Low Back Pain’s Missing Piece Diagnosing the Sacroiliac Joint

Overview Introduction Anatomy of the Spine Understanding Lower Back Pain Diagnosing SI Joint Dysfunction Treatment Options Summary and Q&A

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 reached $86 Billion

Anatomy - Spine 24 vertebrae Discs between vertebrae Sacrum Cervical spine Thoracic spine Lumbar spine 24 vertebrae Base of Skull to Pelvis Building blocks Discs between vertebrae Cushions between bones Protects Spine Cord Nerves exit spinal cord Last segment, the sacrum, connects to the pelvis

Anatomy – Where is the SI Joint?

Anatomy – Ligaments Strong ligaments encase each joint Ligaments affect stability If damaged, may have excessive motion Excessive motion may inflame and disrupt the joint and surrounding nerves Sacroiliac ligaments

Anatomy – Nerve Supply of Pelvis Nerves exit Lumbar Spine & Sacrum Provide sensation to legs Several levels innervate the SI Joint

SI Joint Dysfunction: Causes 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)

SI Joint Dysfunction: Symptom Presentation Low back pain Buttock pain Thigh pain Sciatic-like symptoms Difficulty sitting in one place for too long due to pain

Diagnosing: SI Joint 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 is important Pain can mimic discogenic or radicular low back pain Potentially leading to misdiagnosis and lumbar surgery

Diagnosing: Imaging Plain film, CT scan, & MRI may be ordered Often misleading One study, CT scans were negative in 42% of symptomatic SI joints1 MRI has not been proven to have positive correlation 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: Criteria Criteria for diagnosis of SI joint pain:1 Pain is present in the region of the SI joint. Provocative test – reproducing pain in joint. Injecting the joint relieves the patient of pain. 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: Pain Localization Fortin Finger Test1 Point to pain while standing Able to localize pain with one finger Within 1 cm of PSIS (inferomedial) Consistent over at least 2 trials Tenderness over SIJ sulcus Posterior SIJ tender to palpation Not sitting on affected side. Position tests to check for symmetry. From Forst SL et al. Pain Physician 2006. 1. Fortin JD. Am J Orthop 1997;26(7): 477-80.

Diagnosing: Provocative Tests 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. FABER Test The leg is brought up to the knee, and the knee is pressed on to test for hip mobility.

Diagnosis: SI Joint Injections 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.

Treatment: Overview 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.

Treatment: SI Belts SI Belts: Wraps around the hips Hold the SI joint tightly together Reduce motion to reduce pain Goal: Decrease joint mobility

Treatment: Physical Therapy Lumbar stabilization program: strengthening abdominals and buttock muscles Improve flexibility in lower extremity musculature Lower back stretches Goal: Decrease mobility

Treatment: SI Joint Injections Includes Corticosteroid in injection Reduce your inflammation May provide months of relief Treats symptoms, doesn't stabilize an incompetent joint.

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

Treatment: iFuse Implant System Stabilization of SIJ Minimally Invasive Small incision Doesn’t require bone for fusion Short procedure length ~ 1 hour Restores quality of life

Treatment: iFuse Implant System

iFuse Implant Technology Why unique shape? Cannulated screw may loosen Design: Triangle vs. Round More surface area Unique coating allows for bony ingrowth Ingrowth creates fusion Permanent solution, 4X stronger than screw r=3.5 mm 12.124 mm R=7mm

iFuse: Clinical Outcomes “How much pain are you in at this time?” (1-10) n=35

iFuse: Patient Satisfaction “Would you choose to have this procedure for the other side if needed?” (Y/N)

Summary SI joint dysfunction is underdiagnosed Have your physician examine SI joint, diagnosis to confirm or rule out If SI joint is diagnosed, treatment goals: Reduce symptoms Stabilization of SI joint If recurrent pain after treatment, consider a minimally invasive surgical stabilization

Questions & Answers