Moderator: Bruce E. Dall

Attendees: E. Jeffrey Donner, Michael Moore, Sonia Eden, Arnold Graham Smith, Michael Rahl

Question #1:

BD: Jeff, would you start out with that?

EJD: Sure. Over 25 years ago I was trained in orthopedics and subsequently completed a spinal surgery fellowship in Philadelphia. I can confidently say, at that time, there was no discussion about sacroiliac dysfunction, pain, or treatment in either of those training programs other than if the patient had some type of pelvic trauma. Even within that group of patients with residual sacroiliac pain, the prognosis was “your pain will go away in time,” and there was no direction beyond this.

BD: OK, Michael Rahl. You are our only physical therapist in the author group, and we would certainly be interested to hear what a physical therapist was taught about the dysfunctional SIJ.

MR: Well, sure. When I was in school, I think we spent one laboratory session, so about 2 h worth, talking about the biomechanics of the SIJ and learning different special tests to try to help identify SIJ dysfunction. We discussed how the reliability and sensitivity of the special tests were lacking and how cluster testing could be useful to help identify the SIJ or surrounding areas as the pain generator. We also discussed how special tests used to identify abnormal motion of the SIJ were not useful. In regard to treating dysfunction of the SIJ, there was really no discussion on treatment, what would be effective, or what would be the best approach to improving these patients. I think the instructors, like many PTs out there, were not well versed in the SIJ. I think, unfortunately, we as students left the class with the same lack of understanding. Since that point, I have tried to improve my knowledge of the SIJ through continuing education courses, reading the current literature, and talking with others involved with treating the SIJ.

BD: Thank you very much. OK, the floor is open. Who else would like to comment on this?

BD: OK, I would have to say after lecturing to groups of orthopedic surgeons and groups of physical therapists, I was really amazed at the lack of understanding or knowledge base either of these groups had. I actually put on a symposium in our region in 2001 associated with Michigan State University on the diagnosis and treatment of the dysfunctional SIJ. The reason I did that was because I knew very little about it. I invited people from multiple disciplines to come in and lecture on it for a day. It was an extremely eye-opening experience for all of us, which probably is culminating in me wanting to put this book together 10 or 15 years later.

MM: Could I respond, Bruce?

BD: Yes.

MM: I had the good fortune of actually having some training during residency at the University of California at San Diego by one of the members of our faculty, David Gershuni, who is primarily a trauma surgeon. He would take care of most of the major pelvic trauma that came into our Level I trauma unit. In the course of following up some of these patients and other patients who did not have major pelvic trauma, we had a small number of patients who seemed to have pain arising from the SIJ. David is now deceased, but he basically taught me as a senior resident that some people do have pain arising from the SIJ. The way you diagnose it is by doing a CT-guided injection of local anesthetic into the synovial portion of the joint. If that relieves their pain transiently, they will respond positively to a sacroiliac fusion. We had about five patients on whom we operated and he showed me a modified Smith-Peterson technique of performing that surgery. What I recalled at the end of residency is that those patients had all done well. That was the extent of my formal training. I started looking for the problem as a fellow during my spine surgery fellowship and also early in practice. It was really quite by happenstance and by having this experience with that particular attending that I did receive some small portion of formal training, which ended up being a very positive experience in terms of developing an interest in this.

BD: Thank you very much. Let’s go on to the second question.

Question #2:

BD: Who would like to answer that question?

BD: I would answer that question by saying we have actually studied this at our institution. The people who do not send SIJ patients to a surgeon like me for potential SIJ fusion are chiropractors and pain doctors; at least that has been my experience. Many of the patients I have ultimately operated on had been in years of continuous chiropractic treatment as well as getting injections one after another in situations where a firm diagnosis of SIJ dysfunction had long been made by the injecting clinician. In our study we found over half of the patients referred to our office, who ultimately went on to have an SIJ fusion, were referred by either their primary care physician or by their physical therapist. The rest of them literally found our office through the Internet after being told by their injection pain doctor “you need a SIJ fusion,” but not being able to tell their patients where to go to get that done.

BD: Someone else?

EJD: One of the main referrers to my practice is me. I initially incorporated fluoroscopic injections into my practice a year after I went into clinical practice. I did not learn this in training, but I was very frustrated with the fact there were a lot of people I would see and could not give them the answer as to why they were having the variety of pains in their back, buttock, and leg. I also became very involved in the International Spinal Injection Society, which is now called International Spinal Interventional Society (ISIS). I learned these injection techniques and found I was eventually able to diagnose sacroiliac pain under fluoroscopy by blocking the SIJ if I could not reproduce pain with discography or eliminate it with facet injections. I believe a lot of these patients I see come to me because no one else could identify the source of their problem, especially 25 years ago when very few people were doing this. This experience led to my early adoption of sacroiliac dysfunction as a legitimate diagnosis and eventually, especially with Dr. Moore’s help, I identified ways to treat this surgically.

BD: Very good. Thank you Jeff.

AGS: Bruce, can I answer the last question?

BD: Yes, please go ahead.

AGS: I would say the same that the Internet has been a steady source of referrals. Having taught in the community and in the state of Florida, I have found the people in the community and elsewhere in Florida who did not want to get involved in sacroiliitis would send the patients to me. So, I have had in-state referrals from local teaching and out-of-state referrals from the Internet.

BD: OK, thank you, Arnold.

Question #3:

BD: Anyone want to tackle that?

MM: If I could respond to that, I believe at this point my first choice in treating someone with SIJ dysfunction would be one of the minimally invasive types of interventions of which there are several available now. I think there are some patients for whom that is not a practical consideration. For example, someone who has had a very extensive bone graft harvest from the ilium on the affected side may not have sufficient bone stock for one of the minimally invasive techniques to be successful. Again, this is just a personal bias based on dealing with these patients and is not really based on the data because such data does not exist. I think there are some patients for whom an open procedure is necessary because of unfavorable anatomy or because of prior surgery. If you need to perform extensive bone grafting in order to achieve an arthrodesis or stabilization, I think an open procedure may be preferable to one of the minimally invasive procedures. So, I do think there are some circumstances in which you have to modify your preferred procedure in order to accommodate the patient’s pathology.

BD: Thank you, Mike.

SE: This is Sonia Eden. I just wanted to add that I agree with that. In addition, in certain patient populations, when we are addressing both spine and SIJ pathology on them simultaneously, there are some options for fusions of the SIJ in those patients that we can do at the same time we are doing the spine surgery. These may not necessarily have to be the lateral approach but perhaps could be the posterior approach that we do at Borgess.