SpinelessWenchMemberSeptember 28, 2012 at 9:30 amPost count: 38
During the past few weeks, both a primary surgeon and my PM team are beginning to strongly suspect that the severe pain (9/10 and 10/10) and very specific symptoms in my low back are due to Sacroiliac Joint Dysfunction. I appreciate your most recent reply, indicating that SIJD should be cautiously suspected in light of other vertebral or disk-related conditions. I’ve spent a good portion of the past 2 weeks reading orthopedic journal articles, case studies, neurosurgery articles, and other reliable literature whose focus is on the etiology, presentation, and treatment of SIJD. I’ve also viewed any number of medical conference presentation videos on this condition, and have learned a great deal about this emerging area of orthopedic focus. We’re not omitting my significant spine disease and surgical history as a potential suspect, yet all three of my attending specialists are growing increasingly more confident that SIJD is the primary suspect right now. I’ve found your replies to past questions really helpful, and hope you have time for a few more.
The extant literature, most of which is fairly recent, indicates that patients with histories of multi-level fusions are much more likely to develop SIJD within 5 years of their last lumbar fusion. Those whose surgeries involved iliac crest bone harvest are at even higher risk. Other correlates include patients with leg shortening unilaterally, those with premature development of DDD (< 35 years old), patients near 50 years of age, and women. QUESTIONS: 1. In your own chiropractic and surgical experience, do these correlates match those that you’ve personally seen in patients? I am a 48-yr-old female with an extensive history of DDD, onset at 18 years old. I’ve also had 5 lumbar surgeries, two of which were multi-level instrumentation fusions. The first fusion, in 1991, was augmented with autologous harvested iliac crest bone. 2. From the available research, I understand that most cases of SIJD are unilateral, although bilateral cases do happen in patients with advanced stages. The pain is severe, and originates lower than that associated with traditional lumbar discogenic, facet, or stenotic conditions. But, since the pain is so close to that of LBP, physicians oftentimes mistakenly overlook it. My doctors are fairly sure this is what happened with me… I presented with severe (9/10) pain, radiating across the sacral region to the pelvic crest, then downward to the groin and anterior thigh. I could not take what you’d consider a normal-length stride, and I described my pain to one surgeon as, “feeling as though my sacrum and hips were broken.” Due to titanium artifact on my MRI, it was simple for him to dismiss me with FBSS, saying my symptoms, “didn’t match anything on my MRI.” The research also indicates that surgeons should listen for a patient’s anecdotal symptoms as well as those considered more “important.” For example, clinical studies point to symptoms such as a patient’s inability to roll over or even move upon waking in the morning, and having extreme difficulty walking or standing without support. Other symptoms include poor sleep, waking with severe pain during the night, and an intolerance for positional variations such as Graeslen’s maneuver, distraction tests, and lying prone. If I attempt any of these positions, I am *literally* unable to move, feeling as though my low back and pelvis are broken and in severe spasms. If on my back supine, I am forced to roll like a log to my side, bring my knees to waist height, grab a shelf or significant other or tabletop or dog, and slowly bring myself upright again. If no one is here, then the entertainment value increases exponentially. In your extensive experience, would my symptoms piqué your suspicions for SIJD, in light of an MRI whose results are still debatable, and in light of normal AP/LAT/FLEX/EXT films? My pain is replicated upon all 5 biomechanical tests typically conducted to rule in SIJD. So… #3. If you had a patient whose pain was replicated on these maneuvers, and you felt an SI Joint anesthetic injection were warranted for a definitive diagnosis, how would you carry out the procedure on a patient who could not tolerate the prone position? Can patients be sedated for SI Joint injections? Even a pillow under my abdomen doesn’t help. #4. Once SIJD is diagnosed, what is the treatment for a patient with extensive instrumentation from L3/S1, and with the advanced symptoms I’ve described? Would any mode of PT be advised? Are iFusion procedures helpful in improving QOL and pain to manageable levels? What is a patient’s ROM like once fully recuperated from an SI Joint fusion? That’s all I want right now. To be comfortable, and to ride my Harley or walk my dogs. Apologies for the length of the post. I’m just trying to do as much research as possible until my next appointment. S.W., NCDonald Corenman, MD, DCModeratorOctober 1, 2012 at 12:43 amPost count: 8468
First, you have really taken the bull by the horns to do research on this disorder and you should be commended. It is difficult to fend through all of the information on the internet as some of it is incorrect at best.
You are correct in that sacroiliac syndrome (SIJD) can be associated with multilevel lumbar fusion (greater than two levels). Iliac crest bone graft taken during spine surgery is highly correlated with SIJD. Thankfully, most patients no longer need that graft.
I disagree with leg length discrepancy as a cause as well as age as SIJD is much less common as we get older (the joint stiffens with age which reduces the chance of pain).
You have two significant risk factors for SIJD, multilevel lumbar fusion and especially prior iliac crest bone graft. Most SIJD cases I have seen are unilateral but there are occasional bilateral cases I have seen. Inflammatory disorders have to be ruled out in any patient with SIJD as cases of psoriatic arthritis, inflammatory bowel disease, ankylosing spondilitis, and Reiter’s syndrome can cause SIJD.
SIJD typically do not refer pain to the groin. Groin pain with SI pain leads me more toward hip disorders and radiculopathy. I am not stating that groin pain fully rules out SIJD but puts that diagnosis further down on the differential list. Also, SIJD pain typically will not wake you up but is mechanical in nature (pain with standing and walking as well as transition pain- pain with changing positions- sitting to standing).
Mechanical tests to diagnose SIJD are notoriously unreliable. That is, many different disorders will be aggravated by these maneuvers. The one most specific maneuver is the Gaenslen’s test and that is still a non-specific test.
I do believe that the best test to diagnose SIJD is the intra-articular injection (the joint is both fibrous and capsular). This is not a 100% test in that even patients with radiculopathy can have relief with this injection but that is a more unusual finding. This injection can be performed in the lateral decubitis position (lying on your side) but more standard is the prone position. Yes, a short term hypnotic (Versed) can be used for the injection but the relief of pain in the short term (three hours) is the most important information that needs to be collected (see pain diary). If you are too sedated and do not try to reproduce the symptoms during the first three hours, the diagnostic value is lost.
Treatment of SIJD has three potential therapies. One is prolotherapy. Injection of a sclerosing agent into the joint can cause fibrosis and pain relief. There are complications associated with this therapy. The second is rhizolysis. This therapy attempts to “kill” the nerves that supply the joint with pain fibers. The last therapy is surgical fusion of the joint. This is the “last resort” and in very good hands, has a 70% satisfaction rate.
Dr. CorenmanSpinelessWenchMemberOctober 1, 2012 at 2:32 amPost count: 38
Thank you so much for replying.
My longtime attending neurosurgeon contacted me Friday… He’s performed, or assisted on, 5 of the 9 surgeries on my cervical and lumbar spine. I admire him both as a friend (our patient / physician relationship spans 24 years), and as a surgeon and symptomatic detective. He travels around the country attending seminars, conferences, and groundbreaking surgical techniques, and has developed an interest in the SI Joint as a tandem suspect in neurogenic pain. Plus, I’ve likely put both of his daughters through school with my medical bills.
He’s seeing me personally this week, then while I’m there in town (he’s 3 hrs away), he’ll schedule me for the joint injection and any other diagnostics. As with any good surgeon and clinician, he’s not ruling my lumbar spine out, and remains open to other etiologies of pain whose symptoms mimic SIJD.
Should my physical exam in his office (imagine that… a real physical exam, complete with physical contact with the patient, a gown, and no cowboy boots) confirm SIJD, he will then refer me to an orthopedic colleague of his who has performed the iFuse procedure numerous times, with good results. Surgery may, or may not be, an option for me, however with my spine fused to S/1, the impossibility of PT that involves lower spine and sacroiliac adjustment, and with my history of poor results from injections, this might be the only thing that improves my current QOL and pain levels. Plus, I teach college, and miss being in the classroom… So, I want, and need, to get back to work. Another point of admiration for this guy… Should the orthopedist recommend the iFuse procedure, my neurosurgeon plans to attend and observe the procedure in the OR. He’s attended numerous seminars and surgical conferences on the procedure, but has never observed one. So, I think it’s cool that he’s using this opportunity to continue learning in his field.
QUESTION REGARDING SYMPTOM:
The radiating pain I’m experiencing, again, is across the area 2 inches above the gluteal cleft (I still like ‘butt crack’), runs bilaterally out to the top of the hips, then down the anterior thigh. My specific question is about the type of pain this is… Usually, it’s a horrible spasmodic stabbing pain, especially first thing in the morning. I am literally unable to roll myself over, sit up, or stand without help. I have to get out of bed using the infamous “roll and stand in one swift motion like a log” thing. Throughout the day, however, I’ll experience completely unpredictable “jolts” of pain, best described as an electrical shock, that, 1) originates at the area between the edge of the sacrum and the top of the hip where nurses give you injections sometimes; then, 2) shoots along a VERY distinct route along that seam of the SI Joint; then finally, 3) travels along a route down the side of my hip and down the anterior thigh. This “jolt” follows the same path every single time. It occurs when I’m standing, or as I’m sitting in my recliner. If I attempt to relax my entire low back, and attempt to “un-tense” myself, this happens. It will literally cause me to jump, almost like being hit with a taser gun. My friends find it amusing, especially after several cocktails. I find it a literal pain in the ***. Plus, it hurts beyond description.
Also, if I’m asked to lie on a completely flat, in-cushioned surface or exam table, I’m completely unable to do so. Upon lying supine and relaxing my back, I immediately experience a 10/10 spasmodic, stabbing pain in the areas of my sacrum and hips. It’s almost as if my hips don’t rest on the table with equal distribution (like one is slightly off the table or something). I’m suspecting this may be due to abnormal rotation or subluxation of the SI Joint. And, it sounds correlated with the replicated pain described in journal articles whose topic focuses on PT biomechanical exams. Your thoughts?
Any further thought as to whether these “jolts”, and positional anomalies, sound affiliated with the SI Joint, or does it sound associated with nerve root compression or facet pain *below* L4? My obvious concern is that on my MRI, the areas below L4 were, “largely unreadable and obscured by titanium artifact.” If the area below L4 was obscured, then a surgeon would be unable to assess whether all of these issues are originating there, rather than the SI Joint. In my opinion, the surgeon who ordered my MRI, and the second surgeon who said he couldn’t see anything due to artifact, should’ve considered ordering another diagnostic test that would better illuminate those lower levels instead of writing me off and not taking this case seriously. I’m not a doctor (well, medical anyway), but I think surgeons and providers have a professional and ethical obligation to investigate a patient’s symptoms if an initial diagnostic exam is inconclusive or otherwise rendered illegible. Am I missing something here?
Thanks again, and I look forward to hearing from you. In early August, we took a cross-country trip out west, and drove right through your area via I-70 West. What a beautiful region in which to live, and practice. You’re lucky.
S.W., NCAlbertDisuzaMemberSeptember 25, 2013 at 4:35 pmPost count: 26
It is really nice to read all this information that you have tried to convey to us through your well researched questions.The information given in your post is so helpful for me as i am also going through the problem of sacroiliac joint dysfunction.Thanks once again.Scott1MemberAugust 4, 2014 at 1:29 amPost count: 1
I am scheduled to have surgery with you on Aug 13th. We will be fusing C5-6 and replacing the C6-7 disc. During my office visit you mentioned that you would harvest the graft material from my hip. While reading about harvesting from the iliac crest and this thread, I have learned that there are possible side effects with doing so. Could you educate me on what method you use to harvest the graft and how you mitigate damage that would possibly result in SI joint dysfunction?
Also, what are possible causes for heterotopic ossification around the replacement disc and what are ways to reduce the possibility of this happening?
Thank you very much!Donald Corenman, MD, DCModeratorAugust 4, 2014 at 12:36 pmPost count: 8468
The autograft or iliac crest bone graft is not taken anywhere near the sacroiliac joint. The pelvis is a ring that is open in the front on the top but closed on the bottom. You can feel this by putting your hand on your “hips” where your belt line is. You can follow your pelvis from the back around to the front but this bony line stops at your ASIS (anterior superior iliac spine). This is really not a “spine” but the front endpoint of the upper ring.
If you palpated deeply, you would find that this ring drops but continues around at your pubis, the hard bony “knot” at the front of the groin.
The graft is taken from the top side of the pelvis at about the front third of the wing of the pelvis. This area is not weight bearing and the width of the graft is almost a perfect fit for the disc space of the cervical spine. The incision is small and a study I performed (unpublished) found that after six weeks, only 2% of patients has symptoms of a 1-2 on a 1-10 scale.
There is no risk to the sacroiliac joint and I have never had a patient with sacroiliac joint dysfunction who had a graft from the pelvis.
I have for the past 8 years given patients the option of placing sterile coral- yes coral in the graft site. Coral is calcium carbonate and the porosity of coral is almost exactly like bone. Bone grows into this material and incorporates like it was bone. This in my opinion alleviates any pain or discomfort from the graft site and is very well accepted.
The only downside is that patients will develop gills behind their ears and webbed fingers but no one has complained about this side effect;)
Hetertopic ossification is bone formation in regions that it is not functional (not useful and hinders the function of the region). Artificial discs do have the possibility of this abnormal bone formation but I have not had this happen to any of my patients. I believe that my preparation of the disc site reduces the chance of this from occurring but certainly this abnormal ossification is a possibility.
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