Treatment for Sacroiliac Joint Dysfunction

Patients will often come into our office with an MRI, low back pain and a diagnosis of sacroiliac joint dysfunction. They are in our office because they may have been told that they should consider a surgical recommendation to spinal fusion. For many of these people, the MRI was the confirmation that their surgeon needed to go ahead with the surgical recommendation. For many patients, this may have been the same doctor who had taken them through a course of conservative treatments. These treatments may have included long bouts with anti-inflammatory medications, back braces, physical therapy, and cortisone injections.

All of these treatments did not help them. Why? A recent study in the Clinical Spine Journal (1) offers the suggestion that sacroiliac joint dysfunction patients do not get treatment relief because they do not have sacroiliac joint dysfunction. This may be somewhat difficult for you to believe because all along you have been told you have SI joint pain.

Look at what the doctors of this study reported: Confusion and a lot of it.

A person goes to the doctor for pain in the pelvic / hip / groin lower back region.

The currently reported incidence of primary sacroiliac joint ranges from 15% to 30%. (In other words 15% to 30% of these people will get a diagnosis of sacroiliac joint dysfunction.)
When they do not get a diagnosis of sacroiliac joint dysfunction, they may get a diagnosis of:

• pain generated from the lumbar spine, (degenerative disc disease),
• sacroiliac joint dysfunction, (but not as the primary cause of their pain and therefore not the primary target)
• and the hip joint.

When these researchers re-examined these patients, with the goal of proving or disproving sacroiliac joint as the primary cause, what they found after a complete diagnostic workup was:

• 112 (90%) had lumbar spine pain,
• 5 (4%) had hip pain,
• 4 (3%) had primary sacroiliac joint dysfunction pain, and
• 3 (3%) had an undetermined source of pain upon initial diagnosis.

Patients did not have sacroiliac joint dysfunction as the primary source of their pain. In fact the sacroiliac joint was found to be a rare pain generator (3%-6%) in patients complaining of more than 50% sacroiliac joint region related pain. Pain in the sacroiliac joint area is commonly a referral pain from the lumbar spine (88%-90%).

This is why treatments including the use of cortisone will not work in patients with sacroiliac joint dysfunction. The wrong area is getting treated OR the right areas are not getting treated. The right areas may include:

• The axial low back,
• buttock/leg region
• groin/anterior thigh region

Nerve blocks do not work for some patients with sacroiliac joint pain. The reason? The patient does not have primary sacroiliac joint dysfunction

I will often receive an email that will describe to me cortisone injections or nerve blocks that did not help the e-mailer with their low back pain. As we have seen in many patients, the hip-spine-sacroiliac joint complex is a challenging one to differentiate where the pain is coming from. Injections into the hip may not provide relief if the pain is in the sacroiliac joint region. Injections into the sacroiliac joint region may not work if the pain is from the hip or groin.

A study in the medical journal Pain Physician looked at various treatment recommendations for patients suffering from sacroiliac joint pain. These treatments incldued burning the nrves, freezing the nerves, applying cortisone and Botox.

The researchers found the following:

• “The evidence for cooled radiofrequency neurotomy (freezing the nerve) in managing sacroiliac joint pain is fair.
• The evidence for effectiveness of intraarticular steroid injections is poor.
• The evidence for periarticular injections of local anesthetic and steroid or botulinum (Botox) toxin is poor.
• The evidence for effectiveness of conventional radiofrequency neurotomy (burning the nerves) is poor.
• The evidence for pulsed radiofrequency is poor.” (2)

Why did they find so many poor results? The chances are the patient did not have sacroiliac joint dysfunction.

Let’s look at another study. This time from June 2017 in the journal Medicine.(3) In this research, doctors from Korea investigated the degree of pain reduction following intra-articular pulsed radiofrequency stimulation of the sacroiliac joint in patients with chronic sacroiliac joint pain that had not responded to corticosteroid injection.

These research too found disappointing results:

• Intra-articular pulsed radiofrequency stimulation of the sacroiliac joint was not successful in most patients (80% of all patients). Based on our results, we cannot recommend this procedure to patients with chronic sacroiliac joint pain that was unresponsive to corticosteroid injection. 

Here is where treatments that are not helping the sacroiliac joint can become dangerous. How so? Because they will lead to a surgery that will not work either.

This was also suggested by a late 2019 study.(4)

• “The rationale for SI joint fusion is to relieve pain created by the movement of a joint through the removal of movement by arthrodesis (fusion) of the joint space. Only few comparative studies of percutaneous SI joint fusion and denervation have been reported, and they had limited clinical evidence.

Neurosurgeons suggest that treatment for sacroiliac joint pain should not include spinal fusion.

This is the title of a paper published in the journal Neurosurgery clinics of North America : “Sacroiliac Fusion: Another “Magic Bullet” Destined for Disrepute.”(5)

This is what the paper says:

“Pain related to joint dysfunction can be treated with joint fusion; this is a long-standing principle of musculoskeletal surgery. However, pain arising from the sacroiliac  joint is difficult to diagnose. . . Evidence establishing (successful) outcomes (of spinal fusion) is misleading because of vague diagnostic criteria, flawed methodology, bias, and limited follow-up. Because of nonstandardized indications and historically inferior reconstruction techniques, SI joint fusion should be considered unproven. The indications and procedure in their present form are unlikely to stand up to close scrutiny or weather the test of time.”

The challenge of sacroiliac joint dysfunction may be a ligament problem.

Doctors at the Mayo Clinic have published a paper entitled: Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. In this paper the Mayo Clinic researchers wanted to make a clear definition between two problems affecting low back pain patients.

• First, that pain could be coming from the discs.
• Second that pain could be coming from the spinal ligaments.

The Mayo researchers suggest that recognizing how the spine moves is essential for distinguishing between the many different types of spinal disorders, and a diagnosis which may ultimately, and erroneously lead to back surgery.

• If a patient has instability, excessive movement, and decreased stiffness, doctors should examine for ligament damage.
• If the opposite, less movement, more stiffness, the doctor should look for disc disease.(6)

This information can help determine the true cause of a patient’s sacroiliac joint dysfunction. When nothing is working, look at the ligaments. How do you look at the ligaments? Through physical examination.

A diagnosis which may ultimately, and erroneously lead to back surgery.

In our own published peer-review research appearing in the July 2018 in the Biomedical Journal of Scientific & Technical Research (BJSTR), July 2018, (6) we examined treating spinal ligaments with low back pain. Below is an explanatory adaption of the introductory paragraph of that study. It gives a good understanding of the importance of understanding that we should be looking at the ligament problems in back pain.

• • An Orthopaedic Knowledge Update from the American Academy of Orthopedic Surgeons tells its surgeon members that muscle strains, ligament sprains, and muscle contusions account for up to 97% of low back pain  in the adult population (7)
  • Additionally, researchers wrote in the Spine Journal that spinal ligaments are often neglected compared to other pathology that account for LBP (8). This could be due to the over-reliance of MRIs to guide physicians to correct diagnoses. They write: The influence of the posterior pelvic ring ligaments on pelvic stability is poorly understood. Low back pain and sacroiliac joint pain are described being related to these ligaments.When these ligaments are damaged or weakened, they serve as generators of low back pain.

Our treatment options

We offer stem cell therapy and Platelet Rich Plasma Therapy 

PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge in order to separate the platelets from the red cells. The platelets are the key to the treatment. The collected platelets are then injected back into the injured area of the spine to stimulate healing and regeneration of soft connective tissue, specifically the ligaments that hold the vertebrae in place and the tendons that attach the muscles to the spine.

PRP concentrates specific healing factors in an attempt to accelerate healing. Blood is made up of four main components; plasma, red blood cells, white blood cells, and platelets. Each part plays a role in keeping your body functioning properly. Platelets act as wound and injury healers. They are first on the scene at an injury, clotting to stop any bleeding and immediately helping to regenerate new tissue in the wounded area.

A soldier gets PRP treatment for SI joint pain

A case report in the August 2020 edition of the journal Military medicine (9) offers an insight into how PRP therapy can help a patient with SI Joint pain. The patient in this case history is an military members. Here is what the researchers reported in their observations of how PRP treatment to the low back could help reduce the need for opioid medications.

Darrow Stem Cell Institute research article published in the Biomedical Journal of Scientific & Technical Research (BJSTR), July 2018. This article presents highlighted portions of that research.

You can read about 4 patient’s cases studies here:

Study’s findings: This is the first reported study treating low back with bone marrow aspirate (BMC) stem cell injections to the ligaments, fascia, and muscles surrounding the lumbar spine. It is promising that at one-year follow-up, 100% of patients in this study experienced a decrease in resting and active pain in addition to performing daily activities with less difficulty.

• All four patients experienced sustained or increased improvement at annual follow-up compared to short-term follow-up.
• On average, patients reported:
  • 80% decrease in resting pain,
  • 78% decrease in active pain,
  • and a 41% increase in functionality score.
• Additionally, patients reported a mean 80% total overall improvement following
  treatment.
• The two patients who considered surgery prior to BMC treatment no longer felt the need for it.
• These results provide evidence that appropriately chosen patients with low back pain may find relief with BMC injections.

References:

1 DePhillipo NN, Corenman DS, Strauch EL, Zalepa LK. Sacroiliac Pain: Structural Causes of Pain Referring to the SI Joint Region. Clinical spine surgery. 2018 Oct.
2 Hansen H, Manchikanti L, Simopoulos TT, et al. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician. 2012 May;15(3):E247-78.
3 Chang MC, Ahn SH. The effect of intra-articular stimulation by pulsed radiofrequency on chronic sacroiliac joint pain refractory to intra-articular corticosteroid injection: A retrospective study. Medicine. 2017 Jun;96(26).
4 Chuang CW, Hung SK, Pan PT, Kao MC. Diagnosis and interventional pain management options for sacroiliac joint pain. Ci Ji Yi Xue Za Zhi. 2019 Sep 16;31(4):207-210. doi: 10.4103/tcmj.tcmj_54_19. PMID: 31867247; PMCID: PMC6905244.
5 Bina RW, Hurlbert RJ. Sacroiliac Fusion: Another “Magic Bullet” Destined for Disrepute. Neurosurgery Clinics of North America. 2017 Jul 31;28(3):313-20.
6 Ellingson AM, Shaw MN, Giambini H, An KN. Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. Comput Methods Biomech Biomed Engin. 2016;19(9):1009-18. doi: 10.1080/10255842.2015.1088524. Epub 2015 Sep 24. PMID: 26404463; PMCID: PMC4808500.
7 Marc Darrow, Brent Shaw BS. Treatment of Lower Back Pain with Bone Marrow Concentrate. Biomed J Sci&Tech Res 7(2)-2018. BJSTR. MS.ID.001461. DOI: 10.26717/ BJSTR.2018.07.001461. 5/
8 An HS, Jenis LG, Vaccaro AR (1999) Adult spine trauma. In Beaty JH (Eds.). Orthopaedic Knowledge Update 6. Rosemont, IL: American Academy of Orthopedic Surgeons pp. 653-671
9 Broadhead DY, Douglas HE, Bezjian Wallace LM, et al. Use of Ultrasound-Guided Platelet-Rich Plasma Injection of the Sacroiliac Joint as a Treatment for Chronic Low Back Pain. Mil Med. 2020;185(7-8):e1312-e1317. doi:10.1093/milmed/usz398