My name is Charles Fredrick Harvey, MD. I’m
a neurosurgeon in Kankakee, Illinois, employed by Riverside Medical Group. I’m going to be
talking about the diagnosis and treatment of the sacroiliac joint. I first became interested
in the sacroiliac joint as a spine surgeon because I had patients coming and telling
me that they had pain in their back going down their leg. I couldn’t account for that
pain easily with the MRI findings that I saw. The sacroiliac joint is the main joint connecting
the spine with the pelvis. It allows energy transfer between the torso and the legs.
I see three major categories of patients with sacroiliac pain. One category is patients
who’ve had trauma, for example, a fall on the buttock, a twisting injury or even a car
accident. A second category is women who have pain that’s persistent in the back of the
pelvis after pregnancy. In my personal experience, out of my first 100 patients with sacroiliac
surgery, 24 of them have previous lumbar spine surgery. About 20% of patients who come to
their doctor with low-back pain actually have pain coming from the sacroiliac joint. Studies
have shown that patients who have persistent back pain after lumbar surgery frequently
have sacroiliac joint disorders as a source of their pain.
Patients with sacroiliac joint pain have disability and pain comparable to lumbar stenosis, knee
arthritis or hip arthritis. The degree of disability can be worse than asthma, heart
failure or COPD. The diagnosis of sacroiliac joint pain requires care and attention. This
isn’t something where simple x-rays or an MRI or a CAT scan clearly demonstrate the
diagnosis. Symptoms of SI joint pain can include low-back pain radiating into the buttock or
leg, hip pain, groin pain, a feeling that the leg is giving away, trouble with sleeping
or pain rolling over in bed, trouble with sitting especially putting pressure on the
affected side and pain going from sitting to standing.
The pattern of pain can be similar between facet pain, sciatica, disk herniation or sacroiliac
joint pain. Careful physical exam by a trained physician can help determine whether pain
is coming from the hip, the low back or the sacroiliac joint. Some patients find that
their pain is worse when they stand on the affected leg or with prolonged walking. Other
patients complained of pain with sexual intercourse or changing positions. Patients sometimes
describe that their pain is better if they shift their weight away from the affected
side, they lie on the unaffected side and some patients have relief from a back brace
or sacroiliac belt. A set of five physical examination maneuvers
that put specific stress on the sacroiliac joint help us narrow down the diagnosis and
demonstrate that the sacroiliac joint is the cause of the pain. If the patient’s history,
physical examination and pain provocation tests suggest the SI joint is the source of
the pain then we consider diagnostic SI injections. A diagnostic injection is done under X-ray
guidance to make sure that the injection is in the right place. We use Lidocaine or Novocaine
like when you go to the dentist’s office. If there is 50 to 75 percent improvement in
the pain, even briefly, that’s the sign that the sacroiliac joint is the source of the
pain. The patient is asked to keep track of their
pain before the procedure and after and sometimes keep a pain diary for the first few hours
after the injection. If they have significant improvement then we like to think that’s the
spot that’s causing the pain. Most patients with sacroiliac pain do not need surgery.
The range of treatment options available to a patient include medications, physical therapy,
external support like a brace or a sacroiliac belt, therapeutic SI injections where Cortisone
is added, radio frequency ablation is another possible treatment that is given by some pain
management physicians. Traditional open sacroiliac fusion is a big
surgery, relatively bloody and has a long recovery. Recent advances in minimally invasive
sacroiliac fusion offer a new option. The iFuse implant system is a technique for minimally-invasive
stabilization and fusion of the sacroiliac joint. The unique triangular shape of these
implants minimizes rotation and movement of the implants providing immediate stabilization
of the joint. This is done under X-ray guidance through an inch and a half incision under
general anesthesia. A series of specialized tools are used to prepare the bone for placements
of three triangular iFuse implants. Final X-rays are taken to confirm proper placement,
safely within bone and away from the exiting nerves. I participated in the first national
multicenter, randomized controlled trial of minimally-invasive sacroiliac joint fusion.
In the INSITE trial, 148 patients were randomized to surgical treatment with the iFuse system
or best medical management for six months. Patients who received the iFuse implants had
significant improvement in their post-operative pain, described less disability and an improvement
in their quality of life. For more information about diagnosis and treatment, please see
the SI-BONE website.

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