Low Back Pain’s Missing Piece Diagnosing the Sacroiliac Joint

1. Low Back Pain’s Missing PieceDiagnosing 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 • 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 Cervical spine Thoracic spine Lumbar spine Sacrum

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. ElgafyH, Semaan HB, Ebraheim NA, et al. Computed tomography findings in patients with sacroiliac pain. ClinOrthopRelat 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. MerskeyH, 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 Orthop1997;26(7): 477-80.

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

20. Treatment: Radiofrequency Ablation 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? • Cannulatedscrew 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=7mm 12.124 mm r=3.5 mm

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