[SpinelessWench]

#6989

Dear Dr. Corenman,

Given the less-than-ethical treatment I received by a new orthopedic surgeon last month (regarding presumed severe bilateral foraminal stenosis in my previously fused lumbar spine), I elected to contact my prior neurosurgeon to get his opinion and assessment of other potential causes for my severe low lumbar pain, groin-to-extremity pain which stops at the anterolateral knee / calf, and other specific symptoms. He listened carefully and intently, then afterward, stated, “I am over 90% sure, just from your detailed description of symptoms, distribution and intensity of pain, and your issues with neurogenic claudication, that I know what this may be.” His working theory is based upon several reliable and valid orthopedic clinical studies whose samples consisted of patients with symptoms consistent with Sacroiliac Joint Degeneration & Dysfunction. In one study, 75% of patients whose histories included one or more lumbar fusions developed symptoms identical to mine; nearly all were definitively diagnosed after the implementation of two diagnostic tests. The first was the SI Joint Injection to assess either significant pain relief, or the complete eradication of pain within 10-15 minutes of the injection.

The second diagnostic tool is the subject of my question to you. Recent medical journals and other similar sources have mentioned a rather new form of diagnostic imaging known as SPECT / CT Imaging. Traditional X-rays, MRI imaging, and CT scanning typically have not been effective in identifying degeneration, arthrosis, or abnormalities in the SI Joint — articles suggest that patients would present with very specific symptoms (identical to mine), yet their imaging results from traditional modalities yielded no discernible disease of that joint, and patients just like me were sent out the door with catch-all, vague diagnoses such as Failed Back Surgery Syndrome. Thus, intra-articular injections, until recently, have been the only somewhat reliable method for diagnosing SIJD.

First, can you tell me as to whether most major medical facilities now have SPECT / CT, and how “new” this imaging option is?

Second, what differentiates traditional Computerized Tomography machines from SPECT / CT? Are the machine designs basically similar, or are there differences?

Third, what is imaging like using SPECT / CT? Does it yield images in 3-D, or are the images clearer?

Finally, why is SPECT / CT imaging capable of detecting SI Joint Dysfunction as opposed to standard MRI, CT, and X-rays, whose images rarely reveal anomalies in the SI Joint?

As I mentioned above, my neurosurgeon is cautiously optimistic that my symptoms are correlated with Sacroiliac Joint Dysfunction — if he calls this week and indicates that the SI Joint is the likely instigator, I’ll request imaging via SPECT / CT, along with the injection that I’m sure he’ll order. My next step will obviously be to locate a facility with this type of machine.

Thanks, as always, for your time.

S.W., NC

[Donald Corenman, MD, DC]

#6993

The SPECT scan is an older test (bone scan) that involves an injected radiographic tracer and a scan like a CT scan (SPECT= single photon emission computed tomography). The technetium 99 radioisotope injected accumulates in bone with high turnover rate. This would be bone under stress (osteoarthritis or tumor).

Yes, the SPECT scan will help to diagnose sacroiliac disorders to some extent but in my opinion, this test has been supplanted by the MRI of this joint with STIR sequences. There is no radiation exposure with an MRI and the sequences yield more information than the SPECT scan will.

Be careful with the sacroiliac disorder diagnosis. This syndrome does occur but it is relatively rare and over-diagnosed in my opinion. I would rule out other potential pain generators, scan the SI joint with MRI, X-ray and CT and then have a positive SI block before this joint is implicated as the cause of your symptoms.

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]

#6997

Dr. Corenman,

I really appreciate your time with this. I think we’re focusing on the SI Joint as the etiology because my spine has been “scanned to death”… While my last MRI did yield probable stenosis at L3/4, there seemed to be this circus of indecision as to whether, A) it was actually there in the image at all, and B) if it were there, a 6th lumbar surgery would likely result in a 3rd fusion extension to T/11, rendering me as about as flexible as a telephone pole. I’m mentally spent from surgeons looking at me with this blank stare, saying, “You’ve had a lot done to your back, so there’s no wonder it hurts. It’s nerve damage… It’s muscle damage… It’s failed this… It’s failed that.” While a small percentage of surgeons sleep well at night having earlier dismissed or blown off a patient in pain, they leave a line of patients in their wake who only needed one surgeon to think outside the box for an answer. It’s absolutely frustrating to the point of controlled anger. I’m sure you’ve treated patients who are at the ends of their proverbial ropes, just like me.

Another reason for perhaps investigating the SI Joint is that my symptoms, according to orthopedic clinical studies and research, are classic. Even down to variables such as the inability to roll over in the morning, to uneven leg length (my right leg is 1/2 inch shorter than my right), being stopped in mid-stride by a severe “catch” in the region of the joint, to the pattern of pain distribution. Per your advice, I recently had my PM anesthesiologist order AP/LAT films with extension and flexion views. Not to sound arrogant, but the radiologist’s reading and impression seemed woefully inadequate. Although the sacral region was ordered for the films, he mentioned nothing in terms of even looking at them, or acknowledging whether the area appeared normal or not. All his reading said, roughly, was “There is evidence of extensive prior surgeries. I see bolts and screws and a wristwatch and a Cracker Jack prize. Disk spaces are narrowed at all levels. I’m going golfing now. The end.” His impression said nothing about instability, pseudoarthrosis, or osteophytes, or the Chupacabra.

The neurosurgeon to whom I sent my records and MRI films should be calling this week with his ideas and theories as to the SI Joint Dysfunction. Obviously, he wanted to see a concise list of my symptoms prior to initiating any treatment or diagnostics. Money is also a factor for me… Although I’m a college professor, I don’t live in the Hollywood Hills (although our students think otherwise)… One advanced diagnostic scan of my SI Joint is more cost-effective for me than three more tests on my lumbar spine. Right now, I’m being “$100’d to death” with out of pocket charges for lumbar MRIs, X-rays, and pre-implant screening procedures for the neurostimulator.

QUESTION: Are neurostimulators indicated for patients with SIJD, should this be my ultimate diagnosis? I’m scheduled for implant within the next three weeks for lumbar-related pain, but am recommending my implant procedure be delayed only until the SIJD is ruled in or out. Is this a good decision?

Just being offered a definitive diagnosis at this point would do a world of good for me. I’m exhausted mentally from being labeled “beyond help”, or as having this nebulous, vague condition of Failed Back Syndrome, when my back may not be the culprit at all… Sometimes patients begin to think that surgeons and doctors are forgetting about being good investigators and seekers of the causes of symptoms. So, thank you for what you do, and again, your reply to my question is appreciated.

S.W., NC

[Donald Corenman, MD, DC]

#6998

Failed back surgery syndrome (FBSS) is a syndrome of many different disorders. The disorders can be separated into failure of fusion (pseudoarthrosis), failure of decompression of the neural elements, instability of a segment or segments, surgery for the wrong diagnosis and finally chronic nerve injury which includes chronic radiculopathy (injury to one nerve root) and arachnoiditis (see website for explanation).

Sacroiliac disorders do exist and do have more association with a prior lumbar fusion (normally of more than three motion segments or four vertebra). However pain in the region of the sacroiliac joint is typically not associated with sacroiliac syndrome. This area is the most common referral location for radiculopathy (nerve root disorders) and L4-S1 disc disorders.

A typical work-up for FBSS starts with an MRI with gadolinium, a CT scan, X-rays including flexion and extension and a thorough physical examination. After that, a differential diagnosis is formulated. Provocative tests (discograms) or anesthetic tests are then performed (SNRB, epidural steroid injections, facet blocks, SI blocks). An EMG might be required if there is thought of nerve injury or peripheral neuropathy is suspected.

All the results are correlated and a diagnosis is formulated. The problem is surgically fixed if this disorder is a decompression problem or a failure of fusion. A spinal cord or peripheral nerve stimulator is used if there is arachnoiditis or chronic neuropathy.

By the way, I like that you still have your sense of humor. Believe it or not, that is a very good sign for the chances of recovery.

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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