Seminarios para Pacientes

El Dolor Lumbar y la Articulación Sacroilíaca: Seminario para el Paciente

El Dolor Lumbar y la Articulación Sacroilíaca: Seminario para el Paciente

En este seminario informativo para el paciente, el Dr. A. Nick Shamie* analizará:

• ¿Qué son los trastornos de la articulación sacroilíaca?
• ¿De qué forma los trastornos de la articulación sacroilíaca pueden imitar un dolor similar al de la ciática (hernia de disco)?
• ¿Cómo diagnosticar con precisión los trastornos de la articulación sacroilíaca?
• ¿Cuáles son sus opciones de tratamiento?


*Consultor remunerado de SI-BONE, Inc y con participación accionaria en la compañía.

"I appreciate it.  Well, I wanted to thank you guys for making it out here.  I know how hard it is for all of us to travel in this time of the day and the traffic.  And that just speaks to the fact that there is probably something serious that you wanna get more informed about and that's why you're here, the issue of back pain.  So I'm here to talk to you guys about that problem, and I'm thankful that you're here, and hopefully this will be valuable information for you.  So the general focus of this talk really we start with the problem of back pain.  Back pain is really a big problem that most Americans are faced with at some point in their lifetime.  I'll talk about back pain, and I'll talk to you a little bit about the anatomy of the spine to understand a little bit what areas of the spine cause back pain.

And then hone in and focus on this problem of sacroiliac joint which causes symptoms in about 20 percent of people with back pain, and talk about some of the treatment options, and at that point, we can open up the floor for some Q&A.  So please reserve your questions until the end of the presentation.  Thank you.

So it's been estimated that 85 to 90 percent of Americans at some point suffer from back pain.  Fortunately, most of those individuals get better without any surgical treatment or really any significant treatment at all.  If you give it time, most of these back pains will get better.  Most of them are muscular.  But there are about ten percent of those patients who continue suffering from low back pain, so they develop chronic back pain, and this becomes more of a problem.  And it results in a significant number of patients coming to our offices for treatment of this back pain.  It is only second in rank to the common cold for the number of visits patients make to their doctor's offices, and it has been estimated 15 million office visits annually are for the treatment of back pain.  It is ranked fifth as the cause for hospital admission, so either for preemptive for surgery or for pain control for back pain.  

And the cost as we are hearing more and more about cost of healthcare these days with the changes that we are seeing with healthcare, this is a significant cost for our taxes and our healthcare.   It has been estimated 86 billion dollars is spent for treatment of back pain.  That's why there's such a big topic that you hear about in the papers.  

Just to go over a little bit on the basic anatomy of the spine.  As many of us have seen and studied in our anatomy classes in school, we have basically 24 vertebrae.  It starts from the base of the skull down to the pelvis, and there are discs between the vertebra, and we hear a lot about discogenic back pain where the discs wear out, which happens in everybody but doesn't always cause pain.  But the problem is, when we get an MRI of someone's back who happens to have that muscular back pain, chances are their discs are also worn out.  So the challenge is, is the disc causing the back pain or is it the muscle?  And that's why we as spine surgeons have a big challenge in front of us when we see a patient with back pain.  And in addition to the discs between the vertebrae, we are now paying more and more attention to the sacroiliac joint because that is also another source of the pain.  We will talk about that a little later.  

But in addition to the disc wearing out and causing discogenic back pain, those discs can put pressure on the nerves, and the other joints in the spine, namely the facet joints can cause some back pain as a result of degeneration in those facet joints.  The spine is like a three-legged stool.  Each segment has one leg as the disc and the two legs in the back as the facet joints.  So when one leg, the disc degenerates, that in turn puts more stress on the joints in the back of the spine.  So we have all of these areas in the spine and surrounding the spine that could result in the typical back pain.  So our job is to diagnose where this specific pain is coming from.  And that has been the challenge and continues to be a challenge for us as spine specialists.

In the last segment of the spine, in the bottom where the sacrum connects to the pelvis as this video will show you is where the sacroiliac joint is.  So, if you look at the bottom of the spine, the sacrum is highlighted there, and that is the ilium, and the sacroiliac joint rests between the sacrum and the ilium.  And as you can see, the spine is right on top of the sacrum, so all of the forces and the load of the body that's going through the spine in turn transmits to the sacroiliac joint, and it's like a keystone of a bridge.  The sacroiliac joint is shaped this way much like how a bridge sits on a keystone, so there is a tremendous amount of force that goes through the sacroiliac joint.  Fortunately, most sacroiliac joints are stable enough that this long-term stress on it does not cause it to degenerate or cause pain, but there are a subset of patients with low back pain that do have a condition of sacroiliitis, which is the inflammation of the sacroiliac joint.

And the anatomy, if you delve into the anatomy of the sacroiliac joint further, you'll see that there are really thick ligaments supporting the sacroiliac joint, and these ligaments further stabilize the joint itself.  And when there's disruption of these ligaments, that's one of the reasons why people will have a little bit more motion than normal in the sacroiliac joint.  The things that cause sacroiliac joint pain, which we're learning more and more about as we speak, but what we believe causes pain in the sacroiliac joint is not just one thing, it's several things.  One of those things is hypermobility in the joint.  Normally there is about a 1-to- 5-degree rotation or motion in the sacroiliac joint; more motion in females than males.  But when you have too much motion, that could cause extra stress on the joints in the sacroiliac joint, and that extra motion like extra motion in many other joints in the body can cause pain.

The other thing that can cause pain is if the joint becomes so rigid that the forces are transmitted through the joint itself, and therefore there's not that gliding, the minimal gliding that distributes some of the forces, and that could possibly be another source of the pain.  The other thing that could cause the pain, there could be something internal in the joint that could cause the pain; either a trauma or long-term degeneration of the joint that could result in the joint become painful.  The other thing that can happen is tears in the ligaments around the joint, and as you can see here, there are really thick ligaments that could cause these types of problems that we talked about.  There 's also an abundant innervation or nerve endings that go around and into the joint itself or the capsule of the joint.  So you can imagine why if you have an inflammation in the joint, the surrounding tissues once they're inflamed can irritate those nerves and result in pain.

The other thing that we see here is that these nerves that cross over the sacroiliac joint ultimately will end up going partly down the leg, sometimes all the way down to the leg.  So that's why in some cases as I'll highlight later that there may be some referred pain down the leg from sacroiliac joints.  So if you have inflammation of the sacroiliac joint, the nerves that are innervating or going into the joint or the capsule of the joint may partly be also going down the leg.  And the brain can't differentiate whether this nerve is being irritated at the sacroiliac joint or the SI joint, or it's being irritated when it's going down the leg.  So the brain will fool you and give you the pain sensation down the leg instead of actually in the SI joint.  So there is some overlap of pain in the sacroiliac joint versus a pain that's coming distinctly from a nerve like a disc herniation pain that also can affect that same nerve.  So there is some overlap of diagnoses that we have to be careful about when we're trying to figure out where this pain is coming from.

So the common causes of sacroiliac joint dysfunction are typically degenerative processes.  As we age, as we have an aging population, in fact, the baby boomers are now just beginning to go into the Medicare and 60+ age, so we're going to have a big population, American population who are not getting older.  So all the degenerative processes that we see including lumbar stenosis, which some of you have heard about and the problems with the knees and the hips are gonna become more and more common; same thing with the sacroiliac joint.  This joint over time may degenerate, and that may cause degenerative pain in this joint.  There could also be a history of trauma that was the onset of this pain.  You can have a trauma in the joint as we talked about or the capsule, the ligaments around the joint could be injured, and that could be the onset or the start of the pain, and there may be a history of that in the patient's history.

Other causes that are less common is pregnancy.  In fact, many women as they're going through labor, because of the size of the baby, they need to have their pelvis open up for the baby to pass through the opening.  The body has a great way of relaxing those ligaments by producing this hormone called relaxant in the placenta that loosens those ligaments to allow for that childbirth.  Sometimes as a result of childbirth and the stretches of these ligaments, patients may start having some sacroiliac pain.  That typically resolves after a few months following the delivery of the child because those hormones leave the body, and the ligaments tighten up again, but sometimes we do see sacroiliitis in patients who have just gone through childbirth because of all the stresses that go through the sacroiliac and pelvic area.

The other finding that we have is that sometimes with patients who have fusion in their lumbar spine let's say, so if you have fusion in this region, as we know with any fusion, you're gonna transmit some of the forces or some of the motion from the fused levels to the adjacent levels, so you have a nonmobile segment of the spine where you've fused, and that results in increased motion either above the fusion or below the fusion.  A lot of times when we fuse to the sacrum, that means that the sacroiliac joint have to move more.  When there's abnormal motion, that could cause inflammation or damage to the joints, and this is something that we also see as a cause of sacroiliitis.  So some patients may have adjacent level disease as a result of a long fusion that will give them sacroiliac pain.  

There are other unknown reasons why we have this sacroiliac joint pain because not everyone has these findings as we talked about here, but we're learning more and more about this problem of sacroiliitis.  And the disruptions can also be due to injury, trauma, or repetitive trauma.  The activities of daily living can be partly traumatic on our tissues.  Like for example, sitting down itself causes extra stress on the discs and the sacroiliac joint.  And if you have a work that requires you to sit down for long periods of time without a break, that could be the microtrauma that causes the disruption in these soft tissues.  
So what are the patient's presenting to our offices with, patients who have sacroiliitis?  They come and tell us they have back pain, so low back pain is a common complaint in patients who have sacroiliitis.  The other complaint is buttock pain.  Most people who even have buttock pain, they don't come and tell us they have buttock pain.  They say I have hip pain, but when we ask them where is their hip, they actually point to their buttocks so much like patients who have disc herniations or lumbar stenosis, which is a pinching or irritation of the nerve who have buttock pain, sacroiliitis patients can also have buttock pain for the reasons we discussed earlier.  Some patients may also have thigh pain, pain radiating down the leg, again for the reasons we discussed because those same nerves pass over and around the sacroiliac joint.  

The other complaint that we hear about is patients have a hard time sitting or getting up from a seated position, so any motion that causes any rotation in the sacroiliac joint may result in the onset of the pain or elevating the pain.  So those are all conditions that we typically see, but the most common complaint is pain right over the sacroiliac joint.  So basically, the sacroiliac joint we have known in our literature in orthopaedic and spine surgery literature that it exists, but until recently we haven't had an easier way or less morbid way for us to treat the patients.  What I mean by that is the surgery was worse than the problem, and that's why this is an important thing to discuss today because many surgeons still to this day are not either embracing or not aware of the new technologies that we have available to us to treat this problem of sacroiliitis.

So just like myself three years ago wasn't looking for the sacroiliitis, I would just tell the patient you know what, your MRI of your lower back looks fine.  I don't see any disc bulge.  I don't see a reason why you should be having pain in the sacroiliac area or your buttock, so I don't think there's anything for me to offer you, and I hadn't been checking specifically for sacroiliitis.  And that's a really important take-home message here is that if you do have back pain that has no other causes, explainable causes, or if you've had surgery and the back pain is still persisting, it's important to discuss with your physician, your specialist, about sacroiliitis and ask him to examine this condition.  And just like everything else in spine surgery or any other medical condition, diagnosis is critical in successful treatment because if you don't have the appropriate diagnosis, any treatment that you offer is gonna miss the target of whatever that target is, and this is not unique in spine surgery.  It's true in every field in medicine.

And what we're here today to discuss is that there is a sacroiliitis problem, it does exist, and if we don't look for it, you will not find it, and therefore you have missed the target.  How do we image or further study sacroiliitis.  One of the challenges here with the problem of sacroiliitis is oftentimes we do not see a thing on the MRI or CT scan that jumps out at us and says I have sacroiliitis.  So the MRI findings and CT findings are not always conclusive.  A lot of times patients have pain in the area, we look at the CT scan and MRI, and there is not one side that looks worse than the other unlike a hip arthritis where you say okay, there's clearly arthritis here.  Why?  Because ligaments don't always show up brightly on CT scans and MRI.  It obviously doesn't show up on the CT scan, but even on the MRI, if it's micro-tears in the ligaments, we don't see it on the MRI.

And perhaps there's another study that we're gonna have to work on coming up with that will specifically look at sacroiliitis joints to help us with the diagnosis, but currently there is no gold standard as far as imaging, CT scan, x-ray, or MRI that we can say is best for diagnosing a sacroiliac joint.  That makes our job more complex, doesn't it?  But that's a really important point to highlight.
So what is the criteria for sacroiliitis?  So if a patient comes in and says I have pain in my buttock region and my sacroiliac joint and I can't diagnosis it with an MRI, CT scan, or an x-ray, what do I use for a diagnosis?  Sacroiliitis diagnosis is a diagnosis of exclusion.  So as we talked about, we have to make sure there is nothing else going on that could mimic those symptoms.  So if the patient a huge disc herniation that's pushing on the nerve and that patient has shooting pain down their buttock to their thigh, and I push on their sacroiliac joint and they have pain there, I'm not diagnosing that patient with sacroiliitis.  I'm gonna first make sure that that disc herniation is not causing that pain in the buttocks.  But in many patients that we see, they don't have a disc herniation.  They don't have a lumbar spinal stenosis, so that's the first thing.  We gotta make sure that there's nothing else going on, and that number of patients who are left with no diagnosis, then we gotta make sure that their pain is not elicited by pressure over the sacroiliac joint.

And most patients with sacroiliitis even come and tell us that using their thumb or their finger, they point to that point of the Fortin sign, which I'll go over in a second, and they say this is where my pain is, and they push right on the sacroiliac joint and when I go to press on that spot, that's where they jump off the table and they say that's where the pain is.  So that's the number one point of diagnosis, the examination, besides the history of the patient as we talked about earlier.  

Then we look at the imaging, and we look at the studies, and then another key point of diagnosis is provocative tests, which I'll go over in a second.  These are maneuvers that stress the sacroiliac joint to try to mimic what the patient does when they're moving around in their daily activities to see if that elicits the pain.  Then we compare that to the other side, and it becomes very helpful if the other side is completely normal.  Sometimes patients have bilateral sacroiliitis, but oftentimes patients have unilateral or one-sided sacroiliitis, and when one side the provocative tests are positive, the other side's negative, that further confirms our diagnosis.  And then finally to confirm that diagnosis, we do an injection in the sacroiliac joint, an injection of a numbing medication, and if that specifically, that specific injections relieves the pain, the pain that the patient is suffering from, then that confirms our diagnosis.  
So what is the Fortin finger test which I have been mentioning a couple of times?  Basically, it's putting the finger right at the posterosuperior iliac spine or right over the sacroiliac joint.  That's where the point of pain is.  Sometimes the patient's don't have pain when I push on it, but they say this is exactly where the pain's coming from.  The patients are oftentimes able to localize the pain within one fingerbreadth from the sacroiliac joint, and it's usually consistent with two trials based on a study by Fortin himself, which was published in 1997, which means that if you ask the patient a couple of times, they'll point to the same location.  It doesn't travel.  They don't point to their middle back and then the spot.  So if you ask patients a couple of times, they consistently, patients who have sacroiliitis, they consistently point to the same location.

And sitting on the effected side is oftentimes eliciting the pain, so that's another finding on patient questioning or in the exam room.  And then you also ask if the patient has asymmetry meaning that one side is painful or the other side is much less painful or not painful at all.  A lot of times patients say they can't walk on that side where the sacroiliitis is because if you put weight on that side, as you're lifting your other leg, the contralateral or opposite, to swing it as you're walking, you're putting a lot of stress on that sacroiliac joint.  And that oftentimes causes so much pain that the patients have the sensation that their legs are giving out on them on the side of the pain as they're walking.  So that just points to the fact that the sacroiliac joint in some patients could be so painful that even with walking, they have distinct pain in that location.

So once we examine the patient and ask them the questions first, then we examine them with a Fortin sign, we go to the provocative tests, which are shown here.  I will not go into too much detail, but basically the distraction, compression test, Gaenslen's, and Patrick's test all are trying to produce some motion in the sacroiliac joint which should in addition patient with sacroiliitis induce the pain, and that's what we're basically doing with these tests.  The one that's most widely used is the Patrick's test, which is shown on the bottom here where we have the patient bend their knee on the side where the sacroiliitis is and put their ankle right above the other side knee or right above the knee.  And we basically push on the middle part of the knee as it's, the bent knee, and hold the pelvis with the other hand, and that pressure on the medial aspect of the knee or the middle part of the knee causes motion and rotation in the sacroiliac joint, and that typically brings on the pain in the symptomatic side.

And that's called a Patrick's test or Faber's test.  Some doctors call it the Faber's test.  So once we have confirmed diagnosis of sacroiliitis with our history and our examination, then the real confirmatory test is to inject that same joint, the symptomatic joint, with a numbing medication, and if that injection of the numbing medication relieves the pain, that further confirms the diagnosis.  Because if the pain is coming from the hip joint or the knee joint or the spine, the injection of numbing medication in the joint itself should not relieve the symptoms.  The key point here, though is that the injection needs to be done under live x-ray.  And the pain management specialists or the surgeons who do these injections are very well aware that if you inject the joint without having live x-ray, you may end up in the wrong place.  

You have to have good visualization of where this injection is going, and oftentimes we inject a contrast that on x-ray shows that this contrast is filling up the joint before the numbing medication injected.  Some injectionists typically withdraw that contrast because there's not a whole lot of room in that joint after the confirm that the needle's in the joint, and then they inject the numbing medication, but that confirmatory x-ray before the injection is done is really critical and important.

So what is the treatment after we diagnosis a patient with sacroiliitis or sacroiliac dysfunction?  Anti-inflammatory medications are a great first step for treatment of any musculoskeletal problem because a lot of these musculoskeletal problems are causing pain because of inflammation, and nonsteroidal anti-inflammatories by definition cause a decrease of inflammation without having the steroid which can have bad systemic affects.

So then after the nonsteroidals have been tried, the other things that can be done are chiropractic manipulations, physical therapy either loosening stiff joints or tightening loose joints with physical therapy and those both can be done depending on why the patient is having sacroiliitis or sacroiliac pain and dysfunction.

The other thing that is very helpful is if motion is causing pain in the sacroiliac joint.  You can actually put a pelvic belt right above the pelvic brim and tighten that belt that will secure the sacroiliac joint, and many patients find that to be very helpful.  And with those modalities, you may never need to have further treatments like steroid injections or radiofrequency ablations, which come down further down the line if all those things haven't worked.  But before we go there, I wanted to show you what that sacroiliac belt looks like.  So this is basically a belt that patients wear right below the top of the pelvis, and that belt secures the sacroiliac joint so there's no significant motion in that joint, and that's basically bracing the sacroiliac joint and oftentimes relieves some discomfort that patients have from this abnormal motion.  So the goal is to basically decrease the joint mobility.
Physical therapy, you know the lumbar stabilization programs, strengthening abdominals, and buttock muscles, improving flexibility in the lower extremity and musculature, and the low back stretches are used, and the goal for physical therapy is basically to decrease mobility in patients who have abnormal motion, which is most commonly the reason why people have sacroiliitis or mobilize the joints that are so stiffened and causing pain.
And then finally, the sacroiliac injections that we talked about can be tried if everything else has failed and also for confirming the diagnosis.  And at this point, not only can the numbing medications can be injected, but corticosteroids which are steroidal anti-inflammatories because steroids also decrease inflammation and are much more powerful than NSAIDs or nonsteroidal anti-inflammatory can be directly in the joint and hopefully that will relieve some of the inflammation that's causing the pain.  But the important thing is that steroid injection is typically short lived because if there is abnormal motion in that joint, that steroid does not slow down the motion.  The abnormal motion continues, but the steroids have temporarily reduced the pain.  

There are some patients who we just need to break this cycle in because there's inflammation, and a little bit of motion causes more inflammation, so with steroids, we cut down the inflammation to a lower degree, that little motion that's causing the elevation of the inflammation does not happen and they can get relief with the steroids; in a subset of patients, that happens.  

And then finally, the last nonsurgical modality or treatment that can work is to, for a lack of better term, burn the nerve endings that are feeding the capsule in the joint, and this is called radiofrequency ablation.  This is done by typically with an ultrasound probe that is inserted in the joint itself, and this probe then in turn with the heat of whatever form of heat that's delivered in the joint causes an ablation or burning of the nerve endings.  So because these nerve endings don't offer any true function for the joint, they don't go to the muscles that help you walk, and they're purely sensory nerves, then burning the nerves is not going to cause a dysfunction, but it's going to give you pain relief because these nerve endings are no longer there where there's significant inflammation and irritation of these nerves.  So that's the final nonsurgical treatment.

There's still some patients who don't get better from these treatments.  So what is this surgery we're talking about?  So once everything else fails and the patients have significant sacroiliac joint pain that's not getting better with all the other things we've talked about, then there's gotta be a way to stabilize that joint.  If the patient is having pain with all the things we talked about and this joint is causing a tremendous amount of pain because of this abnormal motion, the nice thing is now we have a way to fuse that joint with these rods called the iFuse Implant System where we are putting these triangular-shaped rods and inserting it percutaneously meaning with a small incision on the lateral buttocks over guidewires under live x-ray through the joint.  
And these rods, three of them are typically placed, cross the joint immediately stabilize that joint.  There's a process that we go through to place these pins in the right place under live x-ray, and then we drill over these pins, and then we put this thing called a broche that creates a triangular-shaped hole in the sacroiliac joint and in the ilium and the sacrum, and then we place these implants in.  And when we put these implants in, they're going to be pressed-fit against the bone and immediately stabilize the bone and the joint.  And let me just show you what this surgery is.  You can see how on this side there's inflammation and there's a tear of the ligament, and there's abnormal motion in the sacroiliac joint.  And what this iFuse Implant System does, is again with the least amount of opening on the skin and a minimally invasive approach, we are able to put these three rods through the sacroiliac joint stabilizing that joint.  
Typically the patients are going home the next day after the surgery.  Some of my patients have eagerly gotten up and wanted to leave the same day, but I hold onto them just so we can make sure that the wound is healing well and there are no issues before we send them home.  But it's truly a minimally invasive surgery compared to what we had available to us before, which did not make sense to treat sacroiliitis with.  With this technology, less invasive technology, minimally invasive technology, it makes sense for patients to get treated with this condition, and I'm excited to say that we now have an option for patients who are continuing to suffer from this sacroiliitis.
What is some of the specifics of this implant and why is this implant better than what we had available because we had these screws also that we could put through the sacroiliac joint, why didn't we use those?  The shape of the implant is triangular, and that gives us a very nice surface area where the bone and the implant are intact.  And that's why the pyramids in Egypt were pyramids, and that's why they have withstood centuries of earthquakes and all the stressors that the earth has caused them.  And a pyramid shape in an engineering sense is the most stable dimension.  In addition to having a large surface area, the dimension of this implant makes it a very rigid implant.  We have screw breakages that happen in orthopaedic surgery, but with this rod in its triangular shape, because of its triangular shape, it's gonna be much more rigid in addition to offering this wide surface area of bone ingrowth.

So the bone grows onto the surface of this implant after we put this in.  So the patients that we have implanted this device in so far we have polled, and what we have seen is some exciting data that I would like to share with you.  So when we asked the patients how much pain are you in at this time?  We have their scores before surgery, which is shown in this lighter color, and we have asked the same question after we did the surgery.  And as you can see from a scale of one to ten, the patients on average had just below eight out of ten pain before surgery.  When compared to their pain level right after surgery or three months after surgery, you can see how the pain was decreased by approximately 50 percent.  And the exciting thing is, as the bone starts healing, it seems like these patients start doing even better.  So at six months, the pain goes to around three out of ten, and it's maintaining its efficacy at 12 months based on the results of this questionnaire.

And the other important question that is valid to ask our patients is would you choose to have this procedure for the other side if you needed it?  That tells us how much pain relief patients have and how cumbersome it was for the patients to heal from this surgery.  Even though they may get pain relief, the surgery may be such a big deal like our previous surgeries that we had available, that they don't wanna have the surgery.  This was not the case with this minimally invasive surgery.  Ninety-plus percent of the patients said that they would still have this procedure if the other side needed it.  So that's really encouraging to see.

So in summary, SI joint still remains to be a misdiagnosed condition.  Many patients who are suffering from sacroiliac joint are not being diagnosed because of the issues that we discussed because we didn't really have until recently a less invasive effective way to treat patients with sacroiliitis.  So myself, I wasn't looking for sacroiliitis until a year and a half ago, so still many surgeons are not looking for this condition, so therefore I believe it is underdiagnosed in many patients who are suffering from back pain.  And as we talked about 20 percent of patients literature shows who are suffering from low back pain are having sacroiliitis either in addition or by itself causing this low back pain that this patient is having experienced.  So what are the treatment goals when the sacroiliac joint is diagnosed?  It is to reduce the symptoms and if the nonsurgical treatments have not worked, then we stabilize the joint, and that is an option that's available to us now.  

I appreciate your time and your attention, and I hope that this has given you some information about this poorly diagnosed condition, and I hope that we can increase our knowledge as treaters and also as patients about this condition.

Questioner:  On the charts that you showed where six and 12 months after the pain was 50 percent less, my question is if it was properly diagnosed, the joint is stabilized, why is there not zero pain?  What is causing the pain after six to 12 months?

Answer:  That's a great question, and I think getting back to the chart, is 50 percent relief in pain significant?  The answer is in our medical literature where we have strict criteria for success, that would be considered a success.  But you're right.  Why is the pain not zero?  Well, the reason is most of these patients with this type of a problem have arthritis in other joints in the area, so I always tell patients with spinal conditions that I'm gonna focus my treatment on the worst level where I think most of your pain is coming from.  And if you have this surgery, you may still continue having some pain, and the most significant pain is what we typically target.  And I always tell patients I can't make 15, 20 again because there are other joints in the body that are gonna be arthritic, but that is the reason why I think the pain is not zero is because there are other conditions that patients complain of even after their sacroiliac joint is relieved with surgery.
The other point to consider is that this is only a mean, so there are some patients who get zero pain or one out of ten pain, and there are some patients who have seven or eight out of ten pain after surgery.  But on average, we have been able to diminish the pain to a 50 percent level, which is quite significant.

Questioner:  One of the symptoms that I have is generally dismissed when I try to explain it to people.  I have a very difficult time walking on an incline, you know where my foot is really flexed.  I usually will have to turn around and walk backwards.  That's the only way that I can really comfortably get up an incline, and I don't know why that is.

Answer:  Interesting.  And are you having pain over the SI joint when you're going up the incline?

Questioner:  Yes.

Answer:  So you are basically leaning forward when you're going up the incline.  When you're going downhill, you're kinda leaning back.  When you're going uphill, you're kinda leaning forward, so that motion could be stressing your sacroiliac joint, which in your case is more distinctly causing some abnormal motion in your sacroiliac joint that's causing the pain.

Questioner:  And so that would be similar also like walking on sand or unlevel ground, any of that lack of stability probably also would indicate that?

Answer:  Yes.  As a fulcrum of your weight and the keystone of your body's weight, that joint could be stressed in anything that you do, especially being upright, and if you have an inflamed sacroiliac joint, all of those things could irritate it whether you're going uphill or downhill, or you're putting more weight on that side, those can all go along with the diagnosis of sacroiliitis.

Questioner:  Okay.
Thank you very much for your attention.  Please help yourself to the refreshments that we didn't really delve into that much.  Thank you."