SI Joint: A Few Additional Questions

Viewing 3 posts - 1 through 3 (of 3 total)

Author

Posts
SpinelessWench
Member

October 15, 2012 at 2:30 pm

Post count: 38

#7167

Dr. Corenman,

I have a surgical consult this coming Thursday with an ‘iFuse System’ orthopedic specialist, and look forward to some sort of resolution soon. Last week, my SI joint anesthetic injections provided 100% relief for approximately 3 hours, and my pain was replicated in all five clinical maneuvers of the joints. In the meantime, I had a few more general questions regarding some symptoms, as well as modalities of PT that may, or may not be, recommended before or after my procedure(s):

1. One of my more significantly painful symptoms is the inability to lie completely flat on my back for any length of time. For instance, during my recent clinical exam, which involved undergoing the 5 diagnostic provocative SI maneuvers, I was asked to lie supine on the exam table. As soon as I lie completely flat and attempt to fully relax or “un-tense” my lumbar and pelvic regions, my sacral area and low back literally “lock up”… By this, I mean that I’m completely unable to roll myself back over, and if asked to raise my leg off the table (straight-leg raise from the hip), the pain is excruciating and is localized to the areas just right and left of where the top of the sacrum begins and L-5 ends. It then migrates through both hips, but does not feel like the radiculopathy experienced by, say, a ruptured disk (the pain is more of an intense stabbing pain rather than burning or tingling, etc.). Your thoughts on this?

2. My lumbar spine is fused from L3 to S1.. I also have a significant discrepancy in leg length, with my right leg being over 3/4-inch shorter than my left. In patients who’ve been fused to this level, are there modes of PT or gentle adjustments that can correct this discrepancy? Will an SI fusion prevent any efforts at correcting this in the future? Can you please explain how leg length discrepancies are adjusted?

3. Once my SI joints are fused, what modalities of PT will I be able to tolerate? Since the purpose of lumbar or SI fusions is to immobilize those areas, are there any adjustments or manipulations that can be done without causing damage or irritating those fused areas?

4. Some of the orthopedic peer-reviewed literature suggests that SIJD can be attributed to misaligned or otherwise “torsed” pelvic structures, and / or stretched or abnormal ligament and tendon positions. Can these be corrected or adjusted prior to an SI joint fusion? If the supportive network of ligaments and tendons is out of alignment, won’t this defeat the purpose of stabilizing the joint(s)? If those structures aren’t properly realigned before surgery (via PT or chiropractic manipulation), couldn’t this just continue the pain and postural problems?

5. Finally, I recall you stating that the sacrum can’t actually be displaced. I’ve seen some literature in PT journals that speak to the issue of the sacrum being subluxed, or otherwise “popped out of place”… Can you expound on this a bit to clarify what they’re referring to?

Thank you so much, as always.

S.W., NC

Donald Corenman, MD, DC
Moderator

October 17, 2012 at 2:56 am

Post count: 8660

#7171

“Locking up of the lumbar spine” while lying flat on the back could be caused by the SIJ, the hip joints or by the lower back.

A problem you face is the fusion of L3-S1 with a short leg on one side. Normally, the lumbar spine compensates for a short leg. However, with a fusion to L3, if the fusion is perfectly straight, compensation cannot take place. If the fusion is somewhat curved to the side of the long leg, then the pelvis is balanced with the spine.

The sacroiliac joint cannot compensate for a short leg. There is only one degree of motion in a normal sacroiliac joint which is far too little to correct the imbalance of a short leg. If the leg is short and symptomatic (most short legs are not symptomatic), then a heel lift that is 1/2 the height difference needs to be placed in the shoe of the short leg.

Once the SI joint is fused, manipulation of the joint will be useless. The purpose of fusion is to stop motion. Now the muscles can still be addressed through therapeutic muscle work but that is different than joint manipulation.

The “alignment” of the joint with fusion does not really matter as the joint can only move about one degree. It is the movement of the joint that is painful. The fusion will stop this motion and should relieve the pain. Remember that my colleague found a 70% success rate for this procedure.

The sacrum can be overly mobile (hypermobile) to cause pain. As a chiropractor, I have manipulated thousands of these joints and do get a “release” pop which does indicate the joints have some mobility. Even though it appears that you have sacroiliac syndrome, I will say that sacroiliac syndrome is vastly over-diagnosed in general.

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
Member

October 17, 2012 at 8:47 am

Post count: 38

#7174

Hi Dr. Corenman,

Thank you so much for your reply regarding my earlier questions.. I have one additional question that relates to the positional “locking up” of the lumbosacral region and / or hip joints..

Given your extensive experience in both chiropractic and surgical treatment of the spine, can you please explain how, and why, the lumbar spine / SI / hip structures actually “lock up”, thus preventing a patient from rolling over? I use the term “locking up” because I can’t figure out a better way of describing the sensation … Is this actually what’s happening? If so, what’s occurring in the lumbosacral area that causes a person’s low back to seize up like this? In my particular situation, it occurs when I lie flat on my back (either in bed, or on an exam table) and completely relax my hips and low back. Seconds later, I start looking like a distressed insect that can’t flip itself back over.

I guess I’m just trying to figure out whether this is musculoskeletal (acute spasms, etc.), strictly orthopedic, or a combination of the two? Thanks so much for taking the time to clarify..

S.W., NC
Author

Posts

Viewing 3 posts - 1 through 3 (of 3 total)

You must be logged in to reply to this topic.

Donald Corenman, MD, DC

Average rating:

81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

Submit your review
First Name, Last Initial:
Email:
Review Title:
Rating:	1 2 3 4 5
Review:

Check this box to confirm you are human.
Submit Cancel