Lower Back PainSacroiliac Joint, A Common Cause That is Often Overlooked

Agenda

• Introduction• Anatomy of the Spine• Understanding Lower Back Pain• Symptoms• Treatment Options• Summary and Q&A

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Epidemiology

• Up to 85% of all people have lower back pain (LBP) at some point in life

• 2nd only to common cold in office visits• 15 million office visits annually• 5th ranked cause of hospital admission• Annual direct and indirect costs have reach

$86 Billion

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Anatomy - Spine

• 24 vertebrae– Base of Skull to Pelvis– Building blocks

• Discs between vertebrae– Cushions between

bones• Protects Spine Cord• Nerves exit spinal cord

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Anatomy – Ligaments

• Strong ligaments encase each joint

• Allow for about 2-4 millimeters of movement

• If damaged, may have excessive motion

• Excessive motion may inflame and disrupt the joint and surrounding nerves

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Anatomy – Nerve Supply of Pelvis

• Nerves exit Lumbar Spine & Sacrum

• Provide sensation to legs

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Sacroiliac Joint Problems

Common causes:•Degenerative disease•History of trauma•Pregnancy/childbirth•Lumbar Fusion•other unknown reasons.

Disruption due to: •Injury, traumatic event or repetitive trauma•or may suffer from sacroiliitis (swelling)

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Symptoms

• Back pain - low back pain

• Buttock pain • Thigh pain • Sciatic-like pain• Difficulty sitting in one

place for too long due to pain

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Diagnosing

• SI Joint – being “rediscovered”• Not usually part of LBP work-up• Often misdiagnosed or not evaluated• Physicians are not trained to look for it• Proper Diagnosis important– Pain can mimic discogenic or radicular low back

pain– potentially leading misdiagnosis and lumbar

surgery

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Diagnosing - Imaging

• Plain film, CT scan, & MRI maybe order– Often misleading– One study, CT scans were negative in 42% of

symptomatic SI joints1

– MRI has not been proven to have positive correlation

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1. Elgafy H, Semaan HB, Ebraheim NA, et al. Computed tomography findings in patients with sacroiliac pain. Clin Orthop Relat Res. Jan 2001;112

Diagnosing - Imaging

• International Association for the Study of Pain (IASP) criteria for diagnosis of SI joint pain:1

– Pain is present in the region of the SI joint.– Stressing the SI joint by performing clinical tests

that are selective for the joint reproduces the patient’s pain.

– Selectively infiltrating the putatively symptomatic joint with local anesthetic completely relieves the patient of pain.

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1. Merskey H, Bogduk N. Classification of chronic pain. In: Merskey H, Bogduk N. Descriptions of Chronic Pain Syndromes and Definition of Pain Terms. 2nd ed.8

Diagnosing – Physical Therapy

Distraction Test•The sacroiliac joint is stressed by the examiner,

attempting to pull the joint apart Compression Test•The two sides of the joint are forced together.

Pain may indicate that the sacroiliac joint is involved.

Gaenslen's Test• lay on a table, one leg drops over the edge and

the supported leg is flexed. In this position, sacroiliac joint problems will cause pain because of stress to the joint.

Patrick's Test•The leg is brought up to the knee, and the knee

is pressed on to test for hip mobility.

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Diagnosis – SI Injections

SI Joint Injections:•Gold standard•Confirm or deny SI Joint is

source of pain•20-30 minutes after the

procedure, you will move your back to try to provoke your usual pain.

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Conservative Treatment

• Non Steroid Anti-Imflamatory Drugs (NSAIDS)• Chiropractic Manipulation• Physical Therapy• Loosen/Stretch for hypomobility• Strengthen for hypermobility

• Pelvic Belt• Steroid injections•Others: RF ablation, etc.

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Conservative Treatment – SI Belts

SI Belts:•Wraps around the hips•Hold the sacroiliac joint

tightly together•Reduce motion to reduce

pain•Goal: Decrease joint mobility

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Conservative Treatment

Physical Therapy•Lumbar stabilization program:

strengthening abdominals and buttock muscles

• Improve flexibility in lower extremity musculature

•Lower back stretches•Goal: Decrease mobility

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Conservative Treatment – SI Injections

Treatment:•Same procedure as diagnosis•Includes Corticosteroid in

injection– Reduce your inflammation– May provide months of relief

•Treats symptoms, not joint mobility

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Treatment – Radiofrequency Ablation

“Burns” small nerves that provide sensation to SI joint •In theory, this treatment:– Destroys any sensation – Makes joint essentially numb

•Not always successful– Temporary, nerves regenerate.

•Treats symptoms, not joint mobility

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Surgical Treatment – iFuse Implant

• Decrease mobility of SIJ– Same rationale as SI Belt

• Minimally Invasive– Small incision

• Doesn’t require bone for fusion

• Potential for less OR time• Restore Quality of Life

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Surgical Treatment – iFuse Implant

• 3 or 4 pins a cross SIJ• High success rate: 90%

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Conclusion

• SIJ is underdiagnosed• Have your physician examine SI Joint,

diagnosis to confirm or rule out• If SI Joint is diagnosed, treatment goals: – Reduce symptoms– Decrease mobility of SIJ joint

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