Low Back Pain & The Sacroiliac Joint - Patient Seminar

Well, I want to thank you all for coming here. I know how difficult it is for all of us to travel and at this time of day in traffic, and that just speaks to the fact that there is probably something serious that they want. to be more informed and that is why you are here, the problem of

back

pain

, so I am here to talk to you about that problem and I am grateful that you are here and I hope this is valuable information for you. The general focus of this talk we really start with the problem of

back

pain

.

Back pain is really a big problem that, as you know, most Americans face at some point in their lives. I will talk about back pain and talk to you. a little bit about the anatomy of the spine to understand a little bit what areas of the spine cause back pain and then focus on this

sacroiliac

joint

problem that causes symptoms and about 20% of people with back pain and talk about some of treatment options and at that time we can open the floor for some questions and answers, so please save your questions until the end of the presentation.

Thank you, it is estimated that, fortunately, between 85 and 90% of Americans suffer from back pain at some point. most of those people get better without any surgical treatment or really any significant treatment if you give it time most of these back pain will get better most of them are muscular but there are about 10% of those

patient

s who continue to suffer from back pain low. pain, so they develop chronic back pain and this becomes a growing problem and results in a significant number of

patient

s coming to our offices for treatment for this back pain. It is only second in rank after the common cold in number of visits.

Patients come to the doctor's office and it is estimated that 15 million office visits annually are for the treatment of back pain. It ranks fifth as a cause of hospital admission, whether for preventive surgery or to control back pain. And you know the cost, as we hear more and more about the cost of healthcare these days with the changes we are seeing in healthcare. This is a significant cost to our taxes and our healthcare. It has been estimated at eighty-six billion dollars. is spent on the treatment of back pain, that is why there is such an important topic that you hear about in the newspapers just to review a little the basic anatomy of the spine, as many of us have seen and studied in our classes of anatomy at school.

We basically have twenty-four vertebrae, it starts from the base of the skull all the way to the pelvis and there are discs between the vertebrae and we hear a lot about discogenic back pain where the discs wear out, which happens in everyone, but not always. causes pain, but the problem is when we do an MRI of the back of someone who has that muscle pain in their back, their discs are probably worn out as well, so the challenge is whether the discs cause the back pain or are the muscles and That is why we, as spine surgeons, have a great challenge ahead of us when we see a patient with back pain and, in addition to the discs between the vertebrae, we now pay more and more attention to the

sacroiliac

joint

, because that is also another source of pain we will talk about that a little later, but in addition to the discs wearing out and causing discogenic back pain, those discs can put pressure on the nerves and the other joints of the spine, it is That is, the facet joints. causes some back pain as a result of degeneration and those facet joints, the spine is like a three-legged stool, each segment has one leg as a disc and the two legs in the back as a facet joint, so when a leg the disc degenerates that in turn puts more stress on the joints and the back of the spine, so we have all these areas in the spine and around the spine that could result in typical back pain, so that our job is to diagnose where this specific pain is coming from. and that has been the challenge and continues to be a challenge for us as excellent specialists and the last segment of the spine at the bottom, where the sacrum connects to the pelvis, as this video will show you, is where the sacroiliac joint is, so if you look at the bottom of the spine the sacrum is highlighted there and that's the ilium and the sacroiliac joint rests between the sacrum and the ilium and as you can see the spine is right above the sacrum so All the forces and load of the body passing through the spine are in turn transmitted to the sacroiliac joint and is like the cornerstone of a ridge.

The sacroiliac joint is shaped much like a bridge sits on a keystone, so there is a tremendous amount of force passing through the sacroiliac joint. Fortunately, most sacroiliac joints are stable enough that this long-term stress on them will not degenerate or cause pain, but there are subsets of low back pain patients who have a condition of sacroiliitis, which is inflammation of the joint. sacroiliac. and the anatomy, if you delve deeper into the anatomy of the sacroiliac joint, you will see that there are very thick ligaments that support the iliac joint or the iliac joint and these ligaments further stabilize the joint itself and when there is a disruption of these ligaments, that is a of the reasons. why people will have a little more movement than normal in this sacroiliac joint the things that cause sacroiliac pain we're learning more and more about as we talk, but what we think causes pain in the sacroiliac joint is not just one thing, several things One of those things is hypermobility in the joint.

There is typically 1 to 5 degrees of rotation or movement at the sacroiliac joint, more movement in women and men, but when there is too much movement, that could cause additional stress on the joints. sacroiliac joint and that extra movement like extra movement and many other joints in the body can cause pain. The other thing that can cause pain is if the joint becomes so stiff that the forces are transmitted through the joint itself and therefore there is no such gliding. minimal slip that distributes some of the forces and could possibly be another source of the pain the other thing that could cause the pain there could be something internal to the joint that could cause the pain either trauma or long term degeneration of the joint This could cause the joint to become painful.

The other thing that can happen is tears and the ligaments around the joint and as you can see here, they are very thick ligaments that could cause these types of problems that we talked about. There is also abundant innervation or nerve endings that surround and enter the joint itself or the joint capsule, so you can imagine why if you have inflammation in the joint, the surrounding tissues once inflamed can irritate those nerves. and cause pain. The other thing we see here is that these nerves that cross the sacroiliac joint will ultimately end up going partially down the leg, sometimes into the lake, so in some cases, as I'll highlight later, there may be some referred pain going down. down the leg from the sacroiliac joints, so if you have inflammation of the sacroiliac joint, the nerves that supply or enter the joint or joint capsule may also be partly going down the lake and the brain can differentiate whether this nerve is being irritated in the sacroiliac joint or the SI joint or being irritated when it goes down the leg, so the brain will trick it and give you the sensation of pain in the leg instead of the SI joint, so there is some overlap of pain in the sacroiliac joint versus pain that is clearly coming from a nerve, such as pain from a herniated disc, which can also affect that same nerve, so there is some overlap in diagnoses that we need to be careful with when we try to figure out where this is. pain comes from, so the common causes of sacroiliac joint dysfunction are typically degenerative processes that are known as we age, as we have an aging population.

In fact, baby boomers are just beginning to enter Medicare and are over 60 years old. We're going to have a large American population that is now aging, so all the degenerative processes that we see, including lumbar stenosis, which means some of you have heard of problems with knees and hips, which are going to be more and more. The same goes for the sacroiliac joint. This joint over time can degenerate and that can cause pain and degenerative pain in this joint. There could also be a history of trauma that was the beginning of this pain. You can have trauma and the joint as we know it.

As mentioned or the capsule, the ligaments around the joint could be injured and that could be the beginning or beginning of the pain and there may be a history of that in the patient's history. Other causes that are less common are pregnancy when, in fact, many women. While they are going through labor due to the size of the baby they need to have their pelvis open for the baby to pass through the opening, the body has a great way of relaxing those ligaments by producing this hormone called relax and relax in the placenta which loosens those ligaments to allow for childbirth, sometimes as a result of childbirth and stretching of these ligaments, patients may begin to have some sacroiliac pain which usually resolves after a few months after childbirth due to those hormones.

They come out of the body and the ligaments become stressed again, but sometimes we see sacroiliitis in patients who have just given birth because of all the stresses that go through the sacroiliac and pelvic area. The other finding that we have sometimes is in patients who have fusion in their lumbar spine, let's say if you have fusion in this region, as we know, with any fusion, you will transmit some of the forces or some of the motion from the fused levels to the adjacent, so you will have a non-mobile segment of the spine where it fuses and that results in increased motion either above or below the fusion many times when we fuse with the sacrum, that means that the sacroiliac joints They have to move more when there is abnormal movement that could cause inflammation or damage. to the joints and this is something that we also see as a cause of sacroiliitis, so some patients may have disease at the adjacent level as a result of a long fusion that will give them sacroiliac pain.

There are other unknown reasons why we have this pain in the sacroiliac joints because not everyone has these findings as we talk about here, but we are learning more and more about this problem of sacroiliitis and the interruptions can also be due to injuries, trauma or repetitive trauma , activities of daily living can be partly traumatic on our tissues such as sitting itself causing additional stress on the discs and sacroiliac joint and if you know a job that requires you to sit for a long period of time without rest, that could be the microtrauma that causes the alteration in these soft tissues, so what do patients present to our offices with patients who have sacroiliitis?

They come and tell us that they have back pain, so low back pain is a common complaint in patients who have sacroiliitis, the other complaint is pain in the buttocks, most people who even have pain in the buttocks, do not They come and tell us they have pain in their buttocks, they say I have pain in my hip, but when we ask them where the pain is in my hip, they actually point to their buttocks, much like patients who have a herniated disc, Zoar lumbar stenosis, which is a pinching or irritation of the nerve who have pain in the buttocks Patients with sacroiliac sacroiliitis may also have pain in the buttocks for the reasons we discussed above some patients may also have pain in the thigh pain that radiates towards the lake again for the reasons we discussed because those same nerves pass around and around the sacroiliac joint, the other complaint we hear about your patients, you have difficulty sitting down or getting up from a sitting position, so any movement that causes any Rotation in the sacroiliac joint can cause pain to appear or increase pain.

So those are all conditions that we typically see, but the most common complaint is pain right above the sacroiliac joint, so basically the sacroiliac joint we know about in our literature and in the orthopedic and spine surgery literature, sorry. , exists, but untilWe didn't have it recently. There was an easier or less morbid way for us to treat patients. What I mean by this is that the surgery was worse than the problem and that is why it is an important topic to discuss today because many surgeons to this day are not adopting either option. or I am not aware of the new technologies that we have available to treat this sacroiliitis problem, so like me three years ago, who was not looking for this sacroiliitis, I would simply tell the patient that you know what the MRI of your lower back.

Well, I don't see any bulges on the disk. I don't see any reason why you should have pain in the sacroiliac area or butt, so I don't think there is anything I can offer you and I hadn't been specifically checking. for sacroiliitis and that's really an important take home message: if you have back pain that has no other explainable causes or if you've had surgery because your back pain still persists, it's important to talk to your doctor and specialist about sacroiliitis and have him look at this condition and like everything else in spine surgery or any other medical condition, diagnosis is critical to successful treatment because if you don't have the right diagnosis, any treatment you offer will fall short of the goal .

Whatever that goal is and this is not unique to spine surgery, it is true in all fields of medicine and what we are here today to discuss is that there is a sacred problem that does exist and if we do not look for it. you will not find it and therefore you will miss the target, how can we visualize or further study sacroiliitis One of the challenges here with the problem of sacroiliitis is that many times we do not see anything on the MRI or CT scan that calls us attention and say: I have sacroiliitis, so MRI and CT findings are not always conclusive.

Many times patients have pain in the area that we see on the CT scan and MRI and there is no one side that looks worse than the other, unlike hip arthritis, where you say it's fine, clearly there is arthritis, year why, because the ligaments don't always look shiny. On CT scans and MRIs, she doesn't show up on CT scans, but even on MRI, if it's micro tears on the MRI or in the ligaments, we don't see it on the MRI and maybe there's another study that We will have to work to find something that specifically looks at the sacroiliac joints to help us with the diagnosis, but currently there is no gold standard for CT, X-ray or MRI imaging that we can say is best for diagnosing a sacroiliac joint. articulation that makes our work more complex, right?

But that's a very important point to make, so what is the criteria for sacroiliitis? If a patient comes and says: I have pain in my gluteal region and in my sacroiliac joint and I can't diagnose it with an MRI, CT scan or X-ray, what do I use for diagnosis? The diagnosis of sacroiliitis is a diagnosis of exclusion, so as we talked about, we have to make sure that there is nothing else that can mimic those symptoms, so if a patient has a huge herniated disc that is pushing on the nerve and that patient He has a shooting pain in his buttock, his thigh and I push on his sacroiliac joint and he has pain there.

I'm not going to diagnose that patient with sacroiliitis. I'm going to First, make sure that the herniated disc is not causing that pain in the buttocks, but in many patients that we see they don't have a herniated disc, they don't have lumbar spinal stenosis, so that's the first thing we have to make sure of. that nothing else is happening and that many patients were left undiagnosed, then we have to make sure that their pain is not caused by pressure on the sacroiliac joint, most patients with sacroiliac itis or even come and tell us that they use their thumb . or with their finger they point to that point of Fortin's sign that I will go over in a second and they say that this is where my pain is and they push on the sacroiliac joint and when I go to press on that place that is where they jump over the table and say that this is where it is the pain, so that's the number one point of the diagnosis that they look at in addition to the patient's history as we talked about before, then we look at the images and we look at the studies and then the other key point.

The diagnosis is a provocation test that I will go over in a second. These are maneuvers that stress the sacroiliac joint to try to mimic what the patient does when they move in their daily activities to see if that causes the pain. Then we compare. that to the other side and it becomes very useful if the other side is completely normal sometimes patients have bilateral sacroiliitis but often patients have unilateral or unilateral sacroiliitis and when one side the provocation tests are positive the other side is negative, which which further confirms our diagnosis and then finally, to confirm that diagnosis, we do an injection into the sacroiliac joint, an injection of an anesthetic medication and if that specific injection relieves the pain that the patients are suffering, then that confirms our diagnosis, then , what is the Fortin finger test?

I've mentioned a couple of times, basically, it's putting your finger right on the posterosuperior iliac spine or right over the sacroiliac joint, which is where the point of pain is. Sometimes patients don't feel pain when I push, but they say this. is exactly where the pain comes from, so patients can often localize the pain with a finger by breathing from the sacroiliac joint and is generally consistent with two trials based on a study by Fortin himself that was published in 1997, which which means That's what you know, if you ask the patient a couple of times, he will point to the same place, he doesn't move, he won't point to the middle of the back and then it will be the place, so if you ask patients a couple times.

Patients who have sacroiliitis constantly point to the same place and sitting on the affected side often causes pain, so that is another finding in the patient's questioning or in the examination room and then also asking if the patient has a symmetry. meaning one side hurts or the other side is much less painful or doesn't hurt at all. Many times patients say that they cannot walk on the side where the sacroiliitis is because if you put weight on that side while you are lifting the other leg to the contralateral or opposite side to swing it while walking, you are putting a lot of stress on that sacroiliac joint and that It often causes so much pain that patients feel like their legs are failing. them on this side of pain while walking, so that's enough, that just points to the fact that the sacroiliac joint in some patients can be so painful that even when walking they have a distinctive pain in that place, so once we examine to the patient and Ask them the question, ask them the questions first, then we examine them with a strange sign, we go to the provocation tests shown here.

I won't go into too much detail, but basically the distraction compression test, the doors lens, and the Patrick test are trying to produce some movement in the sacroiliac joint that in a patient with sacroiliitis should induce pain and that's what What we are basically doing with these tests. The one that is most widely used is the Patrick test, which is shown at the bottom here where we have the patient. bend the knee on the side where the sacroiliitis is and place the ankle just above the knee on the other side, just above the knee and basically we push the middle part of the knee as it is with the bent knee and we support the pelvis with the other . hand and that pressure on the medial aspect of the knee or the middle of the knee causes movement and rotation in the sacroiliac joint and that typically causes pain on the symptomatic side and that's called Patrick's test or Faber's tests um some doctors do it They call the Faber fa BER test, so once we have confirmed the diagnosis of sacroiliac assistance with our history and our exam, the true confirmatory test is to inject that same joint, the symptomatic joint, with an anesthetic medication and, if that injection, The medication relieves the pain, which further confirms the diagnosis because if the pain is coming from the hip joint, knee joint, or spine, injecting an anesthetic medication into this joint should not relieve the symptoms.

However, the key point here is that the injection must be done with live in the wrong place, you have to have a good visualization of where these injections are going and often we inject a contrast that on the x-ray shows that this contrast is filling the joint before the anesthetic medication is injected. Usually, some injection is removed because there is not much space in that joint. after they confirm that the needles are in the joint and then they inject an anesthetic medication, but that confirmation x-ray before doing the injection is really critical and important, so what is the treatment after diagnosing a patient with sacroiliitis or sacroiliac dysfunction?

Medications are an excellent first step in treating any musculoskeletal problem because many of these musculoskeletal problems cause pain due to inflammation and nonsteroidal anti-inflammatories, by definition, caused a decrease in inflammation without having the steroid, which can have negative systemic effects, so then after the non-steroidals have been tried, the other things that can be done, our chiropractic manipulations, physical therapy, either loosening the stiff joints or tightening the loose joints with physical therapy, and both are can do depending on why the patient has sacroiliitis or sacroiliac pain and dysfunction. Another thing that is very useful is that if the movement causes pain in the sacroiliac joint, you can place a pelvic belt just above the pelvic brim and tighten that belt which will secure the sacroiliac joint and many patients find it very useful and with You may never You may need to get more treatments for those modalities, like steroid injections or radiofrequency ablation switch, which are reduced later if all those things haven't worked, but before we continue, I wanted to show you what the sacroiliac belt looks like, so this is basically a belt that patients wear just below the top of the pelvis and that belt secures the sacroiliac joint so that there is no significant movement in that joint and that basically reinforces the sacroiliac joint and many times relieves some discomfort that patients have due to this abnormal movement, so the goal is basically to decrease the mobility of the joints.

Physiotherapy already knows the lumbar stabilization program. Strengthening of the abdominal and gluteal muscles is used. Improves flexibility in the lower extremities in the muscles and stretches the lower back. The objective of physical therapy is basically to reduce mobility in patients who. have abnormal movements which is the most common reason why people have sacroiliitis or mobilize joints that are so stiff and causing pain and then finally sacroiliac injections as we mentioned can be tried if all else has failed and also for confirm the diagnosis and at At this point and then anesthetic medications can be injected, but corticosteroids, which are steroidal anti-inflammatory drugs because steroids also decrease inflammation and are much more potent than NSAIDs or non-steroidal anti-inflammatory drugs, can be injected directly into the joint and hopefully that will alleviate some. of the inflammation that is causing the pain, but the important thing is that the steroid injection is usually short-lived because if there is abnormal movement in that joint, that steroid does not slow down the movement, the abnormal movement may continue, but the steroids They have done it temporarily. reduced the pain, there are some patients where we simply need to interrupt this cycle because there is inflammation and the small movement causes more information, so if we take steroids we reduce the inflammation to a lower degree, that small movement that is causing the elevation of this inflammation does not occur and they can get relief with steroids in a subset of patients, that happens and eventually with non-surgical.

The last modality or non-surgical treatment that may work is, for lack of better force, the term burn the nerve endings that feed the capsule and the joint and this is called radiofrequency ablation. This is usually done with a probeUltrasound is inserted into the joint itself and this probe then in turn heats it with whatever form of heat it may be. delivered into the joint causes an ablation or burning of the nerve endings, so because these nerve endings offer no real function to the joint, they do not go to the muscles that help you walk and are purely sensory nerves which then burn . the nerves will not cause dysfunction, but they will relieve pain because these nerve endings are no longer there where there is significant inflammation and irritation of these nerves, so that is the ultimate non-surgical treatment.

There are still some patients who do not receive it. better with these treatments, so what is the surgery we are talking about? Once all else fails and patients have significant sacroiliac joint pain that doesn't get better with all the other things we talk about, then there has to be a way to stabilize it. joint if you know if the patient is in pain with all the things we talked about and this joint is causing a tremendous amount of pain because of this abnormal movement. The good thing is that now we have a way to fuse that joint with these rods called the ifuse implant system where we place these rods in a triangular shape and insert them percutaneously, that is, with a small incision in the lateral buttocks over guide wires under x-ray live through the joint and these rods, three of them, are usually placed through the joint and immediately stabilize that joint, there is a process that we go through to place these pins in the right place under live x-rays, then we drill over these pins and then we place something called a broach that creates a triangular shaped hole in the sacroiliac joint and in the ilium and the sacrum and then we place these implants and when you place these implants, they will snap fit against the bone and immediately stabilize the bone and the joint and let me show you what this In surgery you can see how on this side there is inflammation and there is tear of the ligament and there is abnormal movement in the sacroiliac joint and what this ocular fuse implant system does is again with the smallest amount of opening in the skin in a minimally invasive approach.

I can place these three rods through the sacroiliac joint to stabilize that joint. Patients usually go home the day after surgery. Some of my patients got up excitedly and wanted to leave that same day, but I held on. just so we can make sure the wound is healing well and there are no problems before sending him home, but it is really a minimally invasive surgery compared to what we had available before, so it didn't make sense to treat sacroiliitis with this technology less invasive technology minimally invasive technology it makes sense for patients to be treated with this condition and I am pleased to say that we now have an option for patients who continue to suffer from sacroiliitis.

What are some of the details of this implant and why is this implant better than the one we had available because We also had these screws that we could place through the sacroiliac joint. Why don't we use them? The shape of the implant is triangular and that gives us a very nice surface where the bone and the implant are in contact and that is why the pyramids. In Egypt there were pyramids and that is why they have withstood centuries of earthquakes and all that, all the stresses that the earth has caused them and a pyramid shape in an engineering sense is the most stable dimension in addition to having a large surface area.

Because of this triangular shape, it will be much more rigid for the patients we have implanted this device in so far. We have extracted and what we have seen is interesting data that I would like to share with you, so when we ask patients how much pain they are feeling right now, we have their scores before surgery, which are shown in this lighter. color and we asked the same question after the surgery was performed and as you can see on a scale of 1 to 10, patients on average had just under 8 out of ten pain before surgery compared to their pain level right after After surgery or three months after surgery you can see how the pain decreased by about 50% and the exciting thing is that as the bone begins to heal, it seems that these patients start to do even better, so At 6 months the pain increases to around 3 out of 10 and is maintaining its effectiveness at 12 months according to the result of this questionnaire and the other important question, although it is valid to ask our patients, would they choose to undergo this procedure in the other side if I needed it?

That tells us how much pain relief. that patients have and how burdensome it was for patients to recover from this surgery even though they can get pain relief, that the surgery can be as important as our previous surgeries that we had available that they do not want to have the surgery. This was not the case with this minimally invasive surgery, over 90 percent of patients said they would still have this procedure if the other side needed it, so it's really encouraging to see, in short, the SI joint is still a condition misdiagnosed in many patients. Sacroiliac joint sufferers are not being diagnosed due to the problems we discussed because until recently we did not have an effective less invasive way to treat patients with sacroiliac ice, so I was not looking for sacroiliitis until a year ago.

A year and a half ago, many surgeons still do not look for this condition, so I believe it is underdiagnosed and many patients suffer from back pain and, as we have talked about, 20% of the patients that the literature shows suffer from low back pain. having sacroiliitis in addition or on its own causing this lower back pain that page has experience with, so what are the goals of treatment when diagnosing the sacroiliac joint? It is to reduce the symptoms and if non-surgical treatments have not worked, then we stabilize the joint and that is an option that is available to us now.

I appreciate your time and your attention and I hope this has given you information about this misdiagnosed condition and I hope that we can increase our knowledge as treaters and also as patients about this condition in those charts oh I'm the charts that you showed we are six and Twelve months after the pain was 50% less my question is if it was properly diagnosed the joint is stabilized why is there zero? non-zero pain, what's causing the pain after six to twelve months, that's a great question and I think going back to the chart, the relief is 50 percent and the pain is significant.

The answer is in our medical literature, where we have strict criteria for success that would be considered. as success, but you are right, why is the pain not zero? The reason is that most of these patients with this type of problem have arthritis and other joints in the area, so I always tell patients with spinal conditions that I will focus my treatment on the worst level of where I think they will be. most of your pain is coming from and if you have this surgery you may still continue to have some pain and the most significant pain is what we usually address and I always tell patients that I can help them. fifteen twenty again because there are other joints in the body that are going to be arthritic, but that is the reason why I believe that the pain is not zero because there are other conditions that patients complain about even after the pain of the sacroiliac joint is relieved with surgery, the other point to consider is that this is only an average, so there are some patients who feel no pain or one in 10 and there are some patients who have seven or eight out of ten pain afterwards of the surgery, but on average I have been able to reduce the pain to a level of 50%, which is quite significant.

One of the symptoms I have that is usually ignored when I try to explain it to people is that I have a hard time walking on a slope, you know where? My foot is very flexed. I usually have to turn around and walk backwards. That's the only way I can climb a hill comfortably and I don't know why. Do you have sacroiliac joint pain? you're going up the incline yeah so you're basically leaning forward when you're going up the incline when you're when you're going downhill you're leaning back when you're going uphill you're kind of leaning forward so the movement could be stressing your sacroiliac joint. , which in your case is most clearly causing some abnormal movement, and your sacroiliac joint that is causing the pain, so it would also be similar to walking on sand or uneven ground, any of those faults. of stability which probably also indicated that as the fulcrum of your previous weight and the cornerstone of your body weight, that joint could be stressed in anything you do, especially being upright and if you have a swollen sacroiliac joint, all those things they could irritate it whether you're going uphill or downhill or you're putting more weight on that side those can all go with the diagnosis of sacroiliac like 'thank you so much for your attention and you already know please help yourself to the refreshments we really didn't go too deep into that, thank you.