SI Joint Introduction

The sacroiliac joints are common, under-recognized pain generators in the low back area. I had my lumbar spine surgically fused twice before SI pain was even suspected. SI pain is twice as common in women (often initiated or exacerbated by pregnancy) as in men. Below is information I've picked up about the SI joint in a search for diagnosis and treatment of my severe, incapacitating SI pain.

Anatomy

Pain Scenario and Diagnosis

Sacroiliac joint pain is often mistaken for low back pain. Pain from a degenerating disc can be referred to the SI joint areas, so SI joint pain can often be mistaken for disc pain. The discogram tests I underwent in August 1998 demonstrated (in a very convincing manner) that my L5-S1 intervertebral disc was a source of my pain. Six months after my last spine fusion, an injection of local anesthesia into my right SI joint relieved 75% of my pain for 3 hours. This indicates that the SI joint was contributing to my pain at the time of the discogram or that the SI pain arose after the surgery.

In recent years several physicians have manipulated my SI joint in an attempt to see if it was the source of my pain. A dysfunctional SI joint is often painful to the touch. Manipulation which tends to open or collapse the joint (i.e. contraction or extension of the hip girdle) can replicate the pain as well. These tests were unable to demonstrate my SI problem. The message here is that if you suspect that SI joints may be a problem, negative manipulation tests do not rule out the problem (this assertion is supported by recent research published in Spine). Get the diagnostic injection.

In August 1999 an anesthesiologist injected cortisone into my right SI joint. This potent anti-inflammatory had no real effect on the pain. The day after the injection was REALLY painful (a common reaction to cortisone). Two days after the injection things felt a bit better than normal. Since that time I have not noticed any difference. This injection was done flouroscopically (with contrast dye, under x-ray visualization). It is imperative that SI injections are performed flouroscopically. The joint is so formed that injecting anesthesia into the wrong part can give inaccurate results. The lower part of the SI joint is "synovial"; like a knee joint, it has a fluid-filled capsule which allows for smooth (if minor) motion. The upper part of the SI joint comprises two fairly rough surfaces attached with numerous ligaments. It is important to insure that the anesthesia is injected into the synovial sack (this requires flouroscopy), otherwise the anesthesia is more likely to leak out and affect neighboring nerves, giving a false-positive.

In early September, 1999 I had some more diagnostic injections. A spine surgeon injected local anesthesia and cortisone into the area of the L4-S1 nerve roots on the right side. This procedure failed to affect my pain and seems to indicate that my pain is not of lumbar spine origin.

The question arises: were the spine fusions a mistake? At this time I am guessing that my original pain had at least two places of origin: the L5-S1 disc and the right sacroiliac joint. For those suffering with sacroiliac joint problems, the WORST possible orthopedic surgery is lumbar spine fusion. Loss of motion in the lumbar spine is directly compensated for by increased motion in the sacroiliac joints. My pain diagnosis was incomplete. It relied on a pain provocative test known as a discogram (see main page). The discogram demonstrated pain originating in the L5-S1 disc, but it did not rule out additional sites contributing to the pain. If I had undergone diagnostic injections of local anesthesia into various places (discs, facets, sacroiliac joints, pyriformis muscles, etc.) it is likely that ALL my pain sites would have been found. Presumably, if local anesthesia were injected into the L5-S1 disc, it would not have taken away all my pain, and we'd have known to look for additional pain generators.
 
 

Non-Surgical Treatment Options

The first thing to do when you get a reliable diagnosis of SI joint dysfunction is to be put under the care of a REALLY GOOD physical therapist, preferably one with lots of experience treating SI joint dysfunction. The joint can be well stabilized by strengthening various hip and low back muscles. If this fails, here are 7 more treatment options. They are not in any particular order and your physician can discuss their relevance to your situation. There is abundant information on the web about many of these treatments.

Sacroiliac Joint Belt: This device is essentially a thick belt that wraps around the pelvic girdle. When cinched down, it can decrease SI joint motion up to 30%. It reduced my pain by about 20%. Be sure you wear these belts correctly or they won't work at all (they are worn 2-3" lower than a normal belt). These devices are simple and inexpensive, check out backmagic.com for purchase online.

Prolotherapy: A saline solution is injected into the sacroiliac joint ligaments, a little bit at a time, at many sites along the joint. This leads to local inflammation, increased circulation, and an eventual firming of the joint tissues. I have not tried this procedure. It often takes months to begin working. Those people who gain relief from this approach are LOVING IT! There are no significant risks involved.

Synvisc Injections: Synvisc is a lubricating fluid that is injected into the joint capsule. It seems to rejuvenate it and reduce pain for some people. This procedure is new. I haven't tried it. It doesn't sound very risky.

Manipulation Under Joint Anesthesia: As it sounds, this procedure involves anesthetizing the joint and then having it forcefully manipulated. It involves several sessions with an anesthesiologist and a chiropractor. I haven't tried it but it sounds safe and is claimed to be effective. This seems like an especially appropriate treatment for an SI joint that is "locked in the wrong position".

Radiofrequency Lesioning: SI sensory nerves are cooked with radiofrequency needles. These deadened nerves usually re-grow in 6 months to 2 years. This procedure often fails because neighboring nerves begin sending the pain signals in place of the deadened nerves. Also, the joint is very complex and many of the nerves are difficult or impossible to get to (such as those innervating the anterior SI ligament).
I underwent RF lesioning of my right SI joint in late October, 1999. The procedure was a breeze (they used a sedative called versed, it made me forget everything). Unfortunately, all I got out of it was a numb spot on my butt cheek, the pain remained. In fact the pain was worse for a while, but that may merely have been from the mechanical irritation of the numerous needle entries into the joint area.

Neuroaugmentation: For some reason, sending a constant, weak, electrical impulse through a nerve tends to decrease the severity of pain signals it may carry. Implanted devices designed for this function can be used to decrease pain carried by sacral nerves.
During one of my diagnostic spine injections, the surgeon "poked at" my L5 nerve root with the needle, this replicated my pain precisely; the L4 nerve was painless. This indicates that the L5 nerve root is carrying some (maybe a lot) of the pain. Since sacral neuroaugmentation focuses on the sacral nerves, not the lumbar nerves, I may be a poor candidate for this.
Recently I experimented with Spinal Cord Stimulation as a means to control my pain.

Morphine Pump Implantation: An implanted morphine pump can deliver morphine directly to nerves carrying pain signals, thereby potentially cutting the pain by quite a bit.
I underwent a trial spinal injection of morphine in December, 1999. It did reduce the pain markedly, but not enough to get me out of bed more than 1/2 hour per day. Significant side effects I suffered were nausea, itching, and urine retention; I am told these side effects diminish with time. My experiences with spinal morphine were not good enough to make it a more appealing option than SI joint fusion.

None of these options are likely to relieve all the pain, and in many, the chances of acceptable pain relief are scarcely better than fusion. The good thing about these procedures is that the risks associated with them are small, especially when compared to SI fusion.
The last three procedures don't actually seem to fix the problem, they merely cover it up. The SI joint is actually a very durable joint; the likelihood of it "falling apart" because pain signals were ignored is extremely small. Therefore, if we re-define the SI problem as "unnecessary pain arising from an otherwise functional structure", we can contend that successful Band-aid procedures are valid and fusion is not!

Surgical Fusion of the Sacroiliac Joint

On February 16, 2000, an orthopedic surgeon fused my right sacroiliac joint. He made a 12" vertical incision in my low back/hip area and proceeded to remove the posterior superior iliac spine, the bony protuberance which overlies much of the SI joint. After this was removed, he scraped out the joint capsule and connective ligaments and prepared the subtending bone for fusion. Then he packed the pulverized posterior superior iliac spine bone tissue into the joint space. This done, he bolted the joint together with a 17mm titanium bolt (see below).

I was in the hospital for 3 nights after this experience. Recovery was certainly painful but distinctly easier than recovery from posterior L4-S1 spine fusion.

SI joints can also be approached from a frontal incision. I have heard of fusions involving no hardware, fusions involving up to 3 screws, and fusions involving metal plates. People who have had lumbar spine fusions are not good candidates for SI fusion surgery. The lost mobility in the lumbar spine results in increased stress on the SI joints, inhibiting bone fusion. Furthermore, even if good bony fusion is attained, other joints in the area can react badly to the increased stress. These factors are responsible for the abysmal success rate of SI fusion in people with prior lumbar spine fusions. I would place the success rate at about 65%.

In my case, there is ample x-ray evidence of good bony fusion at the erstwhile SI joint; my pain may be arising from elasticity of the new bone.
 

Final Observations

The question is "has the SI fusion been worthwhile?" So far, the answer is yes. My recovery is glacially slow (much slower than normal), but I am better than I was before the SI fusion. After my second spine fusion (L4-S1), I could tell within 2 weeks that it had not addressed my pain at all. My pain sensation and pattern is distinctly different now (and better). It still keeps me in bed all day, but at least I’m not writhing in pain. The pain is, as it always has been, restricted to my (erstwhile) right SI joint; it is an intense, dull ache. Sometimes it is relieved when I get up (but more often the opposite is true). Evenings are often quite painful.

A disturbing new symptom arose after the SI fusion: my right leg now turns purple when I stand up! It is not painful but the skin on my right leg is drier and shinier - malnourished due to poor blood flow? Occasionally, my right foot gets cold too. This condition almost certainly arises from dysfunction of the sympathetic nervous system.

There is surprisingly little sacroiliac joint information out there. It is a very poorly understood joint. To my knowledge, there is no existing medical book dedicated to the SI joint, although numerous spine books have chapters about it. For an excellent in-depth discussion of sacroiliac joint anatomy, go to Dr. Wazman's SI joint anatomy page.

Thoracolumbar Junction Syndrome has symptoms very like those of sacroiliac joint dysfunction. It is downright uncanny.... If your pain scenario indicates SI problems, check out the above hyperlink before you do anything else. SI joint dysfunction and Thoracolumbar Junction Syndrome can exist together, again highlighting the value of diagnostic injections.

The pyriformis muscle is in the pelvic area and often masquerades as SI/low back pain; see the search engines for more detail.

I don't normally link to private pages, but Kalindra's is a special case. She has posted numerous professional papers and lots of other great SI info too.

An excellent place to learn more about SI problems and solutions is the Delphi Sacroiliac Forum. In order to do more than just read other people's postings, you will have to register with Delphi.com (they host thousands of forums). It is a great group of caring, knowledgeable, and experienced SI sufferers (and even a Dr. or two). These lucky people have undergone just about every SI procedure you can think of and they are more than willing to share their experiences.

This posting discusses a patient's positive experience with the diagnosis of sacroiliac joint dysfunction. A new procedure, sacroiliac joint debridement, is also described. Please e-mail me if this link goes dead.