Where is the Pain Coming From?

David W. Polly, Jr., MDJames W. Ogilvie Professor

and Chief of Spine Surgery

Catherine Mills Davis endowed chair

Department of Orthopaedic Surgery

Professor of Neurosurgery (w)

University of Minnesota

Past President Scoliosis Research Society

Common Sources

• Spinal pathology• Intrinsic - HNP, stenosis, facet arthropathy, DDD• Alignment – flatback syndrome

• Hip pathology• Trochanteric bursitis, osteoarthritis, labral tear, CAM impingement

• Sacroiliac joint

• Quadratus lumborum spasm

• Piriformis syndrome

• Others……

• Failed spine surgery….

Prevalence of SI Joint Pain15-30%Component of LBP

22.6%

30.0%

18.5%

27.0%

14.5%

0%

5%

10%

15%

20%

25%

30%

35%

Bernard1987

Schwarzer1995

Maigne1996

Irwin2007

Sembrano2009

32-43%Symptomatic Post-Lumbar Fusion

32% Katz 2003

35% Maigne 2005

43% DePalma 2011

40% Liliang 2011

DePalma – Pain Med 2011

9

Sacroiliac Joint (SIJ) Innervation

• Literature confusing• Hilton’s Law: A nerve that

crosses a joint innervates the joint.

SUPINE

LATERAL PRONE

DISTRACTION PATRICK’S THIGH

THRUST

GAENSLEN’SCOMPRESSION SACRAL

THRUST

3 or more positive- >85% PPD of positive response to diagnostic injection

Diagnosis Validation: Level 1 Paper“SIJ diagnosis among the best”

12

Evidence supports a Clinical Diagnostic Rule (CDR) for SI joint pain

Results are as good or better than rules for other lumbar spine conditions

2017

DDX Buttock Pain

From Dr. Baronio, Lombardia Italy

Quadratus Lumborum

Quadratus Lumborum Stretch

Trochanteric Bursitis

Piriformis Syndrome

Failed Back Surgery Syndrome

6 years later

Axial L2-3

CT 2008

CT 2008

CT 2008

CT 2008

Sagittal Parameters• PI 56

• LL 46

• T10-L2 23

• TK 26

• PT 37

• Summary • slightly inadequate lumbar

lordosis• marked abnormality T10-L2 • compensated for by pelvic tilt

(retroversion) and thoracic hypokyphosis

Initial Evaluation Outside Hospital

• PI 43

• LL 41

• L4-S1 31

• T10-L2 5

• TK 35

• PT 13

• Hips and knees flexed a bit unclear why

Diagnostic Dilemma

• SI joint?

• Pseudarthrosis?

• Other?

• PI 45

• LL 22

• L4-S1 22

• T10-L2 22

• TK 21

• PT 27

• PI 45

• LL 22

• L4-S1 22

• T10-L2 22

• TK 21

• PT 27

• PI 41 (measurement variability?)

• LL 37

• L4-S1 24

• T10-L2 14

• TK 42

• PT 17

Summary

• The usual spine pathology

• Look at the alignment in every patient having a fusion

• For patients with buttock pain• Check the SI joint• The hip• Muscle and nerve pathology

• For failed spines• Look at alignment• Is the fusion solid• Did they wear out an adjacent

segment• If fused to the sacrum or pelvis

look very carefully at the SI joint• Differential diagnostic injections

are probably the best we have• Have to be done right look at the

images not just the report or patient response