Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, U.S.A.
Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.
Pain Pract. 2021 Feb;21(2):204-214. doi: 10.1111/papr.12950. Epub 2020 Oct 24.
To date, there have been no acceptable and accurate diagnostic criteria or standards of care for the management of sacroiliac joint (SIJ) pain. Several studies have yielded different contributions of clinical presentation, history, and physical examination in the diagnosis of SIJ pain. Our goal in this study was to assess the sensitivity and specificity of the diagnostic clinical tests and their predictive value in accurately diagnosing SIJ pain.
Upon enrolling 200 eligible patients with SIJ pain as their primary diagnosis, they were re-evaluated and their verbal rating scale (VRS) pain scores and demographic data were obtained. Thereafter, three SIJ diagnostic tests were performed: the thigh thrust test, the Patrick test, and a modified version of the Gaenslen test that is referred to as the Mekhail test. Subsequently, the patients were taken to the procedure room to undergo SIJ injection, for which a confirmative result was ≥50% pain relief. The physicians performing the procedure were blinded of the results of the 3 tests performed. Results from the 3 tests were incorporated with the procedure results, from which we drew statistical and medical conclusions determining their predictive value and degree of aid to physicians in diagnosing SIJ pain.
We found that the cumulative effect of adding simultaneous tests increased the sensitivity of the testing but decreased the specificity, which generates a powerful screening tool. The combination of the Patrick and Mekhail tests demonstrated the best accuracy, with 94% sensitivity, 17% specificity, 81% positive predictive value, and 44% negative predictive value. The Patrick test was better than other tests for differentiating patients with SIJ pain from those with non-SIJ pain. No combination yielded both significant sensitivity and specificity. Generally, the overall predictive value of any of the tests on their own or their combination did not vary significantly from the predictive value of baseline demographics, including pre-injection pain score and pain referral diagram.
In conclusion, our study results were similar to those of previous investigators who found that physical examination plays a limited role in diagnosing SIJ pain. Specifically, we found that the clinical tests and/or their combinations added no significant predictive capacity compared to patients' baseline characteristics in predicting the response to diagnostic SIJ injection, albeit the combination of the Mekhail and Patrick tests yielded high sensitivity (94%), making them viable for consecutive screening, possibly reducing the unnecessary costs of diagnostic SIJ injection procedures.
迄今为止，尚无针对骶髂关节（SIJ）疼痛管理的可接受且准确的诊断标准或治疗标准。几项研究表明，临床症状、病史和体格检查在 SIJ 疼痛的诊断中具有不同的作用。我们在这项研究中的目标是评估诊断性临床检查的敏感性和特异性及其在准确诊断 SIJ 疼痛中的预测价值。
在纳入 200 名符合条件的以 SIJ 疼痛为主要诊断的患者后，对他们进行重新评估，并获得他们的视觉模拟评分（VRS）疼痛评分和人口统计学数据。此后，进行了三项 SIJ 诊断性检查：大腿推力试验、Patrick 试验和改良的 Gaenslen 试验，称为 Mekhail 试验。随后，将患者带到治疗室进行 SIJ 注射，该注射的确认结果为疼痛缓解≥50%。进行该程序的医生对所进行的 3 项检查的结果并不知情。从这 3 项检查结果和治疗结果中得出了统计和医学结论，以确定它们对医生诊断 SIJ 疼痛的预测价值和辅助程度。
我们发现，同时进行多项检查的累积效应提高了检查的敏感性，但降低了特异性，从而生成了强大的筛查工具。Patrick 试验和 Mekhail 试验的组合具有最佳的准确性，其敏感性为 94%，特异性为 17%，阳性预测值为 81%，阴性预测值为 44%。Patrick 试验在区分 SIJ 疼痛患者和非 SIJ 疼痛患者方面优于其他检查。没有任何组合同时具有显著的敏感性和特异性。通常，任何检查或其组合的总体预测价值与其基线人口统计学特征（包括注射前疼痛评分和疼痛放射图）相比，均无明显差异。
总之，我们的研究结果与先前的研究人员的结果相似，他们发现体格检查在诊断 SIJ 疼痛方面的作用有限。具体来说，我们发现与患者的基线特征相比，临床检查和/或其组合在预测诊断性 SIJ 注射的反应方面并未增加显著的预测能力，尽管 Mekhail 和 Patrick 试验的组合具有很高的敏感性（94%），使其成为可行的连续筛查方法，可能会降低不必要的 SIJ 诊断性注射程序的成本。
