Thomas Freeman, MD, Professor of Neurosurgery at the University of South Florida, talks about a new way to treat sacroiliac joint pain.
Let’s talk about 20 percent of these cases are misdiagnosed. Let’s get into the 20 percent statistic right now.
FREEMAN: So low back pain that’s surgical is very severe. I would call that a seven, eight, nine or ten out of ten. Twenty percent of the time where that happens where it’s surgical is from the S.I. joint. It’s not coming from the spine. So it’s frequently misdiagnosed.
The new way to treat it? Can you get into that and why?
FREEMAN: So the sacroiliac joint has not been treatable. People have been trying since the ’20s. John F. Kennedy had S.I. joint pain and it was unsuccessful in the treatment. A new way to treat this has started about a decade ago. And the news is that we now have a new way to treat it that is different than the one that was introduced ten years ago. Ten years ago, people started treating the sacroiliac joint coming from the side. And we now have a new way to do it coming from posteriorly. And it seems to be very reliable in our first few patients where we’ve done it. It’s an improvement on a way that we were trying to do it about five or six years ago as well.
The piece that you showed me, that’s the big difference?
FREEMAN: The new device is coming in from posteriorly, so there’s less risk from a neurologic perspective. There’s less risk from vascular injury perspective. Plus, we get a true fusion with this device rather than having just a stabilization. We actually have the sacrum and the ilium fused together. So these are all the improvements of the new device.
So the misdiagnosis for this patient that we talked to you went on for 16 years dealing with this terrible pain. Is that something common that’s happening, you think or?
FREEMAN: Unfortunately, it’s been misdiagnosed in so many people for so long. My average patient has had sacroiliac joint actually pain from anywhere from two years to 35 years. I had a 70-year-old lady who had pain for over half of her life. And she was in tears afterwards, not because of pain, she actually had a great result, but because of having lost half of her life to this misdiagnosed problem. And the patient you will interview, Mr. Mitchell, he had pain for 16 years.
Wow. And so it’s just tricky to misdiagnose or?
FREEMAN: Once you understand it, it’s very easy to diagnose. But because it was not treatable, most people didn’t pay attention to it as a problem because they couldn’t fix it. So it’s now my job and the other experts in the field to train the rest of the spine surgeons in America and the rest of the world on how to properly diagnose it so we can recognize it when somebody comes into the clinic and we see them in the room. And there’s a few things that really pop out to make it easy to diagnose.
And what are some of those things?
FREEMAN: So sacroiliac joint pain can cause back pain and pain going into the leg. And very often those people get fusions, and they don’t help. Sacroiliac joint pain is easy to recognize because it causes pain directly in the buttock in the place where the dimple is on the statue of David on his buttock, that area. Everybody knows that. And it’s worse sitting down. And back pain is typically worse standing up where you load it with gravity and better lying down where you take the gravity off. S.I. joint pain can be worse lying down, but it’s worse lying down on the same side as the S.I joint pain because that rotates the pelvis leading to pain and it’s better in a recliner. Also, S.I. joint pain can cause pain going down the leg, but it’s worse when you sit. And it refers pain to the front of the thigh, side of the thigh or the groin area. And those things, when you put them together, you see the pattern the second you walk in the room. If I walk in the room and somebody’s sitting with one buttock up in the air, my entire thought process changes.
Is there a way to prevent this from becoming a problem for people or what do you notice with the common patients?
FREEMAN: So I notice that with patients that have sacroiliac joint pain that’s on a one to 10 scale of five or six or below, almost all of them will get better with conservative therapies. And by that I mean physical therapy and bracing and even chiropractic care. I’ve seen some people get better with that or injections. The patients that have ten out of ten pain, sometimes seven or eight or nine out of ten pain, they usually go to need surgery, but we try the conservative therapies before surgery as well.
Is there a cause for this? I mean, that’s the million dollar question.
FREEMAN: There is, a lot of patients get this after they’ve had a spinal fusion because the fusion is like a crowbar and that puts a lot of force onto the sacroiliac joint, which is directly below it. And over half of those patients get S.I. joint pain within five years. They go back to the doctors. They have normal MRIs except for the operative changes, and they get thrown out of the office when in fact they have S.I. joint pain. That’s the most common cause of misdiagnosis. Another is slipping and falling, landing on the buttock. So in Minnesota, a lot of patients will slip and fall on the ice. Another cause has been rear ended in a car crash where the seat hits the sacrum really hard, causing a slip in the S.I. joint that is not treatable with therapy sometimes. So those are common causes, but it can also get worse as a degenerative problem, just like the spine can get worse with age. And a lot of women have experienced S.I. joint pain when they’re pregnant because the ligaments loosen up in order to allow the pelvis to open up for the delivery. And usually that type of joint pain gets better after the delivery because the hormone status goes back to normal.
So being able to operate on this like you’re doing, I feel like that’s like in the breakthrough category and can help a lot of people.
FREEMAN: It’s a very important new field of surgery and it’s so new that many spine surgeons don’t even yet appreciate that it’s a real therapy. And even if they do, they don’t understand how to do it yet. So it’s an evolving area. And I think now the biggest obstacle is how to train enough people to do this. There are seven million people that actively have severe S.I. joint pain in America alone. So these new techniques for fixing the sacroiliac joint all have in common very little blood loss. If you lose 25 ccs of blood during one of these cases, you’re having a bad day. So for diagnosis, just considering the diagnosis of S.I. joint pain when a patient comes to see a spine surgeon will save society three thousand dollars because it’s so often misdiagnosed. If a misdiagnosis occurs and a patient has the wrong operation, that costs society about two hundred thousand dollars, not even taking into account lost income and pain and suffering for that poor patient. So to diagnose it, the first thing, consider it. You have to consider the diagnosis if you’re going to get it correct. Then typically it’s the hallmark is pain in the buttock area worse with sitting but also worse going from sitting to standing and laying on the left side, walking up steps, walking up an incline and better in a recliner. There’s a number of things that these patients all typically report. Then there are five physical exam findings that every spine surgeon has to know how to do. And if you do all those five, if three of them are abnormal, the diagnosis is probably going to be correct in the range of about 20 percent. Then you can do a confirmatory block where you inject steroids or some other medicine into the joint. And if it gets better temporarily, like when you go to the dentist you get Novocain, it wears off. But if it gets better, that confirms the diagnosis. But the physical exam is actually the most accurate part of the diagnosis.
And to not go the surgery route, is it possible, if it’s not as severe, you can treat it other ways?
FREEMAN: Yeah. In my experience, physical therapy to stabilize and mobilize the S.I. joint works in almost everybody that has pain that’s a five out of ten or better.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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