Marc Darrow MD,JD

Patients will often come into our office with an MRI, low back pain and a diagnosis of sacroiliac joint dysfunction. They are in our office because they may have been told that they should consider a surgical recommendation to spinal fusion. For many of these people, the MRI was the confirmation that their surgeon needed to go ahead with the surgical recommendation. For many patients, this may have been the same doctor who had taken them through a course of conservative treatments. These treatments may have included long bouts with anti-inflammatory medications, back braces, physical therapy, and cortisone injections.

All of these treatments did not help them. Why?

One of my patients is a woman in her early seventies. She presented with her husband after not one, but two sacral fusions, one on the right and one on the left. You might be appalled if you saw the amount of metal that was used to do the fusion. Huge screws, too. Because of continued pain on the left side, her surgeon wanted her to redo the left fusion. She came to me for advice.

During examination, I pressed on her gluteus muscles, away from the fusion site and she winced in pain. I immediately told her that her pain was not coming from the sacroiliac joint, and that she simply had a strain where the muscles were attached to the pelvis. I asked her if the surgeon actually examined this area and to my astonishment, her answer was, “no”. She and her husband looked like deer in headlights, confused as to what I was telling them. How could her pain not be related to the joint, and the subsequent fusion, when she had surgery for that issue. I told them I was sorry, but the surgery never needed to be done if this is where the pain had been. It took about a half hour for them to digest this information, and we proceeded to inject PRP though the muscles down to the bone interface. We call that the enthesis.

Sacroiliac joint dysfunction patients do not get treatment relief because they do not have sacroiliac joint dysfunction

A recent study in the Clinical Spine Journal (1) offers the suggestion that sacroiliac joint dysfunction patients do not get treatment relief because they do not have sacroiliac joint dysfunction. This may be somewhat difficult for you to believe because all along you have been told you have SI joint pain.

Look at what the doctors of this study reported: Confusion and a lot of it.

A person goes to the doctor for pain in the pelvic / hip / groin lower back region.

The currently reported incidence of primary sacroiliac joint ranges from 15% to 30%. (In other words 15% to 30% of these people will get a diagnosis of sacroiliac joint dysfunction.)
When they do not get a diagnosis of sacroiliac joint dysfunction, they may get a diagnosis of:

  • pain generated from the lumbar spine, (degenerative disc disease),
  • sacroiliac joint dysfunction, (but not as the primary cause of their pain and therefore not the primary target)
  • and the hip joint.

When these researchers re-examined these patients, with the goal of proving or disproving sacroiliac joint as the primary cause, what they found after a complete diagnostic workup was:

  • 112 (90%) had lumbar spine pain,
  • 5 (4%) had hip pain,
  • 4 (3%) had primary sacroiliac joint dysfunction pain, and
  • 3 (3%) had an undetermined source of pain upon initial diagnosis.

Patients did not have sacroiliac joint dysfunction as the primary source of their pain. In fact the sacroiliac joint was found to be a rare pain generator (3%-6%) in patients complaining of more than 50% sacroiliac joint region related pain. Pain in the sacroiliac joint area is commonly a referral pain from the lumbar spine (88%-90%).

This is why treatments including the use of cortisone will not work in patients with sacroiliac joint dysfunction. The wrong area is getting treated OR the right areas are not getting treated. The right areas may include:

  • The axial low back,
  • buttock/leg region
  • groin/anterior thigh region

The challenges of diagnosis and management of Sacroiliac joint dysfunction

A October 2021 paper (2) discusses the problem of Sacroiliac joint dysfunction being “often overlooked or under diagnosed and subsequently under treated.”

“Sacroiliac joint (SIJ) pain is one of the most common causes of low back pain, accounting for 15 to 30% of all cases. Although Sacroiliac joint dysfunction accounts for a large portion of chronic low back pain prevalence, it is often overlooked or under diagnosed and subsequently under treated.”

Next the authors offered guidelines to their fellow practitioners:

“The practitioner must focus on the history, location of pain, observed gait pattern, and perform key points of the physical exam including sacroiliac provocative maneuvers. If the patient exhibits at least three provocative maneuvers (movements that cause pain in the SI joint) then the Sacroiliac joint may be considered as a possible source of pain. Additionally, a thorough review of the imaging should be performed to rule out other etiologies of low back pain. In the absence of any pathognomonic tests or examination findings, diagnostic Sacroiliac joint blocks have evolved as the diagnostic standard.

Conclusion:

“The diagnosis of SIJ pain is a multifaceted process that involves a careful assessment including differentiating other pain generators in the region. This involves careful history taking, appropriate physical examination including provocative maneuvers and diagnostic injections. Once the diagnosis is confirmed, long-term solutions may be considered, including recent advances in sacral lateral branch denervation and sacroiliac joint fusion.”

Here the conclusion ended with the possibility of surgical recommendation.

This is a study from December 2020. The doctors in this study use a much stronger language to describe the increase in the number of SIJ Fusions

This is a study from December 2020. The doctors in this study use a much stronger language to describe the overreliance of SIJ Fusion. The paper was published in the Journal of pain research. (3)

“The sacroiliac joint has been estimated to contribute to pain in as much as 38% of cases of lower back pain. There are no clear diagnostic or treatment pathways. . . “

Here are some of the points provided by this study:

  • “Proposed criteria for diagnosis of sacroiliac joint dysfunction can include pain in the area of the sacroiliac joint, reproducible pain with provocative maneuvers, and pain relief with a local anesthetic injection into the SIJ.
  • Conventional non-surgical therapies such as medications, physical therapy, radiofrequency denervation, and direct SI joint injections may have some limited durability in therapeutic benefit. Surgical fixation can be by a lateral or posterior/posterior oblique approach with the literature supporting minimally invasive options for improving pain and function and maintaining a low adverse event profile.
  • SIJ pain is felt to be an underdiagnosed and undertreated element of low back pain. There is an emerging disconnect between the growing incidence of diagnosed SI pathology and underwhelming treatment efficacy of medical treatment. This has led to an increase in SI joint fixation (fusions).”

SI Fusion is probably better than traditional conservatize care treatments

An August 2022 study (18) found that: “Among patients meeting diagnostic criteria for SI joint pain and who have not responded to conservative care, minimally invasive SI joint fusion is probably more effective than conservative management for reducing pain and opioid use and improving physical function and Quality of Life.” Also noted from these researchers is that side effects and complications “appear to be higher for minimally invasive SI joint fusion than conservative management through 6 months. Based on evidence from uncontrolled studies, serious adverse effects from minimally invasive SI joint fusion may be higher in usual practice compared to what is reported in trials.”

Nerve blocks do not work for some patients with sacroiliac joint pain. The reason? The patient does not have primary sacroiliac joint dysfunction

I will often receive an email that will describe to me cortisone injections or nerve blocks that did not help the e-mailer with their low back pain. As we have seen in many patients, the hip-spine-sacroiliac joint complex is a challenging one to differentiate where the pain is coming from. Injections into the hip may not provide relief if the pain is in the sacroiliac joint region. Injections into the sacroiliac joint region may not work if the pain is from the hip or groin.

A study in the medical journal Pain Physician (4) looked at various treatment recommendations for patients suffering from sacroiliac joint pain. These treatments incldued burning the nrves, freezing the nerves, applying cortisone and Botox.

The researchers found the following:

  • “The evidence for cooled radiofrequency neurotomy (freezing the nerve) in managing sacroiliac joint pain is fair.
  • The evidence for effectiveness of intraarticular steroid injections is poor.
  • The evidence for periarticular injections of local anesthetic and steroid or botulinum (Botox) toxin is poor.
  • The evidence for effectiveness of conventional radiofrequency neurotomy (burning the nerves) is poor.
  • The evidence for pulsed radiofrequency is poor.”

Why did they find so many poor results? The chances are the patient did not have sacroiliac joint dysfunction.

Let’s look at another study. This time from June 2017 in the journal Medicine.(5) In this research, doctors from Korea investigated the degree of pain reduction following intra-articular pulsed radiofrequency stimulation of the sacroiliac joint in patients with chronic sacroiliac joint pain that had not responded to corticosteroid injection.

These research too found disappointing results:

  • Intra-articular pulsed radiofrequency stimulation of the sacroiliac joint was not successful in most patients (80% of all patients). Based on our results, we cannot recommend this procedure to patients with chronic sacroiliac joint pain that was unresponsive to corticosteroid injection.

Here is where treatments that are not helping the sacroiliac joint can become dangerous. How so? Because they will lead to a surgery that will not work either.

This was also suggested by a late 2019 study.(6)

  • The rationale for SI joint fusion is to relieve pain created by the movement of a joint through the removal of movement by arthrodesis (fusion) of the joint space. Only few comparative studies of percutaneous SI joint fusion and denervation have been reported, and they had limited clinical evidence.

Neurosurgeons suggest that treatment for sacroiliac joint pain should not include spinal fusion.

This is the title of a paper published in the journal Neurosurgery clinics of North America : “Sacroiliac Fusion: Another “Magic Bullet” Destined for Disrepute.”(7)

This is what the paper says:

“Pain related to joint dysfunction can be treated with joint fusion; this is a long-standing principle of musculoskeletal surgery. However, pain arising from the sacroiliac joint is difficult to diagnose. . . Evidence establishing (successful) outcomes (of spinal fusion) is misleading because of vague diagnostic criteria, flawed methodology, bias, and limited follow-up. Because of nonstandardized indications and historically inferior reconstruction techniques, SI joint fusion should be considered unproven. The indications and procedure in their present form are unlikely to stand up to close scrutiny or weather the test of time.”

There are many people who may disagree that fusion will not help sacroiliac joint pain. Many people do in fact do get pain relief and benefit from surgery. I don;t see this people in my office. I see the people who did not do well after surgery. A December 2019 still asked “What do we know about the biomechanics of the sacroiliac joint and of sacropelvic fixation?” (8)

Here is an explanation of why this surgery may work for some, but may not work for others. “The sacroiliac joint is characterized by a large variability of shape and ranges of motion among individuals. Although the ligament network and the anatomical features strongly limit the joint movements, sacroiliac displacements and rotations are not negligible. 

Currently available treatments for sacroiliac joint dysfunction include physical therapy, steroid injections, Radio-frequency ablation of specific neural structures, and open or minimally invasive SIJ fusion. Several studies reported the clinical outcomes of the different techniques and investigated the biomechanical stability of the relative construct (the construct being the fusion itself), but the effect of sacropelvic fixation techniques on the joint flexibility and on the stress generated into the bone is still unknown. In our opinion, more biomechanical analyses on the behavior of the sacroiliac joint may be performed in order to better predict the risk of failure or instability of the joint.”

The challenge of sacroiliac joint dysfunction may be a ligament problem.

In the study we just examined, the surgeons wrote there are many factors that would effect the outcome including finding the patient’s true source of pain. Let’s look at a relatively unexplored source of pain. The spinal ligaments.

Doctors at the Mayo Clinic (9) have published a paper entitled: Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. In this paper the Mayo Clinic researchers wanted to make a clear definition between two problems affecting low back pain patients.

  • First, that pain could be coming from the discs.
  • Second that pain could be coming from the spinal ligaments.

The Mayo researchers suggest that recognizing how the spine moves is essential for distinguishing between the many different types of spinal disorders, and a diagnosis which may ultimately, and erroneously lead to back surgery.

  • If a patient has instability, excessive movement, and decreased stiffness, doctors should examine for ligament damage.
  • If the opposite, less movement, more stiffness, the doctor should look for disc disease.

This information can help determine the true cause of a patient’s sacroiliac joint dysfunction. When nothing is working, look at the ligaments. How do you look at the ligaments? Through physical examination.

A diagnosis which may ultimately, and erroneously lead to back surgery.

In our own published peer-review research appearing in the July 2018 in the Biomedical Journal of Scientific & Technical Research (BJSTR), July 2018, (10) we examined treating spinal ligaments with low back pain. Below is an explanatory adaption of the introductory paragraph of that study. It gives a good understanding of the importance of understanding that we should be looking at the ligament problems in back pain.

    • An Orthopaedic Knowledge Update from the American Academy of Orthopedic Surgeons tells its surgeon members that muscle strains, ligament sprains, and muscle contusions account for up to 97% of low back pain in the adult population (11)
    • Additionally, researchers wrote in the Spine Journal that spinal ligaments are often neglected compared to other pathology that account for low back pain (12). This could be due to the over-reliance of MRIs to guide physicians to correct diagnoses. They write: The influence of the posterior pelvic ring ligaments on pelvic stability is poorly understood. Low back pain and sacroiliac joint pain are described being related to these ligaments.When these ligaments are damaged or weakened, they serve as generators of low back pain.

Our treatment options

We offer stem cell therapy and Platelet Rich Plasma Therapy

Darrow Stem Cell Institute research article published in the Biomedical Journal of Scientific & Technical Research (BJSTR), July 2018. This article presents highlighted portions of that research.

You can read about 4 patient’s cases studies here:

Study’s findings: This is the first reported study treating low back with bone marrow aspirate (BMC) stem cell injections to the ligaments, fascia, and muscles surrounding the lumbar spine. It is promising that at one-year follow-up, 100% of patients in this study experienced a decrease in resting and active pain in addition to performing daily activities with less difficulty.

  • All four patients experienced sustained or increased improvement at annual follow-up compared to short-term follow-up.
  • On average, patients reported:
    • 80% decrease in resting pain,
    • 78% decrease in active pain,
    • and a 41% increase in functionality score.
  • Additionally, patients reported a mean 80% total overall improvement following
    treatment.
  • The two patients who considered surgery prior to BMC treatment no longer felt the need for it.
  • These results provide evidence that appropriately chosen patients with low back pain may find relief with BMC injections.

Platelet Rich Plasma vs cortisone for Sacroiliac Joint Injection

PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration.

The platelets contain healing agents, or “growth factors.” Let’s look at some of the growth factors and what they do:

  • Platelet-derived growth factor (PDGF) is a protein that helps control cell growth and division, especially blood vessels. When more blood (and the oxygen it carries) is delivered to the site of a wound, there is more healing.
  • Transforming growth factor beta (or TGF-β) is a polypeptide and is important in tissue regeneration.
  • Insulin-like growth factors are signaling agents. They help change the environment of the damaged joint from diseased to healing by “signaling” the immune system to start rebuilding tissue.
  • Vascular endothelial growth factor (VEGF) is an important protein that brings healing oxygen to damaged tissue where blood circulation might be damaged or inadequate.
  • Epidermal growth factor plays a key role in tissue repair mechanisms.

A study published in Pain practice : the official journal of World Institute of Pain (13) compared the effectiveness of these two injection treatments. These are the paper’s main points:

  • “Despite widespread use of steroids to treat sacroiliac joint (SIJ) pain, their duration of pain reduction is short. Platelet-rich plasma (PRP) can potentially enhance tissue healing and may have a longer-lasting effect on pain.
  • Forty patients with chronic low back pain diagnosed with SIJ pathology were randomly allocated into 2 groups.
    • Group S received methylprednisolone
    • Group P received PRP
  • After treatment:
    • Intensity of pain was significantly lower in the PRP group at 6 weeks  and 3 months as compared to the steroid group.
    • The efficacy of steroid injection was reduced to only 25% at 3 months while it was 90% in the PRP group.
    • A strong association was observed in patients receiving PRP and showing a reduction of pain of more than 50% from baseline. Pain and function scores favored the PRP treatment as well. In the steroid group pain reduction and function improvements were seen up until 4 weeks after treatment and then the effectiveness declined. While the PRP group saw pain and function scores steadily increase at the three month marker.

Conclusion: “The intra-articular PRP injection is an effective treatment modality in low back pain involving SIJ.”

Fluoroscopically-guided intra-articular injection of steroid or platelet rich plasma injection

Giving another opinion is a November 2021 (14) paper. Here doctors compared outcomes with a fluoroscopically-guided intra-articular injection of steroid or platelet rich plasma injection. Follow-up was at 1-month, 3 months, and 6-months.

Results: “At one, three, and six months, both groups improved, however subjects who received steroid injections reported lower pain scores than subjects who received platelet rich plasma. Using categorical data, we observed significantly more responders (defined as pain scores which improved by 50% or more from baseline) at one and three months in the group that received steroids compared to the group that received platelet rich plasma. Conclusion: While both groups showed improvements in pain and function, the steroid group had significantly greater response and significantly more responders than the PRP group. “

In our office, we do not consider PRP a one shot treatment. Often the treatment requires a peppering of numerous PRP injections into the back and more than one treatment occasion. Our process is described below.

A case history from the US military – PRP treatment for a soldier’s sacroiliac joint pain who was taking high-dose opioids

A case history was given in August 2020 in the journal Military medicine (15) of a soldier with sacroiliac joint pain. Here is a summary of this case:

“Back pain and its associated complications are of increasing importance among military members. The sacroiliac joint is a common source of chronic low back pain and functional disability. Many patients suffering from chronic low back pain utilize opioids to help control their symptoms. Platelet-rich plasma (PRP) has been used extensively to treat pain emanating from many different musculoskeletal origins; however, its use in the sacroiliac joint has been studied only on a limited basis.

The patient in this case report presented with chronic low back pain localized to the sacroiliac joint and subsequent functional disability managed with high-dose opioids. After failure of traditional treatments, she was given an ultrasound-guided PRP injection of the sacroiliac joint which drastically decreased her pain and disability and eventually allowed for complete opioid cessation. Her symptom relief continued one year after the injection. This case demonstrates the potential of ultrasound-guided PRP injections as a long-term treatment for chronic low back pain caused by SIJ dysfunction in military service members, which can also aid in the weaning of chronic opioid use.”

An August 2020 study (16) investigated the efficacy of ultrasound-guided platelet-rich plasma in reducing sacroiliac joint disability and pain. in 50 patients diagnosed  with low back pain secondary to sacroiliac joint dysfunction.

“Platelet-rich plasma was injected into the sacroiliac joint under ultrasound guidance. Oswestry Disability Index and Numeric Rating Scale were measured at baseline, 2 weeks, 4 weeks, 3 months, and 6 months after injection.

  • Results: The mean reduction in Oswestry Disability Index and Numeric Rating Scale scores were significantly reduced at 6 months after injection compared with baseline values. All timeframes showed significant mean reduction compared with baseline, but overall improvement tapers off after 4 weeks with no statistically significant reduction from 4 weeks to 3 months or three to six months.
  • Conclusions: Ultrasound-guided platelet-rich plasma injections in the sacroiliac joint are effective at reducing disability and pain with most improvement seen within 4 weeks after injection and with sustained reduction at 6 months.”

We usually ask the patients to return for more treatment if initial results were good and then being to taper off. In our years of experience and as documented in our medical research, we usually find multiple PRP treatments to be more effective than a single treatment. But, people do vary, some may derive benefit from one treatment.

A 2019 study in the journal Pain Physician (17)  posted the following guideline recommendations from the American Society of Interventional Pain Physicians (ASIPP) Guidelines.

“Based on the evidence. . . there is Level III evidence for intradiscal injections of PRP and MSCs, whereas the evidence is considered Level IV for lumbar facet joint, lumbar epidural, and sacroiliac joint injections of PRP, (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis.

Regenerative therapy should be provided to patients following diagnostic evidence of a need for biologic therapy, following a thorough discussion of the patient’s needs and expectations, after properly educating the patient on the use and administration of biologics and in full light of the patient’s medical history.

Regenerative therapy may be provided independently or in conjunction with other modalities of treatment including a structured exercise program, physical therapy, behavioral therapy, and along with the appropriate conventional medical therapy as necessary. Appropriate precautions should be taken into consideration and followed prior to performing biologic therapy.”

Please see our research articles:

Platelet Rich Plasma therapy for chronic low back pain

Four case studies of low back pain treated with stem cell therapy

Do you have questions? Ask Dr. Darrow

Marc Darrow, MD., JD. is the medical director and founder of the Darrow Stem Cell Institute in Los Angeles, California. With over 23 years experience in regenerative medicine techniques and the treatment of thousands of patients, Dr. Darrow is considered a leading pioneer in the non-surgical treatment of degenerative Musculoskeletal Disorders and sports related injuries. Dr. Darrow has co-authored and continues to co-author leading edge medical research including the use of bone marrow derived stem cell therapy for shoulder, hip, knee and spinal disorders.

 


A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
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PHONE: (800) 300-9300 or 310-231-7000

References:

1 DePhillipo NN, Corenman DS, Strauch EL, Zalepa LK. Sacroiliac Pain: Structural Causes of Pain Referring to the SI Joint Region. Clinical spine surgery. 2018 Oct.
2 Buchanan P, Vodapally S, Lee DW, Hagedorn JM, Bovinet C, Strand N, Sayed D, Deer T. Successful Diagnosis of Sacroiliac Joint Dysfunction. Journal of Pain Research. 2021;14:3135.
3 Falowski S, Sayed D, Pope J, Patterson D, Fishman M, Gupta M, Mehta P. A Review and Algorithm in the Diagnosis and Treatment of Sacroiliac Joint Pain. Journal of Pain Research. 2020;13:3337.
4 Hansen H, Manchikanti L, Simopoulos TT, et al. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician. 2012 May;15(3):E247-78.
5 Chang MC, Ahn SH. The effect of intra-articular stimulation by pulsed radiofrequency on chronic sacroiliac joint pain refractory to intra-articular corticosteroid injection: A retrospective study. Medicine. 2017 Jun;96(26).
6 Chuang CW, Hung SK, Pan PT, Kao MC. Diagnosis and interventional pain management options for sacroiliac joint pain. Ci Ji Yi Xue Za Zhi. 2019 Sep 16;31(4):207-210. doi: 10.4103/tcmj.tcmj_54_19. PMID: 31867247; PMCID: PMC6905244.
7 Bina RW, Hurlbert RJ. Sacroiliac Fusion: Another “Magic Bullet” Destined for Disrepute. Neurosurgery Clinics of North America. 2017 Jul 31;28(3):313-20.
8 Casaroli G, Bassani T, Brayda-Bruno M, Luca A, Galbusera F. What do we know about the biomechanics of the sacroiliac joint and of sacropelvic fixation? A literature review. Medical Engineering & Physics. 2019 Dec 19.
9 Ellingson AM, Shaw MN, Giambini H, An KN. Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. Comput Methods Biomech Biomed Engin. 2016;19(9):1009-18. doi: 10.1080/10255842.2015.1088524. Epub 2015 Sep 24. PMID: 26404463; PMCID: PMC4808500.
10 Marc Darrow, Brent Shaw BS. Treatment of Lower Back Pain with Bone Marrow Concentrate. Biomed J Sci&Tech Res 7(2)-2018. BJSTR. MS.ID.001461. DOI: 10.26717/ BJSTR.2018.07.001461. 5/
11 An HS, Jenis LG, Vaccaro AR (1999) Adult spine trauma. In Beaty JH (Eds.). Orthopaedic Knowledge Update 6. Rosemont, IL: American Academy of Orthopedic Surgeons pp. 653-671
12 Hammer N, Steinke H, Lingslebe U, Bechmann I, Josten C, Slowik V, Böhme J. Ligamentous influence in pelvic load distribution. The Spine Journal. 2013 Oct 1;13(10):1321-30.
13 Singla V, Batra YK, Bharti N, Goni VG, Marwaha N. Steroid vs. platelet‐rich plasma in ultrasound‐guided sacroiliac joint injection for chronic low back pain. Pain Practice. 2017 Jul;17(6):782-91.
14 Chen AS, Solberg J, Smith C, Chi M, Lowder R, Christolias G, Singh JR. Intraarticular Platelet Rich Plasma vs Corticosteroid Injections for Sacroiliac Joint Pain—a Double Blinded, Randomized Clinical Trial. Pain Medicine. 2021 Nov 24.
15 Broadhead DY, Douglas HE, Bezjian Wallace LM, Wallace PJ, Tamura S, Morgan KC, Hemler DE. Use of Ultrasound-Guided Platelet-Rich Plasma Injection of the Sacroiliac Joint as a Treatment for Chronic Low Back Pain. Military medicine. 2020 Jul;185(7-8):e1312-7.
16 Wallace P, Wallace LB, Tamura S, Prochnio K, Morgan K, Hemler D. Effectiveness of ultrasound-guided platelet-rich plasma injections in relieving sacroiliac joint dysfunction. American journal of physical medicine & rehabilitation. 2020 Aug 1;99(8):689-93.
17 Navani A, Manchikanti L, Albers SL, Latchaw RE, Sanapati J, Kaye AD, Atluri S, Jordan S, Gupta A, Cedeno D, Vallejo A. Responsible, Safe, and Effective Use of Biologics in the Management of Low Back Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain physician. 2019 Jan 1;22(1):S1-74. 3519
18 Chang E, Rains C, Ali R, Wines RC, Kahwati LC. Minimally invasive sacroiliac joint fusion for chronic sacroiliac joint pain: a systematic review. The Spine Journal. 2022 Jan 10.

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