1. Low Back Pain’s Missing Piece Diagnosing the Sacroiliac Joint

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

3. 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

4. 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

5. Anatomy – Where is the SI Joint?

6. 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

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

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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):

14. 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.

15. 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.

16. 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.

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

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

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

20. 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

21. 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

22. Treatment: iFuse Implant System

23. 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 mm
R=7mm

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

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

26. 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

27. Questions & Answers