"I’m Ralph Rashbaum. I’m one of the co-founders of the Texas Back Institute. I’ll be presenting on the Sacroiliac Joint. My experience both as a spine surgeon for 38 years and a pain practitioner for 36 years. I was smart enough to realize that not all of the people I endeavored to take care of did well and I needed to offer them something else. I hope to cover the causes of this, who has Sacroiliac joint pain, the diagnostic challenges, the treatment options both surgical and non-surgical. I want you to appreciate that the non-surgical treatment options are dealing with mechanical problem and so predictably they will fail.
Now failure is really a consideration the part of the patient. If they’re satisfied with the pain response and they’re willing to leave the office on modest medical management then it’s a success. These are the causes that we uniformly see. Trauma on the left and non-trauma on the right, the left is self explanatory, I will tell you that birthing is a traumatic event. Multiparous women uh have sustainable trauma each and every time. The thing that’s important to me is a manager of fail back surgery is adjacent segment disruption, whether they’re long fusions or short fusions. Obviously, the longer the worst to transfer of, of pressure, the shorter ones will increase joint sensitivity.
Iatrogenic causes when we harvest bone and go through the joint, inflammatory causes which are obviously [apaired 00:01:29] and rheumatoid and that’s a zero positive or a zero negative spondyloarthropathies. Instability and infection, the issue that I have at hand here is I’m not really certain as to why these people joints hurt. In somebody who’s uh observably doesn’t have a click as they walk, that’s a sign of real grows instability. Those are usually trauma induced, I have yet to see any patients that I treat like that.
I do two fellowships, so one with Harry Ballman the other one with Rothman and Simeon [00:02:00]. I was both, I was their first fellow and I will tell you without equivocation I was never taught to examine the sacroiliac joint. So of necessity I actually had to learn how to examine the joint and became aware of the problem. As a pain specialist I’m charged with finding the pain generator. As a spine surgeon I’m charged with finding the pain generator. I’m going to point out to you that patients that come to my practice have what we describe as ticks and fleas. A dog has both problems.
If we’re blinded to finding out pre-operatively the ticks and fleas then we’ll do the wrong surgery at the wrong site and then, unless we learn from our mistake we will repeatedly do that as a [selvic 00:02:41] surgery on the spine over and over, and over. And it’s not until the tension is drawn to the sacroiliac joint as a potential generator that may have been there before the first case and certainly subsequent to a solid fusion that patient will continue to suffer. I will submit to you that of the diagnosis of axial low back pain improve, been proven or disprove as their existence on injection therapy. We need to prioritize the treatment, that’s what I’ve learned.
If the patient has ticks and fleas, if they have a [spundle 00:03:12] of this thesis 4, 5 or 5, 1 and have a sacroiliac joint disruption, if you don’t do the SI joint before diffusion or you don’t do them at the same time that patient predicatively will fail. The examination is a very simple examination that takes within the neighborhood of 90 seconds. 90 seconds, it takes longer to listen to the patient. They’ll tell you what’s wrong and I hope to show you that. After I do this examination on these patients, one of the questions I ask them is “Has this ever been done to you before?” and the answer resoundingly is, “No.” Okay, most often the examination is not complete. Everybody knows what a uh favor for exam is. That is done but uniformly not done right.
Going to the bottom of the slide, this is Ralph’s rules of axial low back pain, the five causes: [00:04:00] facetogenic, discogenic, musculogenic, sacrogenic and psychogenic. Each one of those diagnosis can be proven or disproven. This is my pain had by an injection: facet injections for facet syndrome, trigger point injections for muscular scale disorders, discography – functional ambulatory discography or [zilo cane 00:04:21] discograms, SI joint injections and pain studies. The SI joint injection is fluoroscopic guided and it’s a goal standard for confirmation. Raising the awareness that the patient may have this disease, proving or disproving based on the response I look for then we’ll circle that “Oh my God, what do I mean by that?”
Patient stands up post injection and they move around and recreate their pain process. “Oh my God I don’t have that pain. That pain that I’ve had for two years to 17 years, that pain that I had before my surgery, I don’t have that.” Between 50 and 75% response, that’s the patient that may in fact have an extra articulate cause. Because the real important issue here is that the syndesmosis, the thing that holds the joints together both in the front and the back, they’re very, very well imbued with pain fibers, with no susceptive fibers. And if you do a truly intra-articular injection and you don’t get those fibers then the patient may not respond. Prior to the injection, find out what exaggerates the pain, what causes the pain, the results of a fusion is not judged upon their response.
The patient presents with aggravations associated with body posturing, specific to that site, if a patient walks in with a circumduction gait, spends little time on that side or has what I call the stork sign with a stand on the painful side, lift their leg. As the muscles that balance the pelvis pull down it increases your force between the sacrum and the ilium. This I believe is a process of [00:06:00] sheer force sensitivity. I believe and hopefully I can convince you that the reason that SI bone works is because this absolutely allows us to load share over those devices through that joint.
I want to make you aware of how they sit, the fortin finger sign, how they get up from a chair, how they walk, how they stand, and all the maneuvers that make you more aware of the ultimate necessity of doing that injection to establish that diagnosis. This is a gentleman, ten and a half years ago, he was blown on to his left side on an aircraft carrier in the United States Navy. For 10 years people have been evaluating him for that pain. This is him sitting there, waiting to talk to me. This is him getting up. The patients get up like this. The patient takes one finger and points to a fortin point.
I would present to you that this is quite different from the patient with uh axial back pain of a [spundle agenic 00:07:01] nature. The knuckle sign is midline over the back, fortins finger sign is very specific to the sacroiliac sulcus was, is usually below the level of L5. This is what their pain drawing looks like, I represent to you that the one on the upper left is the knuckle sign that’s facetogenic. This is where people are thrown off, how do you get joint pain, groin pain coming from your sacroiliac joint. Well the L5 nerve drapes over that but also the joint is in the pelvis. So if you look at a herniated nucleus pulposus with butt pain, rating down a specific dermatome with muscle weakness. And look at the same dispersion of the points on the right which is SI joint. There is an accumulation that’s fortins point. You’ll see this time and time again.
What causes the causes the pain in speculation? How could two to four degrees of nutation, the motion about the SI joint is rotation. And I show my patients this is how much it moves, did you see that? [00:08:00] That’s how much it moves, come on guys, how can that really hurt? I believe its immense shear pressure, especially in these patients that are really very, very large. That joint is always in shear no matter what and sometimes it’s your intention does, if and off load if you will of this shear by these devices which ultimately get incorporated into the ilium and the sacrum.
The treatment options I’ll run through quickly. Biggest consideration this treatment options is the fact that we’re doing something that’s non-surgical for mechanical problem. Ultimately the patients will define uh the necessity for me to go from a conserved process, chiropractic physical therapy, rhizotomy, rhizolisis. I use a [valuscul rayor 00:08:45] frequency. We’re only dealing with the patient, the pain. Fibrous dorsal not ventral. [Dipolis 00:08:52] anytime a major nerve crosses a joint, that joint gets innervated. So we obviously have the front part of the spine that never gets desensitized and there in perhaps is why they continue to hurt.
Who’s the candidate? This the candidates that’s looking for a minimally traumatic approach. This is a two inch incision and everything is done through that incision with a muscle splitting approach. We’ve been able to identify the pain generator as a, as a sacroiliac joint. Not necessarily the only but the worst pain generator. The reason that they came to see you. How many patients present in your clinic with global pain, neck shoulder, upper back. I’m going to only deal with a site specific, I’m only going to try and warranty a few well, the site that I injected and the pain that, that was resolved. And I think it’s an important concept because they will come back and tell you now I have midline back pain. The mind can focus on one event at the time.
If they have pain generating from an, a prevailing problem, that’s what they focus on. Take away that problem and they have another problem. I started doing this when the patients were act, asking for better relief. I call it the physical demand characteristics of the [00:10:00] youthful population. Remember when we were doing work camp assessments, we need to look at the job, physical demand characteristics as to what we could return them to. This people will self select the necessity of doing this. At this point I have 37 patients, ages 27 to 77. The bone density scans are very, very important to me. I will not take chances, I will operate on [osteo pain 00:10:23] patients. I will start them on a course of nine months or forteo and then operate on them.
I tried, we tried everything and these patients then ask what is next. My results at this point I have 37, five of them at one year and this is an anecdotal representation of this patient. You can see the pain over fortins point and this is her represent, representation. In conclusion, multiple pain generators can co-exist and if you fix one preoperatively the first time or the second time and ignore what really is there, that pain will now flourish. The SI joint must be part of the work up to include a suspicion, an injection, a confirmation by virtue of how they respond and then an appropriate treatment which may or may not be surgical at first.
This approach may help improve the outcomes of low back pain through identification of their correct pain generator and avoidance of the wrong treatment measure, the infamous failback surgery syndrome. Now thank you for your attention."