Sacroiliac Joint Fusion - Carter Beck, MD

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Dr. Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have as my guest, Dr. Carter Beck. Dr. Beck is a neurosurgeon. Dr. Beck did his medical school training at the University of Chicago School of Medicine. From there he finished a neurosurgical residency at Stanford University. Good morning, Dr. Beck.

Dr. Beck: Good morning, Randale.

Dr. Sechrest: Thanks for joining us today. What I'd like to discuss today is your approach to a very common problem in patients with low back pain which is not necessarily a spine condition, but a condition of a joint right next to the spine called the sacroiliac joint.

Dr. Beck: Yeah, it's an important problem.

Dr. Sechrest: Let's talk a little bit about that joint causes problems. How do you know if you have a sacroiliac joint dysfunction or sacroiliac joint pain?

Dr. Beck: Well, that's one of the problems, I think, for the physicians involved is it can be fairly difficult to tell at times whether the pain somebody's describing is coming from the sacroiliac joint. The sacroiliac joint is a joint that is between the sacrum, which is the tailbone, and the ilium, which is the wing, the fan-shaped bone which goes out to form the hip joint. So it's really the transition between the spine and the hip, and it's been notorious over the years for causing people trouble. Typically people have pain down around their tailbone. It's sort of a V-shaped area that can be tender to the touch. It bothers them when they sit. It bothers them when they stand. It bothers them when they lie in bed, and there is a pattern, which those of us who see a fair amount of it begin to recognize. But it's often difficult to make the diagnosis. One of the first ways to find out whether the sacroiliac joint is the culprit and is what is bothering a patient is to have a steroid injection, and we have physicians who will put a needle into the joint, inject some steroids, and some Novocain, and if that causes a patient immediate or significant pain relief which lasts them a week or two, you have a pretty good idea at that point that that may be the cause of what's bothering the patient.

Dr. Sechrest: Now a couple of questions. In my research, I've talked to folks who deal with patients without spine surgery, who've never had spine surgery, and even in that population the statistics are probably 1 in 5, 20%, of people who come into your office complaining of low back pain. As you go through a history and physical and ultimately make a diagnosis that 20% of those people will actually have pain that's coming from the sacroiliac joint and not coming from the spinal column itself. Now I think that figure even goes up when you're dealing with patients who've had spine fusions, for example, and I'm interested in your take on patients who've had maybe one or two fusions with several segments in the spine, why are these people prone to developing pain after that in that sacroiliac joint? What's causing that?

Dr. Beck: Well, that's an interesting problem and that's one of the things that has gotten me particularly interested in the diseases. Right now the sacroiliac joint is one of the things which is limiting my success, and people who have very diseased spines, I'm able to reconstruct a very, very diseased spine in an elderly patient and take on things that we wouldn't dream of 10 years ago. Sometimes the results, the degree of pain relief, how happy a patient is when I'm finished with that is being limited by what we think is the sacroiliac joint. There's a principle in spine surgery that when you fix one joint, there frequently is a complication or a disease which develops in an adjacent segment. The spine has many joints in it and adjacent segment disease is something we struggle with. Unlike an appendix where you only have one, and when you have appendicitis and you take out the appendix, the patient's never going to have a problem with their appendix again. In the spine, there are dozens of joints and one of the things that we see is that the next joint in line is often the one that goes next. So a patient comes in with a problem at say L4-5, a year or two later they may have a problem with L3-4. The extension of that principle is to say what happens if you've done a reconstruction or a fusion on three levels at the base of the spine and now the sacrum is fused to the lumbar spine, what's the next joint, the adjacent segment to that going inferiorly? Well, that's the sacroiliac joint. So I think that one of the problems with the sacroiliac joint is it's essentially it's adjacent segment disease. It's the next mobile structure, which can be prone to arthritis, to which the forces from the lumbar spine can be transmitted.

Dr. Sechrest: So what's happening is you fix the problem in the spine. That pain goes away. Now all the stress is transferred to the sacroiliac joint and now the patient's complaining of pain in a different area.

Dr. Beck: Exactly.

Dr. Sechrest: That's really aggravated the sacroiliac joint.

Dr. Beck: Exactly.

Dr. Sechrest: Now, you had mentioned that the diagnosis of this is really comes down to injecting the joint and see if you can make the pain go away. Do you ever do any type of imaging studies or x-rays or anything? Will they help you at all make this diagnosis?

Dr. Beck: Yeah, I think all of the above can help, but not with a very high frequency. Something can be learned about the sacroiliac joint on a plain x-ray. We can learn something sometimes on an MRI scan. We can learn something from a CAT scan, or even a bone scan which is a nuclear medicine study where a radioactive tracer accumulates in joints that are arthritic, and there's a classic finding on a bone scan for what we call sacroiliitis which means disease in the sacroiliac joint, arthritic disease.

Dr. Sechrest: And there are lots of things that can cause pain in the sacroiliac joint. I think the Number 1 cause that I see is just what we would consider idiopathic, which means, we don't know what's causing the problem. It's not really an arthritis that you can say, “These people haven't had spine surgery so you can't really blame a spine fusion for it.” But they just walk in off the street and for some reason or a dysfunction in the sacroiliac joint and I don't think we ever know the cause.

Dr. Beck: Right. What most of think is that there's some laxity in the joint, and it seems to be a more frequent problem in women. Women's pelvises are shaped differently than man, and during childbirth, their ligaments all around a woman's pelvis are relaxed to permit the birth of the child. It may be that on some those patients that ligamentous laxity never really restores itself, and over time, 20, 30 years, that laxity becomes painful.

Dr. Sechrest: I think we should point out that there's some systemic arthritides, like rheumatoid arthritis, ankylosing spondyloarthropathy, and even psoriatic arthritis that can affect that joint, because that's a synovial joint like any other joint in the body. So anything that affects the rest of the synovial joints can actually affect the sacroiliac joints and ankylosing spondylitis is one of the classics that actually affects the sacroiliac joints to the point where, late in the disease, they even fuse together like the spine does in ankylosing spondylitis.

Dr. Beck: Absolutely.

Dr. Sechrest: Well, let's move on a little bit to discuss the treatment options for patients who have been identified as having sacroiliac joint pain. What do we do with those patients these days?

Dr. Beck: Well, like all of these arthritic disorders there's a gradation of treatment and there's variation in the severity of the pathology. There are some people who have very mild sacroiliac dysfunction and their pain coming from their sacroiliac joint and simply physical therapy or acupuncture or chiropractic is enough to control it. Sometimes just taking anti-inflammatories will calm it down and make it go away. Sometimes the pain and the discomfort is significant enough that repeated injections become necessary. We certainly see that fairly frequently in our practice, and for patients who have had repeated injection and continue to relapse, continue to be symptomatic and have the most severe case of sacroiliac disease, the option for surgery is now sometimes considered.

Dr. Sechrest: It's interesting because I've read lots of studies with people injecting all sorts of things into that joint. They've tried cortisone. They've tried the new Hyaluronic acid. Some folks of people have injected phenol. There are all sorts of things that have been tried in terms of injecting into that joint. The bottom line is not many of them work. I mean the cortisone works for a short period of time, but everything else has had a pretty poor track record in terms of actually giving people permanent relief from that.

Dr. Beck: Yeah, as we discussed off camera earlier, this is one of those diagnoses that kind of gives a surgeon or a spine specialist the chills because it can be so hard to treat. None of the treatments that we've had over time have been uniformly effective, and there have been a number of different approaches to surgery on the joint which have been tried over the years, and some of them more or less abandon or reserve for only the most extreme cases because they aren't uniformly effective.

Dr. Sechrest: Now you, as a surgeon who deals with this on an ongoing basis because obviously you do a lot of spine fusions and a lot of those patients will end up, or a significant portion of those patients will end up, with some degree of sacroiliac joint dysfunction and pain. When do you advise patients to consider a surgical option for this type of a condition.

Dr. Beck: Well, this is a moving target right now and I would say the short answer to that is very rarely, only in the most intractable cases. I've recently had patients in my practice who have had multiple successful spine surgeries for very significant degenerative problems in their spine, degenerative scoliosis, and spondylosis and stenosis, all of those ‘oses' in the spine, and the spine surgery has worked well on them and they wind up with sacroiliitis. Fortunately it doesn't happen that often, but it does happen. Those patients who then go into injections and the injections work, but unfortunately the relief is brief, and they have repeated injections, and it doesn't go away. Some of those patients may be candidates for surgery. We're, at the moment, in the process of evaluating a modified approach to the surgery for this which is a fusion which may be more effective because of some technological advances.

Dr. Sechrest: Well, describe that for me. In the old days, we made big incisions, we opened up that joint, took all the cartilage off that joint, put big screws across the pelvis, it was a huge operation, and most surgeons would really steer patients away from that type of an intervention. As I understand it, like everything else in surgery, we're moving to more and more minimally invasive techniques. What are we doing these days with the sacroiliac joint? What's available to us?

Dr. Beck: Well, I agree with what you said. In my training, when I was trained, a concept of sacroiliac fusion was thought of as sometimes a treatment worse than the disease, and so we steered clear of it. The modern armamentarium for spine surgery, and by extension sacroiliac joint surgery, offers us an opportunity to look at procedures which are less invasive, less destructive, easier to get over, a lower complication rate. One of the things that has been a big advance in the last 5, 10 years is the occurrence of something called bone morphogenetic protein. There are companies that have developed synthetic, biologically recombinant proteins which are involved in the stimulation of bone fusion or bone formation, and by extension that means that we can stimulate a fusion to occur. Whereas in the old days it was maybe 50-50 on whether a surgeon's operation actually led to fusion as he had intended, today maybe we can approach in other areas of the body, 90, 95, 99% fusion rates. So bone morphogenetic protein is something which may make the sacroiliac fusion, which was in the old days a hit or miss operation, something that's more effective, easier to do, and maybe a solution to this problem.

Dr. Sechrest: So if we go back to the notion of creating a fusion; in the old days, as you said, basically the only thing we had to do was to remove the cartilage or remove the surface of the bone that we're trying to fuse so that we've got raw bony surfaces that are lying together, and then we either put bone graft, which is usually bone that's taken out of the body somewhere else and placed in there. In some ways, that was used as sort of a fertilizer to try to stimulate the bone growth and then hold everything together as tight as we can while it healed. If I understand you correctly the bone, the BMP, the bone morphogenetic protein is actually something that's almost a drug, something that can be squirted into an area and it acts like a stimulant, a fertilizer, that tends to make those two bones more likely to grow together. Is that correct?

Dr. Beck: Exactly right, and it's finding increasing use, this bone morphogenetic protein, what we call BMP, is finding increasing use in orthopaedic surgery and then spine surgery, both areas where sometimes what we need to do with a bad joint is fuse it and, just to be clear like you say, if this is a joint, and it's broken and we can't restore the normal function of the joint what we try to do is get the body to treat that joint like a fracture and get the two bones to fuse together.

Dr. Sechrest: Well, describe for me a little bit about the procedure, the way we use this new technique in the sacroiliac joint. Again, in the old days, we made big incisions so we could see that joint, and that joint's pretty deep down in the body. How are getting into that joint and how are you getting that bone morphogenetic protein into that joint so that it will fuse?

Dr. Beck: Well, one of the modifications of the old operations that I'm evaluating is done through a very small incision over the joint on the back, essentially on either side of the tailbone, and make a small incision, go down, cut the ligaments over the top of the joint, expose the joint, and then drill a hole essentially into the joint which causes either side of the joint to be roughened up, to expose the interior of each of the bones; and then screw in a titanium cage that has many holes in it. It's essentially a cylinder that has perforations all the way around. That cylinder we fill with a sponge that has this bone morphogenetic protein on it, and while we're early in evaluating this technique, the hope is that that will be sufficient to stabilize the joint but maybe some distraction with this cylinder or tensioning of the ligaments, and then stimulating the bones to heal together. The good news on this technique so far is that it's very well tolerated by patients. It is not a painful operation to recover from so far, and we're very early in looking at this approach to this operation. It looks good.

Dr. Sechrest: So, like a lot of minimally invasive procedures, we've reduced the size of the incision and hopefully reduced the amount of destruction of normal tissue we have to make to actually get the job done.

Dr. Beck: Exactly.

Dr. Sechrest: Now is this an outpatient procedure? Or is this something that the patient should expect to stay in the hospital? Overnight? Two days? Three days? How long?

Dr. Beck: Well, I think ultimately if this turns out the way we're hoping, it will be an outpatient procedure. Sometimes that is guided, not by the physician or the surgeon, but by the insurance policy. Medicare, for example, went with any implanted device, tends to want patients in the hospital overnight even if the physician thinks that unnecessary. Whether that's wasteful of the taxpayers' dollar or not is another discussion, but ideally this, I think, will be an outpatient procedure. If we can develop an outpatient procedure which effectively treats sacroiliitis, I think that would be a big step forward.

Dr. Sechrest: No, I think there's a huge population of patients that could benefit from that. Well, let's talk a little bit about the recovery. So, if this gets to the point to where, today, what I heard you say, is probably it's one night in the hospital depending, and if you're elderly and ill, it might be a couple of days in the hospital. But if this gets to be an outpatient procedure, how long does it take for this to heal? What does the patient expect after the surgery is done? How much pain? Are they restricted? How long does it take before it's healed?

Dr. Beck: Well, I'm not sure I know at this point, Randale. I'm early in evaluating this particular approach to this problem and this surgery. But fairly minimal recovery is what it appears. There, of course, will be incisional pain, some soreness, around the joint. That's normal. That kind of incisional pain or muscular pain usually resolves within a week or two of surgery and is usually very well tolerated by patients. Healing in this situation, implies also that the bone is fusing together, and with all fusions, some of the procedures successfully go on to fusion and some don't. In most fusion operations what we expect is a time course of 6 weeks or 3 months before there's been substantial bony healing and essentially the intention of the operation is complete, but we know that that process of fusion actually goes on for much longer than that. I think most patients, though, who undergo any kind of fusion operation, they don't really have symptoms associated with the fusion after the first month.

Dr. Sechrest: Okay. How about the risk to the patient? Do you find that there's any significant risks in this operation that are not present in the general operation?

Dr. Beck: Well, all surgery carries with it risk, as you know. All medical procedures have risk of infection or risk of bleeding, risk of the anesthetic, there are some things we just can't get away from when it comes to operating on human beings. In this instance, the sacroiliac joint is in a relatively safe place in the body. There are not a lot of structures which are jeopardized by approaching this joint posteriorly or from the backside. We really don't have to cut through muscle to get in there. You really don't have nerves, spinal nerves, anywhere nearby that they are jeopardized. So in general I think that addressing this sacroiliitis surgically is intrinsically safe by this method, safer certainly than opening the pelvis or doing more aggressive old style approaches to this problem.

Dr. Sechrest: Now, in terms of restrictions for patients after surgery, do these patients have a cast? Do they have any sort of brace on? Or are you letting them pretty much go on their own and activity as tolerated? What's the norm?

Dr. Beck: Yeah, there's really no effective way to brace the sacroiliac joint. Whereas in the lumbar spine we can put a corset around the patient's middle section. You really can't do that with the sacroiliac joint. It's part of their pelvis and their hip region, and those things need to move unless you're going to put somebody on a stretcher for 3 months. So there is no immobilization. Obviously we wouldn't want a patient waterskiing a week after an operation like this. But activities of daily living, at this point, we think are acceptable immediately after the surgery. I operated on a patient with this disorder yesterday and she's up in the hall walking yesterday afternoon.

Dr. Sechrest: And probably going home today.

Dr. Beck: And going home today.

Dr. Sechrest: What do you think the future for this technique is? Are you satisfied at this point that you're early results are good enough to continue to explore this avenue, and continue to recommend this operation to patients?

Dr. Beck: At the present time, we're using these techniques only for the worst of the worst. Anybody with sacroiliitis doesn't need this operation. We are talking about patients who have had upwards of 5, 6, 7, 12 injections and at one or both of those sacroiliac joints the injections are effective, the diagnosis is not in doubt, but the pain is intractable and we think we've reached the end of utility with injection treatments. So for the worst of the worst, the really intractable cases, we are at this point, recommending this. We do not have any long-term success measures at this point. I think the future, because of the technological advances that we've talked about, may be bright, and this has been a very difficult problem in spine surgery and orthopaedic surgery over the years, and we're going to continue to chip away it and, with any luck, what we're doing today is going to turn out to be the thing.

Dr. Sechrest: Can you give any closing remarks to patients who may be suffering from sacroiliac joint dysfunction and pain? Any sort of pearls of wisdom that you would provide them either about non-operative treatment, things they should try before they consider this operation, and maybe a little bit of advice about when they should consider looking for someone who would potentially do this type of procedure for sacroiliac pain?

Dr. Beck: Well, as I said, I think at this point sacroiliitis is, for the most part, a non-operative problem and I think patients who are really struggling with this and really have this diagnosis should be being treated regularly by somebody has some expertise in treating sacroiliitis. I think that's the most important thing. The sort of "catch as catch can" approach for really a significantly disabling problem is probably not good enough. So, see a specialist, see a physician who thinks critically about sacroiliitis and follow their advice, and that may just be physical therapy and anti-inflammatories. It may be acupuncture or chiropractic. It may be injections and it may ultimately be surgery.

Dr. Sechrest: And it sounds like to me that despite the bleak sort of prognosis for surgical correction of this problem in the past, patients should understand that there may be a much better option on the horizon.

Dr. Beck: Well, we're hoping. We're looking at it and we keep trying to help these patients and we'll find out.

Dr. Sechrest: Thanks very much. Good information.

Dr. Beck: Thank you.

Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you're an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you'll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.

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