In this article, Ross Hauser, MD updates information based on new research on the problems of low back pain as it relates sacroiliac joint dysfunction. Dr. Hauser will explore research on surgery and non-surgical options treatment including the use of Prolotherapy and Platelet Rich Plasma and Stem Cell Therapies.
- If you have questions about Sacroiliac joint pain, Get Help and Information from our Caring Medical staff
Why are doctors rushing to send their patients to unnecessary and possibly dangerous spinal fusion surgery when there are non-surgical SI pain options available that may be more effective?
In the July 2017 edition of the medical journal Neurosurgery clinics of North America, doctors at the Division of Neurosurgery, Banner University Medical Center, in Arizona said this about sacroiliac joint pain, draw your own conclusion:
“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. Several implant devices (fusion techniques) are available that promote fusion by simply crossing the joint space.
(However) Evidence establishing (successful fusion) outcomes 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.”1 Please see our article Spinal fusion surgery complications and treatment options.
The diagnosis of Sacroiliac joint dysfunction and/or Sacroiliac joint (SI) disease is difficult.
There is no consensus in the medical community, based on recent research, that can quantify the amount of pain symptoms sacroiliac joint dysfunction causes or even determine if that pain is in fact coming from the sacroiliac joint. Therefore fusion is not recommended.
The research clinicians say to diagnose sacroiliac joint dysfunction as the cause of pain, you need to be able to find, treat, and alleviate that pain. Typically this is done with a nerve block that offers some degree of sacroiliac pain relief. But . . .
- “The degree of pain relief required to diagnose sacroiliac joint dysfunction following a diagnostic Sacroiliac joint block is not known. No gold standard exists. . . ” and
- “The degree of pain improvement during Sacroiliac joint block did not predict improvements in pain or ODI scores (levels of disability scoring) after spinal fusion.”
- Finally, the determination that “A 50% Sacroiliac joint block threshold (pain reduction) resulted in excellent post-Sacroiliac joint fusion responses. Using overly stringent selection criteria (i.e. 75% in pain reduction) to qualify patients for Sacroiliac joint fusion has no basis in evidence and would withhold a beneficial procedure from a substantial number of patients with SIJ dysfunction.”2
- if a nerve block was seen to offer a 50% reduction in pain, then surgeons should proceed with fusion.
- In our office we would try much less invasive Prolotherapy first. Because the study above still recommends patients should get spinal fusion surgery even without clear evidence to suggest it would work. Please see my article Failed Back Surgery Syndrome.
Spinal surgery causes sacroiliac joint-related pain
In the study above, doctors say spinal fusion can alleviate Sacroiliac joint pain. In the studies below, doctors ask, does surgery CREATE sacroiliac joint-related pain?
Doctors in Germany examined a potential connection between lumbar decompressive surgery and new onset of sacroiliac joint-related pain causing a diagnosis of “failed-back-surgery.”
- Patients with lumbar stenosis do have substantially positive results from decompressive surgery.
- HOWEVER the change of body position and walking behavior (anatomical alteration) after successful surgery might lead to changed force effects on the entire spine and on the sacroiliac joint in the future.
In other words, lumbar decompression surgery changed the patient’s natural movement to one that irritated the and caused Sacroiliac joint pain-related pain after surgery.
- The doctors concluded that: “Lumbar decompression patients should be informed about this possible condition to avoid uncertainty, discontent, unnecessary diagnostics and to induce a quick, specific treatment.”3 In other words a diagnosis of a “failed-back-surgery.”
Sacroiliac joint inflammation
- A patient suffering from Sacroiliac joint dysfunction symptoms may have pain from inflammation, sacroiliitis. Sacroiliitis is one cause of the broad picture of sacroiliac joint dysfunction degeneration.
Sacroiliac joint inflammation is a difficult to determine diagnosis as it may come from an infectious disease or be caused by a rheumatology disorder. For many patients inflammation of the sacroiliac joint is NOT caused by infectious disease but by chronic degenerative inflammation including ankylosing spondylitis. In some causes a rheumatologist will be consulted.
Sacroiliitis pain and symptoms include pain on one side of the lower back (unilateral sacroiliitis – one of the SI joints is inflamed) or both sides (bilateral sacroiliitis, both SI joints are inflamed).
Sacroiliitis can be brought on by wear and tear osteoarthritis, by impact or acute traumatic injury, pregnancy causing wear and tear and SI instability and as mentioned, the rare case infection.
The first thing the doctor may offer you is anti-inflammatory medications, a sacral belt (low spine support brace), and a recommendation to change your activities and/or lifestyle to avoid more stress on the sacroiliac joint. Some doctors may suggest cortisone into the sacroiliac joint and warn the patients of possible cortisone injection side effects.
However this approach may not be addressing the problems that weakened or damaged spinal ligaments are the cause of sacroiliac joint instability. This will be addressed below.
Making the case for treating sacroiliac joint dysfunction by treating the spinal ligaments
Doctors from the Low Back Pain and Sacroiliac Joint Center, Sendai Shakaihoken Hospital in Japan wrote of their findings in the European Spine Journal, that said referred pain from the sacroiliac joint can be isolated to the anterior ligament sacroiliac joint region, and that by treating the ligaments pain can be alleviated. 4
This is an interesting study in that it discusses referral pain patterns. It has been well established that an injury in one part of the body can affect other, distant body parts, especially in regard to ligament injury.
Here the Japanese doctors speculated that the sacroiliac joint may be the cause of pain in other parts of the pelvic region and that these pain origins may be centralized to the joint’s posterior ligamentous region.
The doctors divided the posterior sacroiliac joint into four sections-upper = section 1, middle = section 2, lower = section 3, and other (cranial portion of the ilium outside the SIJ – in the illustration above that would be the left most white band in the left side panel) = section 0.
- Referred pain from SIJ section 0 was mainly located in the upper buttock along the iliac crest;
- Referred pain from section 1, around the posterosuperior iliac spine; (the low back area of the iliac)
- Referred pain from section 2, in the middle buttock area;
- Referred pain from section 3, in the lower buttock.
- In all, 22 (44.0 %) patients complained of groin pain, which was slightly relieved by lidocaine injection into SIJ sections 1 and 0.
The research team concluded: “Dysfunctional upper sections of the sacroiliac joint are associated with pain in the upper buttock and lower sections with pain in the lower buttock. Groin pain might be referred from the upper SIJ sections.”
There is so much to discuss here.
- Foremost, the patients in this study had pain from the ligaments of the sacroiliac joint region.
- What if they were sent to traditional treatment, that is a spinal fusion surgery?
- Will the fusion help or hurt these patients?
- If anything the surgery will damage already damaged ligaments and create a high risk for Failed Back Surgery Syndrome.
The link up between groin pain and low back pain
In a paper from October 2017, Japanese researchers publishing in the medical journal Clinical neurology and neurosurgery looked to identify the prevalence of groin pain in patients with sacroiliac joint dysfunction, lumbar spinal canal stenosis, and lumbar disc herniation who did not have hip disorders.
They looked at:
- 127 patients (57 men, 70 women, average age 55 years) with sacroiliac joint dysfunction
Then they looked at
- the pain areas in the buttocks and back; including pain increase while in positions such as sitting, lying supine, and side-lying; an sacroiliac joint dysfunction shear test (manual physical examination of range of motion); and four tender points composed of the posterior superior iliac spine (PSIS), long posterior sacroiliac ligament (LPSL), sacrotuberous ligament (STL), and iliac muscle. Please see our article on the role of ligaments in spinal instability and chronic back pain.
- Fifty-nine (46.5%) patients with sacroiliac joint dysfunction had groin pain, In these patients, pain provoked by the sacroiliac joint dysfunction shear test and the tenderness of the posterior superior iliac spine and long posterior sacroiliac ligament were significant physical signs that differentiated sacroiliac joint dysfunction from lumbar stenosis and lumbar disc herniation.
- The prevalence of groin pain in patients with sacroiliac joint dysfunction dysfunction was higher than in those with lumbar stenosis and lumbar disc herniation.
- When patients who do not have hip disorders complain of groin and lumbogluteal pain, not only lumbar disorders but also sacroiliac joint dysfunction should be considered.
In other words, there was a link up between groin pain and low back pain.13
Treating the ligaments also presents a pain solution in sacroiliac joint pain treatment where some doctors say a solution does not exist. Recently, published research in the medical journal Pain Physician said:
- Doctors generally accept that approximately 10% to 25% of patients with persistent low back pain may have pain arising from the sacroiliac joints.
- Despite understanding this, there are currently no definite conservative, interventional, or surgical management options for managing sacroiliac joint pain in these persistent low back pain 10% to 25% of patients.5
Further, the paper documents treatments that they assess as fair or poor treatments for Sacroiliac joint dysfunction
- The evidence for cooled radio frequency neurotomy 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 toxin is poor.
- The evidence for effectiveness of conventional radiofrequency neurotomy is poor.
- The evidence for pulsed radio frequency is poor.
- A lot of poor results.
But you can offer poor sacroiliac joint pain results more often!
Recently doctors said that image-guided injections of the epidural space and of the sacroiliac joints are effective techniques for the treatment of pain; their effectiveness is sometimes not lasting for long periods of time, but considering the low associated risk when performed by trained personnel, they can be easily repeated. That was published in the European journal of radiology.6
Prolotherapy: Treating the ligaments in sacroiliac joint dysfunction
Ligaments are bands of fibrous tissue that connect bones to each other, like the vertebrae to each other and the sacrum to the pelvis. The sacrum is the part of the spine below the fifth and last lumbar vertebrae and above the coccyx. The uppermost portion of our pelvis is called the ilium. The area that connects these structures is the sacroiliac joint (SI): sacro from the sacrum, iliac from the ilium.
There is an expansive mesh of ligaments that make up this sacroiliac joint which is frequently injured. The function of the SI ligaments and the ligaments of the spine is to provide stability to these bones while allowing normal motion to occur. The hub of many people’s back or pelvic pain is one of both SI joints. A problem here can affect the groin, pubis, hips and lower lumbar areas as well.
Returning to the opening of this article – the diagnosis of sacroiliac (SI) pain is tricky.
Doctors from the Netherlands wrote in the journal Pain Physician: Although the prevalence of sacroiliac joint pain is relatively high there is no unambiguous reference standard to diagnose sacroiliac joint pain pain. Pressure tenderness (palpitation) in the sacroiliac joint pain region is used for diagnostic purposes and it appears to be a reliable method.7
You mean a physical examination? The prefered diagnostic method of a skilled Prolotherapist has always been palpitation – gently press down with your thumb to reproduce pain. “X” then makes that spot. See our article on the Accuracy of MRI for assessing treatment.
As far back as 2009, Caring Medical has published research on outcome results in patients receiving Prolotherapy for low back pain. Here is what was reported on findings of 145 patients with unresolved lower back pain in the Journal of Prolotherapy:
- One hundred forty-five patients, who had been in pain an average of four years and ten months, were treated quarterly with Prolotherapy.
- This included 55 patients who were told that there were no other treatment options for their pain and 26 patients who were told by their doctor(s) that surgery was their only option.
In these 145 low backs:
- pain levels decreased after Prolotherapy; 89% experienced more than 50% pain relief with Prolotherapy;
- more than 80% showed improvements in walking and exercise ability, anxiety, depression and overall disability;
- 75% percent were able to completely stop taking pain medications.
The decrease in pain reached statistical significance for the 145 low backs, including the subset of patients who were told there was no other treatment options for their pain and those who were told surgery was their only treatment option.8
- Research appearing in the Journal of Alternative and Complementary Medicine from doctors at the Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital in Korea, stated that “Prolotherapy provided significant relief of sacroiliac joint pain, and its effects lasted longer than those of steroid injections”9
Prolotherapy Injections a non-surgical alternative for SI pain
Prolotherapy is an injection treatment that stimulates the repair of connective tissues such as tendons and ligaments. It causes a mild inflammatory response which initiates an immune response. This mimics what the body does naturally to heal soft tissue injuries.
We have found that it is fairly rare for people’s SI/back pain to be caused by a pinched nerve or by a slipped or herniated disc. Much more common is a ligament injury which caused ligament laxity or ‘looseness.’
In the scholarly journal Spine, a 1995 article written by A. Schwarzer wrote:
- “ligament laxity in the sacroiliac joint is the number one reason for ‘Sciatica’, or pain radiating down the side of the leg, and is one of the most common reasons for chronic low back pain.”10
Our clinical experience has been that if we treat back pain with Prolotherapy, administering injections into the lumbar and SI ligament attachments that exhibit tenderness, the pain and referred pain diminishes, even when MRI’s showed disc abnormalities. The injections are not given near the discs yet the back pain is completely healed.
Platelet Rich Plasma and Prolotherapy Injections a non-surgical alternative for SI pain and long-term results
New research from a team of university researchers in India, writing in the journal Pain Practice says that “Despite widespread use of steroids to treat sacroiliac joint pain, their duration of pain reduction is short. Platelet-rich plasma (PRP) can potentially enhance tissue healing and may have a longer-lasting effect on pain.”
In this research, Forty patients with chronic low back pain diagnosed as sacroiliac joint pain were divided into 2 groups, steroid group and PRP group.
- Intensity of pain was significantly lower in the PRP group 6 weeks after treatment as compared to the steroid group.
- The efficacy of steroid injection was reduced to 25% at 3 months while it was 90% in the PRP group.
- A strong association was observed in patients receiving PRP and showing a reduction in pain scores. The researchers concluded: The intra-articular PRP injection is an effective treatment modality in low back pain involving sacroiliac joint pain.”11
Doctors at the University of Toronto have published four case studies investigating the long-term benefit of platelet-rich plasma (PRP) injections reducing SI joint pain, improving quality of life, and maintaining a clinical effect.
At follow-up 12-months post-treatment, pooled data from all patients reported a marked improvement in joint stability, a statistically significant reduction in pain, and improvement in quality of life.
The clinical benefits of PRP were still significant at 4-years post-treatment. Platelet-rich plasma therapy exhibits clinical usefulness in both pain reduction and for functional improvement in patients with chronic SI joint pain. The improvement in joint stability and low back pain was maintained at 1- and 4-years post-treatment.12
If you have questions about Sacroiliac joint pain, Get Help and Information from our Caring Medical staff
1 Bina RW, Hurlbert RJ. Sacroiliac Fusion: Another “Magic Bullet” Destined for Disrepute. Neurosurgery Clinics of North America. 2017 Jul 31;28(3):313-20.
2 Polly D, Cher D, Whang PG, Frank C, Sembrano J, INSITE Study Group. Does level of response to SI joint block predict response to SI joint fusion?. International journal of spine surgery. 2016;10.
3 Schomacher M, Kunhardt O, Koeppen D, Moskopp D, Kienapfel H, Kroppenstedt S, Cabraja M. Transient sacroiliac joint-related pain is a common problem following lumbar decompressive surgery without instrumentation. Clinical neurology and neurosurgery. 2015 Dec 31;139:81-5.
4 Kurosawa D, Murakami E, Aizawa T. Referred pain location depends on the affected section of the sacroiliac joint. European Spine Journal. 2015 Mar 1;24(3):521-7.
5. Hansen H, Manchikanti L, Simopoulos TT, Christo PJ, Gupta S, Smith HS, Hameed H, Cohen SP. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions.
6. D’Orazio F, Gregori LM, Gallucci M. Spine epidural and sacroiliac joints injections–when and how to perform. European journal of radiology. 2015 May 31;84(5):777-82.
7 van Leeuwen RJ, Szadek K, de Vet H, Zuurmond W, Perez R. Pain pressure threshold in the region of the sacroiliac joint in patients diagnosed with sacroiliac joint pain. Pain physician. 2016 Mar 1;19(3):147-54.
8. Hauser R, Hauser M, Dextrose Prolotherapy for Unresolved Low Back Pain: A Retrospective Case Series Study Journal of Prolotherapy. 2009;3:145-155.
9. Kim WM, Lee HG, Won Jeong C, Kim CM, Yoon MH. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. The Journal of Alternative and Complementary Medicine. 2010 Dec 1;16(12):1285-90.
10. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine. 1995 Jan 1;20(1):31-7.
11. Singla V, Batra YK, Bharti N, Goni VG, Marwaha N. Steroid versus Platelet-Rich Plasma in Ultrasound-Guided Sacroiliac Joint Injection for Chronic Low Back Pain. Pain Pract. 2016 Sep 27.
12: Ko GD, Mindra S, Lawson GE, Whitmore S, Arseneau L. Case series of ultrasound-guided platelet-rich plasma injections for sacroiliac joint dysfunction. J Back Musculoskelet Rehabil. 2016 Jun 30. NU3617
13. Kurosawa D, Murakami E, Aizawa T. Groin pain associated with sacroiliac joint dysfunction and lumbar disorders. Clinical Neurology and Neurosurgery. 2017 Aug 30.