SpinelessWenchMemberOctober 15, 2012 at 2:30 pmPost count: 38
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., NCDonald Corenman, MD, DCModeratorOctober 17, 2012 at 2:56 amPost count: 8465
“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. CorenmanSpinelessWenchMemberOctober 17, 2012 at 8:47 amPost count: 38
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..
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