SpinelessWench

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

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