Low Back Pain’s Missing Piece - PowerPoint Presentation

Low Back Pain’s Missing PieceDiagnosing the Sacroiliac Joint

OverviewIntroductionAnatomy of the SpineUnderstanding Lower Back PainDiagnosing SI J oint Dysfunction Treatment OptionsSummary and Q&A 2

EpidemiologyUp to 85% of all people have lower back pain (LBP) at some point in life2nd only to common cold in office visits 15 million office visits annually5 th ranked cause of hospital admission Annual direct and indirect costs have reached $86 Billion 3

Sacrum Cervical spine Thoracic spine Lumbar spine 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 4

Anatomy – Where is the SI Joint? 5

Anatomy – LigamentsStrong ligaments encase each jointLigaments affect stability If damaged, may have excessive motionExcessive motion may inflame and disrupt the joint and surrounding nerves 6 Sacroiliac ligaments

Anatomy – Nerve Supply of PelvisNerves exit Lumbar Spine & SacrumProvide sensation to legsSeveral levels innervate the SI Joint 7

SI Joint Dysfunction : Causes Common causes: D egenerative disease H istory of trauma P regnancy/childbirth Lumbar Fusion other unknown reasons Disruption due to: Injury, traumatic event or repetitive traumaor may suffer from sacroiliitis (swelling) 8

SI Joint Dysfunction: Symptom Presentation L ow back pain Buttock pain Thigh pain Sciatic-like symptoms Difficulty sitting in one place for too long due to pain 9

Diagnosing: SI JointSI Joint – being “rediscovered”Not usually part of LBP work-upOften misdiagnosed or not evaluatedPhysicians are not trained to look for it Proper diagnosis is importantPain can mimic discogenic or radicular low back painPotentially leading to misdiagnosis and lumbar surgery 10

Diagnosing: ImagingPlain film, CT scan, & MRI may be ordered Often misleadingOne study, CT scans were negative in 42% of symptomatic SI joints 1 MRI has not been proven to have positive correlation11 1. Elgafy H, Semaan HB, Ebraheim NA, et al. Computed tomography findings in patients with sacroiliac pain. Clin Orthop Relat Res. Jan 2001;112

Diagnosing: CriteriaCriteria 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. 12 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

Diagnosing: Pain LocalizationFortin 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. 13 From Forst SL et al. Pain Physician 2006. 1. Fortin JD. Am J Orthop 1997;26(7): 477-80.

Diagnosing: Provocative TestsDistraction TestThe sacroiliac joint is stressed by the examiner, attempting to pull the joint apart Compression TestThe two sides of the joint are forced together. Pain may indicate that the sacroiliac joint is involved. Gaenslen's TestLay 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. 14

Diagnosis: SI Joint InjectionsSI 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 . 15

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 . 16

Treatment: SI BeltsSI Belts:Wraps around the hips H old the SI joint tightly together Reduce motion to reduce painGoal: Decrease joint mobility 17

Treatment: Physical TherapyPhysical TherapyLumbar stabilization program: strengthening abdominals and buttock muscles Improve flexibility in lower extremity musculature Lower back stretchesGoal: Decrease mobility 18

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

Treatment: Radiofrequency AblationRadiofrequency Ablation: “Burns” small nerves that provide sensation to SI joint In theory, this treatment:Destroys any sensation M akes joint essentially numb Not always successfulTemporary, nerves regenerateTreats symptoms, not joint mobility20

Treatment: iFuse Implant SystemStabilization of SIJMinimally InvasiveSmall incision Doesn’t require bone for fusion Short procedure length ~ 1 hour Restores q uality of life 21

Treatment: iFuse Implant System 22

iFuse Implant TechnologyWhy 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 23 r=3.5 mm 12.124 mm R=7mm

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

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

SummarySI joint dysfunction is underdiagnosedHave your physician examine SI joint , diagnosis to confirm or rule out If SI joint is diagnosed, treatment goals: Reduce symptoms Stabilization of SI jointIf recurrent pain after treatment, consider a minimally invasive surgical stabilization 26

Questions & Answers 27