[GJZH]

I was wondering if anyone has Sacroiliac Joint Dysfunction and if you have it, did you have surgery for it? Has the surgery been successful? As I read more about this I think this might be a part of my pain and problems since my surgery. When I read this article it describes my pain, during the night especially. I really do not want more surgery. If you have had surgery, has it been successful for you? This seems like a very big surgery...I was wondering the success for it. Does anyone know?

A Patient's Guide to Sacroiliac Joint Dysfunction

http://www.eorthopod.com/eorthopodV2...f61e50b/area/5


Introduction
A painful sacroiliac joint is one of the more common causes of mechanical low back pain. Sacroiliac (SI) joint dysfunction is a term that is used to describe the condition - because it is still unclear why this joint becomes painful and leads to low back pain. Sacroiliac joint dysfunction can be a nuisance but it is seldom dangerous and rarely leads to the need for surgery. Most people who suffer from this problem can reduce the pain and manage the problem with simple methods.

This guide will help you understand

how the problem develops
how doctors diagnose the condition
what treatment options are available
Anatomy
What part of the back is involved?



At the lower end of the spine, just below the lumbar spine lies the sacrum. The sacrum is a triangular shaped bone that is actually formed by the fusion of several vertebrae during development. The sacroiliac (SI) joint sits between the sacrum and the iliac bone (thus the name “sacroiliac” joint). You can see these joints from the outside as two small dimples on each side of the lower back at the belt line.

The SI joint is one of the larger joints in the body. The surface of the joint is wavy and fits together similar to the way Legos® fit together. Very little motion occurs in the SI joint. The motion that does occur is a combination of sliding, tilting and rotation. The most the joint moves in sliding is probably only a couple of millimeters, and may tilt and rotate two or three degrees.

The SI joint is held together by several large, very strong ligaments . The strongest ligaments are in the back of the joint outside of the pelvis. Because the pelvis is a ring, these ligaments work somewhat like the hoops that hold a barrel together. If these ligaments are torn, the pelvis can become unstable. This sometimes happens when a fracture of the pelvis occurs and the ligaments are damaged. Generally, these ligaments are so strong that they are not completely torn with the usual injury to the SI joint.

The SI joint hardly moves in adults. During the end of pregnancy as delivery nears, the hormones that are produced causes the joint to relax. This allows the pelvis to be more flexible so that birth can occur more easily. Multiple pregnancies seem to increase the amount of arthritis that forms in the joint later in life. Other than the role the joint plays in pregnancy, it does not appear that motion is important to the function of the joint. The older one gets, the more likely that the joint is completely ankylosed, a term that means the joint has become completely stiffened with no movement at all. It appears that the primary function of the joint is to be a shock absorber and to provide just enough motion and flexibility to lessen the stress on the pelvis and spine.

Causes
What causes this problem?

There are many different causes of SI joint pain. Pregnancy may be a factor in the the development of SI joint problems later in life. Also, if a person has one leg is shorter that the other, the abnormal alignment may end up causing SI joint pain and problems. Often, an exact cause leading to a painful SI joint condition can't be found. The joint simply gets painful, and the patient and provider don't have an answer as to why the joint has become painful.

The SI joint is a synovial joint, similar to all joints such as the knee, hip and shoulder. Because of this, different types of arthritis that affect all the joints of the body will also affect the sacroiliac joint. This includes conditions such as rheumatoid arthritis, gout and psoriasis. The joint can be infected when bacteria that travel in the blood settle in the joint causing a condition called septic arthritis. This is perhaps the most worrisome cause of SI joint pain and may well require surgery to drain the infection.



Injury to the SI joint is thought to be a common cause of pain. Injury can occur during an automobile accident. One common pattern of injury occurs when the driver of a vehicle places one foot on the brake before a collision. The -->magnetic resonance imaging (MRI) scan can be used to look at the lumbar spine and pelvis in much more detail and to rule out other conditions in the area. The MRI scan uses magnetic waves rather than x-rays and shows a very detailed picture of the soft tissues of the body.

A computed tomography (CAT) scan may also be used to show a much more detailed look at the bone of the pelvis and the sacroiliac joint.

A bone scan is useful to see how the skeleton is reacting to any type of "stress," such as an injury, an infection, or inflammation from arthritis. This test involves injecting chemical "tracers" into your blood stream. The tracers then show up on special spine X-rays. The tracers collect in areas where the bone tissue is reacting strongly to some type of stress to the skeleton, such as arthritis and infection of the SI joint.

The most accurate way of determining whether the SI joint is causing pain is to perform a diagnostic injection of the joint. Because the joint is so deep, this must be done using X-ray guidance with a fluoroscope (a type of realtime X-ray) . Once the doctor places a needle in the joint, an anesthetic is injected into the joint to numb the joint. If your pain goes away while the anesthetic is in the joint, then your doctor can be reasonably sure that the pain you are experiencing is coming from the SI joint..


Treatment
What treatment options are available?

Nonsurgical Treatment
Doctors often begin by prescribing nonsurgical treatment for SI joint dysfunction. In some cases, doctors simply monitor the patient's condition to see if symptoms improve. Anti-inflammatory medications, such as ibuprofen and naproxen, are commonly used to treat the pain and inflammation in the joint. Acetominiphen (for example, Tylenol) can be used to treat the pain, but it will not control the inflammation.

Your doctor may ask that you rest your back by limiting your activities. The purpose of this is to help decrease inflammation and calm the muscle spasm. Some patients benefit from wearing a special brace called a sacroiliac belt. This belt wraps around the hips to hold the sacroiliac joint tightly together, which may ease your pain.


Patients often work with a physical therapist. After evaluating your condition, a therapist can assign positions and exercises to ease your symptoms. The therapist may design an exercise program to improve the strength and control of your back and abdominal muscles. Some therapists are trained in manipulative techniques that attempt to treat the pain in this manner. You may be able to learn how to adjust your SI joint yourself and ease the symptoms. If your physical therapist is not trained in manipulation, he/she may be able to suggest a chiropractic physician or osteopathic physician in your area who can provide this treatment.

If conservative treatment is unsuccessful, injections may be suggested by your doctor. As described above, injections are used primarily to confirm that the pain is coming from the SI joint. A series of cortisone injections may be recommended to try to reduce the inflammation in and around the SI joint. Cortisone is a powerful anti-inflammatory medication that is commonly used to control pain from arthritis and inflammation. Other medications have been injected into the joint as well. A chemical called hyaluronic acid has been used for years to treat osteoarthritis of the knee. This chemical is thought to reduce pain due to its lubricating qualities and the fact that it nourishes the articular cartilage in the synovial joints. The true mechanism of action remains unknown, but it has been used with some success in the SI joint. All of these injections are temporary and are expected to last several months at the most.

Another procedure that has been somewhat successful is called radiofrequency ablation. After a diagnostic injection has confirmed that the pain is coming from the SI joint, the small nerves that provide sensation to the joint can be "burned" with a special needle called a radiofrequency probe. In theory, this destroys any sensation coming from the joint, making the joint essentially numb. This procedure is not always successful. It is temporary but can last for up to two years. It can be repeated if needed.



Surgery
Surgery may be considered if other treatments don't work. Surgery consists of fusing the painful SI joint. A fusion is an operation where the articular cartilage is removed from both ends of the bones forming the joint. The two bones are held together with plates and screws until the two bones grow together, or fuse, into one bone. This stops the motion between the two bones and theoretically eliminates the pain from the joint.


This is a big operation and is not always successful at relieving the pain. The operation is not commonly performed unless the pain is debilitating. SI joint pain is seldom this severe.

Rehabilitation
What should I expect as I recover?

Nonsurgical Rehabilitation
Doctors often recommend physical therapy for patients with SI joint dysfunction. Patients are normally seen a few times each week for four to six weeks. In severe and chronic cases, patients may need a few additional weeks of care.

When movement of a joint is limited, the pain and symptoms of SI joint dysfunction may worsen. Getting more motion can give you the relief you need for daily activities. If you don't have full range of motion, your therapist has several ways to help you get more movement including joint manipulation, stretching, and exercises. Active movement and stretching as part of a home program can also help restore movement and get you better faster.

Therapists commonly prescribe a set of stretches to improve flexibility in the muscles of the trunk, buttocks, and thighs. In addition to the treatment you receive by your therapist, you may be given ways to help your own SI joint if your pain returns. These exercises usually require that you position your hip and pelvis in a certain way and either stretch or contract and relax specific muscles. Follow the instructions of your therapist when doing these exercises.

If the SI joint has too much mobility and problems keep coming back, you may need extra help to stabilize the SI joint. You may be issued a SI belt to stabilize the joint. A belt like this can often ease pain enough to let you exercise comfortably.

You'll learn some exercises to help you build strength, muscle control, and endurance in the muscles that attach around the SI joint. Unfortunately, few muscles actually connect to both the sacrum and the pelvis. Key muscles to work are the gluteus maximus, as well as the abdominal and low back muscles.

After Surgery
You will normally need to wait at least six weeks before beginning a rehabilitation program after having SI joint fusion surgery. You should plan on attending therapy sessions for six to eight weeks. Expect full recovery to take up to six months.

During therapy after SI joint surgery, your therapist may use treatments such as heat or ice, electrical stimulation, massage, and ultrasound to help calm your pain and muscle spasm. Then you'll begin learning how to move safely with the least strain on the healing area.

As your rehabilitation program evolves, you'll begin doing more challenging exercises. The goal is to safely advance your strength and function.

As your therapy sessions come to an end, your therapist helps you get back to the activities you enjoy. Ideally, you'll be able to resume your normal activities. You may need guidance on which activities are safe or how to change the way you go about your activities.

When treatment is well under way, regular visits to your therapist's office will end. Your therapist will continue to be a resource. But you'll be in charge of doing your exercises as part of an ongoing home program.

[Curious]

i have spondylolisthesis from a back injury. mine has been progressive. last time a dr checked..i was at a stage 4. but oh man...what you posted is discribing the pain i have been having for the last few months. i have been over doing it getting ready to move.

can't help on the surgery part. i haven't had any for my back.

gentle hugs. back pain sucks!

[AK Kid]

Hello GJZH!

I suffer daily from pain originating in my SI joint. I was in the Army and during a pt test (after 3 days in the field, in full battle dress, carrying a 40 pound rucksack, and a 35 pound M-60 - my back herniated at L-5/S1 during the situps - I continued on with the 2 mile run though) I had severe cramps going up and down both legs and spasming at the same time. This was the worst run of my life - and at that point I had been running for 15 years - daily.

Suffice it to say that along with the low back injury - the SI joint pain is the worst.

I was told that the SI joint ligaments were torn. As a result in an office visit my doctor showed that one leg was longer than the other, because the more injured side had retracted.

As a result the joint has never worked the same since. I walk with a limp.

Apparently when the ligament is torn and frozen in a certain position it aggravates the SI nerve. I was only recently told about options for surgery but the neurosurgeon I spoke to talked about cutting the nerve completely - my Orthopedic Surgeon disagrees with doing that because then I would lose all feeling in my legs. After they both spoke another option was inserting a pain stimulator into the base of my back - supposedly that would also help with the SI joint pain.

Would your doctors consider the pain stimulator for you? At least it is reversable - which is not so with the more invasive surgeries.

While waiting for the pain stimulator - I cope by stretching, exercising and I see a chiropracter who manipulates me to pull out my legs. Meds cannot calm this pain - Ice packs work wonders.

All the best to you.....

Kim

[Bobbi]

Yep, I do. I've not had surgery, but my ortho. surgeon noted that I'm a "candidate" for bilateral SI Joint "arthrodesis."

He also stated (to me and in his written reports to my other docs) that a university surgeon would have to perform the surgery, since it's rarely done by those in private practice - at least in the area where I live (the nearest teaching university is UC Davis, and the nearest counties where I live are packed with hospitals that do perform myriad spinal surgeries, but not SIJ fusion).

To help ease the pain, I've had bilateral SI Joint injections (late in 2005 and early 2006); I've also had multi-level, bilateral pulsed RF (radiofrequencing) from the L-4 - S1.

My bone scans and CTs helped my docs in making the dx, thankfully (by that I mean, the films also helped positively rule out bone cancer, which was what the neuroradiologist was thinking was going on). The SI Joint probs., I can live with, as much as pain as it is; the bone cancer scare helped put stuff into perspective for me.

Other than fusion, what options have your docs mentioned?

For me, the surgery isn't "right" right now; my surgeons have assured that they will tell me when "it is time." (They've also my C- and T-spine that they're monitoring closely. No time, to me, would be the "right" time, but... .)

Because I do have Ankylosing Spondylitis (AS), and fusion is an effect, one "benefit" of the SI fusion would be to better assure that proper alignment has an increased chance of happening.

I had posted some links, I found helpful, here:

http://neurotalk.psychcentral.com/sh...17&postcount=2

[GJZH]

Bobbi, AK, and Curious,


Thanks for answering this post....It is the most response I have gotten from anyone on the boards...My pain doc suggested this to me as a pain generator. I asked the surgeon that did my cervical fusion a few weeks ago about it and he would not discuss it with me. He was just furious that I went ahead with the lumbar fusion.

I see the surgeon that did my lumbar fusion tomorrow...I am going to speak to him about this as being a possible pain generator. It makes sense to me since I have been reading about it.

The surgeon that did my cervical fusion has suggested a spinal cord stimulator for the pain, but I have been told since my pain is all over the spine it would not help much. I have cervical pain as well. They could only get rid of the pain in either the back or the legs too not both so I do not know how much good that would do either...It seems as though I would still be on drugs...and then be hooked up to wires...though it is something to think about....

I will talk to my surgeon tomorrow about the SI Joints to see what he determines...He is a smart guy and top doc....He knows more than any of them....

Have any of the treatments helped you Bobbi?

[Curious]

i don't post much about my back. why? don't really know. i'm in constant pain and have been for year and years. i have nevr been able to tolerate pain meds. i just can't function.

i do lurk. but i promise i will get more active here. i hope you get lots of feedback.

i'm glad you made the choice yourself about the fusion. i know it is the pits to have dr's not agree with treatments.

[GJZH]

Curious,

Thanks for posting...Please post more often....I think it is great that this site is here for us...and we need to keep it going....

Bobbi,

Thanks for the links....I am going to try to get to those tonight and print out material to read on my way into NYC tomorrow...I know you have been getting these injections for awhile Bobbi....Do they seem to help you?

My only problem is that I think I need facet and SI injections. Would they do both? I had hoped the cages they put into the front of the spine would have helped with the facets, but I think they have not...I need to ask tomorrow why they have not...At least on the right side they have not....I still have a lot of right sided pain...Unless, it is scar tissue...I had not thought about scar tissue, but that would be a possibility too, I guess...

Gloria

[Bobbi]

For me, the injections did help tremendously. I know that, for some, they either provide little relief or shorter term relief. Mine? The effects or benefits (pain relief) was longer lasting.

I think what helped was that my doc did other things (like testing, testing 1-2-3 ) and nerve blocks prior - to assess whether I was in the running as a candidate for, i.e., RF'ing.

I've had facets and nerve nuking of my C-spine, T-spine, L-spine and the good ol' SI Joints.

Because my doc does use steriods (though he can leave that component out), and with all the radiographic imaging I've had since my fall, I've not had any procedures in a while.

I was a bit worried about the cummulative toll everything combined was having on my body; my adrenal glands were acting screwy and it was also messing up my cycles - to the point (you may recall, and if not, that's okay) I was mis-dx'd as prematurely post-menopausal. That would have been okay, only it was incorrect and I spent so much time at labs, etc., being poked and prodded with U/Ss - since the lining measurements would have been too high if I were post menopausal; those levels were scaring my OB/GYN. Normal levels, though, for someone not post-menopausal.

Because the procedures do make the pain bearable (some of it, depending where, such as the scapulas, non-noticeable), I will have the procedures again, only without steroids in the mix.

Before my first procedure, I did cancel it; I just didn't know enough about it and was scared outta my mind. It was before I interacted with others whom are familiar with the procedures. Only people I was getting info. about ESIs from, for instance, was women whom have gone through childbirth. They had never heard of ESIs in the C-spine, etc.

Until I felt that I really understood the procedures, I waited.

If my foot could have reached, I would have kicked my own bum for waiting so long. Seriously.

Diff. docs approach things differently, as you know . Mine has a certain protocol he uses, and, so far, it's worked like a charm for my pain management.

I don't expect any of my doctors to be Mr. or Ms. Personality of the Year, yet it does help greatly when there is a solid rapport and the communication doesn't leave me feeling as if I may have understood, but that I do understand.

As you might also remember, I have a set of steps I also follow (created from trial-and-error) that I use before each procedure. I think that that has also helped me in the recovery time. If you do have any injections, and if you want the list, I'd be happy to share it . It's just simple things, but... they do work for me.


P.S.: I don't know if you've had a doc check out your PSIS (Posterior Superior Iliac Spine), yet that might be something to have looked at as well. Mine gets "knotted" at times. Too, if you've not had a bone scan or CT since the pain, it's something I'd also not rule out. Mine did discern inflammation, among other things.

[GJZH]

Bobbi,

I saw my surgeon on Thursday...He has ordered a test of the right sacroiliac joint only. I really think he should have ordered both since I think both sides are symptomatic, but that is just my way of thinking...

He thinks that the screw, looks to me to be about six inches long, into the pelvis for pelvic fixation, is causing the pain into the sacroiliac. They are going to do the injection next Thursday with both numbing medication and steroids. Please tell me what to expect with this and how to prepare.

If this is the pain generator, he will then do surgery to remove the screw into the pelvis. I really do not look forward to this, but another surgeon, the surgeon that did my cervical fusion, told me these screws break at about the two year mark. It might be a good thing to have it removed, but I really, really had hoped this would be last surgery. I really do not know though if this screw could be causing hip and sciatica pain too...We shall see....

[GJZH]

Bobbi,

Do you know anything of the following procedure? It seems rather simple or reads as a rather simple procedure....I think if they detect I have problems with the sacroiliac....this sounds like an option...but it does say that a contraindication is pelvis fixation...so that might rule me out...as usual...I have been reading up on sacroliliac fusion....It seems like a gruesome, fusion...Just the incison alone seems horrific...I am hoping the injection works..and I do not have to go the route of screw removal...



Sat., 10/11/03 Pediatrics/Spine, Paper #60, 11:49 AM

Iliosacral Screw Stabilization Guided with Computed Tomography for Treatment of Posttraumatic Sacroiliac Disease: Preliminary Report

Bruce H. Ziran, MD1; Dan J. Heckman, MD1; Wade R. Smith, MD2;

1University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA;
2Denver Health Medical Center, Denver, Colorado, USA
Purpose: The sacroiliac joint is a common location of chronic lower back and pelvic pain with many known causes. When a painful sacroiliac joint is refractory to nonoperative therapy and causes severe functional inhibition, fusion of the sacroiliac joint may be considered. The traditional techniques for sacroiliac joint fusion involve an extensive surgical exposure with union rates of 60 to 85%, but the risks of bleeding, neurovascular injury, and infection are significant. A surgical protocol for sacroiliac joint stabilization without formal joint exposure and grafting, stemming from a technique described previously for fixation of posterior pelvic ring fractures, was evaluated. Our hypothesis was that, instead of achieving true arthrodesis, stabilization of the sacroiliac joint with the described technique would sufficiently stabilize it to provide ongoing relief. We report on the preliminary clinical outcomes and efficacy of this technique for treatment of sacroiliac joint disease.

Methods: Seventeen patients with chronic sacroiliac joint pain after some traumatic event, ranging from low-energy lifting and twisting, childbirth, to a nonoperatively treated posterior ring injury, were treated. Patients who had had prior posterior pelvic fixation were excluded. All patients underwent out-patient percutaneous CT-guided sacroiliac joint fusion with use of conscious sedation and local anesthesia. With use of the technique, at least one screw was placed into both S1 and S2, with an occasional third screw if sacral morphology permitted. Preoperatively, diagnostic CT-guided sacroiliac joint bupivacaine-steroid injections were used to confirm the sacroiliac joint as a source of pain and to quantify the response to intervention. Pain levels, evaluated by using a visual analog scale from 0 to 10, were assessed before injection (PRE-I), after injection (POST-I), and at the last follow up after fixation (FIX). Univariate analysis was used to compare interval scores, and Spearman correlations were performed to compare relations between pre- and post-injection and final scores. Only patients who experienced some pain relief after the diagnostic injection were offered the procedure. Perioperative and outcome data were recorded, including procedure time, amount of local anesthetic and intravenous sedation used, complications (infection, blood loss, nerve injury, or technical failure), accuracy of screw placement, pain relief, and cost. All procedures were performed on an outpatient basis, and patients were restricted to partial weight-bearing with an assistive device for 6 weeks. No other restrictions applied. At the first follow-up examination, patients were evaluated for their recall of the procedure.

Results: Forty-nine iliosacral screws were placed in 17 patients (10 women, 7 men) with a mean age of 35 years (range, 24 to 45) and a mean follow-up of 24 months (range,11 to 48). There were no complications, technical difficulties, or misplaced screws. The mean procedure time was 26 minutes per screw. The average amount of intravenous sedation was 142 mcg of fentanyl and 3 mg of versed, and the average amount of local anesthetic was 19 cc of lidocaine and 11 cc of bupivacaine. The mean pain levels were 8.3 (range, 3 to 10) PRE-I, 3.5 (range, 0 to 8) POST-I, and 3.3 (0 to 9) FIX. Overall, four patients (17.6%) had complete and 11 patients had significant pain relief at the final follow-up examination. Two patients (11.8%) experienced little to no pain relief; however, both suffered from multiple pain sources not of sacroiliac origin and had a limited response to the preoperative injection. None of the patients experienced increased pain after the procedure, and there were no infections or hardware or technical complications. Patients had little recall of the procedure. Univariate analysis found statistically significant differences between the patient's response to the diagnostic injection (PRE-I vs. POST-I, P <0.0001) and the patient's final condition compared with that before the procedure (PRE-I vs. FIX, P <0.0001) but not between the post-injection state and the final condition (POST-I vs. FIX, P = 0.8906). A statistically significant correlation (Spearman coefficient +0.57, P <0.02) was found between final pain score (FIX) and the magnitude of response to the diagnostic injection (difference of POST-I to PRE-I). Surgeon/implant/medication fees for the procedure averaged approximately $2600 per case as compared with the cost for standard sacroiliac screw placement in the operative suite ($12,500).

Conclusions: In the present study, we found that CT-guided stabilization of the sacroiliac joint for chronic dysfunction seems to provide satisfactory relief of sacroiliac joint pain. We found that patients with the greatest response to the diagnostic injection experienced a higher likelihood of pain relief. We surmise that by using two screws with some separation, the sacroiliac joint may be sufficiently stabilized that either a stable ankylosis or a spontaneous fusion occurs. Although we did not perform a CT evaluation of the sacroiliac joint looking for bony fusion, it is possible that, in the absence of such a phenomenon, there would be loosening over time and recurrence of symptoms. Thus far, this has not happened and the poor results appear related to selection criteria. Because the cause of vague and recalcitrant pelvic pain is complex, a diagnostic injection is not only important but also prognostic of response to treatment. The percutaneous approach under conscious sedation minimizes procedure time, recovery time, and complication rates relative to open fusion techniques. The results of this study are useful for traumatologists because we are often consulted regarding posttraumatic pelvic pain.