Solving Sacroiliac Joint Pain

Patients with sacroiliitis often arrive at a physician's office at the end of the road. They're distraught and emotionally drained after suffering with lower back pain for years. They often feel as if they've run out of options after having sought help from multiple doctors without receiving a proper diagnosis. Thankfully, better evaluations and testing are allowing more patients to take advantage of underused implant systems that can end the pain they feel every time they sit, stand, sleep or simply try to get through their day.

Many physicians and patients don't know that 15% to 20% of back pain is related to sacroiliac disorder, according to Jordi Kellogg, MD, a neurosurgeon with Kellogg Brain & Spine who operates in outpatient surgery centers in Portland, Ore. When one or both sacroiliac joints, located at the intersection of the lower spine and the pelvis, are inflamed, patients feel pain in the lower back and buttocks that often radiates down one or both legs. That's why sacroiliitis is often mistaken for sciatica, and often goes untreated for years, says Dr. Kellogg.

The condition also mimics symptoms of herniation and spondylosis and is often misdiagnosed as one of those conditions.

Properly working sacroiliac joints stabilize and support the body and absorb much of the impact from walking, lifting and other activities. Sacroiliac dysfunction, essentially, is when the joints start to shift. The unwanted articulation is caused by all kinds of trauma, including multiple or traumatic pregnancies, motor vehicle accidents and falls, says Omar Gonzalez, a physician's assistant at Kellogg Brain & Spine. Sacroiliitis can also be a sequela of previous spine fusions, which increase the load on the sacroiliac joints. The symptoms often appear years after the fusions took place.

Dr. Kellogg has used an implant system more than 20 times over the last three years that he thinks offers his patients a better option than other surgical treatments. The minimally invasive technique includes making 3-cm incisions along the side of the buttocks. Three titanium implants are then placed in the sacroiliac joints, using continuous intraoperative fluoroscopic guidance to line up the appropriate anatomical landmarks and ensure proper placement. Pins and markers are used to determine the correct trajectory for the implants. The pre-op set up, including securing the patient to the table and taking all the necessary measurements, takes 15 to 20 minutes.

The implants, known as cages, are triangular, which Dr. Kellogg prefers to other systems that use round screws. "The concern with screws is that implants can rotate around them, because they're round," he says.

"Triangular cages provide immediate fixation with the bone."

The triangular implants, about the size of a pinky finger, are also porous, which helps to promote the eventual fusion to bone. "Immediate bony ongrow occurs because the implants are triangular, and eventual bony ingrow happens because of their rough and porous texture," says Mr. Gonzalez.

The procedure, performed with general or spinal anesthesia, takes less than an hour to complete and patients go home about two hours later. Most patients use a cane or a walker or are on crutches for at least three weeks after getting the implants to speed up the fusion of the bone to the cages.

"With the proper implant design, the anatomy is laid out very well, which makes the associated risks incredibly small," says Dr. Kellogg.

"I'm very impressed by our outcomes."

Future growth

Dr. Kellogg and Mr. Gonzalez hope that more physicians will become aware of sacroiliitis as a culprit of lower back pain and that bringing the diagnostic regimen to the forefront will result in more implants that will improve patients' lives (see "Identifying Candidates for Surgery").

"Triangular cages provide immediate fixation with the bone."
—Jordi Kellogg, MD

A few months after the surgery, many patients return for their final post-op check-up and express their gratitude. The relief they feel is as intense as the despair they felt when they first came in for their pre-op evaluations. "That's what makes this particular procedure so gratifying," says Dr. Kellogg.

"Mostly, they thank us for listening," says Mr. Gonzalez.

"That's really the most important part of the process. Patients almost always tell us everything we need to know. The surgery is simply what follows the right diagnosis, which we're able to provide if we listen." OSM