Sacroiliac Joint Disorder

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An Often Missed Source Of Back Pain

Low back pain is very common and affects approximately 70% of people in their lifetime (1). For anyone who has experienced low back pain, it can be very disabling. But sometimes low back pain is not “spine pain.” The sacroiliac joint (SIJ) often can be the pain generator and may be missed if all of the focus is on the lower spine. Studies have shown that in 13-30% of individuals with chronic low back pain, the sacroiliac joint was found to be the source of their pain (1). So out of 10 patients seen in a physician’s office for low back pain, the sacroiliac joint is the culprit in 2-3 patients.

Sacroiliac Joint: What is it?

The sacroiliac joint is wedged shaped and joins the spine to the pelvis. It is a diarthrodial joint connecting the sacrum to the ilium and contains synovial fluid and is surrounded by a fibrous capsule. Its job is to absorb forces from the spine and transfer them to the pelvis and lower extremities and vice versa. It is only 1-2mm wide and moves only minimal amounts, about 2-3 degrees. There is some debate about which nerves innervate the sacroiliac joint but there is agreement that there are nerve receptors in the joint which transmit both pain and position sense (1, 2).

Clinical Presentation:

Some of the common causes of sacroiliac pain include falling directly on the buttock; a rear-end motor vehicle accident with the foot on the brake or a broadside accident with a blow to the side of the pelvis; stepping into a hole or a misstep (2). Athletes in sports who require unilateral loading with kicking or throwing, or landing on one leg (figure skater) have a higher risk. It has been found to be more common in cross country skiers and rowers. During pregnancy, the combination of hormones increasing the laxity of the joint, weight gain, and altered posture increases the frequency of sacroiliac problems. In addition, individuals with certain types of polyarthritis are at risk for sacroiliac problems (1, 2).
Persons with sacroiliac pain often report pain in the low back and buttock. Usually the pain is 3-10cm below the posterior superior iliac spine and typically doesn’t go above the beltline. Pain is usually unilateral compared to bilateral in a 4:1 ratio. Some individuals report numbness, popping, clicking, and groin pain. Some feel there may be some communication between the SIJ and nearby nerve structures. This may explain why pain may be referred into the buttock and lower extremities at times (1,2).

Diagnosis of Sacroiliac Joint Problems

Many studies have been done evaluating what examination techniques are the most accurate at diagnosing sacroiliac joint problems. Some of the sacroiliac clinical tests used to diagnose include FABER, distraction/ compression tests, focal SIJ tenderness, femoral shear tests, modified Gaenslen’s and others. When 3 or more tests are positive it increases the probability that the SIJ is the source of the pain. Unfortunately, studies show that even a combination of positive tests still is not very accurate at diagnoising SIJ pain. Diagnostic imaging with X-rays, CT, and MRI are most useful in ruling out other causes of pain such as fractures, tumors, and inflammatory arthritis as is appropriate screening blood tests (1-2).
Fluoroscopically (X-ray) guided SIJ injections are felt to be the closest thing to a “gold standard” for confirming SIJ problems. It is extremely important to have the injection done with imaging guidance by a person trained in the protocol of doing SIJ injections. SIJ injections without fluoroscopy were shown to be in the sacroiliac joint only 22% of the time (1).

Treatment of Sacroiliac Joint Disorders

In the acute period, conservative care includes icing, relative rest, anti-inflammatory medications, and appropriate pain medications. As pain begins to subside in the recovery phase, the goal is to maximize function despite the pain. Pelvic stabilization exercises and muscle balancing in physical therapy and possibly manipulation with manual medicine can help restore normal SIJ mechanics. A sacroiliac joint belt often can help provide stability, position sense, and decrease pain (1,2).
When some of the above treatments fail or are less effective, a fluoroscopically guided SIJ intra-articular injection with corticosteroid can help therapeutically and diagnostically. These injections often can help avoid unnecessary tests and surgery, reduce pain, and facilitate rehabilitation (2).
Other treatments that are being studied include radiofrequency neurotomy, prolotherapy, cryotherapy, and surgical fixation (arthodesis) of the joint. Research is ongoing, but there is limited evidence on the effectiveness of these treatments (2).


The sacroiliac joint is a common and often overlooked source of low back pain. At Sierra Regional Spine Institute, our team is trained and experienced in the evaluation, diagnosis, and management of sacroiliac disorders. We use the latest research and technology to direct both conservative and more complex treatment. When appropriate, our physicians perform fluoroscopically guided diagnostic and therapeutic sacroiliac joint injections. At Sierra Regional Spine Institute, our goal is to determine and treat the source of a person’s back pain and return them to the road to recovery.

  1. Foley BS, Buschbacher RM. Sacroiliac joint pain: anatomy, biomechanics, diagnosis, and treatment. Am J Phys Med Rehabil 2006; 85: 997-1006.
  2. Forst SL, Wheeler MT, Fortin JD, Vilensky, JA. The sacroiliac joint: anatomy, physiology, and clinical significance. Pain Physician 2006; 9: 61-68.

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Artificial Disc Replacement

At Sierra Regional Spine Institute, we believe that the future is restoration of anatomy and function through motion. The artificial disc replacement is the answer to that problem. Sierra Regional Spine Institute continues to be a leader in Nevada when disc replacement surgery is needed.
It is a surgical procedure in which degenerated intervertebral discs in the spinal column are replaced with artificial disc implants in the lumbar or cervical spine.

The procedure is used to treat chronic, severe low back pain and cervical pain resulting from degenerative disc disease.

Artificial disc replacement has been developed as an alternative to spinal fusion, with the goal of pain reduction or elimination, while still allowing motion throughout the spine. Another possible benefit is the prevention of premature breakdown in adjacent levels of the spine, a potential risk in fusion surgeries.

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Revision Spine Surgery

Revision spine surgery is a surgery procedure performed in certain patients to correct the problems of earlier spine surgery. Revision surgery is only when working with patients who experience chronic pain or any worsening symptoms even after the initial surgery.
Other factors that can indicate the need for revision spine surgery include:

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At Sierra Regional Spine Institute we use Decompression in a few ways to treat and make the process of recovery smoother for people with fractures: Microdiscectomy, Microendoscopic Laminectomy, Minimally Invasive Cervical Foraminotomy (MICF), Vertebroplasty and Kyphoplasty.


Microdiscectomy, also called microlumbar discectomy (MLD), is a very common MIS decompression procedure performed in patients with a symptomatic lumbar herniated disc. The operation consists of removing the portion of the intervertebral disc that is herniated and compressing a spinal nerve root.

Minimally Invasive Cervical Foraminotomy

This is a MIS cervical foraminotomy decompression procedure that enlarges the space in which a spinal nerve root exits the cervical spinal canal (intervertebral foramen). This narrowing can be caused by a herniated disc, bone spurs, thickened ligaments or joints, which may result in pinched nerves.


Vertebroplasty for the treatment of vertebral compression fractures (VCFs) was introduced in the United States in the early 1990s. The procedure is usually done on an outpatient basis, although some patients stay in the hospital overnight. The procedure may be performed with a local anesthetic and intravenous sedation or general anesthesia.

Using x-ray guidance, a small needle containing specially formulated acrylic bone cement is injected into the collapsed vertebra. The cement hardens within minutes, strengthening and stabilizing the fractured vertebra. Most experts believe that pain relief is achieved through mechanical support and stability provided by the bone cement.
Kyphoplasty involves an added procedure performed before the cement is injected into the vertebra. First, two small incisions are made and a probe is placed into the vertebral space where the fracture is located.

The bone is drilled and one balloon (called a bone tamp) is inserted on each side. The two balloons are then inflated with contrast medium (which are visualized using image guidance x-rays) until they expand to the desired height and removed. The spaces created by the balloons are then filled with the cement. Kyphoplasty has the added benefit of restoring height to the spine.

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Cervical Fusion

Cervical Fusion is an operation that creates a solid union between two or more vertebrae in the upper spine (neck) area. This procedure may assist in strengthening and stabilizing the spine and may thereby help to alleviate severe and chronic back pain.
The best clinical results are generally achieved in single-level fusion, although fusion at two levels may be performed in properly selected patients.

Bone grafts may be taken from the hip or from another bone in the same patient (autograft) or from a bone bank (allograft). Bone graft extenders and bone morphogenetic proteins (hormones that cause bone to grow inside the body) can also be used to reduce or eliminate the need for bone grafts.

Fusion sometimes involves the use of supplemental hardware (instrumentation) such as plates, screws, and cages. This fusing of the bone graft with the bones of the spine will provide a permanent union between those bones. Once that occurs, the hardware is no longer needed, but most patients prefer to leave the hardware in place rather than go through another surgery to remove it.

Fusion can sometimes be performed via smaller incisions through MIS techniques. The use of advanced fluoroscopy and endoscopy has improved the accuracy of incisions and hardware placement, minimizing tissue trauma while enabling an MIS approach.

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Lumbar Fusion

This is a MIS technique that is performed in patients with refractory mechanical low back and radicular pain associated with spondylolisthesis, degenerative disc disease, and recurrent disc herniation. The procedure is performed from the back (posterior) with the patient on his or her stomach.

Using x-ray guidance, two 2.5-cm incisions are made on either side of the lower back. The muscles are gradually dilated and tubular retractors inserted to allow access to the affected area of the lumbar spine.

The lamina is removed to allow visualization of the nerve roots. The disc material is removed from the spine and replaced with a bone graft and structural support from a cage made of bone, titanium, carbon-fiber, or a polymer, followed by rod and screw placement.

The tubular retractors are removed, allowing the dilated muscles to come back together, and the incisions are closed. This procedure typically takes about 3 to 3 1/2 hours to perform.

Outcome & Benefits

Pioneers of both surgical and non-surgical techniques


Minimally Invasive Spine Surgery

MIS was first performed in the 80s but has recently seen rapid advances. Technological advances have enabled surgeons to expand patient selection and treat an array of spinal disorders, such as degenerative disc disease, herniated disc, fractures, tumors, infections, instability, and deformity.
This can result in quicker recovery, decreased operative blood loss, and speedier patient return to normal function. In some MIS approaches, also called, “keyhole surgeries,” surgeons use a tiny endoscope with a camera on the end, which is inserted through a small incision in the skin. The camera provides surgeons with an inside view, enabling surgical access to the affected area of the spine.

Benefits of Minimally Invasive Surgery

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