Sacroiliac joint surgery is drastic if it is done incorrectly. The major cause of the failure of surgery is the failure of the surgeon to understand the presence of secondary lesions that also need to be treated. Stabilization of the joint by reinforcing these ligaments is most important if there is evidence of SI joint injury, then fusion as well as stabilization is required. It is esstential that the joint be fixed in its normal anatomic position. Thus a a surgeon (or a PT who works together with the surgeon) must have a thorough knowledge of manual techniques and the ability to provide such for the patient who is a candidate for SI Surgery…
10 THINGS YOU NEED TO KNOW BEFORE HAVING SI SURGERY:
IF you do end up considering surgery, in my experience, I’ve learned that the following are some good questions to ask…
1. “During your SI surgeries, do you conduct INTER-OPERATIVE NERVE MONITORING and testing SIMULTANEOUS to implant insertion and do you also test for nerve root interaction via EMG nerve conduction testing once they have been fully inserted, prior to closing the wound?” This is to ensure NONE of the implants have a positive reading which would indicate that the implants are pressing on or have passed though or caused injury to the sacral nerve roots…read more about this procedure at: http://www.sacroiliacsurgery.com/surgical-stabilization-of-the-si-joint.php
*After my 1st SI surgery which failed due, we believe, to surgical oversight…my Nerve Conduction testing revealed that I had very significant positive readings from the screws and my nerves on my left side. This is very painful and means that the screws were touching my nerves on my left side(it is good if there is NO positive feedback…this was part of the significant amount of pain I continued to have post-operative but even worse was the huge problems I experienced which came from being surgically positioned out of alignment.
2. “WHAT specific methods do you use to diagnose your patients with SIJD? HOW do you determine if a patient is an SI surgery candidate?”
- “A clear understanding of the difference in the signs and symptoms of sacroiliac joint dysfunction and other pathologies is key in making the proper diagnosis. Because the diagnosis of SI joint dysfunction is made primarily from the patients subjective complaints and the physical evaluation, it’s diagnosis is somewhat problematic for the clinician. Diagnostic testing, such as X-ray, CT scan or MRI, do not usually reveal abnormalities; therefore, they cannot be used for diagnosis of sacroiliac joint dysfunction.“http://www.sacroiliacsurgery.com/general-information.php
3. Do you also test/examine me for associated conditions which often contribute to SI instability and might affect my surgical outcome?’ Specifically, list these associated conditions:
THE “TERRIBLE TRIADS” (Vicki Sims, P.T.):
- 1. Sacroiliac Joint Dysfunction
- 2. Piriformis Syndrome: via EMG with Fair testing(must be with “fair testing”), this is a specific test to determine Piriformis Syndrome. This is very common associated condition and culprit for yanking the SI out of alignment, buttocks pain and Sciatic-like symptoms! There are very few SI surgeons who test for this condition and perform “Piriformis Release”, most don’t address this huge secondary condition. The Piriformis Muscle is the second strongest muscle in the body (as explained by Dr.Earnest Howard, in Atlanta, GA. He performs this and other tests and is the MOST wonderful doctor I’ve ever had the privilege of being a patient of!)!
- 3. Lumbar Radiculitis: via EMG nerve testing around the Lumbar spine. This will determine if the lumber spine is also contributing to your SIJD symptoms (discs at level L5, S1 and/or L4, L5 are common contributor’s with SIJD)
4. “Will you MANUALLY ALIGN MY SI Joints prior to my sedation so I can personally ‘feel’ if you have indeed aligned my SI Joints? Additionally, while you ONCE AGAIN MANUALLY ALIGN my SI Joints after I have been MOVED and am sedated ON the OPERATING TABLE just prior to my fixation/fusion?”
5. “Do you KNOW HOW to correctly MANUALLY align SI Joints? If so, what method(s)/technique do you use and who/where did you learn this? If not, can I bring in my own PT to align me in the operating room?” This STEP IS ESSENTIAL and is to ensure you are not permanently fixated/fused out of alignment, in a subluxated (partially dislocated) position!!! This can wreak havoc on your spine etc.
6. “Will you supply me with a customized POST-OP THERAPY PROGRAM SPECIFIC ONLY to SACROILIAC Fixation/Fusion? (in light of how my body has been affected/compromised by SIJD) If so, may I have a copy of it now to review?”
- It is a good idea to study up this prior to your surgery and compare to see if it lines up with what a correct SI post-op program should be.
7. IF you are out of state: “When I return home, I will not have access to any SI surgeons or doctors, in light of this-will you be available for counsel should I have questions or concerns regarding my rehabilitation post-op in the months following my SI surgery?”
8. “Is this procedure reversible? If it ends up causing me more pain, can it be undone?”
- This is also VERY important to find out!
9. “How many patients have you performed SI Surgery on? May I please speak with some of YOUR SI Surgery post-op patients?”
- hopefully you will be able find and hear about/or from more than just the “perfect” surgery outcomes!
10. “Prior to your commencement with SI Surgery, how did what was your treatment plan for patient’s who presented with the symptoms of Sacroiliac Joint Dysfunction?”
- the purpose of this question is for you to gain insight into whether or not this surgeon has a TRUE understanding of the SIJD condition and what his/her track record has been with them BEFORE they could put their SI patients on the operating table and make money off of them! (…PLEASE understand I do not typically think this way of surgeon’s! Yet, sadly, sometimes this is the case)
Most of the SI Surgeries I know of, fall into 1 of these 4 MAIN CATEGORIES of SI Surgery (with some variations):
1. Sacroiliac (SI) FIXATION:using titanium screw IMPLANTS, WITHOUT FUSION of any kind.
2. Sacroiliac (SI) FUSION: using traditional bone grafting technique, WITHOUT the addition of IMPLANTS.
3. SI FIXATION AND FUSION: using TRADITIONAL FUSION technique with bone grafting packed between the joint, WITH the addition of screw IMPLANTS .
4. SI FIXATION LEADING TO FUSION: using IMPLANTS which have been designed to stimulate bone fusion (around the implant).
*a brief explanation of each category will follow…
——————————————————————————————————————————————————————————————————————————————————- NOTE: My CONCERN for ALL SACROILIAC SURGERIES, no matter what product is used for the implant, is aimed at the protocols and PROCEDURES used with the surgical candidates…again, in my personal experience and after hearing from several other post-op patients, I credit a large part of the success or failure of SI SURGERIES to whether or not effective steps have been taken at all stages:(1)PRE-OP examination and testing…incl.diagnosing and testing for associated conditions common to SIJD (2)SURGICAL protocols and procedures…incl.correct SI alignment and nerve monitoring (3)POST-OP protocols for rehabilitation
As with many surgical procedures, protocols can vary from one surgeon to another but with SI Surgery it is IMPERATIVE that specific steps be taken! And so, it is still in the best interest of SI patient’s looking into surgery to use the list of questions I provided to determine which surgeon CAN and WILL incorporate these essential protocols with their SI Surgery (also inquire about what technique the surgeon uses to diagnose for candidacy, what technique they use to align the SI Joints etc., where/who they learned these techniques from and how they can tell if a patient is in fact aligned not…be sure to research each surgeon’s SIJD post-op patient success record (the good and the bad) and how many patients they have operated on.
>>>THE FOLLOWING ARE BRIEF EXPLANATIONS OF THESE 4 TYPES OF SI SURGERIES>>>: >1. Sacroiliac (SI) FIXATION: using titanium screw IMPLANTS, WITHOUT FUSION of any kind:
- SI joint fixation which uses plain titanium screws, to stabilize the joint(s). SI joint fixation is a minimally invasive surgical approach via a small incision in which 2 screws are inserted across the SI joint in order to stabilize the joint(s). IMPORTANT: the SI Joints MUST be manually aligned on the operating table, prior to fixation; the screws should be monitored for any possible injury to sacral nerve roots while implant is inserted…check out: www.SacroiliacSurgery.com
Fixation: to stabilize the sacroiliac joint(s), cannulated screws will be placed through the ilium and sacrum. The cannulated screws that your physician will use for stabilization are approved by the U.S. Food and Drug Administration (FDA) for fixation of fractures of large bones. It is inferred from this that they are solid enough for sacroiliac stabilization for which they are commonly used. **This procedure CAN BE UNDONE if necessary with little to no damage to the joints.
(…due to my 1st SI surgery which failed to bring good results due to misalignment, failed fusion and nerve interaction. I underwent my 2nd SI Surgery (corrective surgery) with a different surgeon. I had to be ‘unscrewed’, aligned and then ‘re-screwed’!)
>2. Sacroiliac (SI) FUSION: using traditional bone grafting technique, WITHOUT the addition of IMPLANTS:
- Traditional Fusion uses bone grafts and/or biological products to pack into the joint in order to stimulate bone growth across the joint and eventually fuse them together.
NOTE: PLEASE keep in mind that SI FUSION WITHOUT ALSO receiving surgically placed IMPLANTS (screws ) to KEEP THE JOINT STABILIZED UNTIL FULL FUSION has been achieved is ESSENTIAL…some surgeon’s merely perform traditional SI Fusion WITHOUT ALSO SECURING THE JOINT. Stabilizing the SI Joints is important so that the SI Joints/Pelvic Girdle can remain aligned and stable in order to fuse! (FULL fusion typically takes up to 6mos but can even take up to a year in some patients though less common) .
>3. SI FIXATION AND FUSION: using TRADITIONAL FUSION techniques via bone grafting, WITH the addition of screw IMPLANTS:
- SI Fixation using cannulated titanium screws as implants to maintain SI Joint alignment and stability while bone growth is underway towards fusion,
- SI Fusion using the traditional technique of bone grafting and/or biological products pacted into the joint(s).
Fixation: to stabilize the sacroiliac joint(s), cannulated screws will be placed through the ilium and sacrum. The cannulated screws that your physician will use for stabilization are approved by the U.S. Food and Drug Administration (FDA) for fixation of fractures of large bones. It is inferred from this that they are solid enough for sacroiliac stabilization for which they are commonly used.
Fusion:Fusion between the sacrum and the ilium may also be necessary. This is done by scraping the bone on both sides and placing a graft taken from the iliac crest at the surgical site between the two sides. Artificial graft can also be used.
Personally, my successful SI Surgery was performed and orchestrated by this unique and experienced SI Surgery TEAM: Dr.David Weiss, MD and Vicki Sims, PT in Gainesville, GA. I underwent Fixation and Fusion bilaterally, this was corrective surgery, a was a complete revision of (my 1st failed SI Surgery which was done by a different surgeon who had claimed to follow the protocal I’ve listed as important and assured me that he was capable of aligning the SI Joints for surgery)…please do your HOMEWORK BEFORE you get on the operating table!http://www.sacroiliacsurgery.com/surgical-stabilization-of-the-si-joint.php
NOTE: If necessary, this procedure CAN BE undone/corrected post-op as long as FULL FUSION has not already occurred...believe it or not this has been a necessary intervention due surgeons who DO NOT a CORRECTLY ALIGN THE JOINTS on the operating table prior to SI surgery! I already know of a few patients who have had to undergo corrective SI surgery due to malaligned joints (myself included!). For more insightful information about effective pre-op to post-op surgical protocols as well as the SI Surgery procedure itself, check out: www.SacroiliacSurgery.com
>4. SI FIXATION using specific IMPLANTS which are designed to LEAD TO FUSION:
a) SI Bone’s i-fuse implant
- SI Bone is the company which developed the “iFuse ” implant. It is a new procedure which uses a small triangular-shaped titanium ‘rod’ for insertion across the joint(s), typically 2-3 implants are inserted per joint. This procedure is minimally invasive and uses a small incision to perform fixation to offer stabilization, which over time leads to fusion.
- The iFuse implants have triangular cross-sections to keep them from rotating once they have been implanted. They are also coated with a titanium plasma spray that creates a rough latticed structure on the surface of the implants, which is designed to create an interference fit to bone. This helps to better secure the iFuse implants to bone. The stiffness of the implants holds the joint in place.
- The implants are sprayed with a Porous plasma spray coating with irregular surface designed to support stable bone fixation/fusion to lead to bone fusion. http://www.si-bone.com/product-overview.html
**I have been told by SI Bone reps that the iFuse can be removed if necessary (I would add, as long as FULL FUSION has not already occurred). SI Bone explains that if the implants are improperly placed by a surgeon, the surgeon can use a osteotome tool to remove and/or reposition the implant(s).
***Some surgeon’s who use i-fuse may indeed incorporate some of the protocols I’ve listed as important (in my experience). I hope they do and that it is done correctly. Yet, at this stage, it is not mandatory (speaking only in reference to the steps #1-4). Be sure to DO YOUR HOMEWORK in advance to find these things out!!
NOTE: I have no personal experience with the i-fuse implant, but from what I do know…I think that IF the proper steps are taken by your SI Surgeon (steps and protocals #1-4, that I’ve listed previously under, “SI Surgery…I’ve learned that the following things are a good questions to ask:”) it can be a good surgical option for SIJD patent’s. I have had some interaction with patients who have undergone this procedure.
b) DIANA is an implant by SIGNUS The Spine Sign which has been designed to lead to bone fusion around the implant:
- “DIANA: D istraction I nterference A rthrodesis, N eurvascular A nticipating”. “The DIANA system utilizes the distraction-interference method to provide a simple and safe fusion technique for the sacroiliac joint. Predictable and reproducible placement of the DIANA implant is achieved using sequential instrumentation with ligamentotaxis stabilizing the joint during the fusion process.
- With the DIANA method a hollow, specially threaded implant is inserted between the bones of the SI-Joint, to keep the ilial and the sacral bone separated from each other until bony fusion is performed.
- The Titanium-Implant is filled during and after insertion with bone graft. The special disign allows for lasting ingrowth. It serves only to maintain the distraction until bony fusion is completed. Removal of the implant would not weaken the achieved fusion, since the implant is NOT the fusion method.” http://www.si-joint.net/index.php?id=3&L=1
- “Once the fusion is solid the implant could be removed, but we never do. A need to remove would only be in cases of nonunion or infection. The anatomy is ordinarily preserved if the implant must be removed, and a new slightly larger implant can be inserted, reestablishing tension.”http://www.si-joint.net/index.php?id=86&L=1
NOTE: I have just copied and pasted ALL of the above information on the DIANA directly off their website and does not reflect my own explanation or understanding of this product and it’s surgical procedure. Personally, I have little to no knowledge of this implant product and the surgical procedure for it. Additionally, I have no information on patient outcomes (I will follow up with them to learn more) it appears to be quite new.
****DISCLAIMER NOTE: please keep in mind that all of my writings are my opinions and observances and I am I no way a medical professional or a substitute for one. I have formulated my writings independently and is based on the collaboration of the SIJD knowledge I have gained through my 10yr personal battle with SIJD; research study and travel exposure; and going through post-op therapy with and observing (being ‘coached’) by SIJD expert Vicki Sims, P.T. My goal in reaching out to other SIJD patients is to provide support, stir up awareness and offer education on the topic from a Patient’s PERSPECTIVE! You will likely notice a lot of my links lead to online information by Alan Lippitt M.D., David Weiss M.D., and/or Vicki Sims, P.T. There are several reasons for my preference, including (but not limited to): PRIMARILY it is because they have shown themselves to be trustworthy, in my own experience and in many other patients I have spoken with who have been treated by them; the 30 years of research and experience treating patients with Sacroiliac Joint Dysfunction (over 5000 SI patient surgeries! This number does NOT even include the additional thousands of patients who have and do go through their conservative SI therapy treatment numbers!); the extremely high SI patient results success rate and accurate educational research and materials… all contribute to make me feel that I can confidently recommend these medical professionals as a good source to uncovering accurate information and/or diagnosis and treatment on the topic of Sacroiliac Joint Dysfunction.****