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Low back pain occurs in millions of men and women each year and the most common cause is “idiopathic”, meaning the exact cause is either not looked for or not found. It is most often thought to be secondary to the soft tissues that surround the segments of the spine (e.g. muscle, disc, facet joints, nerve roots, ligaments and joint capsules). We also know that internal organs (e.g. large blood vessels, kidneys and their associated structures, female organs (e.g. ovaries), and bowel can cause severe low back pain. The sacroiliac joints have been known to be responsible for generating low back pain for over a century, but the exact definition of how they cause pain and under what circumstances continue to remain elusive. No low back pain examination is considered to be complete today without considering the sacroiliac joints as one of the potential causes, until theyare appropriately evaluated.
Yes! My experience and the literature suggest that up to one fifth of patients having surgery for low back pain have pain generators in both the spine and sacroiliac joints at the same time. This means if only one of the two is appropriately treated surgically for low back pain, the pain from the other will persist after surgery. Since surgeons are not formally trained to look for both areas as potential pain generators and usually just take care of one or the other, it makes for thousands of “failed back surgeries” each year. This is where patients have to be “self-advocates” and ask their surgeons if they could be having pain from both the spine and the sacroiliac joints, preferably prior to any surgery.
The circulating statistic in journals and online is 15-30% any new low back pain could be from the sacroiliac joints.
(more to come in a future blog)
We all have two of them, through which the entire spine is attached to the pelvic bones or hips. If one would find the top of their butt crease and go 1-2 inches to one side or the other, they would feel a small boney knob under the skin. This structure is the Posterior Superior Iliac Spine (PSIS), which is part of the pelvic bone. If pain is felt there or just below (toward the heels) that means the low back pain could be coming from the sacroiliac joints, and they would need to
be ruled in or out as pain generators. This simple test is called “The Fortin Finger Test” and is very sensitive but not very specific.
First everyone should keep in mind that 95% of all acute low back pain (new low back pain), regardless of the cause (including from the SIJ), will be gone in 6-12 weeks as long as the action(s) that caused it is not repeated. This means that using common sense over the counter measures, avoiding actions that cause re- injury, and buying time are the best treatments during this period. The causes for low back pain that are bad (cancer, infections, and fractures) occurs less than 1-3% of the time, so it’s up to you and your mental comfort level if you want to seek
professional help sooner. Otherwise, only if no improvement is occurring after 6-12 weeks should you be searching for doctors or therapists to diagnose and treat you. The clinicians that are most capable of diagnosing sacroiliac joint pain are physical therapists, chiropractors, and pain doctors (physiatrists and anesthesiologists). If you start with your primary care doctor and your symptoms persist, you will most likely end up with one of these three clinicians. They all know how to diagnose the sacroiliac joint as a pain generator (using both manual and injection techniques), and they each use different forms of conservative treatments (manipulation, core stabilizing exercises, and injections). It is thought that the success rate for all conservative measures in treating sacroiliac joint pain is 75-80% successful.
To qualify for surgery on your sacroiliac joints you need to meet the
following criteria:
1. Have consistent pain for 12 or more weeks.
2. Had a diagnostic injection performed by a trained specialist percurrently accepted standards.
3. Have failed all reasonable attempts at conservative treatments.
4. Have ruled in or out any associated lumbar spine pain generators, and, ifpresent, have a plan to deal with them too.
5. Proven to be mentally and emotionally stable and understanding of the surgery and all potential results to include potential complications.
No surgeon in America is formally educated about patients with dysfunctional sacroiliac joints, the severe disabling pain that can be caused by them, or when and how to properly perform surgery on these joints by any nationally accredited surgeon educational university or institution. The only training a surgeon (orthopedic or neurosurgical) gets to perform these surgeries is from surgeons who have taught themselves through trial and error or by the industries that manufacture the implants used in these surgeries. Once again the patient is forced to be a “self-advocate” in order to navigate a successful pathway to finding a surgeon that does understand the sacroiliac joints and has the experience to make a proper diagnosis and perform an appropriate surgery. Patients should be looking for established spine surgeons who have displayed an interest in these joints, has published papers or chapters on surgeries for the
sacroiliac joints, and can offer patients both different surgical options depending on anatomy and pathology and offer past patients to question about long-term results. If a potential surgeon does not meet the above criteria or is working with one company using only one device these should be considered red flags.
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