#10 Sacroiliac Joint Pain & Dysfunction (SI Joint Fusion)

In this episode, we explore another common cause of low back pain, especially in patients who have a history of lumbar spine fusion. We discuss the diagnostic and therapeutic options for sacroiliac joint pain as well as advanced techniques like minimally invasive SI joint fusion.

Transcript

SPEAKER_00 0:00

The reason we are doing this is because every day folks are dealing with new pain that doesn't go away.

SPEAKER_01 0:07

Pain's a difficult thing to understand. So let people know what kind of options they have. Welcome back everyone to Maximized Life Advanced in Pain Treatment. I'm here with Dr. Glazer. Um Dr. Powers, we're coming to you from Burridge, Illinois, Pain Specialist of Greater Chicago, which is uh we're in the suburbs of Chicago. Um Dr. Glazer, what are we talking about today?

SPEAKER_00 0:29

Well, you know, we've covered a lot in our first how many eight podcasts, I believe.

SPEAKER_01 0:34

We've got nine episodes. Nine. This is number ten.

SPEAKER_00 0:37

But we haven't covered everything, and we may never cover everything. Got a lot to cover. But let's let's talk about something that uh you'll notice a lot of patients coming with this diagnosis given to them by a physical therapist. I don't know if you've seen that, but we a lot of patients aren't aware that besides the disc joints and the facet joints, there's a very large joint in their body that is felt to be the third leading cause of lower back pain. And that is uh a joint, it's actually two joints called the sacral iliac joint. And maybe you can show the audience where that joint's located.

SPEAKER_01 1:12

Here, I'll I'll bring it up to the screen.

SPEAKER_00 1:15

Perfect. So each one of these SI joints, they're both the largest surface area of any joint in the body. And it's basically the connection between your torso and your lower extremities. And there is a lot of stress and strain on the joint um with daily living, but especially if you do anything, uh people people who are in car accidents and slam on the brakes, brakes frequently injure their SI joint, um people who uh who are ballet, uh who do ballet, uh ice skaters who leap and jump frequent and land on one leg frequently injure this joint. Um and maybe you can tell them a little bit about what makes this joint unique. Why is it different than other joints?

SPEAKER_01 2:06

Yeah, so it's it's the largest joint in the back. Um it's got it only has about four degrees of motion uh in it. Very little motion. Uh so yeah, normal people with no SI joint problems, you have about four degrees of motion. Of course, some people can have a little bit more, especially if they have hypermobility. Um, but for the majority of people, it's not moving that much. Um and just like any other joint in the body, it can develop arthritis uh over time and it can get inflamed. Um when it gets when you have inflammation in there, you can get pain associated with that.

SPEAKER_00 2:41

Just like any other joint, yeah, we always talk about the knee joint. You know, it's it's it's when there's an injury that doesn't heal. Um that and that's what can happen to a sacraliac joint. Uh so the pain tends to be in your buttock, it frequently radiates to the groin. Um the one of the most well-known physical therapy, excuse me, physical exam diagnostic tests is called the Fortin finger test. You know Dr. Fortin. I I I he did train me. That's right. Thank you for remembering that. Um very incredible guy, but he uh he invented the Fortin finger test because they're trying to figure out you know what what's the best way to tell somebody has SI joint pain. Well the Fortin finger test is if they point with one finger right at the SI joint, the lower pole of the SI joint, they have SI joint pain. That's the highest level of diagnosis we currently have. Of course, like many joints in our bodies, if you do an injection to the joint, um, and we always use local anesthetic for diagnostic purposes. So uh even uh uh uh the highest level of diagnosis of whether this joint is a cause of your pain would be a diagnostic SI joint injection. And it can be therapeutic as well, obviously. That's why we uh offer a steroid. Um I agree.

SPEAKER_01 4:03

Yeah, it does tend to be very difficult to diagnose uh just on physical exam alone.

SPEAKER_00 4:08

Exactly.

SPEAKER_01 4:09

Yeah.

SPEAKER_00 4:09

And it's it's underappreciated. Uh a lot of patients have pain in their back that radiates over the SI joint, and you treat the back and they get partial relief of the back pain, but they still have this pain in their buttock, which you know, pain in the buttock can come from a disc joint, a facet joint, it could it can be something called referred somatic pain, right? Or it can be from nerve inflammation, it could be the you know, like ridicular pain. So when you have pain in your buttock, it's not automatically SI joint pain, but certainly suspicious. And then go sorry. I was just gonna say if you rule out other causes, then certainly you'd want to treat the SI joint. Maybe you'd like to talk about the treatment options.

SPEAKER_01 4:51

Yeah, and I'll just add to that. Um, the other confusing part for people about SI joint pain is it can radiate down the leg. It usually does not pass the knee. Um, although I've seen patients who have pain that radiates past their knee, you treat the SI joint, it gets better. So I I think this kind of goes with everything in this field. Exactly. Not everyone follows the textbook, and most people do not follow the textbook.

SPEAKER_00 5:17

It's so true. I mean, I I immediately think of all these anecdotes I've had over the years of of uh people who um people who had surgery on their knee or their hip, and then it turns out they have a back problem. Yeah. I mean, and then I I remember another guy, uh he was sent to me by an orthopedic group doctor and said, you know, pick this, you know, I think he needs a SI joint injection. And he had his pain over the SI joint. But then I talked to the guy, he goes, Well, it all started when I was swinging a golf club and I felt a pop in the middle of my back. And he goes, I go, do you have pain in your lower back and lumbar spine? No. I just feel it down here over my buttock, and I go, but it started there. And then I actually pressed uh on the uh in the lumbar spine, and he goes, Oh man, I'm tender there. So he was only feeling the pain in the buttock, but the pain was coming from his uh from his lower back, and we actually got an MRI, and he had a you can't usually see this, but he had actually one facet joint that had fluid in it. That I mean he'd injured a facet joint. And we injected that, even though he had no pain, that facet joint was. We injected the facet joint and took away his pain in his buttock. Wow. Anyhow, we we all have anecdotes like that.

SPEAKER_01 6:36

Yeah, yeah. Um well we're we're gonna talk about treatments of uh SI joint pain. By far no, no, no. Thanks for the I mean I I think this these stories though are w some of the most interesting part about this, uh about this podcast, and I and I think that um this that's really and the audience can tell us otherwise, but I I think that's what people like to hear because you know, these personal stories. Yeah, no, no. Um of course we we're gonna talk about the treatments and and the the you know the pathology behind uh some of these pain conditions, but I think people like to hear these stories.

SPEAKER_00 7:11

That's an excellent point. I mean we look we were we want to we want to make the science you know accessible uh to for everybody, but yeah, after all these years, all these patients I've treated, I've got a story about every single pain probably. But go ahead, talk about the treatments.

SPEAKER_01 7:27

Yeah, so uh, you know, treatment of SI joint pain, um, there should always be some type of physical therapy involvement um in SI joint pain that's that really helps you with uh body mechanics, um uh improving the pain condition over a long time, preventing a reflare up of uh of SI joint pain. So I always encourage patients that come in with SI joint pain to make sure that um you know they've either done physical therapy for they got some some sort of home exercise plan. It's also a lot of things that you can find on YouTube these days for SI joint uh therapy, and sometimes that's a nice uh ease in for patients who maybe you know they have a busy work schedule, they're not able to do uh physical therapy three times a week. Um, so I I I usually start with uh uh yeah, some sort of therapy. Anti-inflammatory medications can be another option. Um so things like NSAID uh medications, people think of ibuprofen neproxin can be helpful, Tylenol can be helpful for this condition. But a lot of the patients that we're seeing have tried some of these things before and they're coming to see us for uh more advanced options. So um, as you were alluding to before, something that can be diagnostic and therapeutic, and I feel like I say this a lot in clinic and and uh you know it really requires explanation. When we call a procedure that we do diagnostic and therapeutic, the diagnostic part is really answering a question. And there are some procedures that we do purely for a diagnostic purpose. So, you know, a person comes in and they've got a very particular pain, we look at their imaging and they've got, let's say, arthritis um throughout their spine. We may do a diagnostic uh procedure to try to isolate where what exactly is causing their pain. Where are where what joints in the back are causing the pain? So, in a very similar way, we could do that with sacroiliac uh joint pain or suspected SI joint pain. So if we suspect someone has SI joint pain, the the really the only gold standard way to prove it is by uh an injection into the SI joint. So injection of local anesthetic is the diagnostic part. If you feel better after that, this pain is coming from your SI joint. That's the way to prove that.

SPEAKER_00 9:50

And before you move on to other treatments, I want to reiterate how important that is because this comes up in lawsuits and workers' com cases. The you cannot tell what's causing pain from an MRI. You may have some suspicion, but unless it shows cancer or a fracture or you know something you didn't expect, you can't just tell like an MRI what's causing their pain. And that'd be you know, uh case in point, the most common cause of lower back pain is the facet joints. But because the facet joints aren't seen on the MRI as as um as um sort of as clearly as the disc joint, um radio just talk all about the disc joint. They'll do paragraph after paragraph about the appearance of the disc joint, and they won't say anything about the facet joint because it's just it's a different joint, it's smaller, it's at an angle from the from the uh the way they collect the information for the MRI scan. So you have all this information about the disc joint, patients read that, oh, it's gotta be my disc. Well, it's not the most common cause of pain is the facet joints. They may not mention the anything about the facet joints. And there might not be anything you can see because our imaging has not caught up with with, you know, it's better than it used to be, but it's not diagnostic. The procedures we do in the response to the local anesthetic, scientifically the most most accurate uh diagnostic uh uh criteria. There's there's just never been anything proven to be better than that. But go ahead with the treatment plan.

SPEAKER_01 11:29

Yeah, well, and and you talk about the utility of imaging in the lumbar spine and looking at the joints in the lumbar spine for the SI joint, it's there's there's really no imaging that you can do that has been shown to have a good correlation to uh to SI joint pain. There's no utility uh really in the imaging. Um sure, if you've got a very, very arthritic looking SI joint uh that just happened to be caught on an MRI, you know, could could it key you in maybe, but I I really put no weight on on any sort of imaging when I um am thinking about SI joint pain. Right. Um so the uh the injection that uh an SI joint injection, I talk about kind of it's a it's a joint. It's a joint, just like you have a knee joint, a shoulder joint, we we can inject into that joint to to provide pain relief. So um uh that injection includes local anesthetic and steroid typically. Um it's only a very small amount of volume, even less than I put in a knee or or or a shoulder, because this is this is a joint that typically does not have much at all in it. Two and a half milliliters, right? Yeah, yeah. Well, and and now I've even seen some coverage denials if you don't include uh that you will put less than two mls of fluid into the joint. It's just it's something interesting I've seen. So I've actually started to put in my notes sometimes that I will inject less than two mls purely for insurance reasons. It's crazy, but um uh yeah, so so uh steroid into the joint can help reduce uh inflammatory signals um uh uh in the joint um that that can result in pain. Um so SI joint injections can be very beneficial for people. Typically, we want them to last at the very least three months, ideally, much longer than that. Um we don't typically like to do uh more than uh you know one injection into the SI joint uh every three months. So you're talking about four times a year. There are some people where they maybe get great relief from an SI joint injection, but it just doesn't last. You know, let's say it lasts for a month, month and a half. Maybe they have some sort of occupation or some type of social uh uh reason why they tend to reflare their their SI joint uh more often than than other people. So you know, in the past there really wasn't much you could do about that besides for uh uh people would have SI joint, uh invasive SI joint fusions, surgical fusions.

SPEAKER_00 14:16

Surgical fusions, right.

SPEAKER_01 14:17

With um with screws that were placed uh through uh basically the the ilium or the the the hip through the sacrum. Um and and that was really the only way that you know that those were your two options. You could get injections or you could have a very large uh screw and and multiple screws placed through um the joint. Uh in the past few years, there have been just an explosion of of companies coming out with products for minimally invasive SI joint fusion. And uh infusion is is probably for some of these companies, even uh a large statement for what you act what the procedure actually is. Um in a very similar way that we do injections, we can use uh a needle in the joint uh to place bone allograft, um, which can cause a fusion. Um in by fusion we mean it it it stops that that motion that happens in the SI joint.

SPEAKER_00 15:20

There's little movement already, very little movement, and now we're gonna try to give it or make it less movement.

SPEAKER_01 15:26

Make it less movement, yeah, yeah. And um what I find uh kind of nice about uh at least one of the products that that we've really uh looked into is that patients don't need to be non-weight bearing afterwards. And for a lot of SI joint fusions, you do, you know, you do have to be non-weight bearing. So there are products that allow people to continue more or less uh a normal life after the procedure as well. Um and and the intent of of these minimally invasive SI joint fusions uh is to maintain pain relief past uh you know, hopefully well past uh that three month mark that usually it's the frequency that you could get SI joint injections. It's much more permanent. It's much more permanent, yeah, exactly. And uh at least this one, this bone allographed, doesn't prevent people from if they need surgery one day, they can have surgery. This is bone allographed in there, this is not metal.

SPEAKER_00 16:25

Yeah, like a lot of procedures are procedures, at least it's not burning a bridge where you know one fusion procedures for lumbar spine problems or sacral joint problems. I mean that's the ultimate, the nuclear bomb. That's when all else has failed. Now we have another procedure that's gonna be helping a significant number of patients. Probably not all of them, obviously. Nothing does in medicine, unfortunately, but it's safe and it's unique. Um and there's different ways to do this fusion. There's different there's a posterior approach and a lateral approach. Is that am I correct?

SPEAKER_01 16:59

Yeah, and there's a posterior lateral approach. So 45 of these companies. I think my last count was 45 of these companies. Uh let's not bore the yeah, yeah, we won't bore, but there's a lot of different options right now. Um, and I think a lot of pain docs right now are also going through this evaluation phase to figure out you know what product seems to be the best. Um, you know, and in and really that just involves us uh doing our due diligence, looking at the research, um, looking at uh, you know, of course, if you could get a non-industry sponsored study, that would that would be ideal. That's not always the case, but you could still have uh good studies um that that help us evaluate what would be um the best product for a particular patient.

SPEAKER_00 17:44

And I'm excited about the fusion devices too, but you know, we did kind of skip over uh there is another option uh short of that, uh, which involves similar to the facet joints, you can denervate uh the SI the SI joint. The the sensory innervation SI joint is pretty well known. Um it comes from the L5 dorsal ramus, S1 lateral branch, S2 lateral branch, S3 lateral branch. There's four nerves that innervate the SI joint. And insurance companies don't love it, but you know, it's like another thing that we don't have a as much science behind as we I wish we did. But it certainly has been shown to be helpful for a certain number of patients. Either the nerve block itself, just like facet joints, it's diagnostic in some patients it's therapeutic. If it's diagnostic but not therapeutic, you can try a radio frequency ablation of these four nerves, very similar to the way you you treat a facet joint. And I've been doing these for years, and you know, can I guarantee success? No. But a patient up until these creation of these new fusions, there was no other option uh for these patients, except a major spinal, you know, spinal surgeon uh uh fusion of the SI joint. So I'm really excited about the fusion devices. There is a step, you know, just to just to go back and put it all together. If you got pain in your right in your buttock and it's not going away, it may be SI joint pain. Umly way to prove that is with an injection. X-ray guided fluoroscopic injection where we can inject dye and we see the contrast going up in both planes of the joint. And uh if that doesn't provide long-term relief, there's the nerve blocks and radio frequency ablation or there or and or fusion, uh, these minimally invasive fusions. Um it's exciting stuff.

SPEAKER_01 19:42

Yeah. All right. Anything else you wanted to add about SI joint?

SPEAKER_00 19:47

No, I bet you people are falling asleep.

SPEAKER_01 19:49

Yeah, probably. Um well, maybe uh me next time you want to talk about lumbar spinal stenosis.

SPEAKER_00 19:55

Yeah, I know we talked about the minute man, but I think uh which would which um talk about mild? Right. Talk about mild minute man, um, and just the symptoms and what people who with spinal stenosis uh the kind of things they suffer. Thanks a lot. I appreciate it.

SPEAKER_01 20:13

Yeah, all right. Thanks, Dr. Glazer. Thank you everyone for tuning in. Uh uh again, Max Mide's Life Advanced in Pain Treatment. We'll see you in the next episode.