SIJ DISFUNCTION AND LOW BACK PAIN…

“The most common symptom of sacroiliac joint dysfunction is low back pain with or without buttock pain. Sacroiliac or SI joint pain may spread (radiate) into the groin, hips, back of the thighs, and feet.” writes Spine Universe.

Sacroiliac joint dysfunction and pain can be difficult to distinguish from pain originating in the hip joint or lower back which is a bit of a problem for me. Although I was treated with injections for my SI Joint Dysfunction the pain came back and on the right-hand side. Fortunately, my consultant had sent me for a right hip MRI before I had the injections as I had mentioned my right hip was giving me a lot of pain. The MRI showed I have degenerative wear in my hip which is obviously contributing to the pain from SI Joint Dysfunction.

The most common symptom of sacroiliac joint dysfunction is low back pain with or without buttock pain. Sacroiliac, or SI joint pain may spread (radiate) into the groin, hips, back of the thighs, and feet.

Like other types of pain, each patient does not experience the same symptoms. Pain may be described as a minor ache, and the intensity of pain can range from mild to severe. Symptoms may be episodic, infrequent, brought on by everyday activities, or constant (chronic).

Bipolar Radiofrequency Neurotomy (or Radiofrequency Ablation) is a minimally invasive procedure performed to help relieve symptoms related to SI joint dysfunction which is offered if steroid injections helped the pain in the first instance.

The sacroiliac joint is located on either side of the sacrum, which is in the low back and the pelvic areas. The SI joints are a pair of joints that connect the sacrum to the ilium, the large pelvic bone. Unlike other joints in the body, the surfaces of the SI joint are covered in two types of cartilage: one slick and the other spongy. The movement of the SI joint is minimal and results from stretching and is sometimes described as a gliding joint unlike the knee (hinge-type motion) or hip (ball and socket) joints.

Bipolar radiofrequency is a modified version of a procedure termed Radiofrequency Therapy (RT), also called Radiofrequency Ablation (RFA), a procedure developed more than 30 years ago. Bipolar radiofrequency is still new, but more pain management specialists are performing this procedure to treat painful sacroiliac joints.

Like its predecessor, bipolar radiofrequency applies a precisely targeted electrical field to create a lesion (change in the body’s tissue)—in this case, in small branches of spinal nerves, rendering them incapable of transmitting pain signals. The difference with the bipolar radiofrequency is that two needles are used to guide the electrical energy in a line between the two needles. This allows the pain specialist to “mold” the location and shape of the lesion to exactly match the SI joint. The applied electrical field can then target these tiny nerves just as they enter the SI joint.

My consultant would like to do this procedure when I feel ready to go ahead with the procedure and explained that for many patients who suffer chronic low back pain, bipolar radiofrequency of the SI joint is an effective treatment that may provide relief for months or longer. Even when the target nerves regenerate (grow back), pain relief may continue. If the patient responded well to the first bipolar radiofrequency, a second may be considered if pain resumes. Of course, each patient is unique, and it must be remembered that what works well for one person, may not work well or at all for another. 

The entire procedure is performed using fluoroscopic guidance. Fluoroscopy is like a real-time x-ray and allows the physician to see the patient’s anatomy while guiding and positioning the special radiofrequency needles.

The SI joint must move for the pelvis to tilt and rotate, but its range of motion is meant to be extremely limited. Strong ligaments help keep the joint in proper alignment and prevent excessive movement when walking, running, or simply standing. Although these ligaments keep motion in check, they stretch just enough so that the joint can carry out its complex combinations of rotating, sliding, or tilting during weight-bearing activities. When the ligaments fail to provide adequate support, destabilization of the SI joint and pelvis can occur. Conditions that can place undue stress on the Si joint and contribute to destabilization can include arthritis, inequality in leg length, sacrum tilted out of normal anatomical position, pregnancy – widening and hypermobility of the SI joint or in my case could have been caused due to all my previous lumbar surgeries. 

Most people suffering from SI joint dysfunction find it difficult to remain in one position for any length of time. Pain is felt at the base of the spine and is often described as “gripping” or “stabbing.” Difficulty walking or climbing stairs, and pain while lying on one side (especially at night) are common symptoms. I find getting off to sleep extremely painful and uncomfortable and it can disturb my sleep most nights.

I investigated the radiofrequency ablation and on a NHS website it explained what this type of treatment is for and what happens during the treatment. 

Each of the sacroiliac joints has its own nerve supply, the lateral branch nerve, which normally carries information about the state of the joint to your brain e.g., pain caused by inflammation, joint position etc. These nerves can be numbed / blocked by your doctor using a local anaesthetic to assess if they are transmitting pain signals (Diagnostic). Radiofrequency denervation, which is the burning of these nerves, is then performed at a later stage to interrupt the nerve supply and pain messages for a significantly log time. This prevents the passage of pain signals to the rest of the nervous system. The aim of this treatment is to interrupt the nerve supply to the affected sacroiliac joints.

The treatment involves –

• A small needle is placed in the back of your hand for sedation or emergency drugs.
• SIJ RFD is performed lying face down.
• Your back is cleaned. The skin is numbed with some local anaesthetic is injected which stings a little.
• A special X-ray and a radiofrequency generator machine will be used by the doctor to identify the location of the nerve.
• Electrical tests will enable the tip of the specially designed needle get close to the nerve. The final electrical test is done to make sure that the needle tip is well away from the main spinal nerve to your leg, thereby improving the safety of the procedure.
• When the doctor is happy with the needle position, local anaesthetic is injected before a high frequency (radiofrequency) electrical signal is passed down the needle for 90 seconds.
• You may feel discomfort at this stage.
• After each lesion, the area is injected with a mixture of local anaesthetic and steroid, to help reduce discomfort afterwards.
• Depending on the technicality of the procedure and your medical condition, you may be offered a pain killer or sedative as agreed with your doctor.
• There are of course a few complications that could arise but that applies to any type of treatment even with the steroid injections. 
• In an article on the Spine-Health website, it says that the success rate has conflicting results. Success usually depends on the accuracy of diagnosis, variations in the anatomy of the nerve, and the type of technique used. Some patients have reported up to 100% reduction in pain from RFA. 

Typically, if effective, RFA may provide pain relief lasting 6 months up to 2 years. However, some studies have shown patients experiencing pain relief up to 3 years. During or after this period, however, the nerve usually regenerates, and the pain may or may not return. The pain relief from this treatment is usually more significant when performed on the facet joints as compared to the sacroiliac joints. Some patients may not experience any relief from pain after this procedure.

Source: Spine Universe, NHS, Spine-Health