Eight out of 10 Americans will experience a lifestyle-altering episode of back pain at some point in their lives. Roughly 90 percent of single episodes of back pain reoccur.
While certain diseases and traumatic injury can cause back pain, research shows that the most common causes of back pain or injury are; poor physical condition, poor posture, improper body mechanics, and the prolonged repetitive use of incorrect bending or lifting techniques.
Preventing and relieving back pain and spine disorders are our specialties.
Dr. Steven Gogela, neurosurgeon with Neurological & Spinal Surgery, discusses SI joint pain and new treatments available at Bryan Health.
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New Treatment for Your SI Joint Pain
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Learn more about Dr. Steven Gogela
Steven Gogela, MD, Neurological & Spinal Surgery
Dr. Steven Gogela is a neurosurgeon with Neurological & Spinal Surgery.Learn more about Dr. Steven Gogela
Transcription:
New Treatment for Your SI Joint Pain
Melanie Cole (Host): Eight out of ten Americans will experience an episode of back pain at some point in their lives. My guest today is Dr. Steven Gogela. He’s a neurosurgeon with Neurological and Spinal Surgery. Welcome to the show Dr. Gogela. So, today’s topic, we are talking about SI joint pain. Please give a little physiology lesson. Where is the SI joint and what does it do?
Dr. Steven Gogela, MD (Guest): Good afternoon and thanks for having me today. So, the SI joint is the joint where the sacrum connects with the pelvis, the ilium of the pelvis, so it is the sacroiliac joint. So, all forces that are loaded on your spine are split between the two sacroiliac joints and then go down to your pelvis and into your legs from there. So, it is a very large and important joint in the body and can be a pain generator for some folks.
Melanie: So, why is it a pain generator? What causes pain in the SI joint?
Dr. Gogela: There are a couple different types of pain in the sacroiliac joint. Some are due to advanced degenerative changes and thus they are not very mobile, they are quite rigid but the degenerative changes kind of like arthritis in a knee or other joints causes significant pain. At other times, they can become hypermobile and that’s the pathology in younger females, especially. So, there are a couple different ways that the joint can be painful.
Melanie: So, is someone is feeling that pain, and if you have had back pain ever in your life it can be quite debilitating; what would they feel? What would that look like?
Dr. Gogela: So, back pain can be from multiple different sources. There are a number of pain generators in the lumbar spine and then in the musculoskeletal system in general. SI pain in particular, is typically below the belt line, usually in the midline or off to one side, especially if it is unilateral sacroiliac pain, it will be off to one side, chiefly in the buttocks, below the belt line and it can radiate down the back of the leg. For some people, it comes around their hip or into their groin. It may hurt when people are trying to sleep or if they sit on that affected extremity. Sometimes people feel as though because of the pain, that leg buckles or gives way and one really significant symptom that folks typically have is difficulty standing from a seated position, because that motion really stresses the SI joint and can be very painful.
Melanie: Dr. Gogela, when you mentioned radiating down, people hear about that and they hear about sciatica. Is that – is there involvement with the sciatic nerve when you have SI joint issues?
Dr. Gogela: There is not. It is more referred pain, so it’s not a nerve compression phenomenon. That certainly is a pain generator in the leg when there is a compressed nerve, however, this is different, but it can be confusing. So, there are ways that we can tease that difference out.
Melanie: So, what are those ways? Because that’s the reason I asked you is because it does – people get confused about that and right away that’s what they assume. So, how do you tell the difference?
Dr. Gogela: Much of the diagnosis can be made just based on somebody’s history, if there is any history of trauma, where somebody fell on their buttocks or had some other kind of traumatic injury or just the distribution of their pain and the character of it, however, for SI joint pain in particular, a physical exam is crucial and typically is the deciding factor as to whether or not we go down that treatment pathway. So, there are a number of physical exam maneuvers that can really pinpoint pain coming from the sacroiliac joint and we can reliably tell patients in that visit this seems to be an inflamed joint for you and we should target this in your treatment going forward.
Melanie: So, what does the treatment plan look like Dr. Gogela and so, what is your first line of defense and then where do you go from there?
Dr. Gogela: So, anti-inflammatory medications as with other types of joint pain or arthritis, anti-inflammatories are key. Physical therapy is the mainstay in treatment for SI joint pain and there are various targeted activities, strength training etc. for the sacroiliac joint, in particular. Certain physical therapists have a particular interest in sacroiliac pain and thus we tend to try to refer to those therapists who we know and work with all the time. Now, physical therapy doesn’t work for everybody and one very important portion of the treatment paradigm is an injection, and this is a different injection as to an injection in the hip or one in the lumbar spine or something of that sort. This is more of a diagnostic injection where a very small amount of numbing medication is injected into the joint under x-ray guidance to confirm that that’s the location of the pain. So, it’s more of a diagnostic injection as opposed to a therapeutic injection. So, if somebody has that injection with a very small amount of antiesthetic and their pain is essentially eliminated and then it comes back within a couple of days as that injection wears off, then we have a diagnosis and then we can really target the rest of the treatment to that joint.
Melanie: And if none of these first line treatments are working for the patient, then tell us about your new treatment that you are doing there.
Dr. Gogela: So, I’ll say that the great majority of patients are able to improve and be in a better situation and less functionally debilitated with therapy. And it can be ups and downs, but usually long-term folks can do well with therapy alone and hopefully and usually we don’t have to do anything more significant. But there are – there have been technological advancements over the past several years that are allowing us to do minimally invasive fusions of the sacroiliac joint. It can be done outpatient. Sometimes you come to the hospital for a night or two depending on your circumstances and your age, but it is a much less traumatic approach and procedure than how sacroiliac fusions have been done in the past and folks tend to do very well. It’s been a heavily scrutinized and researched topic and if people are very clearly patients with sacroiliac pain and they go through the necessary treatment protocol; they have resolution of their pain with injections and they just cannot get over the hump with physical therapy; those patients do very well with the procedure. It doesn’t necessarily remove 100% of someone’s pain, but typically patients are much better off and very pleased that they went forward with it. And that has been born out in multiple big studies here in the United States and abroad.
Melanie: So, what’s the difference between a minimally invasive procedure versus the traditional? Why would a patient be psyched about this?
Dr. Gogela: Well in the past, it was an open procedure. An open procedure requires a larger incision, more dissection of muscle tissue etc. to be able to visualize landmarks that you are working with. Minimally invasive approaches really cut down on the trauma to tissues, trauma to muscles and thus hopefully pain and problems stemming from the surgery long-term. So, utilizing fluoroscopy or x-ray; I make a small incision and place three implants under x-ray guidance so, I’m not directly visualizing the implants, but I’m checking it constantly with different x-ray views in order to ensure that it’s in a safe trajectory and getting the necessary bony purchase for the procedure. And using these techniques; it is really quite a straightforward procedure and it is not too much time in the operating room and risk is certainly decreased with the minimally invasive techniques.
Melanie: So, these implants. Is this now something that you would ever have to redo? Are they something that will set off alarms at the airport? Tell us a little bit about these titanium implants.
Dr. Gogela: So, they should not set off anything at the airport, metal detectors or things of that sort. And typically, they are not revised. Sometimes instrumentation can fail, but these are very well studied, very well-designed implants and that if I were having this procedure done to myself; I would not fear that the instrumentation was going to break; although it can. There can be fractures of it. There can be fractures of the bone that it is going into such as the pelvis, but long-term, these implants are incorporated into the bone across the sacroiliac joint to cause a bony fusion in that location. And there is excellent evidence that this does occur over the first six to twelve months after surgery.
Melanie: So, wrap it up for us Dr. and tell the listeners what you would like them to know about SI joint pain and back pain and when it’s time to really see a specialist and discuss other interventions.
Dr. Gogela: So, back pain is a massive problem. I see folks in my office on a daily basis with severe back pain and there are many different causes of back pain. This has given us an avenue to have a very good viable treatment that can make a big difference for people who have pain from this source. This is not going to fix everybody’s problem, but patients who have sacroiliac pain can really benefit from this treatment protocol and in cases where they don’t succeed with therapy, then eventually with this minimally invasive surgery. So, typically if somebody has an acute back strain, resting, using anti-inflammatories, trying to avoid activities that flare up back pain is the initial treatment. If this persists then it’s time to check in with your primary care provider, they are kind of your quarterback and can give you the guidance into the next stages of your treatment and then if it persists too long; you typically get referred to a specialist like myself who can identify what the particular pain generator is in your particular case and then treat you appropriately. But this does give us an excellent treatment paradigm or protocol for this particular entity and it’s really helped a lot of patients over the past several years. So, we are very excited about it.
Melanie: Thank you so much Dr. Gogela for being with us today. If you would like to know more about your treatment options for SI joint pain; go to www.bryanhealth.org/sijoint , that’s www.bryanhealth.org/sijoint . This is Bryan Health podcast. I’m Melanie Cole. Thanks so much for listening.
New Treatment for Your SI Joint Pain
Melanie Cole (Host): Eight out of ten Americans will experience an episode of back pain at some point in their lives. My guest today is Dr. Steven Gogela. He’s a neurosurgeon with Neurological and Spinal Surgery. Welcome to the show Dr. Gogela. So, today’s topic, we are talking about SI joint pain. Please give a little physiology lesson. Where is the SI joint and what does it do?
Dr. Steven Gogela, MD (Guest): Good afternoon and thanks for having me today. So, the SI joint is the joint where the sacrum connects with the pelvis, the ilium of the pelvis, so it is the sacroiliac joint. So, all forces that are loaded on your spine are split between the two sacroiliac joints and then go down to your pelvis and into your legs from there. So, it is a very large and important joint in the body and can be a pain generator for some folks.
Melanie: So, why is it a pain generator? What causes pain in the SI joint?
Dr. Gogela: There are a couple different types of pain in the sacroiliac joint. Some are due to advanced degenerative changes and thus they are not very mobile, they are quite rigid but the degenerative changes kind of like arthritis in a knee or other joints causes significant pain. At other times, they can become hypermobile and that’s the pathology in younger females, especially. So, there are a couple different ways that the joint can be painful.
Melanie: So, is someone is feeling that pain, and if you have had back pain ever in your life it can be quite debilitating; what would they feel? What would that look like?
Dr. Gogela: So, back pain can be from multiple different sources. There are a number of pain generators in the lumbar spine and then in the musculoskeletal system in general. SI pain in particular, is typically below the belt line, usually in the midline or off to one side, especially if it is unilateral sacroiliac pain, it will be off to one side, chiefly in the buttocks, below the belt line and it can radiate down the back of the leg. For some people, it comes around their hip or into their groin. It may hurt when people are trying to sleep or if they sit on that affected extremity. Sometimes people feel as though because of the pain, that leg buckles or gives way and one really significant symptom that folks typically have is difficulty standing from a seated position, because that motion really stresses the SI joint and can be very painful.
Melanie: Dr. Gogela, when you mentioned radiating down, people hear about that and they hear about sciatica. Is that – is there involvement with the sciatic nerve when you have SI joint issues?
Dr. Gogela: There is not. It is more referred pain, so it’s not a nerve compression phenomenon. That certainly is a pain generator in the leg when there is a compressed nerve, however, this is different, but it can be confusing. So, there are ways that we can tease that difference out.
Melanie: So, what are those ways? Because that’s the reason I asked you is because it does – people get confused about that and right away that’s what they assume. So, how do you tell the difference?
Dr. Gogela: Much of the diagnosis can be made just based on somebody’s history, if there is any history of trauma, where somebody fell on their buttocks or had some other kind of traumatic injury or just the distribution of their pain and the character of it, however, for SI joint pain in particular, a physical exam is crucial and typically is the deciding factor as to whether or not we go down that treatment pathway. So, there are a number of physical exam maneuvers that can really pinpoint pain coming from the sacroiliac joint and we can reliably tell patients in that visit this seems to be an inflamed joint for you and we should target this in your treatment going forward.
Melanie: So, what does the treatment plan look like Dr. Gogela and so, what is your first line of defense and then where do you go from there?
Dr. Gogela: So, anti-inflammatory medications as with other types of joint pain or arthritis, anti-inflammatories are key. Physical therapy is the mainstay in treatment for SI joint pain and there are various targeted activities, strength training etc. for the sacroiliac joint, in particular. Certain physical therapists have a particular interest in sacroiliac pain and thus we tend to try to refer to those therapists who we know and work with all the time. Now, physical therapy doesn’t work for everybody and one very important portion of the treatment paradigm is an injection, and this is a different injection as to an injection in the hip or one in the lumbar spine or something of that sort. This is more of a diagnostic injection where a very small amount of numbing medication is injected into the joint under x-ray guidance to confirm that that’s the location of the pain. So, it’s more of a diagnostic injection as opposed to a therapeutic injection. So, if somebody has that injection with a very small amount of antiesthetic and their pain is essentially eliminated and then it comes back within a couple of days as that injection wears off, then we have a diagnosis and then we can really target the rest of the treatment to that joint.
Melanie: And if none of these first line treatments are working for the patient, then tell us about your new treatment that you are doing there.
Dr. Gogela: So, I’ll say that the great majority of patients are able to improve and be in a better situation and less functionally debilitated with therapy. And it can be ups and downs, but usually long-term folks can do well with therapy alone and hopefully and usually we don’t have to do anything more significant. But there are – there have been technological advancements over the past several years that are allowing us to do minimally invasive fusions of the sacroiliac joint. It can be done outpatient. Sometimes you come to the hospital for a night or two depending on your circumstances and your age, but it is a much less traumatic approach and procedure than how sacroiliac fusions have been done in the past and folks tend to do very well. It’s been a heavily scrutinized and researched topic and if people are very clearly patients with sacroiliac pain and they go through the necessary treatment protocol; they have resolution of their pain with injections and they just cannot get over the hump with physical therapy; those patients do very well with the procedure. It doesn’t necessarily remove 100% of someone’s pain, but typically patients are much better off and very pleased that they went forward with it. And that has been born out in multiple big studies here in the United States and abroad.
Melanie: So, what’s the difference between a minimally invasive procedure versus the traditional? Why would a patient be psyched about this?
Dr. Gogela: Well in the past, it was an open procedure. An open procedure requires a larger incision, more dissection of muscle tissue etc. to be able to visualize landmarks that you are working with. Minimally invasive approaches really cut down on the trauma to tissues, trauma to muscles and thus hopefully pain and problems stemming from the surgery long-term. So, utilizing fluoroscopy or x-ray; I make a small incision and place three implants under x-ray guidance so, I’m not directly visualizing the implants, but I’m checking it constantly with different x-ray views in order to ensure that it’s in a safe trajectory and getting the necessary bony purchase for the procedure. And using these techniques; it is really quite a straightforward procedure and it is not too much time in the operating room and risk is certainly decreased with the minimally invasive techniques.
Melanie: So, these implants. Is this now something that you would ever have to redo? Are they something that will set off alarms at the airport? Tell us a little bit about these titanium implants.
Dr. Gogela: So, they should not set off anything at the airport, metal detectors or things of that sort. And typically, they are not revised. Sometimes instrumentation can fail, but these are very well studied, very well-designed implants and that if I were having this procedure done to myself; I would not fear that the instrumentation was going to break; although it can. There can be fractures of it. There can be fractures of the bone that it is going into such as the pelvis, but long-term, these implants are incorporated into the bone across the sacroiliac joint to cause a bony fusion in that location. And there is excellent evidence that this does occur over the first six to twelve months after surgery.
Melanie: So, wrap it up for us Dr. and tell the listeners what you would like them to know about SI joint pain and back pain and when it’s time to really see a specialist and discuss other interventions.
Dr. Gogela: So, back pain is a massive problem. I see folks in my office on a daily basis with severe back pain and there are many different causes of back pain. This has given us an avenue to have a very good viable treatment that can make a big difference for people who have pain from this source. This is not going to fix everybody’s problem, but patients who have sacroiliac pain can really benefit from this treatment protocol and in cases where they don’t succeed with therapy, then eventually with this minimally invasive surgery. So, typically if somebody has an acute back strain, resting, using anti-inflammatories, trying to avoid activities that flare up back pain is the initial treatment. If this persists then it’s time to check in with your primary care provider, they are kind of your quarterback and can give you the guidance into the next stages of your treatment and then if it persists too long; you typically get referred to a specialist like myself who can identify what the particular pain generator is in your particular case and then treat you appropriately. But this does give us an excellent treatment paradigm or protocol for this particular entity and it’s really helped a lot of patients over the past several years. So, we are very excited about it.
Melanie: Thank you so much Dr. Gogela for being with us today. If you would like to know more about your treatment options for SI joint pain; go to www.bryanhealth.org/sijoint , that’s www.bryanhealth.org/sijoint . This is Bryan Health podcast. I’m Melanie Cole. Thanks so much for listening.