SI Joint - A Component of Low Back Pain

Steven Garfin, MD

During an SI-BONE event at the 2011 NASS meeting, Dr. Steven Garfin presents on the sacroiliac joint as a component of low back pain.

In this presentation, Dr. Garfin discusses:

  • The causes of sacroiliac joint pain
  • A female patient, a horseback rider, who suffered a fall that damaged her SI joint

Disclosures - Dr. Garfin is a paid consultant and ownership interest in SI-BONE Inc.

All patient data presented were from patients treated for sacroiliac joint disruptions or degenerative sacroiliitis.

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

"Hi, I’m Steve Garfin.  I’m from San Diego.  While Jeff is lining things up, I’ll just tell you how I got involved in this.  I know where the SI joint is, but it’s not part of anything clinical.  And they had a summit, and they had some, to me, very prestigious people, including Mark Reiley who’s one of the brightest people I’ve ever met and clinical very clever if that’s the word.  But also David Polly, Mark Swiontkowski, John Sembrano.  Had some really strong people, John Glazer, who talked about the SI joint like it was a real thing, like it really could create symptoms, and there may be some treatment considerations that for over 25 years I’ve completely missed.  So Mike Moore, who’s here, would say you’re exactly right.  You’ve missed it for at least since 1992, since he got involved.  

So I’m just gonna go and sorta show you very fast a snapshot of what I learned and what I’ve since learned and understand about the SI joint and what’s out there.  And I am a consultant for SI Bone and being a naysayer, the obvious thing was for Mark and Jeff to appoint me to PI for the their national study.  Anyhow, overview, so who has SI joint pain?  It is a diagnostic challenge, which Dave Polly will talk about later, but SI joint of course is at the hip and the lumbar spine and can create symptoms in either location that are confusing and confounding.  And then what do you do with it?  And is there a diagnostic algorithm or best direction?  And I think Dr. Ferguson will talk about that.

So the SI joint is a sacrum that’s wedged between the illi.  It is a large surface area.  The anterior inferior portion is the joint.  So if you’re doing injections you gotta get into the right place, which is not always so clear for who’s ever doing the injection, particularly if it’s not a surgeon’s.  There is a minimal capsule, but there’s very, very strong ligaments, so these could be disrupted.  These could be arthritic, just like any other joint in the body even though the motion is minimal.  It is innervated.  If you go through the literature, it is not clear where the innervation comes from, somewhere in the lumbar spine from L2 to S2.  It could be ventral rami.  It could be dorsal rami, anterior column, posterior column of the joint.  

It’s a little hard for me, and maybe some of the speakers will address it, about RF ablation, when the nerves are going into your posterior from multiple places.  It’s a little unclear how can you just kill a nerve and get rid of a pain in a joint like this, but it certainly can sense pain.  There’s changes with age just like any other joint.  It starts out smooth, and it gets very irregular.  The motion may change, but it doesn’t change necessarily reproducibly in symptomatic individual, but the changes can be construed as arthritic and a cause of pain, like again other more ball and socket types of joint.

There is motion.  It’s not increased as I’ve said in symptomatic individual.  It’s not decreased.  There’s no direction that it goes.  The total motion is less than four degrees.  It’s just not a lot, so it’s almost impossible to measure on plain x-rays.  So the challenges for maybe many of you, maybe not, but for people like me was just awareness of it, identifying and localizing the source of the pain, which you’ll hear more about today.  And as David Polly talks about, the pain can be from there and other places, like the back and the hip, and then what’s the treatment?  

The causes of SI joint, most of it is not known, but let’s assume like the low back, it’s degenerative.  Everybody can come up with a history of a fall on their buttock, or sitting hard, or riding a horse, but there’s no consistency with that.  I started, as I’ll show you an example of, with seronegative spondyloarthropathies.  It’s very easy.  It’s a clear diagnosis.  There’s lots of drugs.  If they fail, there’s something to do, and that’s when I raise my hand and call Mark Reiley to please come down and let’s do a case.  And infections, which also are pretty obvious.

What I’m gonna show you is just some examples, and you don’t have to read ‘em all, but the literature is pretty full of talking and articles on the SI joint, whether in a degenerative nature or non-clearly diagnosed nature, goes back to 1987 if not before that and very recent.  There’s lots of literature on SI joint pain after lumbar sacral fusion.  It can be due to long fusions where the motion is picked up by the SI joint or the stresses or loads.  It could be when we took a lot of bone graft and we used to harvest the whole crest, we violated the SI joint.  Or maybe now screws or rods crossed the joint.  There’s a fairly strong literature showing it’s about, I don’t know, 20, 34, 35 percent of long fusions that go to the sacrum may develop SI joint pain.

You can’t read this.  I know you can’t read that.  This is not why I’m showing it to you.  There’s also an abundance of literature on the SI joint as a cause of pain, and diagnosing, and perhaps treating it with SI joint injections that are all radiologically controlled.  So the SI joint is a component of low back pain.  The exam, at least as I was taught it, did not include a complete exam of the SI joint.  It takes less than five minutes.  I do now include that in my residence.  And fellows now include that.  It’s still not easy to separate from the spine.  It’s pretty easy to separate from the hip I think.  Provocative pain tests for SI joint are not used regularly by many of us surgeons.  I have subsequently learned that anesthesia pain people pay a lot of attention to the SI joint.  

The strange thing to me is if they inject it so much, and it relieves pain, and the pain comes back, why they don’t refer them for surgery.  And it may be because the surgery we had, which was open and only 70 percent successful at best with the high pseudarthrosis rate just wasn’t so good for the most part prior to this meeting that Dave Polly and his friends put on.  I absolutely wouldn’t have done anything even if they sent me a patient with an SI joint injection.  And I wouldn’t have sent a patient for an SI joint injection, but I do now.  And our, I think, spine surgeons in general, they approach the SI joint as it’s very rare, as Jeff said.  It’s unknown, and it probably just comes from the back anyhow.

So this is that example of my first case, a patient who after years of being treated for seronegative spondyloarthropathy, literally came in in a wheelchair.  I talked to her about open surgery, and I talked to her about the SI bone, and she waited six months, I think, wasn’t it Mark, that we tried to get a time to get this all cleared?  And it is cleared by the FDA.  She had bilateral pain, the worst radiographically and clinically was the left.  This is a representative example of the eroded joints, left and right.  We put these, Mark and one of our trauma surgeons, put these bolts across.  Within two weeks she was pain free.  I had her scheduled six months later for her right side, just ‘cause Mark said that’s a reasonable time.  She canceled that.  I continue see her.  She’s now two and a half years out.  There’s absolutely no left or right leg pain, does not use a cane, does not use a brace, does not use a walker, and as off a lot of the meds she was on for that joint pain.

Another example perhaps on the other extreme is a physician who was a horseback rider, had one clear fall that she remembers.  She came to me for an SI joint fusion, nothing too remarkable.  Maybe the joint on your left is a little wider looking on that film.  We did the left side.  She felt so good, she came back in three months for the right side.  And this is a physician seeking this treatment, doesn’t mean physicians are nuts too, but she got better.  She’s back at work and reduced her meds significantly and her ambulatory aides.

So I think the key take home points from my part of it and what you’ll get at the end of the day is the SI joint should be part of a comprehensive evaluation in patients with low back pain, so I thank David for teaching me that and Mark Reiley.  Multiple pain generators need to be evaluated.  This is one of them.  It’s not a complicated exam.  And include the lumbar spine, the SI joint, and the hip.  And successful treatment depends on thorough evaluation and thinking about it.  If you think about it you can get there.  If you don’t think about it you can’t ever get there.  And _________ treatment may offer new options for failed spine fusion and failed, non-operative care if one chooses, which is what I assume you’re all here for to learn more about it."