Dr. Nordt responds to recent SI Joint Article in the Journal of Bone and Joint Surgery
March 30, 2019
March 19, 2019
Editor
Journal of Bone and Joint Surgery
Dear Sirs:
I am writing this article commenting on the “randomized trial of sacroiliac joint arthrodesis compared with conservative management for chronic low back pain attributed to the SI joint.” This article is in the Journal of Bone and Joint Surgery volume 101, pages 400-411, March 6, 2019. The assumption in this article is the SI joint is the sole source of pain and was subjected to conservative versus surgical management.
Pain is a symptom, not a diagnosis. An assumption like this is flawed without any description or discussion of a differential diagnosis, a basic first year medical school concept.
Mention of “conservative care” is not clearly outlined nor described. A differential diagnosis would be 1) degenerative L4-L5 disc, 2) a degenerative L5-S1 disc, 3) degenerative facets at L4-L5 or 4) degenerative facets at L5-S1. A degenerative disc can be treated with non-steroidal anti-inflammatory medications and a core strengthening program of muscle strength with an endpoint of 5/5 strength from a perceived de-conditioned state. There is no mention of any degenerative changes or any spinal findings. When one says 15-30% of patients with chronic low back pain is from the sacroiliac joint, that may be in the literature, but in my practice of 40 years of spine, I have never seen that. I see muscle problems in the buttock muscles which I will discuss in a moment. The problem here is clarification of what is causing the perceived pain in that area. A pain generator needs to be described and proven. I always state that if your car is in the parking lot and does not start, you just don’t go change the battery. It appears they are changing the battery on these cases without really clarifying.
The differential diagnosis. Aggravation of the gluteus medius muscles and the gluteus maximus which become spinal extensors can be the source. There can be significant weakness in this muscle group preceding a back fusion or because of back pain or after a back fusion because these muscles are over-utilized as compensatory spinal extensors. Injections can relax the muscles around the SI joint and cause significant short-term benefits. At no time was a physical therapy program ever mentioned in detail as far as what was done or how it was done. Hydrocoilator packs and massage certainly are not the solution but stretching of the gluteus medius and gluteus maximus with slight hip flexion of 20-30% and internal rotation across midline would stretch these muscles. Palpation of this muscle in my practice diagnoses about 100% of the time of real tight band in these interesting patients. At any rate, I have reviewed the article that was totally funded by the industry SI Bone which is a serious conflict of interest. Also association of all the doctors that are involved with SI Bone is a conflict of interest. What was clinically relevant pain originating from the SI joint, which is an assumption as I mentioned earlier, was randomized either to conservative treatment or sacroiliac arthrodesis. I find we are underlying an assumption of etiology without any documentation. I could go into detail about discography and facet injections, all of which can be used to diagnose correctly.
I again would like to reiterate that the conservative treatment was 25 physical therapy sessions over the first six months is sort of irrelevant. I try to have people go to therapy three times a week for four weeks and then assess an improvement focused on the problem. Six months of therapy once or twice a week is certainly not appropriate, especially without a clear diagnosis.
The mentioning of active straight leg raise showed no significant improvement in conservative management assumes that a straight leg raise is positive with a sacroiliac joint problem and that is not the case. A straight leg raise is only positive at 30 degrees with a windlass effect pulling the nerve root against a projection from the spine itself like a herniated disc, it is not diagnostic of an SI joint problem. If a straight leg raise is beyond 50 to 80 degrees and there is a myofascial stretching that can duplicate the pain in a generic sense. Unfortunately, the use of opioids is frowned on in my practice, and this has been used quite a bit with residual opioid use clouding the picture.
I am concerned about the adverse events with surgery which I think would not be present if the surgery was not done. Without non-steroidal anti-inflammatory medications and no clarification of a differential diagnosis, I have an issue with the comments that are made in this particular article. I would like to quote in the article, “the sacroiliac joint has very little inherent motion,” and I think that is the crux of the matter. I agree with that statement, and without motion of the sacroiliac joint, is there really a problem? I have never seen that in 40 years of practice except for pelvic fractures, and I question the validity of this diagnosis at ail. It seems to be low hanging fruit for a minimally invasive surgery done by either an orthopedist or a non-bone trained, non-musculoskeletal trained neurosurgeon.
Superiority over a sacroiliac joint arthrodesis over conservative treatment is comparing apples and oranges, and that clarification was never really made. It is mentioned that more conservative intensive management might be provided with better results, but nobody ever mentions what the conservative care was to begin with or what diagnoses they are treating. I find in my practice that sacroiliac joint arthrodesis is not needed, and we are just discussing an industry led procedure with a majority of the surgeons from Europe, which used to be less discriminating than many American surgeons were 20 or 30 years ago, especially in neurosurgical procedures. This is not a neurosurgical procedure so therefore I question the validity of neurosurgeons even understanding the musculoskeletal system, the hips, stabilizers and other non-neurological causes of back pain. I find it sad that orthopedics has allowed this to happen and be removed from their specialty.
In summary, I find the article to be unfortunately poorly supporting the premise of conservative care versus operative care. It is a diagnosis that I find hard to believe and now has come to the forefront. I don’t believe that that this diagnosis has been missed the past 40 years by myself in private practice, and many others.
Respectfully yours,
