Determination of the Prevalence from Clinical Diagnosis of Sacroiliac Joint Dysfunction in Patients with Lumbar Disc Hernia and an Evaluation of the Effect of this Combination on Pain and Quality of Life.

The level of sacroiliac joint dysfunction was 33.3% in the study population. Accordingly to the surveys were used in this study, the neuropathic pain level, also the presence of kinesiophobia and depression were significantly higher in the group with sacroiliac joint dysfunction. Additionally, functional capacity was observed worse.

T he point prevalence of lumbar pain, which affects approximately 50% to 80% of people in industrialized Western societies at certain periods of their lives and that is one of the main causes of workforce losses, medical costs, and disability, is between 15% and 30%. [1][2][3] 2% to 3% of all lumbar pains are those developing in association with lumbar disc herniation (LDH). Seventy percent of cases occur in the 30 to 50 age group, while 10% appear after 60. LDH in childhood is very rare. 4 One of the many agents leading to lumbar pain is sacroiliac dysfunction, the prevalence of which, based on clinical assessments, is 15% to 30%. 5 The sacroiliac joint (SIJ) was first described as a joint causing lumbar pain by Goldwaith and Osgood in 1905. 6 In a study from 1909 involving SIJ dissection in 50 cadavers and seven cases, Albee described this as a genuine, mobile joint, and reported that lumbar pain and sciatica emerge when it is injured. 7,8 The joint has its own particular biomechanical characteristics, anatomical variations, and diffuse neural innervation. The clinical presentation and pain patterns of sacroiliac joint dysfunction (SJD) are therefore still controversial.
The purpose of this study was to establish the prevalence of SJD in patients with LDH and to examine the variations in clinical parameters cause by this combination.

MATERIALS AND METHODS
This cross-sectional study investigated patients aged 20 to 60 presenting to the Okmeydani Training and Research Hospital Physiotherapy and Rehabilitation Clinic, Turkey, due to lumbar-leg pain between January and April 2015. Two hundred thirty-four patients with diagnoses of LDH confirmed by clinical and radiological evaluations were enrolled in the study.
Patients aged 20 to 60, diagnosed with LDH, with cognitive levels sufficient to complete the assessment forms, and agreeing to participate were enrolled. Patients with lumbar pain, the etiology of which was suspected to be inflammatory in character, with structural vertebral deformity or fracture, with severe and progressive neurological deficit, with a history of severe psychiatric disease, with substance and/or alcohol dependence, with uncontrolled diabetes mellitus (DM), malignancy, spinal infection or a history of vertebral surgery, and pregnant subjects were excluded.
Demographic characteristics such as patients' age, height, body weight (BW), body mass index (BMI), marital status, education level, and occupational status, and information concerning history of trauma, and the character, duration, and site of pain were investigated and noted on a case report form.
Before undergoing physical examination, all patients were evaluated in terms of pain threshold measurements using a Visual Analogue Scale (VAS), using the Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale (LANSS) to the determine character of pain, with the Beck Depression Inventory (BDI) for psychological state, using the Health Assessment Questionnaire (HAQ) for quality of life and the Tampa Scale for Kinesiophobia for aversion to movement.
Lumbar spine flexion, extension, and right-left lateral flexion ranges of motion were determined using a universal goniometer and clinical tests were evaluated at physical examination.
In terms of clinical tests, Lasegue test, contralateral Lasegue, and the femoral nerve stretch test were used to determine LDH and six provocation tests (distraction, compression, Gaenslen, thigh thrust, sacral thrust, and Fleksiyon-Abduction -Eksternal Rotasyon (FABER) tests) for the SIJ. Based on the data from previous studies, patients with three or more positive provocation tests were diagnosed with SJD. [11][12][13] In addition, all patients were asked about SIJ pain (pain when rising from a seated position, getting out of cars, and climbing stairs), and the data were recorded.

Sample Size
A power analysis using the formula n ¼ t2pq /d2 was performed to determine the sample size. Based on those data we concluded that a minimum of 174 and a maximum of 322 patients would be required to achieve significant results, and 234 patients were enrolled.

Statistical Analysis
The study data were expressed as mean plus standard deviation (SD) for constant variables values and as number and percentage for categoric variables. The chi-square test was used to analyze categoric variables. Results were evaluated at a 95% confidence interval at a significance level of P < 0.05. The analysis was performed on SPSS (Statistical Package for the Social Sciences -SPSS Inc., Chicago, IL) for Windows 16.0 software.
The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline has been implemented in this manuscript.

RESULTS
Two hundred thirty-four patients, 148 females (63.2%) and 86 males (36.8%), with a clinical diagnosis of LDH and with disk protrusion and/or extrusion identified at magnetic resonance imaging (MRI) were included in the study. The presence of SJD was determined in 78 (33.3%) of the 234 patients using provocation tests. Dysfunction in the SIJ was determined on the right in 52.6% of patients and on the left in 47.4%. Patients were divided into groups, with or without SJD, and then compared.

Demographic Characteristics
The ages of the 234 subjects in the study ranged between 20 and 60, the mean age being 46.72 AE 11.14. There was no statistically significant difference between the groups in terms of height, body weight, BMI, age, marital status, education, or employment (P > 0.05). A significant difference between the groups was observed only in terms of sex, the presence of SJD being higher in women (P ¼ 0.005). Demographic data are shown in Table 1.

Pain Characteristics
Comparisons were performed between the groups in terms of location of pain, pain in the hip (SIJ), remaining standing for long periods, walking some distance and pain when rising from a seated position, getting out of a car or walking upstairs. Statistically, significant variation was determined in terms of the location of pain and prolonged standing (P < 0.05). No statistically significant variation was observed at a comparison of the location of pain and pain arising with prolonged standing (P > 0.05). The findings are shown in Table 2.
No statistically significance was determined between the groups in terms of duration of pain, VAS at rest, VAS during activity, and nocturnal VAS scores (P ¼ 0.79, P ¼ 0.96, P ¼ 0.13, and P ¼ 0.07, and P > 0.05, respectively).

Imaging Findings
Although greater lumbosacral joint and SIJ degeneration were determined at radiological imaging in the SJD group, the differences were not statistically significant (P ¼ 0.33 and P > 0.05, respectively).

Examination Findings
Tests aimed at assessing LDH revealed no statistically significant difference between the groups in terms of Lasegue test, contralateral Lasegue, and the femoral nerve stretch test (P ¼ 0.18, P ¼ 0.13, and P ¼ 1.00, P > 0.05, respectively). However, a statistically significant difference was observed in tenderness along the sciatic nerve (Valleix point) (P ¼ 0.003, P < 0.05). No statistically significant difference was determined between the groups in terms of lumbar range of motion, hand-ground distance sensory deficit (root level), or decreased deep tendon reflexes in the patellar and Achilles tendons (P ¼ 0.55, P ¼ 0.76, P ¼ 0.71, P ¼ 0.33, and P ¼ 1.00, P > 0.05, respectively). No statistically significant difference was determined between the groups at evaluation of extremity length measurements (P ¼ 0.72, P > 0.05), while comparison of SIJ provocation tests revealed significant variation in increasing pain with the Compression Test and the FABER, Gaenslen, Posterior Shear Test (POSH), and Sacral Thrust tests (P < 0.001).

Questionnaires
Significant variation was observed between the groups in terms of the Beck Depression Scale, LANSS pain scale, HAQ, and Tampa kinesophobia scale (P < 0.05).
When BDI results were evaluated, the presence of moderate and severe depression was significantly higher in the SJD group, while in the non-SJD group, the non-depression group was significantly higher.
Patients were also evaluated using LANSS for neuropathic pain. The findings revealed that the presence of neuropathic pain was significantly higher in the SJD group.
The HAQ was used to evaluate the quality of life in our population and quality of life was significantly lower in SJD group.
Aversion to movement, evaluated using the Tampa Scale for Kinesophobia, was significantly higher in the group with SJD.
The findings are shown in Table 3.

DISCUSSION
The purpose of this study was to determine the incidence of SJD in patients diagnosed with LDH through clinical examination and lumbar MRI presenting with lumbar-leg pain to the Okmeydani Training and Research Hospital PTR clinic and to assess the effect of this combination on clinical status, pain, and quality of life. No significant difference was determined between the SJD and non-SJD groups in terms of age, BMI, marital status, or education levels. The incidence of SJD was higher among women in this study. Madani et al 9 described female sex, a history of recurring lumbar pain and a heavy workload as significant risk factors for SJD. In that study, 55.9% of patients with SJD were female. It has been suggested that the greater incidence of SJD in female patients may be due to the effects on the SIJ of fertility, lifestyle, or low levels of exercise. 9 Some studies have reported a decrease of at least 80% in VAS scores with local anesthesia injection guided by fluoroscopy, the gold standard technique for the diagnosis of SJD syndrome. 10 Since SIJ blocks only provide information about pathologies of joint origin and SJD developing secondary to pathologies of structures around the joint can be overlooked, SIJ provocation and palpation tests also need to be used for diagnosis. The studies evaluating the validity and reliability of provocation tests in the diagnosis of sacroiliac joint dysfunction reported that three or more positive provocative tests, which include especially Ganslen, FABER, thigh thrust (POSH), compression and distraction tests, were highly sensitive and specific. [11][12][13] However, all of these studies reported that should be used multiple tests for the diagnosis of SIJD and individual tests exhibited low reliability. Dreyfuss et al 14 examined SI joint tests in a group consisting of asymptomatic individuals and observed symptoms of SIJD in 20% of asymptomatic patients. van der Wurff et al 15 reported that the presence of three or more positive provocation tests in patients with pain deriving from the SI joint varied between 65% and 93%. Six provocation tests used in the diagnosis of SJD were performed on all patients in this study, and SJD was confirmed in the presence of three or more positive results.

HEALTH SERVICES RESEARCH
The Prevalence of Sacroiliac Joint Dysfunction Telli et al The prevalence of SJD has been reported at 24% to 72.3% in previous studies. 9,17,20,21 Madani et al 9 investigated 202 patients aged 19 to 70, with LDH, determined at imaging and with physical findings of lumbosacral root irritation and reported SJD in 146 (72.3%) subjects. The authors reported that the estimated prevalence of SJD being significantly higher (72.3%) than that in previous studies [16][17][18][19] might be explained in terms of the importance of nonjoint factors that cannot be identified with SJD blocks. 9 The prevalence of SJD in this study was 33.3%. SJD was located on the right in 52.6% of patients and on the left in 47.4%. Madani et al 9 reported involvement on the left in 95.2% of patients with SJD, on both right and left in 2.1% and on the right in 2.7%. Slipman et al 20 reported SJD on the right in 45% of cases, on the left in 35%, and bilateral in 20%.
Fortin et al 22 reported the need to establish a pain chart in the diagnosis of SJD and showed on the basis of that chart that pain in patients with SJD was generally unilateral in the posterior superior iliac spine region. Pain diffusion map data are consistent with those of several previous clinical studies. 15,19,[23][24][25][26][27][28][29] In terms of pain distribution, van der Wurff et al 15 reported that in SJD the patient directly indicated the painful joint. Weksler et al 21 concluded that pain in 50 cases of lumbar pain and LDH diagnosed with SJD was distributed at 36% in the hip, inguinal in 26%, in the knee in 14%, in the calf in 14%, and in the foot in 10%.
Slipman et al 30 reported hip pain in 94% of patients with SJD, lumbar pain in 72%, lower extremity pain in 50%, leg pain descending below the knee in 28%, and pain in the foot in 1%.
Analysis of pain location in the patients in our study population revealed that subjects most commonly presented with lumbar-leg pain, if no discrimination is made between right and left sides, and with lumbar and lumbar-left leg pain if right and left sides are differentiated. When the SJD and non-SJD groups were analyzed separately, greater lumbarleg pain was observed in both groups than lumbar pain. However, when right and left side pain location differentiation was performed, right or left lumbar-leg pain was greater than lumbar pain in the SJD group, while in the non-SJD group lumber pain was greater than right or left lumbarleg pain.
Evaluation of pain in the hip and gluteal region revealed no hip pain in 28.6% of patients, while in subjects with hip pain, levels of right and left side pain was similar, but slightly higher on the left. In the SJD group, the pain was present in 73.3% of patients, and pain in the left hip and the gluteal region was more prevalent than pain on the right. In the non-SJD group, the distributions of patients with no hip pain and of patients with pain in the right or left hip were approximately equal.
Evaluation of the BDI results in the patient population showed that subjects without depression constituted the majority in both groups. In the SJD group, the presence of moderate and severe depression was significantly higher, while in the non-SJD group, the non-depression group was significantly higher. These findings show that the prevalence of depression was higher in the SJD group and that such patients should be particularly evaluated in terms of depression.
Since our study evaluated patients with LDH, which directly concerns the neural stems, and considering the proximity of the SIJ to neural structures, patients were also evaluated using LANSS for neuropathic pain. The findings revealed neuropathic pain in 39.7% of the SJD group and in 21.2% of the non-SJD group. On the basis of these data, a significant difference was determined the prevalence of neuropathic pain was greater in the group with SJD. In addition, evaluation of sensitivity along the sciatic nerve (Valleix points) revealed 46.2% positivity in the SJD group and 26.3% positivity in the non-SJD group. On the basis of these findings, the presence of sensitivity along the sciatic nerve (Valleix points) was significantly higher in the group with SJD. In the literature, the presence of sensitivity and neuropathic pain along the sciatic nerve is thought to be associated with neighboring piriformis muscle spasm and sciatic nerve irritation secondary to SJD pathologies. 31 Cheng and Ferrante 32 compared patients diagnosed with lumbar radiculopathy and patients with SJD, assessing McGill pain scores, visual analog scores, and short form-36 quality of life scales. They concluded that there was no statistically significant difference between the patients with SJD and those with lumbar radiculopathy. The HAQ was used to evaluate the quality of life in our population and in agreement with the literature, statistically significant elevation was determined the group with LDH and SJD, indicating poor quality of life.
Aversion to movement, evaluated using the Tampa Scale for Kinesophobia, was significantly prevalent in the group with SJD, similarly to the prevalence of poor quality of life. Our scan of the literature revealed that the Tampa Scale for Kinesophobia and BDI had not previously been used in studies of patients with SJD. We think that in the light of the determination in this study of the fact that the presence of SJD accompanying LDH causes an increase in the prevalence of both kinesophobia and depression, these two conditions should be assessed separately both in daily practice and in future studies.
There are a number of significant limitations to this study. The inclusion of patients with lumbar pain secondary to LDH may have led to the relation between the prevalence of SJD and other clinical entities being overlooked. In addition, fluoroscopy-guided local anesthesia injection into the SIJ, one of the criteria set out in the diagnosis of SJD by the International Association for the Study of Pain in 1994, was not performed. However, we think that the appropriate patient number in the study population, an upper age limit of 60 being imposed, rheumatological diseases being regarded as an exclusion criterion and patient examinations and all assessments being performed by a single physician being under equivalent conditions for all patients increase the reliability and validity of the data.
In conclusion, SJD is a pathology accompanying disc degeneration at a level of approximately one in three in patients with LDH, and this condition should be considered when planning a conservative treatment protocol for patients with lumbar or lumbar-leg pain. SIJ involvement should be determined using SIJ provocation tests in patients with LDH, particularly when conservative treatment is unsuccessful. In this way, the attention of physicians and surgeons can be diverted from the intervertebral disk to the SIJ for the avoidance of unnecessary lumbar region surgery based on pain indications.

Key Points
One of the many agents leading to lumbar pain is sacroiliac dysfunction, the prevalence of which, based on clinical assessments, is 15% to 30%. The level of sacroiliac joint dysfunction was 33.3% in our research population. In terms of sex distribution, the proportion of women was higher in the group with sacroiliac joint dysfunction. The level of neuropathic pain, the presence of depression and kinesophobia were significantly higher in the group with dysfunction. In addition, functional capacity was worse in the group with sacroiliac joint dysfunction.