[SpinelessWench]

#7115

Hi Dr. Corenman,

This past Thursday, I underwent diagnostic testing for suspicion of SI Joint Dysfunction. All 5 provocative maneuvers on the sacral and pelvic area were positive (with the first 2 maneuvers being the most critical). The exam was actually intolerable at some points. I then underwent a bilateral SI Joint anesthetic injection under fluoroscopy, which after 10 minutes resulted in a 95% resolution of my pain. The orthopedist conducting the procedure also said that the replication of severe pain upon the needle entering the joint (especially when she introduced the dye) was another positive indication of degeneration in the joints. I told her that was just great, but that I’d prefer to not do that again for another 50 years. Or ever.

Until Thursday’s injections, I had been experiencing intractable, chronic pain between 7-10/10. Twenty minutes after the injections, I left the medical center *carrying* my cane, and walking with completely upright posture. Flexion and extension, even with my lumbar instrumentation, was both possible and painless … had there not been a good chance of the police showing up, I would’ve seriously contemplated a celebratory pole dance in the parking deck.. By 11:00 pm that night, the anesthetic dissipated, so I was back to my usual symptoms — but, that was the best 7 hours I’ve had in years.

I’m now scheduled with an orthopedic surgeon who is one of 400 surgeons in the US trained by iFuse to perform the SI Joint fusion implant surgery. He’s done a good number of these, and is highly regarded insofar as successful outcomes. In the meantime, and prior to my surgical consult with him, I had a few questions for you about the iFuse surgery, and I’d really appreciate any input or advice:

QUESTIONS:

1. I need bilateral SI Joint implants. Obviously, I’ll have one side done, recuperate, then have the other done. What is the general recovery time for an iFusion procedure? Partial or non-weight bearing? How long before I could ideally return to the classroom, stand, and lecture for about 4 hours per day? How about driving, household cleaning, and other daily stuff?

2. I’m an avid Harley-Davidson rider. Can patients return to riding a motorcycle? Harleys are notoriously high in vibration… will this be a risk?

3. After bilateral SI implants, how is ROM affected?

4. My right leg is 3/4″ shorter than my left. I’m assuming this is due to the pelvic, lumbar, and sacral ligament complex having to compensate for numerous lumbar fusions. During the iFuse surgery, does the surgeon adjust for this? If the sacrum is subluxed or otherwise out of position, is there a process for realigning those joints prior to fusing them into place? If the sacrum or pelvis is torsed or out of position, will that be corrected in the O.R.?

5. After a bilateral iFuse on a patient with lumbar instrumentation to S-1, what kind of PT, if any, could be recommended to prevent atrophy of the muscle and ligament structures in the lumbosacral and pelvic regions?

The initial recovery protocol is my main concern… I’ve read next-day partial weight-bearing, to partial weight-bearing for 3-6 weeks, and I’ve read non weight-bearing for up to 12 weeks. What’s the truth on this? Will I need someone with me constantly for the first few days, or weeks, or not at all?

Thanks for your help, and time…

S.W., NC

[Donald Corenman, MD, DC]

#7117

The block is a very good indication of the SI joints being the pain generators. It very well may be that the IFuse surgery could be helpful. Don’t think of these in terms of an implantable device (although they are) but in terms of a fusion device that will assist in causing the SI joints to stop moving and generating pain.

The SI joints fibrose when we get older. When young, the motion of the SI joint is about one degree.

Recovery for the IFuse procedure can be from a minimum of eight weeks to sixteen weeks. It depends upon how quickly these devices develop bone ingrowth. There should be no change of ROM noticeable after a solid fusion. Once you have a fusion, you can ride your Harley.

Short legs do not relate to a fusion of the sacroiliac joints as these joints are so rigid that you cannot affect them by the fusion. That is, a surgeon cannot rotate the right SI joint down and the left SI joint up during surgery.

In my opinion, PT is necessary after an SI fusion but not until the fusion is solid.

You should be able to get around with crutches or a walker immediately but you should be living in a one story house. Stairs can be quite challenging. It is surgeon preference for partial weight bearing from six to twelve weeks.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[SpinelessWench]

#7119

Dr. Corenman,

Much appreciated for your quick reply, especially over the weekend.

The majority of the peer-reviewed literature indicates that severe muscle spasms also accompany the other primary symptoms of SIJD. Since the onset of this condition about 12 months ago, I’ve experienced increasingly more intense spasms, especially upon waking first thing in the morning. The spasms are ridiculously bad in and of themselves, but also leave me completely unable to roll over — whether lying on my back, or on my side, it’s almost as if my entire sacral region is “locked”. Once I’ve had help out of bed, I’m unable to stand up anywhere *near* straight for at least one hour, and I’m unable to take normal-lengthed strides… I’m guessing those who’ve had this condition, or currently wrestle with it, can completely understand my describing it as, “my hips and low back prevent my legs from stepping any further out than about 6-inches.” If the police are at the door, a tornado is coming, or the house catches on fire, it’ll take me about 4 days to walk eight feet. This improves some throughout the day, but by far, the dysfunction in those joints prevents a normal heel-to-toe gait.

Some follow-up questions:

1. After the surgeries, and given adequate time for healing, will the intense, severe spasms subside? The joints will be stabilized, but will the complex of ligaments, tendons, and muscles also “settle down” after the fusions? Will my ability to walk with a more normal gait improve once the SI dysfunction has been stabilized?

2. I understand your explanation regarding the leg length discrepancy… thank you for addressing that question. I’m considering seeing a physical therapist prior to my surgeries to assess whether any gentle, subtle adjustments can be accomplished. In your opinion, would a PT assessment be beneficial prior to the fusions? My attending surgeon suggested that while PT won’t “fix” the severe degeneration in my SI joints, it might help in simply having the ligament and muscle complexes evaluated and assessed to possibly alleviate some of the leg length discrepancy. Or, am I just eternally condemned to one shorter leg and walking with a limp? You mentioned post-operative PT, which my attending surgeon also stressed upon solid fusions. For a patient with lumbosacral instrumentation to S/1, and with bilateral SI instrumentation, what modalities of physical therapy might be prescribed? Will I be limited in what types of PT I can do? What will be the ultimate goal of my post-operative physical therapy?

3. Just to clarify… Much of what I’ve read regarding SIJD seems to attribute a good degree of the pain to a subluxation of the sacrum, or a “locked sacrum.” If the orthopedic surgeon performing my fusion(s) identifies a misalignment of the sacrum or other lumbosacral structures, would he repair or otherwise adjust these issues during the surgery?

4. I saw an online news article yesterday which addressed the fact that some insurance plans in a few states do not cover the iFuse procedure. Kansas was identified as one… Do more insurance companies than not cover this procedure? I’ve tried to search my insurance policy information online, but I’m unable to find any indication as to whether it’s covered or not. I also searched my insurance company’s medical code guidelines, but don’t see any summaries of what types of arthrodeses are covered. I plan to call Monday. Have you ever run into a situation, or heard of one, in which a patient’s insurance didn’t cover iFuse?

5. If the iFuse procedure isn’t covered by a carrier, are there other similar or just as reliable SI fusion procedures that *are* covered so a patient can have this condition stabilized?

Again, your help has been appreciated. Thank you.

S.W., NC

[Donald Corenman, MD, DC]

#7120

SIJD is not typically associated with severe muscle spasms. If you have significant spasms in bed, the diagnosis of SIJD goes down in the differential list in my opinion. The sacroiliac joint should not be painful when not loaded and spasms typically are associated with other diagnoses (spinal instability and radiculopathy). Of course, your SIJ blocks yielded great relief so I have to assume that this is a real disorder of these joints.

If there is no other pathology that is also present, the fusion of these joints should give you some relief. I see this disorder about one to two times a year (many patients enter my office with this diagnosis but most of them do not have this disorder). SInce my experience with SIJ fusion is more limited, I called a colleague who has performed 70 of these fusions. He reports that he has about a 70% satisfaction rate for this surgery.

If the disorder you suffer from is only that of sacroiliac joint dysfunction, you have a 70% chance to be satisfied with your results. If you have other underlying disorders, the satisfaction rate will be less.

PT is always valuable prior to surgery to increase conditioning and flexibility. Manipulation of the sacroiliac joints should be avoided as these joints deliver painful movements. You do not want to mobilize a painful joint. After all, you are going to consider having these joints fused due to pain.

You really cannot sublux the sacrum as this joint is interlocked by bony ridges and depressions. The sacroiliac joint is also fitted with very tough fibrous attachments.

The IFuse technique is new and many insurance companies are loathe to pay for new procedures. It will depend upon your insurance policy. There are many other techniques but these techniques are probably not as good as the IFuse technology.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

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