SI Joint Dysfunction, Patient Series Article #3– Adjacent Segment Degeneration Case

Patient Education

Health care practitioners specializing in the diagnosis and treatment of SI joint patients are frequently asked to describe a “typical” sacroiliac joint patient.  This is somewhat challenging as SI joint pain can occur in men and women and in adult patients who are young, middle aged and older.  In the prospective clinical trials, the average SI joint patient age was 51 years old and two thirds of the patients were female (INSITE1, iMIA2, SIFI3).  Three subgroups of SI joint patients are frequently described based on the cause of the SI joint pain.  The first group is women who have SI joint pain that began during pregnancy or soon after delivery.  The second group is people (men and women) who have SI joint pain after a trauma, such as a motor vehicle accident or a slip and fall.  The third group is comprised of individuals (men and women) who have SI joint pain and SI joint degeneration after a prior lumbar fusion. 

We have created three patient stories describing typical patients from each of the previously described sub-groups.  We have based our patient stories on actual patients with similar history and presentation.   We utilized fictional patients for a number of reasons, including patient privacy reasons as we wished to avoid sharing any patient specific information.  Second, we wanted to use these stories to illustrate a focused diagnostic and treatment pathway.  Third, we wanted to illustrate, via the stories, the type of clinical information that would typically be included in a patient’s medical record.  While highly representative of actual patient experiences, these patient scenarios are fictional and the clinical presentation and the response to treatment may not be representative of all patients. 

Adjacent Segment Degeneration Case

The third patient in our series is a 65-year-old male with degeneration (wear and tear) and pain in the left sacroiliac (SI) joint after a multi-level lumbar fusion that was performed 10 years ago. Biomechanical studies have shown that there is increased stress and increased motion at the SI joints after a lumbar fusion (Ivanov 20094).  Radiographic studies have shown increased degeneration of the SI joints after a lumbar fusion compared to individuals who have not had a lumbar fusion (Ha 20085).  

The patient, Bob, injured his back 10 years ago when he lifted a heavy box.  He felt a pop in his back followed by pain in his left lower back with radiating pain down his left leg into his outer foot.  Work-up demonstrated herniated discs with nerve compression at L4-5 and at L5-S1.  Non-surgical treatment was ineffective.  Eventually Bob had surgery to decompress the nerves and to fuse the vertebrae, L4 to L5 to S1.  Bob did well with his lumbar fusion for 10 years.  He did complain of some stiffness in his lower back.  However, he continued to work and continued to participate in his routine activities. 

Bob has had some intermittent pain in the left buttock area for the last couple of years.  Last winter, after shoveling snow, he noticed a sharp pain in the left lower back and buttock.  The pain radiated down the back of his left leg to just above his knee. He was concerned that he had done something to aggravate his lumbar spine and the prior surgery. He made an appointment to see his orthopedic surgeon.

His orthopedic surgeon took his history and performed a physical examination.  There were no clinical findings that suggested pressure on his lumbar nerve roots. Bob was asked to localize the area of greatest pain and he pointed to a spot just below the beltline on the left side. Bob’s physician told him that this was the area of the sacroiliac joint.  Typical of patients with sacroiliac pain, Bob demonstrated a positive Fortin Finger Test by consistently pointing to this anatomic area (Fortin 19976).

The surgeon then tested his SI joint function by having him perform an Active Straight Leg Raise (Mens 20017). He had Bob lift his left leg first and then his right leg, 20 cm off the table and had him hold the leg elevated for a few seconds.  He noted that on the painful (left) side Bob demonstrated significant pain at his left SI joint and he was unable to raise and hold his left leg without great effort and associated pain. Bob was asked to rate the effort to perform the test from 0 (no effort or pain) to 5 (inability to lift the leg) and he rated it a 4.  Bob had minimal difficulty performing the Active straight leg raise test on the right side. 

The surgeon then performed a series of pain provocation tests on Bob’s SI joints. These tests are performed in a series and are meant to stress the SI joint and the supporting soft tissues in a number of different directions. Bob’s surgeon noted that he had a positive Distraction test, Thigh Thrust test and FABER test.

When three or more of these tests are positive, it is highly indicative of SI joint pain (Szadek 20098, Laslett 20089, Laslett 200510). Bob’s surgeon also performed several tests on Bob’s hip joint to make sure he did not have pain coming from the hip on the left side and these tests were all negative. Based on the history of prior lumbar fusion, the onset of Bob’s symptoms and the physical examination findings including; a positive Fortin Finger Test, a positive active straight leg raise test, and 3 positive provocative tests for the SI joint, the surgeon was confident that Bob had pain coming from the left SI joint

The surgeon referred Bob to a physical therapist who performed a history and physical examination. Bob was barely able to tolerate the examination due to the severity of his SI joint pain which he now rated as an 8 on a scale from 0 (no pain) to 10 (the worst pain imaginable). He had trouble getting in and out of his car when traveling to the appointment and getting on and off the treatment table during his PT evaluation. After attempting to go to physical therapy on 2 occasions and having too much pain to even get on the table to do gentle stabilization exercises, he and his physical therapist agreed that he needed to return to his orthopedic surgeon’s office for re-evaluation.

His physical therapist did supply him with an SI belt which he wore tightly around his pelvis. He noticed that the belt did decrease the sharp pain he experienced with movement but did not affect the constant deep ache at his left SI joint. Bob’s surgeon referred him to a pain management physician.  Bob received a fluoroscopically guided intra articular (inside the joint) steroid injection.  The injection contained a local anesthetic, to help with diagnosis and steroid, which can decrease inflammation and pain. He noted that his pain decreased from an 8 to a 2 with the injection of the local anesthetic.  The effect of the steroid lasted for several weeks but the pain intensity eventually returned to an 8 out of 10.

Bob received 2 more steroid injections over the course of the next 6 months.  He was able to attend physical therapy where he learned to move and position himself correctly, performed strengthening exercises for his core muscles (muscles that support the low back and pelvis), performed specific stretches and received soft tissue work on painful areas in his left lower back, buttock and groin muscles called trigger points. Bob was disappointed that, despite all the treatment he received in physical therapy, his still pain returned just a couple of weeks after each of his SI joint injections, and he was unable to function without using his SI belt. He was significantly limited with sitting, standing, and walking, particularly up and down stairs. He had difficulty sleeping at night.  He has been unable to bowl in his league since the onset of his pain.

Bob returned once again to his orthopedic surgeon who documented that Bob had been through more than six months of conservative (non-surgical) treatment and that he was unable to function without pain which ranged from a level of 5-8 in his left SI joint, left posterior buttock and left leg. He referred Bob back to his pain management physician and requested a diagnostic injection. This was different than the therapeutic injections that Bob had received in the past in that he was injected with only a local anesthetic to numb his joint.  Bob was asked to record his pain level after the injection and to bring his pain chart back to his surgeon’s office. Bob noted his pain level decreased from an 8/10 down to a 2/10 after the injection and that he could perform the activities that typically reproduced his SI joint pain for six hours after the injection. He had a second diagnostic injection one month later (per insurance company guidelines) and he had the same positive result.

Bob was scheduled the following month for an iFuse ProcedureTM, a minimally invasive surgery to stabilize and fuse his left SI joint. Bob was given a post-operative guideline brochure by his surgeon which described the exercises he would be doing after the surgery and contained helpful hints regarding how to position himself, control his swelling and move comfortably until his first post-operative visit with this surgeon. His surgery was performed successfully and without complications.

Bob was able to resume most of his normal daily activities within 2 weeks of his procedure and followed his physician’s advice to put only as much weight on his left leg as he could tolerate immediately after the procedure. His physical therapist instructed him prior to his surgery on how to use a cane so that he could decrease the amount of weight he put on his left leg if needed to after surgery. After Bob’s post-operative checkup, his surgeon recommended a short course of physical therapy to address some of the muscle tightness and discomfort that Bob had developed from walking with an altered gait pattern while he had SI pain and to progress his core strengthening exercises.

Bob was amazed that he could perform all the physical therapy exercises without pain at his SI joint and was discharged from physical therapy after only 4 visits. His surgeon allowed Bob to resume bowling 2 months after his surgery. Bob followed up with his surgeon 6 months later and reported that he had minimal pain at his SI joint and that he had resumed all of his routine activities.

References

  1. Polly DW, Swofford J, Whang PG, Frank CJ, Glaser JA, Limoni RP, Cher DJ, Wine KD, Sembrano JN, and the INSITE Study Group. Two-Year Outcomes from a Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion vs. Non-Surgical Management for Sacroiliac Joint Dysfunction. Int J Spine Surg. 2016;10.Article 28. doi: 10.14444/3028.
  2. Dengler J, Kools D, Pflugmacher R, Gasbarrini A, Prestamburgo D, Gaetani P, Cher D, Van Eeckhoven E, Sturesson B. 1-year results from a randomized controlled trial of conservative management vs. minimally invasive surgical treatment for sacroiliac joint pain. Pain Physician. 2017 Sep;20(6):537-550.
  3. Duhon B, Bitan F, Lockstadt H, Kovalsky D, Cher D, Hillen T, on behalf of the SIFI Study Group. Triangular Titanium Implants for Minimally Invasive Sacroiliac Joint Fusion: 2-Year Follow-Up from a Prospective Multicenter Trial. Int J Spine Surg. 2016;10:Article 13. doi: 10.14444/3013.
  4. Ivanov AA, Kiapour A, Ebraheim NA, Goel V. Lumbar fusion leads to increases in angular motion and stress across sacroiliac joint: a finite element study. Spine. 2009;34:E162-9.
  5. Ha KY, Lee JS, Kim KW. Degeneration of sacroiliac joint after instrumented lumbar or lumbosacral fusion: a prospective cohort study over five-year follow-up. Spine. 2008 May 15;33(11):1192-8
  6. Fortin JD, Falco FJ. The Fortin Finger Test: An Indication of Sacroiliac pain. Am J Orthop (Bell Mead NJ). 1997 Jul;26(7):477-80.
  7. Mens JM, Vleeming A, Snijders CJ, Koes BW, Stam HJ Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine. 2001 May 15;26(10):1167-71.
  8. Szadek KM, van der Wurff P, van Tulder MW, Zuurmond WW, Perez RS. Diagnostic Criteria for Sacroiliac Pain, a Systemic Review. J Pain. 2009;Apr:10(4):354-68.
  9. Laslett M. Evidence Based Diagnosis and treatment of the painful Sacroiliac Joint. J Man Manip Ther. 2008;16(3):142-52.
  10. Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: Validity of individual provocation tests and composites of tests. Man Ther. 2005;10(3):207-18.

For comprehensive information about iFuse and some causes of SI Joint pain and dysfunction, please visit

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