SI joint dysfunction? Dr. John Stark

[mmglobal]

Last October, at the NASS meeting in Toronto, I was fortunate to have attended a breakout session with a LENGTHY presentation on SI joint dysfunction. One of the presenters was Dr. John Stark. This session was standing room only… I spent the first half in the doorway, struggling to listen, but I got a seat for the second half and was seated next to some researchers and doctors that I know. I know that I’m easy to impress, but discussing the SI issues with the professionals was very interesting. They were equally impressed.

The pictures he showed of the SI patients who could NOT SIT due to severe SI pain looked EXACTLY like many clients I’ve seen. The stories of spine surgery after spine surgery with no positive result, then having symptoms resolved after SI surgery were quite remarkable. Note that I don’t think that SI surgery is the be all end all treatment, but this diagnosis and treatment option may provide hope for many people who have been dismissed as psych problems, failed back surgery syndrome, etc…. Also, I hope that as ruling out this diagnoses becomes part of the protocol, some patients with SI issues can avoid unnecessary spine surgery and go straight to the problem.

It’s very interesting that many years ago, SI fusions were a common procedure that was a substantial part of the arsenal that the spine surgeons had available. They have fallen out of favor and are so far removed from the mainstream that getting a proper diagnosis for SI can be difficult or impossible. You have to run into a doctor that really knows about it and embraces the possibility. I’ve seen other diagnoses, like piriformis syndrome that even many of the surgeons I know and love, won’t take seriously.

After the session, I went out to dinner with a doctor that I’d met the previous year at NASS in Austin… Dr. George Lewinneck. (“I’m a thin verneer of Harvard Medical School under a thick layer of Wisconsin farm boy.”) His “I’m just an old country doctor, Jim” persona is very charming, but he’s a brilliant man with a very unique background. His take on Dr. Stark’s data was especially interesting because he’s been a spine surgeon long enough to have done SI fusions in the past and stopped (as had most of the industry.) He seemed to be excited about revisiting SI and also about the newer SI fusion techniques that Dr. Stark presented.

I just spent half an hour on the phone with Dr. Stark discussing some very problematic cases. I’ve very pleased to find him, as he seems to be at a place in his career where he is happy to get the difficult cases. I look forward to working with him and I’ll keep you posted as I learn more.

[Nairek]

Hi Mark,

I have an interest in SI joint issues as I feel that I am suffering from this as well as my back issues. I had x-rays taken a few years ago & I found out from the report (not from my doctor, surprise) that there were sclerotic changes in the SI joints.

I had an SI joint injection last November, but had maybe a 20% improvement in pain. I have to wonder if my back pain prevented me from feeling any additional relief from the injection.

I still have a little "hip" pain since my fusion surgery but it's only been 3 1/2 weeks. Guess we'll have to see if it resolves itself over the next few months.

Thank you for the info & I look forward to hearing more updates on this issue.

Karin

[Cindylou]

Mark, thank-you. Very, very interesting. Now, while I am waiting as patiently as I can on my couch with my heating pad for my SI joint injections to kick in, I have a very ignorant question to ask you. Does having my L6-S1 fusion have any bearing positive (or God forbid, negative) on the SI joints? How far from my fusion are the SI joints? I seriously wonder, based on my recent cat scan showing arthritic condition to my SI joints, if fusing them would be the solution to all my problems. As my hip replacement surgery draws nearer these are some of my paranoid questions.

Btw, sorry I missed your phone call the other day. We used the window of my hours of relief from the injections last friday to drive to our cabin in northern Minnesota for the weekend. It was incredible to be in the car for that trip with no pain.

Cindylou

[mmglobal]

Karen and Cindylou,

Note that many diagnostic injections are referred to by some physicians as 'infiltrations'. I assume that refers to the need to infiltrate the specific tissues with the anesthethetic, steriod, contrast, whatever the injectant is. While we would like this to be pure science, much of this is art and luck. False positive results may occur when the injectant flows somewhere unanticipated and generates relief from a location that is other that the target area. False negative results may occur when the injectant does not get to the target tissue because of missed injection, or proper injection with some reason that the injectant doesn't flow as anticipated... scar tissue, stenosis, etc...

Note that mixed results are also possible. By the time most of us get to this type of diagnosis, we have big multi-focal pain problems and periods of relief and bad episodes from each problem is on it's own cycle. It's difficult (or impossible) to unwind it all.

I don't know how tricky SI injections are. I look forward to learning more from Dr. Stark. Cindylou, how close is he to you?

I hate saying this because it is truly my "dumb-assed layperson's opinion", but I believe that I see more problematic cases in people with transitional segments... L6-S1 (lumbarized S1), less so for the L4-S1 (sacralized L5).

One of the more interesting things that Dr. Stark discussed in his presentation was regarding adjacent or transitional segment disorders following treatment of our lumbar spine. When we fuse L4-L5-S1, L3-4 becomes a 'transitional segment' and is subject to higher loading. While I mentioned (above) the concept of treating the spine instead of the dysfunctional SI joints (as part of a missed diagnosis), there is also the issue adjacent segment disease following the reconfiguration of the lumbar spine with fusion, ADR, auto-fusion, collapsed segments, etc... After your lumbar surgery, does the SI joint become a transitional segment BELOW the lumbar spine as it's the next mobile joint in the system?

I wonder if CindyLou might have a double whammy... is the SI a transitional segment in between a dysfunctional hip AND lumber spine???

This is all interesting stuff... I look forward to wathing this discussion unfold as we learn more.

All the best,

Mark

[Justin]

Thanks Mark! I'll have to take a look at Dr. Stark's website. Much appreciated.

[mmglobal]

I just had another conversation with Dr. Stark.

I asked about RF ablations for painful SI joints, much like we see in other area (facets). It has been tried with little success and he does not do them. He says that the SI is too highly inneverated from several sources, so it's not reasonable to consider ablation. You have to either ablate too much, or not do a complete ablation... hence the poor results. (This is me trying to paraphrase what Dr. Stark said... If I'm mistating this, I hope he'll let me know so I can correct this.)

The most important part of our conversation had to do with the discussion of hip dysfunction as it relates to SI pain. Yes, hip issues that cause alignment or mechanical issues can increase the loading on the SI joints, much like a fused or collapsed spinal segment can overload the adjacent segment.

I was specifically asking hypothetical questions about an anonymous person who was pain free for some time following an SI injection, but has hip replacement surgery coming up. While it's impossible to properly discuss any case without real data or examinations, he said that just like with the spine surgeries, he frequently sees patients who have hip replacement surgery with no improvement in their hip symptoms. Then, addressing the SI resolves the symptoms.

Remember, you can have degenerated joints that are not painful. It's possible for SI joint disfunction to mimic hip problems. Note that you can have hips that are painful and SI that is painful too. It may be that we need one, the other or both. However, if there is any reason to suspect possible SI involvement, I'd get properly evaluated by someone who knows SI joint dysfunction BEFORE undergoing hip surgery. Do your homework, make informed decisions.

Lastly, we discussed the improvements in fusion technology. We could not get into specifics because I had an appointment, but the technology has advanced a long way from the SI fusions of old. I look forward to learning more!

All the best,

Mark

[Cindylou]

Mark, again, thank-you. And I needed our phone conversation today. I decided to overnight you my Cat Scan, so you should receive it tomorrow morning, 10:30-ish. Keep me posted.

Thanks again,

Cindylou

[mmglobal]

OK... please GPN clients... keep info about sending films and similar info away from iSpine. I really want this to be a patient community and not have anything to do with GPN.

[Cindylou]

Sorry. Forgot.

[Terry Allen Blackburn]

This is interesting information. I have continued to have some SI joint issues post ADR surgery and it has responded favorably to injections so far. I would not look forward to another surgery as I am already at four major operations and holding. I look forward to hearing more about this in the future.

Terry Newton