Chapter 3

The Importance of Diagnosing SI Joint Disorders in Surgical Practice

The clinical literature shows that between 15 and 25 percent of patients presenting with low back pain have the sacroiliac joint as the source of their pain. 

The sacroiliac joint is subject to both internal and external forces and can be affected by a variety of processes or problems just like any other joint in the body.  One of those problems could be an inflammatory arthritis or autoimmune problem such as rheumatoid arthritis or ankylosing spondylitis. 

The SI joint can become degenerative because of trauma, either acute trauma such as a motor vehicle accident or a fall or a chronic repetitive trauma. In some series, up to 50% of the patients with sacroiliac joint disorders or pain had reported a precipitating traumatic event. The joint could also be subjected to increased stress as a result of being next to a lumbar fusion.  We call that adjacent segment degeneration.

Another common problem with the sacroiliac joint is that it becomes hypermobile.  This would typically occur in a middle-aged woman.  Women are somewhat more ligamentously lax than men and it commonly occurs in women who've had multiple pregnancies.

It's very common for pain arising from the sacroiliac joint to present as pain coming from a facet source, a discogenic source, potentially an intra-pelvic or abdominal source, or even coming from the hip joint. A patient with sacroiliac joint disorders may even present with radicular symptoms with pain radiating down the leg.

Wexler has shown that there are many patients with sacroiliac joint disorders that have been misdiagnosed and ultimately come to have a lumbar fusion instead of treatment of the sacroiliac joint.

Sacroiliac joint disorders should always be considered in patients presenting with low back pain complaints. Many patients with sacroiliac joint disorders are mistreated for discogenic pain.


Dr. Reckling is an Employee of SI-BONE Inc.

The iFuse Implant System is intended for sacroiliac fusion for conditions including sacroiliac joint dysfunction that is a direct result of sacroiliac joint disruption and degenerative sacroiliitis. This includes conditions whose symptoms began during pregnancy or in the peripartum period and have persisted postpartum for more than 6 months. There are potential risks associated with the iFuse Implant System. It may not be appropriate for all patients and all patients may not benefit. For information about the risks, visit: www.si-bone.com/risks

"Sacroiliac joint dysfunction should always be considered in patients presenting with low back pain complaints. The sacroiliac joint has been shown in several large clinical studies to be the pain generator in large series of low back pain patients. It's very important to be aware of this and to be looking for it when working these patients up.

If the knee jerk reaction is simply to perform a lumbar fusion because the patient has two black discs on their MRI, the results are not going to be optimum. If the patient has pain arising from the sacroiliac joint, then the sacroiliac joint should be addressed and treated.

The focus of the orthopedic and neurosurgical community has been the intervertebral disk and the spine and we've concentrated and focused on decompression surgeries, fusion surgeries, really paying attention more to the vertebral column than the sacroiliac joint. This is slowly changing as we become more aware of the diagnosis and of the treatment options for it.

We know, and it's very well-documented in the literature, that when you do a lumbar fusion you transfer the stress that would typically be absorbed at defused levels to the levels of the spine above and below the fusion. Well, the next level below a lumbosacral fusion would be the sacroiliac joint, and the literature is full of examples of degenerative change at the sacroiliac joint after a lumbar fusion.

Ha published a great paper in spine a couple of years ago. He performed a prospective study looking at patients who are about to undergo a lumbar fusion and then followed them up with a CT scan five years later. He showed that there was a 75% incidence of degeneration at the sacroiliac joint after a lumbar fusion.

In my clinical practice, I've had several patients over the years that have had a successful or solid lumbar fusion that continued to have pain. This would support the premise that the pain is coming from multiple or different anatomic areas. There's another pain generator causing discomfort. It's my opinion that the sacroiliac joint is often the second or undiagnosed pain generator.

It's very common for pain arising from the sacroiliac joint to present as pain coming from a facet source, a discogenic source, potentially an intrapelvic or abdominal source or even coming from the hip joint. A patient with sacroiliac joint dysfunction may even present with radicular symptoms with pain radiating down the leg.

Wexler has shown that there are many patients with sacroiliac joint dysfunction that have been misdiagnosed and ultimately come to have a lumbar fusion instead of treatment of the sacroiliac joint. Many patients with sacroiliac joint dysfunction are treated for discogenic pain.

I have become much more aware of sacroiliac joint dysfunction as a true clinical entity. In my practice, I'm looking for sacroiliac joint dysfunction during my history in physical exam procedures. I'm also much more open to treating the sacroiliac joint either instead of or in addition to treating the lumbar spine.     

In my practice, I try and treat the pain generators, both those coming from the sacroiliac joint and those coming from the spine, both surgically and non-surgically and based upon this clinical experience, the sacroiliac joint and potential dysfunction and pain arising from the joint are one of the very first things that I rule out or rule in my workup and treatment of these patients that present with low back pain."