"My name’s Tim Holt. I’m from Montgomery, Alabama. I started doing SI joint fusions back in my residency at Emery. I was lucky to have worked with a very good trauma surgeon, Mike Miller. We’d basically open SI joint fusions pretty much any way you can imagine. We did them anterior. We started off originally doing posterior fusions open with the big old bolts, where you drove two bolts through the posterior superior iliac spine, put the nuts on them and clamp it down, pack bone graft in. Then, we went from that to the way that I actually did them in my practice, until I started doing more minimally invasive stuff, where we would actually place a pelvic reconstruction plate across. Again, you open both sides, clean out the joint, drive a pelvic reconstruction plate across the posterior superior iliac spine, bend it down, put two screws in it. So as you can imagine, that’s a pretty morbid operation.
As the years went by, I tried to stop doing those as much as possible and tried to make it as much of a – tried to convince patients that maybe that wasn’t what they needed to do. So actually, I got to the point where I would make a patient – I would put them in a double pantaloon spica cast for two weeks. I would tell them if you can wear that cast for two weeks, and if you get pain relief, then you have SI joint problems, and then there’s something we can do. Now, of course, we always did injections before that. Disclosures – I’m a paid consultant for SI-BONE. I do some clinical investigation for them. I have cases, but just briefly, the way I do it, I’m a little different from some of the other guys. I do my own injections. I was lucky I was trained by Dr. Rudolph. He showed me all the ins and outs of this early on. He did a great job. I’m not saying I’m a great surgeon, but he did a great job.
But I do my own SI joint injections. Because I’m one of very few physicians in Montgomery – in Alabama who does this, I get a lot of referrals from outside areas, all the way from Mississippi. I get some from West Georgia, southern part of Tennessee, and all the way from the panhandle of Florida. So a lot of these people get to me and they’ve already had injections done, but since I’m gonna buy them, I just tell them up front I have to inject it one time. I have to make sure that that’s what the problem is. So it’s kinda like a pants and suspenders sort of thing, I guess. But I do my own injections. I do them, typically, on a single day. I’ll schedule 10 or 15 of them. What I do is I go in, we do them with sedation; I place my needle, I inject. What I will do is bring them out, and then kind of like – as Dr. Garfin was saying – I’ll give them about 30 minutes, let them kind of wake up from the sedation, and then I go through the five provocative tests.
I’ll see if that helps. If they’ve got pain relief then, I send them home. I tell them to keep a diary, come back two weeks later. The typical thing you see with the ones who wind up with surgery, which in my practice is probably about 20 percent, which is a little bit higher than Dr. Garfin’s practice. But again, I’m getting referrals from a lot of outside sources. But what I typically see is most patients come back and they still have pain relief. Well, if they still have pain relief, I tell them well, you’re not really a candidate for this procedure. You just need to – we’ll do the injections from time to time. When they don’t work anymore, then we’ll discuss the other alternatives. But if they come back and it’s kind like well, you know Doc, for the first five days I felt great, and then I got up one morning and I put my foot on the ground and I thought I was gonna fall on the floor.
Those are the patients that I really think that are helped with this technique. So that’s how I make my diagnosis. I make sure that they understand what we’re doing up front. I go over everything with them clearly. My mix is pretty much the same as Dr. Pledger’s. It’s about probably 2½ to 1, women to men. As far as my cases, this one is a – oh, by the way, I’ve done about 120 – maybe a little bit more – of the SI-BONE implant. I’ve probably done about 250 overall fusions, including my open and my – open and minimally invasive. There was a period of time between the two where I actually did percutaneous fixation of the joint with a _____ screws, where you just go in and you put a couple of screws across. I’ve since revised about eight or nine of those cases because what I’ve found in those people – that immediately, they get pain relief, and it lasts for about maybe a year to 18 months, up to two years.
But unfortunately, you start seeing loosency around that screw. Those are the people that come back with pain. So what I do is I go back and inject them again. If they get pain relief, then what I’ve done is revised those. We’ve had very good success with those ‘cause you’ve kinda done your own little trial, I think. But anyway, the first case, 53-year-old female. She’s a college registrar. She complained of low-back pain, buttock pain. She was treated by a neurosurgeon in a nearby community, and she was referred for evaluation for SI joint. From a treatment standpoint, she’d already gone through all the conservative measures – physical therapy, pain medication. She’d had injections by pain management. Again, this is one of those people I told her before I’ll do it, I have to inject you. Her MRI didn’t show anything significant on the lumbar spine. She had no real significant stenosis.
It did reveal she had had a previous compression fracture, which had been treated with kyphoplasty, but she had been asymptomatic for years from that. We did injection of the left SI joint and gave her pain relief. On her physical examination, she had normal motor testing. There’s a slide missing here, but her Cram’s test was positive. She had a positive Stork sign, which is where you get them to stand on the affected side. When they fall, they say oh, I’m gonna fall, and they start grabbing for the table. She had a positive Point sign or Forten sign. She also had a positive thigh thrust on that side. She had a positive lateral compression test on that side. So she was taken to the operating room. I only put in three implants. We’re lucky to be able to get away with that in Alabama. They would prefer two, but I think that three’s the better number. She had her surgery; she was done; she was kept overnight.
We put in the three implants. This just shows the AP. There’s the _____ view. You can see the three implants have stacked nicely, real contained within the anterior wall. On the lateral view, implants look in good position. Post-op, I saw her 3/23/12. She was doing well, neurologically intact. She was doing quite well. She had returned to her normal activities. Post-operatively, I keep them touchdown weight bearing for three weeks. Because of my practice and the fact that we do get a lot of patients from a lot of surrounding areas, typically, what I will tell them – that we keep them overnight, so that they can see physical therapy and get an idea of what touchdown weight bearing is. But in rural Alabama, the best way to tell them is go to a bathroom scale, put your foot on the scale, when you push down to 45 pounds, that’s touchdown weight bearing. Don’t put any more weight on it.
Of course usually, at three weeks, these people show up; they’re carrying their walker, wanting to know what they need to do with it. This just shows post-op X-Ray. Again, it’s a poor quality film. I apologize for that, but you can see the three implants. Again, she’s done very, very well. You can see the previous kyphoplasty there. Second case, 57-year-old female, disabled veteran. Came in complaining of low-back pain. She had right-buttock pain for several years. She had been treated by a neurosurgeon previously. She was referred for evaluation of her SI joint. Again, she’d gone through all the conservative measures, and again, she had been injected by pain management, and again, I injected her myself just to confirm the diagnosis. Her MRI showed that she had a little bit of degenerative disc disease, but no significant compressive lesions, no significant stenosis.
Her injection shows that she got good pain relief with right SI joint injection. Again, her physical examination Stork sign was positive, positive Forten sign, Crams positive. She had a positive thigh thrust. I think that’s the main thing you need to understand if you haven’t done these is the most important thing of those five provocative tests is the thigh thrust. You’ve gotta make sure that’s positive, I think, at least in my hands. I think that’s the one thing you have to make sure is positive on your provocative exam. We did her SI joint fusion 7/17/12. She had three implants; blood loss of 25 CCs. Home first post-op day. I talk fast, and I apologize. We kept her touchdown weight bearing a little bit longer than usual, but you can see here we got three implants in, look good. Post-op, saw her back in the office. She’s doing well, and she has gotten back to her usual activities. She’s a volunteer at the VA hospital, and she’s back doing that now. Post-operative film just shows the implants there. That’s the inlet, and then that’s a good lateral. That’s all I have."