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General Information About Sacroiliac Surgery
Stop Suffering With Low Back Pain
Millions of people suffer with low back pain. It is a common complaint, which may persist for months or
years. Much of what is thought of as "low back pain" is actually caused by a mis-alignment or sprain
of the sacroiliac joint. The condition often is not diagnosed because only a few health care professionals
are trained to identify the specific symptoms which indicate a sacroiliac joint problem. Sacroiliac, or SI
joint disorders do not usually show up on x-rays. In order to understand the nature of the injury and what
can be done to relieve the pain it is useful to become familiar with the functioning of the sacroiliac joints
which are the point of connection between the lower spine and the pelvis.
Diagnostic testing, such as X-ray, CT scan or MRI, do not usually reveal abnormalities; therefore, they cannot
be used for diagnosis of sacroiliac joint dysfunction.
The sacrum is the lower portion of the spine where several vertebrae are fused together. The sacrum has a joint on
either side with the ilium, the back part of the pelvis. The pubic rami, the front part of the pelvis, fit together in the front forming the pubic
symphysis. The sacroiliac joints are L shaped in contour with a shorter upper and longer lower arm. Normally the sacroiliac joint
is configured in such a way that the bones have an interlocking structure, which assists in keeping them properly
aligned. In some cases the opposing joint surfaces are quite flat. This type of joint is much less stable and can
lead to a shearing or sliding misalignment. Some sacroiliac joints reverse the normal concave-convex 'locking' relationship, which
can lead to rotational misalignment. The variation in joint configuration results in a corresponding variation in integrity. This means
that some sacroiliac joints are inherently weaker or more prone to misalignment.
A clear understanding of the difference in the signs and symptoms of sacroiliac joint dysfunction and other pathologies
is key in making the proper diagnosis. Because the diagnosis of SI joint dysfunction is made primarily from the
patient's subjective complaints and the physical evaluation, it's diagnosis is somewhat problematic for the clinician.
The most common manifestation of sacroiliac joint dysfunction is acute pain in the low back, in the area of the
Posterior Superior Iliac Spine (PSIS) positioned approximately 2 inches from the midline and very deep-seated. Usually, tenderness is found near the lumbo-sacral promontory
and in the PSIS area, one more pronounced than the other. Radiating pain into the buttock, hip, groin and thigh is often
experienced. The pain is frequently increased by prolonged sitting, standing, walking or lying. The patient reports that frequent position
changes are needed to maintain any degree of comfort.
LIST OF COMMON SYMPTOMS OF SACROILIAC DYSFUNCTION
1. Lumbosacral pain
2. Buttock Pain
3. Pain radiating to the leg
4. Hip pain
5. Groin pain
6. Urinary frequency
7. Iliac crest pain
8. Transient numbness, prickling or tingling
9. Increased pain with menstruation
10. Increased pain with sexual intercourse
11. Increased pain with stair climbing
12. Increased pain with sustained positions (i.e., sitting, walking, lying)
Patient self-evaluation of symptoms revealed the following:
96% Increased discomfort with sustained positions (i.e., standing, sitting, lying)
66% Radiating buttock pain
39% Discomfort with stair climbing and/or hill climbing
26% Groin pain
23% Radiating leg pain
20% Pain with forward flexion
15% Loss of stregth in the legs
10% Urinary frequency
The most commonly reported position of comfort by patients in the study was side lying (left or right), with a
pillow between the knees.
The most frequent complaint from patients with sacroiliac joint dysfunction is increased discomfort with sustained positions
such as standing, sitting and lying, with the inability to attain a position of comfort. A disc patient can often find a
position of comfort, especially when lying down. Sacroiliac joint symptoms will intensify with activity and decrease with rest, while disc
symptoms will usually be worse upon rising in the A.M.
The second most common symptom of sacroiliac joint dysfunction is radiating buttock pain. This is reported as a generalized distribution
of "achiness" which can radiate into the thigh.
The third most common symptom is increased discomfort with stair or hill climbing. This is a result of
increased demands on the skeletal and soft tissue system of the pelvic girdle during these activities. This symptom
may also be present in disc pathologies but is primarily reported as increased discomfort with forward trunk flexion.
TREATMENT
Initial treatment is provided by a therapist skilled in diagnosing and treating sacroiliac joint pain. Following evaluation
and mobilization treatment the therapist will instruct the patient on proper biomechanics to avoid unnecessary and improper strain on the
injured joints. Therapeutic exercise is taught to improve neuromuscular stability of the low back and pevis. Self-mobilization
techniques are also given to the patient. Too much movement of the sacroiliac joint may indicate a laxity of ligaments that would
normally hold these joints within a normal range of motion. Therefore, additional stabilization procedures, for example
pelvic belt fixation and taping techniques may be required. Typically the sacroiliac joint dysfunction will stabilize with a good
stabilization program over a 6-week period of time.
A home program of self-mobilization is necessary: either by self-mobilization exercise or by family members who have been taught
to do the family assisted corrections. With those patients who continue to demonstrate hyper-mobility after failing to attain stabilization by conservation means
of rehabilitation, an orthopedic consultation for prolotheraphy or surgical stabilization may be necessary.
TECHNIQUE OF SACROILIAC JOINT STABILIZATION
Injuries to the sacroiliac joint can be intra-articular (fracture or "sacroilitis") or extra-articular (ligamentous). The
primary lesion that we are discussing is concerning extra-articular ligament disruption with subsequent destabilization of the sacroiliac
joint. These lesions cannot be demonstrated with normal imaging studies. The diagnosis is made purely with clinical means based
on thorough knowledge of manual medicine. Various techniques have already been discussed concerning the treatment of extra-articular
sacroiliac joint destabilization via physical therapy means. If these fail, more drastic measures must be taken. Sacroiliac joint surgery
is drastic if it is done incorrectly. The major cause of the failure of surgery is the failure of the surgeon to understand
the presence of secondary lesions that also need to be treated. Stabilization of the joint by reinforcing these ligaments is most important
if there is evidence of SI joint injury, then fusion as well as stabilization is required. It is esstential that the joint be fixed in its normal anatomic
position. Thus a thorough knowledge of manual techniques is required for anyone contemplating doing sacroiliac surgery.
THE SURGERY : BRIEF DESCRIPTION
Fixation: To stabilization the sacroiliac joint, cannulated screws will be placed through the ilium and sacrum.
The cannulated screws that your physician will use for stabilization are approved by the U.S. Food and Drug Administration
(FDA) for fixation of fractures of large bones. It is inferred from this that they are solid enough for sacroiliac stabilization
for which they are commonly used.
Fusion: Fusion between the sacrum and the ilium may also be necessary. This is done by scraping the bone on both sides and placing
a graft taken from the iliac crest at the surgical site between the two sides. Artificial graft can also be used. If your physician determines
that a fusion is not necessary in your case, the joint will be fixed in place using only the screws.
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