine (Phila Pa 1976). 2002;27:1202–7.CrossRefGoogle Scholar
  22. 22.
    Cohen SP, Abdi S. Lateral branch blocks as a treatment for sacroiliac joint pain: a pilot study. Reg Anesth Pain Med. 2003;28:113–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Cox RC, Fortin JD. The anatomy of the lateral branches of the sacral dorsal rami: implications for radiofrequency ablation. Pain Physician. 2014;17:459–64.PubMedGoogle Scholar
  24. 24.
    Yin W, Willard F, Carreiro J, Dreyfuss P. Sensory stimulation-guided sacroiliac joint radiofrequency neurotomy: technique based on neuroanatomy of the dorsal sacral plexus. Spine (Phila Pa 1976). 2003;28:2419–25.CrossRefGoogle Scholar
  25. 25.
    Willard F, Carreiro J, Manko W. The long posterior interosseous ligament and the sacrococcygeal plexus. In: Vleeming A, editor. Low back and pelvic pain (3rd Interdisciplinary World Congress). Rotterdam: ECO; 1998. p. 207–9.Google Scholar
  26. 26.
    Roberts SL, Burnham RS, Ravichandiran K, Agur AM, Loh EY. Cadaveric study of sacroiliac joint innervation: implications for diagnostic blocks and radiofrequency ablation. Reg Anesth Pain Med. 2014;39:456–64. Scholar
  27. 27.
    Forst SL, Wheeler MT, Fortin JD, Vilensky JA. The sacroiliac joint: anatomy, physiology and clinical significance. Pain Physician. 2006;9:61–7.PubMedGoogle Scholar
  28. 28.
    Nakagawa T. Study on the distribution of nerve filaments over the iliosacral joint and its adjacent regio n in the Japanese. Nihon Seikeigeka Gakkai Zasshi. 1966;40:419–30.PubMedGoogle Scholar
  29. 29.
    Broadhurst NA, Bond MJ. Pain provocation tests for the assessment of sacroiliac joint dysfunction. J Spinal Disord. 1998;11:341–5.PubMedCrossRefGoogle Scholar
  30. 30.
    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;49:89–97.PubMedCrossRefGoogle Scholar
  31. 31.
    Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine (Phila Pa 1976). 1996;21:2594–602.CrossRefGoogle Scholar
  32. 32.
    Bernard TN Jr. The sacroiliac joint syndrome: pathophysiology, diagnosis, and management. In: Frymoyer JW, editor. The adult spine. Principles and practice. New York: Raven; 1991. p. 2107–30.Google Scholar
  33. 33.
    Chou LH, Slipman CW, Bhagia SM, Tsaur L, Bhat AL, Isaac Z, et al. Inciting events initiating injection-proven sacroiliac joint syndrome. Pain Med. 2004;5:26–32.PubMedCrossRefGoogle Scholar
  34. 34.
    Ross J. Is the sacroiliac joint mobile and how should it be treated? Br J Sports Med. 2000;34:226.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Jung JH, Kim HI, Shin DA, Shin DG, Lee JO, Kim HJ. Usefulness of pain distribution pattern assessment in decision-making for the patients with lumbar zygapophyseal and sacroiliac joint arthropathy. J Korean Med Sci. 2007;22:1048–54.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Elgafy H, Semaan HB, Ebraheim NA, Coombs RJ. Computed tomography findings in patients with sacroiliac pain. Clin Orthop Relat Res. 2001;382:112–8.CrossRefGoogle Scholar
  37. 37.
    Sung S, Kim HS, Kwon JW. Assessment of sacroiliitis for the diagnosis of spondyloarthropathy: fat-saturated T2-weighted imaging with STIR versus fat-saturated contrast-enhanced T1-weighted imaging. Br J Radiol. 2017; Scholar
  38. 38.
    Zilber K, Gorenberg M, Rimar D, Boulman N, Kaly L, Rozenbaum M, et al. Radionuclide methods in the diagnosis of sacroiliitis in patients with spondyloarthritis: an update. Rambam Maimonides Med J. 2016; Scholar
  39. 39.
    Song IH, Brandt H, Rudwaleit M, Sieper J. Limited diagnostic value of unilateral sacroiliitis in scintigraphy in assessing axial spondyloarthritis. J Rheumatol. 2010;37:1200–2. Scholar
  40. 40.
    Koç ZP, Kin Cengiz A, Aydın F, Samancı N, Yazısız V, Koca SS, et al. Sacroiliac indicis increase the specificity of bone scintigraphy in the diagnosis of sacroiliitis. Mol Imaging Radionucl Ther. 2015;24:8–14. Scholar
  41. 41.
    Haldeman KO, Soto-Hall R. The diagnosis and treatment of sacro-iliac conditions by the injection of procaine (Novocain). J Bone Joint Surg. 1938;20:675–85.Google Scholar
  42. 42.
    Miskew DB, Block RA, Witt PF. Aspiration of infected sarco-iliac joints. J Bone Joint Surg Am. 1979;61:1071–2.PubMedCrossRefGoogle Scholar
  43. 43.
    Hendrix RW, Lin PJ, Kane WJ. Simplified aspiration or injection technique for the sacro-iliac joint. J Bone Joint Surg Am. 1982;64:1249–52.PubMedCrossRefGoogle Scholar
  44. 44.
    Simopoulos TT, Manchikanti L, Gupta S, Aydin SM, Kim CH, Solanki D, et al. Systematic review of the diagnostic accuracy and therapeutic effectiveness of sacroiliac joint interventions. Pain Physician. 2015;18:E713–56.PubMedGoogle Scholar
  45. 45.
    Calodney A, Rosenthal R, Gordon A, Wright RE. Targeted radiofrequency techniques. In: Racz GB, Noe CE, editors. Techniques of neurolysis. Switzerland: Springer; 2016. p. 33–73.CrossRefGoogle Scholar
  46. 46.
    Shealy CN. Percutaneous radiofrequency denervation of spinal facets. Treatment for chronic back pain and sciatica. J Neurosurg. 1975;43:448–51.CrossRefGoogle Scholar
  47. 47.
    Van Zundert J, Sluijter M, van Kleef M. Thermal and pulsed radiofrequency. In: Raj PP, Lou L, Erdine S, Staats PS, Waldman SD, Racz G, et al., editors. Interventional pain management: image-guided procedures. Philadelphia: Saunders; 2008. p. 56–65.Google Scholar
  48. 48.
    Bogduk N. International Spine Intervention Society Practice guidelines for spinal diagnostic and treatment procedures. 2nd ed. San Francisco: International Spine Intervention Society; 2013.Google Scholar
  49. 49.
    Malik K, Benzon HT, Walega D. Water-cooled radiofrequency: a neuroablative or a neuromodulatory modality with broader applications? Case Rep Anesthesiol. 2011;2011:263101. Scholar
  50. 50.
    Patel N, Gross A, Brown L, Gekht G. A randomized, placebo-controlled study to assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint pain. Pain Med. 2012;13:383–98. Scholar
  51. 51.
    Cohen SP, Strassels SA, Kurihara C, Crooks MT, Erdek MA, Forsythe A, et al. Outcome predictors for sacroiliac joint (lateral branch) radiofrequency denervation. Reg Anesth Pain Med. 2009;34:206–14. Scholar
  52. 52.
    Cheng J, Pope JE, Dalton JE, Cheng O, Bensitel A. Comparative outcomes of cooled versus traditional radiofrequency ablation of the lateral branches for sacroiliac joint pain. Clin J Pain. 2013;29:132–7. Scholar
  53. 53.
    Mitchell B, MacPhail T, Vivian D, Verrills P, Barnard A. Radiofrequency neurotomy for sacroiliac joint pain: a prospective study. Surgical Science. 2015;6:265–72. Scholar
  54. 54.
    Cohen SP, Hurley RW, Buckenmaier CC 3rd, Kurihara C, Morlando B, Dragovich A. Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology. 2008;109:279–88. Scholar
  55. 55.
    Ho KY, Hadi MA, Pasutharnchat K, Tan KH. Cooled radiofrequency denervation for treatment of sacroiliac joint pain: two-year results from 20 cases. J Pain Res. 2013;6:505–11. Scholar
  56. 56.
    Yeung A, Gore S. Endoscopically guided foraminal and dorsal rhizotomy for chronic axial back pain based on cadaver and endoscopically visualized anatomic study. Int J Spine Surg. 2014; Scholar
  57. 57.
    Jeong SY, Kim JS, Choi WS, Hur JW, Ryu KS. The effectiveness of endoscopic radiofrequency denervation of medial branch for treatment of chronic low back pain. J Korean Neurosurg Soc. 2014;56:338–43. Scholar
  58. 58.
    Li ZZ, Hou SX, Shang WL, Song KR, Wu WW. Evaluation of endoscopic dorsal ramus rhizotomy in managing facetogenic chronic low back pain. Clin Neurol Neurosurg. 2014;126:11–7. Scholar
  59. 59.
    Choi WS, Kim JS, Ryu KS, Hur JW, Seong JH, Cho HJ. Endoscopic radiofrequency ablation of the sacroiliac joint complex in the treatment of chronic low back pain: a preliminary study of feasibility and efficacy of a novel technique. Biomed Res Int. 2016;2016:2834259. Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2020

Authors and Affiliations

  • Javier Quillo-Olvera
    • 1
  • Jin-Sung Kim
    • 1
  1. 1.Spine Center, Department of NeurosurgerySeoul St. Mary’s Hospital, College of Medicine, The Catholic University of KoreaSeoulSouth Korea

Personalised recommendations