Spine or Sacrum? Diagnosing SI Joint Pain

Nevada Academy of Family Physicians, Winter CME Meeting
Harrah’s Lake Tahoe, January 28, 2016
To obtain an appropriate pain diagnosis.
Spine or Sacrum?
Diagnosing S.I. Joint Pain
Direct the patient to the best treatment option after
presenting the patient all viable options.
John M. DiMuro, DO, MBA
Anesthesiology & Pain Medicine
SpineNevada
Sparks, Reno, Carson City
Interventional Pain Physician
A medical diagnosis is usually a broad, generalized term that is used to
most accurately reflect an appropriate ICD-10 classification code.
Treatment Options
1) Do Nothing
Example: Low back pain
A pain diagnosis is a specific diagnosis made using factual diagnosis.
Example: Lumbar degenerative disc disease vs. radiculopathy
Interventional Pain Physician
Interventional Pain Physician
Treatment Options
1) Do Nothing
Treatment Options
1) Do Nothing
2) Medications
3) Physical Rehabilitation Modalities
2) Medications
Antibiotics, Sleeping aids, anxiolytics, anti-depressants
Anti-inflammatories
Athletic Acupuncture Physical Yoga/Pilates Home Chiropractic
Exercise
Trainer
Therapy
Program
Muscle relaxants
Opioids “Pain killers”
Interventional Pain Physician
Treatment Options
1) Do Nothing
2) Medications
3) Physical Rehabilitation Modalities
4) Further Diagnostic Testing
Thin slice C.T. Scan
Flexion/Extension X-Rays
Interventional Pain Physician
Treatment Options
1) Do Nothing
2) Medications
3) Physical Rehabilitation Modalities
4) Further Diagnostic Testing
5) Specialist Referral
A)Endocrinologist
MRI Neurography
B) Physiatrist
MRI Angiography
C) Neurologist
C.T. Arthrogram
D) Psychiatrist
Interventional Pain Physician
Interventional Pain Physician
Treatment Options
Treatment Options
1) Do Nothing
2) Medications
3) Physical Rehabilitation Modalities
4) Further Diagnostic Testing
5) Specialist Referral
6) Surgical Referral
Neurosurgeon/Orthopedic Spine Surgeon
1) Do Nothing
2) Medications
3) Physical Rehabilitation Modalities
4) Further Diagnostic Testing
5) Specialist Referral
6) Surgical Referral
7) Diagnostic work-up to prove the diagnosis
Orthopedic surgeon
General surgeon
Answer :
It depends upon what condition/diagnosis we are trying to prove.
1) Disc
2) Joint
3) Nerve
1) Disc
How do we figure out if the disc is a source of pain or discomfort?
Is it a clinical diagnosis?
Is it a movement screening diagnosis?
No, it is a scientific diagnosis.
Provocation Discography
4) Muscle
5) Bone
6) Tendon
7) Ligament
8) Peripheral nerve
9) Organ
Discogram
Suspected
Pain Generator
1) Disc
Diagnostic
Procedure
Discogram
A Discogram is a method of stimulating the disc through
pressurization with fluid to see if concordant pain is elicited.
Discogram - Abnormal Tear
Suspected
Pain Generator
1) Disc
Interventional
Diagnostic
Test
Discogram
Treatment Options
If Positive Test
Surgery
Transdiscal
Biacuplasty
2) Joint
Joint Injection
Spinal Joint Injection
(“Zygapophyseal” or “Facet” Joint)
Suspected
Pain Generator
1) Disc
2) Joint
Interventional
Diagnostic
Test
Discogram
Joint Injection
Treatment Options
If Positive Test
Surgery
Transdiscal Biacuplasty
Surgery
Radiofrequency Ablation
3) Nerve
Selective Nerve Root Block
Performed for Suspected Pain in a Dermatomal Distribution
Suspected
Pain Generator
1) Disc
Selective Nerve
Root Block
Interventional
Diagnostic
Test
Discogram
2) Joint
Joint Injection
3) Nerve
Selective Nerve
Root Block
P.T./Chiro/Trainer
Treatment Options
If Positive Test
Surgery
Transdiscal Biacuplasty
Surgery
R.F.A.
Plus Rehab Modalities
Surgery
Epidural Steroid Injection
Phys rehab modalities
Spine or Sacrum?
Overview
Epidural Steroid Injection
SI Joint Injection
Introduction
Anatomy of the Spine
Understanding Lower Back Pain
Diagnosing Sacroiliac (SI) Joint
Pain
• Treatment Options
• Summary and Q&A
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Epidemiology
• Up to 85% of all people have lower back pain (LBP) at
some point in life
• 15 million office visits annually
• 5th ranked cause of hospital admission
• Annual direct and indirect costs: $86 Billion
• Common LBP causes: Spine, SI, Hip, Muscle
Anatomy - Spine
• 24 vertebrae
• Base of Skull to Pelvis
• Building blocks
• Discs between vertebrae
• Cushions between bones
• Protects Spine Cord
• Nerves exit spinal cord
• Last segment, the sacrum,
connects to the pelvis
Cervical
spine
Thoracic
spine
Lumbar
spine
Sacrum
Anatomy – Ligaments
Anatomy – Where is the SI Joint?
• Strong ligaments encase each
Sacroiliac
joint
ligaments
• Ligaments affect stability
• If damaged, may have excessive
motion
• Excessive motion may inflame
and disrupt the joint and
surrounding nerves
SI Joint Disruptions:
Causes
Anatomy – Nerve
Supply of Pelvis
Common causes:
• Degenerative disease
• History of trauma
• Pregnancy/childbirth
• Lumbar Fusion
• Inflammatory Arthritis
(i.e. Ankylosing
Spondylitis)
Disruption due to:
• Injury, traumatic event or
repetitive trauma
• Nerves exit Lumbar Spine & Sacrum
• Provide sensation to legs
• Several levels innervate the SI Joint
SI Joint: Symptom
Presentation
Clinical Diagnosis of SIJ pain
• Referral Zone
• Maximal pain is below the beltline and
can refer into the entire lower extremity
mimicking a sciatica
Sacral Sulcus Tenderness • 94% have buttock pain, 48% have
thigh pain, 28% have lower leg pain
Schwarzer (1995) Spine 20:31-37.
Maigne (1996) Spine 21:1889.
Dreyfuss (1996) Spine 21:2594-2602.
Slipman (2000) Arch Phys Med Rehabil 81:334-338
Diagnosing the SI Joint
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SI Joint now becoming a buzzword
Not usually part of LBP work-up
Often misdiagnosed or ignored
Physicians are not trained to look!
Proper Diagnosis is important
• Presentation can mimic disc pain
• Potentially leading to
misdiagnosis and unnecessary
lumbar surgery
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Low back pain
Buttock pain
Thigh pain
Sciatic-like symptoms
Difficulty sitting / standing
Poor sleep habits
Fortin. Spine 1994; 19:1475‐1482 Diagnosing: Imaging
• Plain film, CT scan, & MRI may be ordered
• Often misleading
• 2001 study showed CT scans were negative in
42% of symptomatic SI joints1
• MRI has not been proven to have positive
correlation
1. Elgafy H, Semaan HB, Ebraheim NA, et al. Computed tomography findings in patients with sacroiliac pain. Clin Orthop Relat
Res. Jan 2001;112
Diagnosing: Criteria
• Criteria for diagnosis of SI joint pain:1
• Pain is present in the region of the SI joint
• Provocative test – reproducing pain in joint
• Injecting the joint relieves the patient of
pain
Diagnosing: Pain
Localization
Fortin Finger Test1
• Point to pain while standing
1.
2.
3.
Able to localize pain with one finger
Within 1 cm of PSIS (inferomedial)
Consistent over at least 2 trials
• Tenderness over SIJ sulcus
• SIJ tender to palpation
• Not sitting on affected side
• Position tests to check for symmetry
1. Merskey H, Bogduk N. Classification of chronic pain. In: Merskey H, Bogduk N. Descriptions of Chronic Pain Syndromes and Definition of
Pain Terms. 2nd ed.8
1. Fortin JD. Am J Orthop 1997;26(7): 477-80.
Diagnosing:
Provocative Tests
Diagnosis: SI Joint
Injections
Distraction Test
• The sacroiliac joint is stressed by the examiner,
attempting to pull the joint apart
Compression Test
• The two sides of the joint are forced together.
Pain may indicate that the sacroiliac joint is
involved.
Gaenslen's Test
• Lay on a table, one leg drops over the edge and
the supported leg is flexed. In this position,
sacroiliac joint problems will cause pain
because of stress to the joint.
FABER Test
• The leg is brought up to the knee, and the knee
is pressed on to test for hip mobility.
SI Joint Injections:
• Confirm or deny SI joint is source
of pain
• 20-30 minutes after the
procedure, you will move your
back to try to provoke your usual
pain.
• After 1 week, second injection
may be recommended to decrease
false positive
Fluoroscopic Imaging
Needle placement
SI joint arthrogram
Treatment: Overview
Conservative Care
• Non Steroid Anti-Inflammatory Drugs
(NSAIDS)
• Opiates, Muscle Relaxants, Topicals
•
Chiropractic Manipulation
•
Physical Therapy
•
Pelvic (SI joint) Belt
•
Steroid injections
•
Others: RF ablation, PRP, Stem cell, Fusion
Treatment: SI Belts
SI Belts:
• Wraps around the hips
• Hold the sacroiliac joint
tightly together
• Reduce motion to reduce
pain
• Goal: Decrease joint
mobility
Treatment: PT
Physical Therapy
• Lumbar stabilization program:
strengthening abdominals and buttock
muscles
• Improve flexibility in lower extremity
musculature
• Lower back stretches
• Goal: Decrease mobility
Treatment:
Radiofrequency Ablation
Treatment: SI Joint
Injections
Treatment:
• Includes Corticosteroid in
injection
• Reduce your inflammation
• May provide months of relief
• Treats symptoms, does not
stabilize an incompetent joint.
RF Probe Technology
Radiofrequency Ablation:
“Burns” small nerves that provide
sensation to SI joint
• In theory, this treatment:
• Destroys any sensation
• Makes joint essentially numb
• Not always successful
• Temporary, nerves regenerate
• Treats symptoms, not joint
mobility or underlining disruption
Anatomical Lesioning
• At right S1 and S2,
create 2:30, 4 and
5:30 lesions; right S3,
2:30 and 4:00
Standard 18 G RF cannula
Ellipsoidal volume
2.5 mm radius
Major axis parallel to tip
No distal projection of lesion
18 G cooled Sinergy probe
Near spherical volume
5.0 mm radius
40% of lesion DISTAL to tip
Lesioning Sites
AP View - Fluoroscopic
AP View - Drawing
• On left S1 and S2,
9:30, 8:00, 6:30; left
S3, 9:30, 8:00.
Cooled-RF Lesion Properties
• Uniform lesions formed in non-homogeneous
tissue
• Lesion Characteristics accommodate for
inconsistent and variable innervation
SI joint RF ablation
RF ablation – AP View
RF ablation – Lateral View
SIJ lesioning targets - Lateral
branches S1, S2, S3
SIJ Innervation- Lateral
branches S1, S2, S3
S1
S2
S3
Yin W, Willard F, Carreiro J, Dreyfuss P (2003) Spine 28:2419‐2425. Images reprinted with permission of Lippincott Williams, 2007. Treatment: iFuse
Implant System
Adapted from: Yin W, Willard F, Carreiro J, Dreyfuss P (2003) Spine 28:2419‐2425. Images reprinted with permission of Lippincott Williams, 2007. Treatment: iFuse
Implant System
• Stabilization of SIJ
• Minimally Invasive
• Small incision
• Does not require bone graft to
create fusion
• Short procedure length ~ 1
hour
Summary
If patient has low back pain, evaluate the following:
• Is it BTB (below the beltline)?
• Is it present at rest or with movement?
• Was the onset of the pain traumatically-induced?
• Is the anatomical area of pain well-localized or does it
radiate in a dermatomal distribution?
• Do I really need imaging?
If SI Joint is considered as a source of pain:
• Numerous conservative care treatment options available
John DiMuro, DO, MBA
Anesthesiology & Pain Medicine
dimuro@spinenevada.com