L.rudolf 1.8.11 presentation

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L.rudolf 1.8.11 presentation

  1. 1. SACROILIAC JOINT DYSFUNCTION ADJACENT SEGMENT DISORDERS LEONARD RUDOLF,MD LEBANON, NEW HAMPSHIRE
  2. 2. DISCLOSURES <ul><li>CONSULTANT: SI-BONE CO. </li></ul><ul><li>STOCKHOLDER: SI-BONE CO. </li></ul>
  3. 3. Sacroiliac Joint Syndromes <ul><li>SI Joint Dysfunction </li></ul><ul><ul><li>“ a state of relative hypomobility within a portion of the joint’s ROM with subsequent altered structural (positional) relationships between the sacrum and ilium.” </li></ul></ul><ul><ul><ul><ul><li>Dreyfuss P. Spine 1994. </li></ul></ul></ul></ul><ul><li>SI Joint Pain </li></ul><ul><ul><li>Pain arising from the SI joint </li></ul></ul><ul><ul><ul><ul><li>Laslett M. Aust J Physiother 2006. </li></ul></ul></ul></ul><ul><li>Sacroiliac Syndrome </li></ul><ul><ul><li>Pain arising from the SI joint and/or its surrounding ligaments. </li></ul></ul><ul><ul><ul><ul><li>Berthelot JM. Joint Bone Spine 2006. </li></ul></ul></ul></ul>
  4. 4. INCIDENCE <ul><li>SIJD in LB Pathology patients </li></ul><ul><ul><li>2% (Manchikanti L et al. Pain Physician 2001) </li></ul></ul><ul><ul><li>18.5% (Maigne JY et al. Spine 1996) </li></ul></ul><ul><ul><li>27% (Irwin RW et al. Am J Phys Med Rehabil 2007) </li></ul></ul><ul><ul><li>13-30% (Schwarzer AC. Spine 1995) </li></ul></ul>
  5. 5. Polly/Sembrano Study 200 Pts <ul><li>82% have spine pathology </li></ul><ul><li>Only 65% have spine only pathology </li></ul><ul><li>15% have SI jt pathology </li></ul><ul><li>25% have SI and/or hip pathology </li></ul><ul><li>12% have hip joint pathology </li></ul><ul><li>10% undefined pain source </li></ul>82% 15% 12% 25% X X 65% 10% ?
  6. 6. SIJ DYSFUNCTION <ul><li>MULTIPLE CAUSES </li></ul><ul><li>INFLAMMATORY </li></ul><ul><li>OVERUSE </li></ul><ul><li>TRAUMA </li></ul><ul><li>PREGNANCY </li></ul><ul><li>SURGICAL DISRUPTION </li></ul><ul><li>MECHANICAL: ADJACENT SEGMENT DISORDER </li></ul>
  7. 7. SIJ DYSFUNCTION CLASSIFICATION <ul><ul><li>TYPE I: PRIMARY </li></ul></ul><ul><ul><li>DEGENERATIVE </li></ul></ul><ul><ul><li>OVERUSE </li></ul></ul><ul><ul><li>GESTATIONAL </li></ul></ul><ul><ul><li>IDIOPATHIC </li></ul></ul><ul><ul><li>TYPE II: INFLAMMATORY </li></ul></ul><ul><ul><li>TYPE III:TRAUMATIC </li></ul></ul><ul><ul><li>TYPE IV:ADJACENT SEGMENT DISORDER </li></ul></ul>
  8. 8. Adjacent Segment Disorder <ul><li>Evolving Concepts </li></ul><ul><li>Hip-Spine Codependence Established </li></ul><ul><li>Lumbar Segments Traditionally Associated with Spinal Fusion </li></ul><ul><li>Studies Show SIJ as Legitimate Site of ASD </li></ul>
  9. 9. Literature Review <ul><li>Longterm Effects of Spinal Fusion on SIJ Accelerated Degeneration </li></ul><ul><ul><li>Frymoyer Clin Ortho 1978 </li></ul></ul><ul><li>Violation of SIJ from ICG </li></ul><ul><ul><li>Ebraheim Spine 2000 </li></ul></ul><ul><li>Adjacent Segment Degeneration Following Spine Fusion Review of Literature </li></ul><ul><ul><li>Levin Bulletin NYU HJD 2007 </li></ul></ul><ul><li>Fusion at Lumbar Spine Increased Motion and Stress at SIJ </li></ul><ul><ul><li>Ianov Spine 2009 </li></ul></ul>
  10. 10. Literature Review <ul><li>34 PTS with Gluteal Pain after Lumbar Fusion </li></ul><ul><ul><li>34 % Very Likely SIJ Pain Generator </li></ul></ul><ul><ul><li>29 % Probably SIJ Pain Generator </li></ul></ul><ul><ul><ul><li>Katz Journal Spine Disorders 2003 </li></ul></ul></ul><ul><li>CT Evalutation of SIJ After Instrumented Lumbar Fusion </li></ul><ul><ul><li>75 % SIJ Degeneration at 5 YRS in Fusion Group </li></ul></ul><ul><ul><li>38 % Control Group </li></ul></ul><ul><ul><ul><li>HA Spine 2008 </li></ul></ul></ul><ul><li>LBP After Technically Successful Lumbar Fusion </li></ul><ul><ul><li>SIJ Block 35 % + </li></ul></ul><ul><ul><ul><li>Maigne Eur Spine J 2005 </li></ul></ul></ul>
  11. 11. LS FUSION AND THR PRIOR TO SIJF
  12. 12. LS FUSION WITH IILIAC CREST GRAFT
  13. 13. L4-S1 FUSION WITH SIJ CONFIRMED PG
  14. 14. DIAGNOSTIC CHALLENGE <ul><li>CHRONIC LOW BACK PAIN ASSESSMENT </li></ul><ul><li>PROCESS OF INCLUSION/EXCLUSION OF ALL POTENTIAL PAIN GENERATORS IN THE LUMBAR-SIJ-HIP AXIS </li></ul>
  15. 15. Paradigm Shift <ul><li>Lumbar- SIJ -Hip Axis </li></ul><ul><li>Adjacent Segment Disorder </li></ul><ul><li>Primary and Secondary Pain Generators </li></ul>
  16. 16. DIAGNOSIS <ul><li>SIJ DYSFUNCTION IS DIAGNOSIS OF EXCLUSION AND INCLUSION </li></ul><ul><li>LUMBAR SPINE-SIJ-HIP AXIS </li></ul><ul><li>ASSESSMENT OF IMAGING STUDIES </li></ul><ul><li>SINGLE VS MULTIPLE PAIN GENERATORS </li></ul><ul><li>INDEX OF SUSPICION FOR SIJ DYSFUNCTION </li></ul>
  17. 17. SIJ Evaluation Overview <ul><li>Acknowledge SIJ as Potential Pain Generator </li></ul><ul><li>Recognize Elements of History Reflective of SIJ Dysfunction </li></ul><ul><li>Perform Physical Examination: </li></ul><ul><ul><li>Palpation </li></ul></ul><ul><ul><li>Provocative Tests </li></ul></ul><ul><li>Review Imaging Studies </li></ul><ul><li>Index of Suspicion </li></ul><ul><ul><li>Low – Assess Alternative Pain Generators in Spine-Hip-SIJ Axis </li></ul></ul><ul><ul><li>High – H+P Suggestive </li></ul></ul><ul><ul><ul><li>Multiple + Provocation Tests </li></ul></ul></ul><ul><ul><ul><li>Other Pain Generators Secondary or Absent </li></ul></ul></ul><ul><ul><ul><li>IMAGE GUIDED CONFIRMATORY INJECTION </li></ul></ul></ul>
  18. 18. SIJ EVALUATION <ul><li>PAIN: KEY ELEMENT IN PRESENTATION </li></ul><ul><li>PATIENT FUNCTIONAL CHANGES VARIABLE </li></ul><ul><li>PHYSICAL EXAM FINDINGS NON-SPECIFIC </li></ul>
  19. 19. SI JOINT INJECTION <ul><li>GOLD STANDARD to confirm SacroIliac joint as Pain Generator </li></ul><ul><li>IMAGE GUIDED: Fluoroscopic or CT </li></ul><ul><li>Blind injection not reliable </li></ul>
  20. 20. GOLD STANDARD <ul><li>IMAGE GUIDED SIJ INJECTION BEST METHOD TO ASSESS SIJ AS PAIN GENERATOR </li></ul><ul><ul><ul><li>MAIGNE </li></ul></ul></ul><ul><ul><ul><li>SLIPMAN </li></ul></ul></ul><ul><li>RESPONSE TO INJECTION CRITICAL FOR SURGICAL INDICATION </li></ul><ul><ul><ul><li>BUCHOWSKI </li></ul></ul></ul>
  21. 21. INJECTION RESPONSE <ul><li>> 75% PAIN IMPROVEMENT: positive test/SIJ considered Pain Generator </li></ul><ul><li>NO RESPONSE: negative test/SIJ not a PG </li></ul><ul><li>50-75% PAIN IMPROVEMENT: EQUIVICAL TEST -repeat to confirm SIJ as PG -consider SIJ as SECONDARY pain generator </li></ul><ul><li>Residual Pain: investigate additional pain generators: LS Spine-hip </li></ul>
  22. 22. Treatment Paradigm Shift <ul><li>Lumbar- SIJ -Hip Axis </li></ul><ul><li>Adjacent Segment Disorder </li></ul><ul><li>Primary and Secondary Pain Generators </li></ul>
  23. 23. SIJ Evaluation in Context of Lumbar Surgery with Residual Pain <ul><ul><li>Index Procedure Related </li></ul></ul><ul><ul><ul><li>Is it “Failed?” </li></ul></ul></ul><ul><ul><ul><ul><li>Surgery Well Performed / No Complications / Well Healed on Examination and Imaging </li></ul></ul></ul></ul><ul><ul><ul><li>Review Pre-Operative Diagnosis: Correct vs Incorrect </li></ul></ul></ul><ul><ul><ul><li>Assess Procedure Indication / Choice: Correct vs Incorrect </li></ul></ul></ul><ul><ul><ul><li>Assess Procedure Outcome: Healed vs Complication </li></ul></ul></ul><ul><ul><ul><li>(50 % of LS Fusions for DDD Do Not Provide Pain Relief) </li></ul></ul></ul><ul><ul><li>Assess Axis For Multiple Pain Generators </li></ul></ul><ul><ul><ul><li>Lumbar: Additional vs Residual Pathology </li></ul></ul></ul><ul><ul><ul><li>Hip </li></ul></ul></ul><ul><ul><ul><li>SIJ: ?primary PG vs ADJACENT SEGMENT DISORDER </li></ul></ul></ul><ul><ul><ul><li>Diagnostic testing results </li></ul></ul></ul><ul><ul><li>Treatment of Confirmed Pain Generators </li></ul></ul>
  24. 24. 5-S1 FUSION/4-5 FUSION RESIDUAL PAIN
  25. 25. SIJ CONFIRMED PG
  26. 26. R SIJF WITH PAIN RELIEF
  27. 27. SIJ Evaluation- New Onset LBP after Lumbar/Hip Surgery <ul><ul><li>Assess Index Procedure: Well Healed vs Complication </li></ul></ul><ul><ul><li>Assess Adjacent Segment Degeneration </li></ul></ul><ul><ul><ul><li>Lumbar Spine-SIJ-Hip Axis </li></ul></ul></ul><ul><ul><li>Treatment of Confirmed Pain Generators </li></ul></ul>
  28. 28. 2 Yrs s/p L4-S1 FUSION
  29. 30. SIJ CONFIRMED AS POST FUSION PG
  30. 31. RIGHT SIJ FUSION WITH PAIN RESOLVED
  31. 32. SACROILIAC JOINT FUSION
  32. 33. Fusion Candidate <ul><li>Longstanding SIJ Pain </li></ul><ul><li>De Novo Pain Secondary to ASD </li></ul><ul><li>SIJ Considered Primary Pain Generator, or Primary PG Treated, with Ongoing SIJ Pain </li></ul><ul><li>> 75 % Unequivocal Response to Diagnostic Injection </li></ul><ul><li>Complaint with Partial-Weightbearing for 3-4 Weeks </li></ul>
  33. 34. SACROILIAC JOINT FUSION <ul><li>Purpose </li></ul><ul><ul><li>Pain Relief Through Fixation of Joint </li></ul></ul><ul><li>Short –Term Goal </li></ul><ul><ul><li>Initial SIJ Stabilization from Fixation </li></ul></ul><ul><li>Long-Term Goal </li></ul><ul><ul><li>Implant-bone Ingrowth for Permanent Stabilization </li></ul></ul><ul><ul><li>Facilitate Boney Arthrodesis </li></ul></ul>
  34. 35. SACROILIAC JOINT FUSION <ul><li>Long-Term Goal </li></ul><ul><ul><li>Implant-bone Ingrowth for Permanent Stabilization </li></ul></ul><ul><ul><li>Facilitate Boney Arthrodesis </li></ul></ul><ul><ul><li>SECOND GENERATION ARTHRODESIS </li></ul></ul><ul><ul><li>Reiley </li></ul></ul>
  35. 36. TECHNIQUE <ul><li>iFuse™ Implants: </li></ul><ul><ul><li>7mm Triangular / Titanium Sintered for Ingrowth </li></ul></ul><ul><ul><li>3 Implants Transversely Across SIJ </li></ul></ul><ul><li>Prone Position </li></ul><ul><li>General Anesthesia </li></ul><ul><li>Double C-Arm Fluoroscopy </li></ul><ul><li>AP/Lateral </li></ul><ul><li>Percutaneous Placement / Lateral 3 cm Incision </li></ul>
  36. 37. RIGHT SIJ FUSION
  37. 38. LEFT SIJ FUSION
  38. 39. HOSPITAL STAY <ul><li>SAME DAY SURGERY </li></ul><ul><li>SDS WITH OVERNIGHT OBSERVATION </li></ul><ul><li>CT SCAN POST-OP PRIOR TO DISCHARGE </li></ul>
  39. 40. POST OPERATIVE COURSE <ul><li>3-4 WEEKS PARTIAL WB: </li></ul><ul><li>CRUTCHES VS WALKER </li></ul><ul><li>2 WEEKS ADVANCE TO FULL WB </li></ul><ul><li>AT 8 WEEKS ROUTINE ACTIVITIES </li></ul><ul><li>XRAYS AT 3-6-12 MONTHS </li></ul><ul><li>CT: 6 & 12 MONTHS TO ASSESS </li></ul><ul><li>SECOND GENERATION FUSION </li></ul>
  40. 41. IMAGING OUTCOMES RADIOGRAPHS <ul><li>X-RAYS DONE AT 3-6-12 MONTHS </li></ul><ul><li>IMPLANT POSTION UNCHANGED </li></ul><ul><li>EDGE-RADIOLUCENCY NON PROGRESSIVE </li></ul><ul><li>BONE INGOWTH DIFFICULT TO ASSESS ON XRAY </li></ul>
  41. 42. 3 MONTH POST OP AP
  42. 43. 1 YEAR POST OP AP
  43. 45. 3 MONTH POST OP AP
  44. 46. 12 MONTH POST OP AP
  45. 47. IMAGING OUTCOMES CT <ul><li>CT AT 6 AND 12 MONTHS POST OP </li></ul><ul><li>AXIAL-SAGITAL-CORONAL IMAGES </li></ul><ul><li>BONE IN-GROWTH SEEN BEST ON SAGITALS </li></ul><ul><li>TRIANGULAR IMPLANT-EDGE HALOS EXPLAIN RADIOGRAPH LUCENCY AS ARTIFACT </li></ul><ul><li>WALL-BONE DENSITY REFLECT INGOWTH </li></ul>
  46. 48. 1 YEAR CT SAGITAL IMAGE
  47. 49. 1 YEAR SAGITAL CT
  48. 50. SIJ DYSFUNCTION ADJACENT SEGMENT DISORDERS <ul><li>PERSONAL EXPERIENCE </li></ul><ul><li>54 Consecutive SIJ Fusion Candidates </li></ul><ul><li>*23 with prior Lumbar Fusion- 43% </li></ul><ul><li>*10 with coexistent Spondylosis (no prior surgery) </li></ul><ul><li>*1 with prior THR- </li></ul><ul><li>20% with multiple PG </li></ul><ul><li>44% with prior surgery- SIJ as PG in the context of Adjacent Segment Disorder </li></ul>
  49. 51. DEMOGRAPHICS <ul><li>54 PTS 36 F 18 M </li></ul><ul><li>RIGHT-38 LEFT-15 BILATERAL-8 (61 JOINTS) THREE PTS WITH SECOND SIDE </li></ul><ul><li>AGE RANGE 24 TO 85 AVERAGE 53.5 </li></ul>
  50. 52. FOLLOW UP <ul><li>3 YR---2 PTS </li></ul><ul><li>2 YR---16 PTS </li></ul><ul><li>1 YR---14 PTS </li></ul><ul><li>6 MO--10 PTS </li></ul><ul><li>NO PT WITH OPPOSITE SIDE DEGENERATION </li></ul><ul><li>NO REGRESSION IN PAIN SCORE IMPROVEMENT </li></ul>
  51. 53. SIJ FUSION OUTCOMES <ul><li>>80% GOOD TO EXCELLENT OUTCOMES </li></ul><ul><li>STRONG CORRELLATION BETWEEN DIAGNOSTIC INJECTION AND SURGICAL IMPROVEMENT </li></ul>
  52. 54. S/P LS FUSION WITH SIJ PAIN
  53. 55. INTRA-OP AP
  54. 56. INTRA-OP LATERAL
  55. 57. POST OP CORONAL CT
  56. 58. POST OP SAGGITAL CT
  57. 59. INTRA OP AP
  58. 60. INTRA OP LATERAL
  59. 61. POST OP AXIAL CT
  60. 62. POST OP CORONAL CT
  61. 63. PRIOR ILIAC CREST GRAFT
  62. 64. PRIOR ILIAC CREST GRAFT
  63. 65. CONTROVERSIES <ul><li>Is Implant/Bone Ingrowth sufficient for longterm Arthrodesis </li></ul><ul><li>Is a single Diagnostic Injection routinely sufficient to indicate for surgery </li></ul><ul><li>Is Fusion a reasonable treatment without prior non-operative management </li></ul><ul><ul><li>Exceptions: </li></ul></ul><ul><ul><ul><li>Post-traumatic Instability </li></ul></ul></ul><ul><ul><ul><li>SIJ pain 2 nd to Adjacent Segment Disorder </li></ul></ul></ul>
  64. 66. CONCLUSIONS <ul><li>SIJ DYSFUNCTION IS A FREQUENT FINDING WITH PREVIOUS LUMBAR SURGERY </li></ul><ul><li>SIJ FUSION CAN SUCCESSFULLY TREAT SIJ DYSFUNCTION FROM ADJACENT SEGMENT DISORDER OR DE- NOVO ONSET </li></ul><ul><li>FUSION IMPLANTS CAN BE INDICATED TO TREAT SIJ DYSFUNCTION </li></ul>

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