Sacroiliac Joint Dysfunction: An Algorithm for Diagnosis and Treatment

The sacroiliac joint is finally getting the attention it deserves from physicians and clinicians who treat the spine because of the pioneering efforts of Bruce E. Dall, M.D.

Dr. Dall, an orthopedic spine surgeon with Neurosurgery of Kalamazoo, part of the Borgess Brain & Spine Institute, developed an algorithm that provides an organized approach to help clinicians recognize a dysfunctional, painful sacroiliac joint. “Sacroiliac Joint Dysfunction: An Algorithm for Diagnosis and Treatment,” published in October 2010 as a white paper by Borgess Medical Center, outlines the steps necessary to fully diagnose this joint as the source of pain and offers an organized approach for treatment based on well-established options.

During his training to become a physician, Dr. Dall says the sacroiliac joint was discussed, but treatment options for it weren’t.

“We could identify it, but it wasn’t diagnosed, and nothing was done about it because not enough was known about it,” Dr. Dall says.

Sonia V. Eden, M.D., a neurosurgeon with Borgess Brain & Spine Institute, assisted Dr. Dall with the formulation 
of the algorithm by researching data 
and literature.

“There are papers out there about biomechanical studies of the sacroiliac joint and different treatment modalities and research done in that area,” 
Dr. Eden says.

Hunter G. Brumblay, M.D., a neurosurgeon who works closely with 
Drs. Dall and Eden at Borgess Brain & Spine Institute, says a lot of attention has been focused on the lower spine instead of the sacroiliac joint.

“Surgeons and neurosurgeons have historically not been taught to look at the sacroiliac joint as a pain generator, whereas pain management and physiatrists regularly diagnose people with sacroiliac joint pain,” Dr. Brumblay says. “They get injected every three months and never make it to surgeons because it’s not considered a surgical disease.”

The Borgess Brain & Spine Institute offers both nonsurgical and surgical approaches. However, surgery is generally a last resort for the majority of patients seeking treatment.

The primary treatment at the Borgess Sacroiliac Joint Program at the Brain & Spine Institute for sacroiliac joint disorders is nonoperative. A regimen of physical therapy — sometimes in combination with steroid injections — is among the most successful pain management therapies. For the small subset of patients who don’t respond well to conservative management, surgery is an option.

Using Dr. Dall’s algorithm as a template, a team of specialists works together to determine the best course of treatment for each patient.

David J. Brockman, M.D., a physiatrist with Borgess Spine, part of Borgess Brain & Spine Institute, says a patient who comes into the Borgess Brain & Spine Institute with lower back pain is first put on a treatment regimen that includes medications and physical therapy. He says there are some patients who respond better to chiropractic manipulation of the spine than physical therapy.

If the pain persists, the next course of treatment is injections. When this fails to provide long-term pain relief, 
Drs. Dall, Brumblay and Eden are called in.

“We’re on the conservative end,” 
Dr. Brockman says. “The surgeons are on the aggressive end.”

Overriding the surgical versus nonsurgical treatment is the comprehensive care and treatment decision patients receive at the Borgess Brain & Spine Institute’s Sacroiliac Joint Program.

“Patients have access to all of the 
care they need,” Dr. Brockman says. “This works great for the patient and 
the doctors.”

The most common cause of sacroiliac joint pain is degenerative arthritis, which takes place over time, Dr. Brumblay says. In addition, he says large numbers of relatively young woman in their childbearing years develop sacroiliac joint pain due to a laxity of the pelvic ligaments to facilitate childbirth, which impacts the sacroiliac joint, making it more prone to injury.

“Most people who have sacroiliac joint pain will really focus that pain in their buttock and often point right over the spot where the sacroiliac is,” 
Dr. Brumblay says.

Dr. Dall’s colleagues at Borgess say one of the telltale signs of problems with the sacroiliac joint is tenderness to palpitation in the joint overlaying the sacroiliac. They also say diagnoses are not always easy because the source of pain doesn’t always present itself in MRIs or other clinical testing.

“There are a million reasons why someone can have pain in his or her lower back,” Dr. Brumblay says. “It’s hard to identify pain generators there as well because it can come from disks, facet joints, pinched nerves — there are tons of things that can cause low back pain, and the sacroiliac joint is one of them. Twenty-five percent of people who complain of lower back pain actually have issues with their sacroiliac joint.”

Dr. Dall’s research has shown that there is no one population that suffers from sacroiliac joint pain more than another. Over the course of the last 20 years, Dr. Dall says he has been “trying to figure out ways to surgically help the person with a painful sacroiliac joint who is in ongoing pain. These people are some of the most desperate people I’ve come across in my practice.”

One of those people was a 74-year-old woman diagnosed with rheumatoid arthritis who sought out Dr. Dall more than 10 years ago.

“She was in a wheelchair and was experiencing terrible pain,” Dr. Dall says. “Her sacroiliac joint was being affected by the rheumatoid arthritis. I did a bone scan, and it lit up like a Christmas tree.”

For this patient, the option of strategically placing screws across the affected area wasn’t going to help because she had osteoporosis, in addition to the rheumatoid arthritis. The literature during that time indicated that putting screws across the pelvis was the way to deal with a fractured sacroiliac joint. Dr. Dall recommended a less invasive posterior approach that relieved his patient’s pain and got her out of a wheelchair and onto a walker.

Since this initial procedure, Dr. Dall has spent the intervening years perfecting the surgical procedure. His technique was published in the December 2008 issue of the Journal of Spinal Disorders 
& Techniques.

“We decided that possibly we could put cages in the sacroiliac joint and not make a long incision,” Dr. Dall says.

The minimally invasive sacroiliac joint fusion procedure is performed through a small, 2-inch posterior incision, and two cages with bone-fusing material are placed longitudinally into the sacroiliac joint line with the aid of radiographic imaging. No muscle is disrupted in any way, and blood loss has been minimal.

Over a 13-month period ending December 2004, 13 consecutive patients, male and female, were determined to be candidates for a sacroiliac joint fusion after each of them had failed conservative therapy lasting from six months to several years.

They were each given the option of continued conservative therapy, traditional open arthrodesis or the new percutaneous technique using threaded fusion cages filled with the bone-fusing material. All of them chose the new technique, which involves the placement of cages into the longitudinal axis of the sacroiliac joint.

“That procedure worked very well with 75% to 80% ‘good’ to ‘excellent’ results,” Dr. Dall says. “We’ve reduced the surgery time down to less than two hours, with immediate weight-bearing capability and a return to normal daily activity within four months.”

The procedure continues to be modified, and Dr. Dall has spent the past three years training Drs. Eden and Brumblay to perform the surgery. Dr. Dall, who is 
semiretired, says Drs. Eden and Brumblay will continue to improve the technique and take it to the next levels.

“Clearly, there’s a population of people who benefit from this surgery, but further studies need to be done to really 
confirm there is a large benefit and which group gets the most benefit,” Dr. Brumblay says. “Some of my patients have really struggled for years after a car accident with miserable pain. Some of them have been told they’re crazy, and when they have relief, it’s just an amazing thing.”

Treatment therapies begin with anti-inflammatory medications, the use of a sacral belt and an alteration of activities, as outlined in the algorithm. Dr. Dall’s research has shown that anti-inflammatory medications in some patients produce miraculous results from the start, suggesting that there is a significant inflammatory component to the sacroiliac joint pain. When these medications don’t work or aren’t effective enough, the addition of a sacral belt may make a significant difference in the amount of pain being felt.

If these treatment regimens bring no significant pain relief after about six weeks, Dr. Dall recommends imaging surrounding areas.

Chiropractic or physical therapy is the next course of treatment that should be considered if more conservative measures haven’t helped and nothing alarming is found on X-ray.

If this course of treatment options does not result in decreased pain levels for the patient, Dr. Dall’s algorithm recommends a formal physical therapy evaluation and treatment program. If six to 12 weeks of this therapy don’t produce results, more costly and invasive treatment methods are introduced, including a fluoroscopically guided intra-articular injection done with a mixture of Lidocaine, a local anesthetic, and triamcinolone, a corticosteroid.

If the patient experiences significant pain relief during this procedure, it is assumed that the sacroiliac joint is the pain generator. It is then hoped that the steroid injected with the anesthetic agent will successfully bring pain relief within 24 to 48 hours and last anywhere from weeks to months. These injections will then be the preferred course 
of treatment.

Chriropractic manipulation or injections into the sacroiliac joint are the mainstay treatment methods, Dr. Eden says.

“They’re used in every patient, and only those who don’t get long-lasting relief are candidates for joint fusion,” says Dr. Eden, adding that the majority of these patients don’t require surgery because of the effectiveness of these other treatment options.

Sacroiliac joint fusion is a last resort and used only in patients who don’t get results any other way, Dr. Eden says.

The majority of surgeons consider fusion of the sacroiliac joint to be the last form of treatment to be performed only on patients who have been in chronic pain for more than six months; are unable to perform tasks associated with daily living; and have failed all reasonable conservative treatments.

For those patients who do not derive significant pain relief from these injections or any other treatment methods in the algorithm, fusion then becomes an option, Dr. Brumblay says.

“Surgery should be the very last thing you do,” he says. “You don’t want to mess with what God gave you. Our big contribution is to put surgery at the end of that algorithm and make that an option.”

Dr. Eden says she thinks the algorithm could become the new standard of treatment for patients with sacroiliac joint pain.

This was Dr. Dall’s goal.

In a letter to the editor published in The Spine Journal, Dr. Dall says, “Every joint in the human body has one or more surgical societies laying claim to and being the most able and the most willing to treat that joint when it becomes symptomatic. The one joint that no society of surgeons seems to want is the sacroiliac joint.”

Dr. Dall goes on to say that the sacroiliac joint is the “last frontier in the musculoskeletal system” that is awaiting efforts to be dealt with for the benefit 
of patients.


MD News Early Summer 2011, West Michigan



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