Dr Mike Stretanski's Bio
This page is still under construction

Recent news for Dr. Mike

It's been busy recently.  Six projects are coming to fruition.

The new edition of the text book entitled
Essentials of Physical Medicine & Rehabilitation  has been officially published.
Dr. Mike is the sole author on 5 chapters in this book.


Official acceptance letter of the article regarding Cobra Envenomation for the journal Neuromodulation !!!
This is Dr Mike's first publication with this particular journal.
(see below)

17-Jul-2008

NER-0373-10-2007.R2 - SCS of Neuropathic Pain Syndrome induced by  

Cobra Envenomation.

Hi Dr. Stretanski,

I hope this message finds you well!

Dr. Krames, Editor-in-Chief, has just finalized the manuscript publication order for
the next two issues of our journal, and I am happy to confirm that your manuscript
will be published in Neuromodulation, Volume 12, Number 1, in January.
Congratulations again!  In late October/early November, Wiley-Blackwell, our
publisher, will be sending your instructions for reviewing your page proofs online.

While preparing the manuscripts, I noticed that the final version of your manuscript
is not appearing properly in Manuscript Central. I'm not certain why this has
happened, but I will look into it.  Could I trouble you to please e-mail the final
version to me at your earliest convenience? It should be dated April 7, 2008.

As always, I appreciate your help.

Many thanks,

Tia

Tia Sofatzis
Managing Editor
Neuromodulation: Technology at the Neural Interface
Journal of the INS and IFESS 
2000 Van Ness Avenue, Suite 402
San Francisco, CA 94109

T: +1 415 567 1219, ext. 233
F: +1 415 567 2534
E: tsofatzis@neuromodulation.com
Web: www.neuromodulation.com










23-May-2008

Dear Dr. Stretanski:

It is a pleasure to accept your manuscript entitled "SCS of Neuropathic Pain
Syndrome induced by  

Cobra Envenomation." in its current form for publication in the Neuromodulation:
Technology at the Neural Interface.  The comments of the reviewer(s) who reviewed
your manuscript are included at the foot of this letter.

We thank you for your fine contribution.  On behalf of the Editors of the
Neuromodulation: Technology at the Neural Interface, we look forward to your
continued contributions to the Journal.

Many thanks,

Dr. Elliot Krames
Editor, Neuromodulation: Technology at the Neural Interface
krames118@gmail.com


Reviewer(s)' Comments to Author:
Reviewer: 1
Comments to the Author
Very nice work and expands the field of SCS specially in difficult situations

Philadelphia College of Osteopathic Medicine.
Cover of Philadelphia Inquirer
Thomas Jefferson University, synthesis and characterization of 1,2-dipalmtoyl-sn-glycerol-3-thiophosphorylic acids, characterization of natural and synthetic membranes, HPLC, GC


Swim coach,  Ballroom Dance (publication link insert here)

  Honduras

Teaching and Direct Care Experiences
The country of Honduras has founded a program of "function therapy" which combines components of Physical Therapy, Occupational Therapy, recreational Therapy and is a "mixed bag" program.  The Honduran students study for for three years.  The third years is mostly spent in clinical contact with other therapists from other countries.  On one
to Honduras the team was American, Canadian and German.










Despite being a rehab trip and a teaching trip, direct patient care is very much part of the deal.  Below Dr Mike is suturing a skin flap back on the hand of an 8 year old local Honduran girl with a near-amputation of her finger.

In a rural setting and being therapists, there are few resources.   Doctors are rare and the ability to do injection-based therapy is even more rare.  medications by mouth consist mostly of donated bottles of Tylenol and ibuprofen.
 
As a result, the therapists took an interest in manual medicine.  In the evening at the "Ranch" in the Olancho region of Honduras, we did manual medicine teaching and tried to educate as much as we could on basic musculoskeletal medicine and the absolute safest way to do things.

As you can see, the students are quite young by American standards.  They finish their primary education and despite being seniors in the functional therapy program are still only in their late teens or early twenties

The clinic at the ranch has some basics and occasionally running water.  Dr Mike brought about 80 pounds of supplies the second and third trips.  the locals would hear we were there and some walked or rode a day to be seen.  There were some supplies left behind from other groups that had come through.  We used everything!  Then, starting shipping stuff fro future trips.
 

You cannot find another dog this sweet or effective for therapy, or just keeping you nice and calm before or after a procedure.

For the record.  Dr Mike is NOT the one who put the pink bows in her hair.  It was Valentine's Day and that is how she came back from the groomer.  Sweetie gets trimmed at "Pampered Pooch" in Mansfield, OH.   Please visit them at skinnypuppies.com and consider adopting a rescue dog like Sweetie.

Title Page

The Sacroiliac Joint Revisited: Osteopathic approach and the role of emerging concepts

Author/Corresponding Author:

Michael F. Stretanski, DO

Medical Director / Fellowship Director

Interventional Spine & Pain Rehabilitation Center, ltd.

295 Glessner Ave.

Mansfield, OH 44903

419 522 1100  Fax 419 522 4118

The author has no conflict of interest.  No funding or support in any form was provided from any source. 
Introduction

The sacroiliac joint (SIJ) has classically been given significant attention in the Osteopathic curriculum.  The classic Osteopathic teaching of the sacrum is a three-dimensional model with 7 axes of motion.  The most documented axis is that of flexion/extension occurring about the S3 sacral segment [Image 1] corresponds roughly to the inferior transverse axis.  Sacral dysfunctions are classically defined in terms of sacral torsions, right or left on a right or left axis, unilateral flexion/extension dysfunctions, and shears, either upslip or downslip.  Innominate dysfunctions are defined as ilium rotation, anterior/posterior, iliac inflare or outflare, additionally there is superior/inferior pubic rami translation or “shear”.  These core concept dysfunctions exist along a spectrum, any of which may be primary, secondary, or viscerosomatic.  Once believed to the primary causative factor of both radicular and axial low back pain, emphasis only began to shift away with Mixter and Barrs 1934 landmark description of the ruptured intervertebral disk.¹   The standard osteopathic vision of this  “joint” is unfortunately being left behind amidst a wave of aggressive, musculoskeletal-oriented, fellowship trained pain specialists.  The opportunity for the DO community to remain at the forefront of this burgeoning research should be enabled.

The progression within traditionally non-manipulation dominated areas involving interventional procedures, histoanatomic study, pain management, rheumatologic perspective, and differing schools of thought in biomechanics, have a seemingly splintered, but progressive viewpoint, which, when taken as a whole, can potentially be tied together in a more comprehensive holistic understanding compatible with Osteopathic philosophy. 

These perspectives, facts and skills sets, in the hands of Osteopathic physicians may lead to a more holistic, broader diagnostic and treatment scope, potentially resulting in more-effective, long-term outcomes.  

It is the goal of this manuscript to review and introduce the mainstream JAOA readership to this potential.

Background

Comprised of sacral and iliac surfaces, the developmental precursor of the SIJ spans the longitudinal distance of 5 developmental somites.  Each vertebrae has three primary ossification centers at birth and five secondary centers that may continue ossification up until 25 years of age.²  This unique and sometimes variable embryological development gives the joint number of unique characteristics and therefore prone to unique pathology.  As with all developmental anatomy, congenital irregularities such as variations in the number of vertebrae, an intervertebral disk at S1/S2, hemivertebrae, batwing vertebrae, coronal lumbosacral (LS) facets, pars interarticularis defects or spina bifida occulta, arise and may need to be considered when formulating a treatment plan, particularly when interventional procedures are under consideration.

Once felt to be a syndesmosis, then later simply a true synovial joint, recent histologic studies have shown a more complex picture.  A significant transition exists with the proximal hyaline cartilage of the sacral and iliac bone being strongly attached to the surrounding stabilizing ligaments that exist in the form of wide margins of fibrocartilage. Between the proximal and distal thirds a variant-rich transition zone exists with the distal one-third to resembling a facet joint with a true inner capsule containing synovial cells.  One study ³ goes as far as to conclude that the SI “joint” should be classified as a symphysis.  The sacral articular surface is covered with hyaline cartilage in the newborn reaching an adult thickness of 4 mm, whereas the iliac cartilage is composed of a dense fibrillar network of right angled collagen bundles, which later becomes hyaline cartilage with a maximum thickness of 1-2 mm in the adult.⁴   This may be the embryological origin of a complex innervation pattern sharing mechanoreceptor and nociceptive fiber origins with the posterior ligamentous structures, whereas fetal histologic studies suggest the blood supply more likely shared with the anterior sacral plexus.⁵  

Early sacroiliac joint involvement is a hallmark of the seronegative spondyloarthropathies (reactive arthritis, Reiter’s syndrome, psoriatic arthritis, arthritis associated with inflammatory bowel disease), a group of arthritides not associated with rheumatoid factor or antinuclear antibodies, but having a high association with HLA-B27 antigen.  Bilateral sacroilitis is typical for ankylosing spondylitis (AS), but asymmetric presentations may be seen.⁶   Unilateral calcification on CT may be seen in calcium pyrophosphate dihydrate crystal deposition disease.⁷    Infection or prolonged inflammation from any etiology may lead to osseous fusion [See Image 2]. 

The higher incidence of SIJ pain in women is felt due to a wider pelvic ring and 12.8 % smaller average (992.5 mm² vs.1138.3 mm²) ⁸ articular surface area – on adult dry bone analysis.

Considering the force arrangement and anatomic change occurring after LS fusion, most notably the increased lever arm length through the sacrum, it seems a forgone conclusion that an increased incidence of SIJ pain occurs post-operatively.  One study in post LS fusion pain showing a 75% pain reduction with intraarticular SIJ injection suggests a claim of the SIJ as the pain generator.⁹   A retrospective study of 24 patients with persistent donor site pain from iliac allograft harvesting site a range of mild to severe degenerative changes along a spectrum of three zones high incidence of inner table disruption in patients with persistent SIJ pain after harvesting, synovial violation showed a direct correlation with greater degenerative change.¹⁰  While this does not support the SIJ as the only cause in low back pain after LS fusion the reported response does assist in incriminating the SIJ as part of the musculoskeletal system dysfunction in these patients. An attempt to categorize 54 injection responsive patients into traumatic (44%), cumulative (21%) and idiopathic (35%) inciting etiologies was specific to include “altered gait due to lower extremity disorder” (n=3/11) in the cumulative category.¹¹   Another study using “ … reversible functional restriction of motion presenting with hypomobility … ” in place of the Osteopathic term “somatic dysfunction” found 46/105 patients with MRI documented herniated nucleus pulposus to have SIJ dysfunction on exam.  The outcomes not only suggest better resolution of radicular symptoms with physical therapy and manual medicine directed toward the SIJ in these non-operative cases, but can infer the presence of SIJ dysfunction, by their definition, to be a positive predictor of outcome of the radicular pain.¹² 

SIJ pain

Several studies unique to SIJ pain may be outside the more mainstream Osteopathic literature and an even cursory understanding may be helpful in caring for the patient with recalcitrant SIJ pain.  Referral mapping had been done using intraarticular SIJ injection [Image3] in assymptomatic volunteers¹³  and further shown to have clinical applicability in clinical screening prior to intraarticular SIJ injection.¹⁴   Any physician involved in the multimodal care of patients with back pain should understand that pattern variability exists and the technique is limited to pain and hypesthesia provoked by intraarticular injection within the joint itself.  There are two problems from an Osteopathic standpoint with this model. First, it does not take surrounding structures (ligaments, tendons and muscles) into consideration. These structures are of quintessential importance from an Osteopathic perspective, when considering the goals of muscle energy and myofascial release techniques.  Secondly, it does not have applicability to an axially loaded joint during locomotion.  Fortin et al ¹⁵ suggested three different pathways based on intraarticular SIJ injection extravasation patterns; posterior extravasation into the dorsal sacral foramina, superior recess extravasation at the alar level to the fifth lumbar epiradicular sheath and ventral extravasation to the region of the lumbar plexus.  The same author went on to conclude that SIJ innervation is largely if not entirely innervated by dorsal sacral rami or medial branches.⁵   

While low back pain in pregnancy is beyond the specific intended scope of this paper, a well-documented “catching” phenomenon in pregnant women with posterior pelvic pain present only in the leg when walking may come from the SIJ and iliolumbar ligamentous structures¹⁶ and the long dorsal sacroiliac ligament has been implicated with a sensitivity of 86% to 98% as the primary pain generator in this sub-population.¹⁷

Five-cm symphyseal separation and SIJ dislocation following spontaneous vaginal delivery of a 5.6 Kg infant has been seen in association with the McRoberts’ maneuver.¹⁸  

Other pathology, such as pustulotic arthro-osteitis¹⁹ violation of the SIJ during iliac bone graft donor site harvesting²⁰ sacral stress fractures either in athletes²¹ or post-partum as a result of osteoporosis of pregnancy ²²  may mimic SIJ or psuedoradicular pain.  These seemingly rare pathologies need to be taken into consideration when making clinical decisions regarding treatment or further diagnostic modalities. 

Infection warrants special mention and is usually pyogenic or granulomatous, but hydatidosis (echinococcosis) of the sacrum extending through the SIJ²³ and salmonella virchow in the pediatric population²⁴ have been reported.  In 44% of all infectious cases no pre-disposing factor can be identified and low back pain is most common presentation.  From an infection standpoint, magnetic resonance imaging is the most sensitive and specific imaging modality, however, Tc(99) MDP blood pool imaging mirrors the clinical therapy and scintigraphy may be the best method to monitor response to treatment.²⁵   

Diagnostics

The most common diagnostic modality of SIJ pain (dysfunction), physical exam, is also the most controversial.  Studies on the same SIJ pain provocation maneuvers used in both Allopathic and Osteopathic paradigms have shown largely unreliable results, even when performed with an inclinometer and handheld calipers.²⁶   Inherent variability has been documented both in total force vector and force components on right to left comparison even with the same therapist in sequential exams on the same patient. ²⁷  Van der Wurff et al²⁸ reviewed 11 studies investigating the reliability of such tests and concluded there were no reliable outcomes and no evidence to base acceptance of SIJ mobility tests into clinical practice, despite acceptable methodological practices in 9 out of the 11 studies. Specifically, the standing hip flexion test used in both Osteopathic and Allopathic pathways has been shown on radiostereometric analysis to be invalid and not recommended for evaluation of joint motion in the SIJ.²⁹   The concept of using intraarticular SIJ injection as the gold standard has also been called into question.  Variable referral patterns exist which are not restricted to what is commonly believed to be the SIJ region or even low back, with a statistically significant trend for younger patients to describe pain distal to the knee.³⁰   The author asks the patient to point to where it hurts the most, or alternatively in chronic cases, where it hurt the most at first.  This is not unlike a previously described technique³¹, which is limited in its documented diagnostic value to intraarticular SIJ injection response and infers no role of the SIJ as a primary or secondary pain generator.  Even this technique of using isolated pain at the ipsilateral sacral sulcus, has been questioned as a valid diagnostic modality.³²    A different type of double-blind controlled study on pain-provocation suggested that when three pain provocation tests are used in conjunction they have a high predictive value, ³³ however, fluoroscopy was not used and the 4 ml volume reported is well beyond the maximum capacity for the SIJ.  It is more likely with this method that anesthetization the posterior joint capsule via regional infiltration of the sacral dorsal rami and ilioligamentous complex was accomplished, thus no real inference about pain origin from the SIJ proper can be made.  Clinically, such anesthetization may create a window of opportunity for active participation in therapy, or osteopathic techniques.

Imaging studies are slightly more consistent, but again have limitation in their ability to show structure, not function or pain.  Comparative studies limited to early seronegative spondyloarthropathies has shown MRI and CT to be equally superior to plain radiographs in staging erosions and osseous sclerosis with MR being superior for changes in sub-chondral bone, subchondral bone and bone marrow fatty accumulation, yet the T2-weighted imaged alone did not contribute to the assessment of sacroilitis.³⁴  The diagnosis is complicated by the fact that as few as 28% of patients who fulfill the New York Modified Criteria for AS are HLA-B27 positive.³⁵    While it is routine to image the SIJ in patients referred for radiographic examination of the lumbar spine, it has been called into question based on the low yield (2/392) whether it is sensible to image and for the radiologist to report on the SIJ without a clinical history of AS.³⁶

An attempt at quantifying bone scan results and correlating pain reduction/response to IA SIJ blockade has been made,³⁷ and a study on quantitative sacroiliac scintigraphy in normal vs. patients with sacroilitis suggested that every institution should establish its own normal sacroiliac index for bone scanning.³⁸   Vacuum phenomenon are frequently found on CT in the sacroiliac joints in elderly women and may co-exist with sacral insufficiency fractures, gas foci in the fracture may even communicate with the SIJ, but the one study found them to be of no diagnostic significance in this sub-population. ³⁹   A controlled study using a new high resolution CT scoring system on patients with SIJ pain, pain suspicious for seronegative spondyloarthiris, SIJ pain with inflammatory bowel disease and a control group concluded HRCT is the reliable method for ‘cold stage’ sacroilitis, detection of erosion and the only method for detection of calcification in the posterior longitudinal ligament.⁴⁰  

One of the few clinical studies on manipulation and imaging joint position,  (n=10, all women) showed that the joint does not move radiographically despite decreased subjective pain perception and normalization of 10-12 of the 12 provocation maneuvers documented.⁴¹ Long-term follow-up or treatment was not reported.

Part of the reason for these discrepancies may be a well-intentioned attempt to isolate the SIJ, anatomically, diagnostically, and therapeutically, from the rest of the musculoskeletal pelvic system.

Treatment

There is no shortage of controversy in either the analysis or validity of treatment programs for SIJ pain.  Treating dysfunctions of this orphan joint usually gets special attention in most Osteopathic medical programs as a part of the manual medicine curriculum. 

The most rational approach is probably the one that begins with the structural exam and progresses to address the kinetic chain.  In getting patients to accept this model, the author often makes the analogy of the pelvis to an egg.  Most people in childhood experimented with pressing an egg end-to-end together in their hand and finding the otherwise fragile structure to have remarkable strength when loaded in this axial fashion.  Like any other circular structure, force alignment is altered when any part of the rim is changed.  For example, there is the need to evaluate for and address a left posterior innominate restriction and right-on-left sacral torsion in a patient presenting with unilateral right anterior innominate dysfunction.  The author finds type II muscle energy and active patient stretches to be of greatest long-term efficacy in such cases.  This is probably because it addresses underlying relative muscle imbalance and ligamentous structures, the importance of which cannot be overstated. 

Due to the inherent differences in body habitus and seemingly limitless number of variables secondary in part to body habitus, a universally applicable set of specific concrete rules pertaining to the kinetic chain is unlikely to gain widespread acceptance in the legitimate peer-reviewed literature.  However, the general concepts should not seem terribly foreign to physicians using manual medicine and affiliated literature can be interpreted to support the application. A particular controlled study of athletes with a myriad of complaints throughout the pelvic musculoskeletal system, showing stress injuries to the pubic symphysis associated with changes in the SIJ that were either degenerative or stress reactions.⁴²  The same study concluded the likelihood of abnormal stress across the pelvic ring leading to another second abnormality within the ring, such as SIJ imaging abnormalities or avulsion of cortical bone at the gracilis tendon insertion site, with pubic symphysis offset, erosions or sclerosis.  Another case report asserts a causal relationship between chronic Achilles tendonitis and SIJ dysfunction in an internationally competitive pole-vaulter.⁴³   Simulated open-book injuries in cadaveric studies, while being a radical example, show inferior-posterior displacement of the pubic bone on the ipsilateral side, with an almost pure rotation of the SIJ parallel to the planar surface without vertical displacement. ⁴⁴  Given the SIJ is the only bony connection between the entire upper torso and ground reaction forces, it should not be difficult to conceive of it as a mechanically high-stress area.  Every sports medicine clinician understands the kinetic energy of a baseball pitch or a boxing jab as originating as a ground reaction force vectoring from below the metatarsal heads, up through the gastrosoleus complex, gluteal muscles, SIJ, axial spine and eventually the upper extremity.  A seemingly esoteric study on rowers demonstrated as high as a 66% seasonal incidence of SIJ pain as a working diagnosis.⁴⁵  Furthermore, anatomic alignment of sacral subchondral bone trabeculae at right angles suggests design for a perpendicular load while iliac subchondral spongiosa shows no definite alignment other than joining thicker subchondral bone in an oblique direction designed more for shearing forces that arise from monopodal support of the gait cycle.  Iliac cartilage undergoes more pronounced morphologic changes earlier whereas sacral cartilage remains largely unchanged until old age.⁴   The author feels this raises the question of whether the superior one-third should be thought of as an obliquely oriented vestigial intervertebral disk remnant.

As with all joints, dynamic and static stabilizers of the SIJ exist and should be evaluated and treated when undertaking rehabilitative efforts around any specific joint.  A supposedly reliable technique⁴⁶  of color doppler imaging with induced oscillation of the SIJ has shown stiffness to increase with even slight muscle contraction, especially with erector spinae, biceps femoris and gluteus maximus.⁴⁷  A related study⁴⁸ limited to pregnant women (36-weeks of gestation) using physical exam parameters, visual analog scale and the Quebec back pain disability scale suggested the same SIJ laxity in moderate to severe pelvic pain as mild to no pain.  One study suggests the role of the transverses abdominus muscle alone in reducing SIJ laxity to a greater degree than even all lateral abdominal muscles, but does not address the role of these muscles to function in concert as the entire pelvic musculoskeletal system.⁴⁹   Supporting data based on surface electromyography suggests delayed onset of obliquus internis abdominus, multifidis and gluteus maximus during standing hip flexion on the ipsilateral side in subjects with clinical SIJ pain.⁵⁰

Posterior periarticular, regional ligamentous and even sacral medial branch spinal nerve injections can be accomplished with reasonable safety in an office setting, and one study even seems to suggest it efficacy.^{51, 52}   The standard-of-care for intraarticular SIJ injections is real-time fluoroscopic guidance with contrast-confirmation of placement [see Image 4], although MRI feasibility and safety for intraarticular SIJ injection has been established⁵³ and CT needle guidance can be performed, but lacks the identification of inadvertent vascular uptake seen on fluoroscopy.^{54, 55}  CT scans have been considered positive 42.5% of patients with positive response under CT guidance⁵⁶ and another report on CT guidance went as far as to suggest intraarticular SIJ injection itself is primarily for diagnostic purposes and the injections had little or no therapeutic benefit beyond 2-14 days in 90% of patients.⁵⁷   There is no shortage of empirical evidence or experienced opinion that would disagree with this discouraging report and at least one study⁵⁸ showing significant improvement in visual analog scale, work status, Oswestry disability scale and a trend toward less medication usage at an average follow-up of 94.4 weeks after fluoroscopic-guided intraarticular SIJ injection.  Theoretically, in a non-inflammatory setting with no inflammation of the joint space, ligaments or surrounding soft tissues, relief should not have lasted any longer than the duration of the local anesthetic, regardless of HLA-B27 status. 

The author uses the technique of a “sacroiliac joint distention arthrogram” under fluoroscopic-guidance with contrast-confirmation while asking the patient if the pain is concordant, discordant or absent - similar to the fashion of a discogram.  While the theoretical risk of anterior extravasation is present, the author has used pulsed 42° C and non-pulsed thermal 80° C radiofrequency of the dorsal sacral nerves and ligamentous structures, with or without intraarticular 50% dextrose, denatured alcohol, glycerin and intraarticular 6% phenol in cases where a competent joint capsule has been demonstrated.  A remotely related case was performed out of desperation on a medically-complicated 400 lb 36 year-old male hemodialysis patient, who had previously responded to lumbar medial branch phenol treatment after three failed radiofrequency attempts. He responded well to sacral dorsal fascia and iliosacral/iliolumbar ligamentous ablation with phenol 4.5%, obtained by mixing phenol 9% with Isovue 200® (iopamidol injection 41%, Braco Diagnostics, Princeton, NJ), 50/50 (v/v) and weight loss efforts continue in an attempt to qualify for placement on a renal transplant list.  Several other seemingly excessive treatments have been reported.  The concept of SIJ fusion in non-traumatic cases has been met with the range of weak optimism to frank heresy.  A recent description unique in avoidance of implanted hardware and preservation of the iliac crest contour, claims to report resolution of five cases if SIJ pain at greater than 2 years.⁵⁹   Such specific outcome measures should be evaluated within the context of secondary musculoskeletal issues and their effects on other pain management requirements and functional independence.  Most radiofrequency procedures are performed under fluoroscopic guidance, although, CT guided percutaneous radiofrequency of the SIJ has been reported.⁶⁰   A preliminary report exists of 4 patients who received intraarticular SIJ Hylan GF 20 for arthrographically and intraarticular SIJ injection diagnosed SIJ pain, 3 of whom had prior spine surgery.⁶¹   A small (n=2) report of severe refractory intraarticular SIJ injection verified pain reported 60% reduction in pain with implanted neuroprosthesis placing the electrodes at the bilateral S3 nerve roots.⁶²  Any healthcare provider involved in long-term musculoskeletal care of the medically-complicated surgically-intolerant patient may understand the circumstances that potentially drive clinically practicing physicians to such efforts.  

The most optimistic outcome study also seems based on the aforementioned kinetic chain approach. A two-year outcome study on structured physical therapy program directed toward the SIJ and pelvic stability reports 95% of patients rating their outcome as good to excellent.⁶³   This approach is based to some degree on sensory-motor-control aspects or what is often referred to as the “mind muscle connection” of trunk and postural stabilization used heavily in clinical physical therapy practice.⁶⁴   

Within the paradigm of Osteopathic perspective, fascia is considered to be supreme, soft tissue, particularly collagen, remodels and muscle imbalance neither occurs nor is corrected instantaneously.  A sudden and complete correction of all primary and secondary dysfunctions may lead to greater subjective discomfort and disability due to fascia, despite proper Osteopathic and orthopedic bony anatomic alignment.  In a fashion similar to the more accepted sequential progressive correction of leg length discrepancy, the author seldom completely corrects massive sacral torsions on initial presentation.  There are other tools at our disposal that can be used to potentiate manual medicine techniques to enable kinetic chain correction.  For example, if the patient mentioned in the earlier paragraph has altered gait mechanics due to pain and is unable to tolerate active treatment, we can start with soft tissue, ligamentous, intraarticular or epidural injection depending upon the results of an electrodiagnostic study.   The patient might then begin active stretches with self-directed muscle energy techniques and lumbar stabilization program under the direction of a licensed physical therapist after the inflammatory component of the pathology is under control. On the other hand, a hypermobile SIJ can be treated with 25-50% dextrose solution with or without sodium morrhuate and implementing an isometric abdomenal stabilization program.  If particularly recalcitrant dysfunctions exist, motor point blocks or soft tissue injections may be performed with increasing concentrations of a long acting local anesthetic immediately before scheduled physical therapy sessions.  This is particularly effective to facilitate type II muscle energy of the agonist group.  Botulinum toxin might be appropriate if there is focal spasticity from a contributing upper motor neuron lesion. Lastly, the patient may undergo more aggressive direct high-velocity low-amplitude or “thrust” techniques if needed, for correction of the torsion component if not already resolved and are still presenting as a clinical issue.  This approach is not presented as the only “right” way.  Results can be obtained using a program linked to the kinetic chain, and tailored to the clinical scenario.

Conclusion

The region commonly referred-to as the SIJ is part of a high-stress complex mechanical arrangement with varied anatomy, histology and a predilection for unique pathology, where an integrated comprehensive treatment program needs to be designed with these facts in mind.

A thorough medical history, static structural, and kinetic chain analysis, as well as, lab and imaging review must be performed within the context of their limitations.  Special attention should be paid on exam to hip abductors, external rotators, tight hamstrings, weak hip flexors and abdominal musculature, after which a rehabilitation program can be implemented toward active involvement of the patient in correction of relative strength imbalances and postural awareness.  This may require significantly more time with the patient that is commonly available in most settings.  A focused role may exist for intraarticular SIJ injection, soft tissue or ligamentous injection of anti-inflammatory, sclerotherapeutic or neurolytic agents, manual medicine in several forms, botulinum toxin, adaptive equipment and passive modalities.  Treatment restricted to the SIJ itself or isolated to any one part of the pelvic musculoskeletal system, will be limited in potential to improve subjective pain assessment, and objective clinical outcomes.

Bibliography

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13. Fortin JD, Dwyer AP, West S, Pier J.  Sacroiliac joint: Pain referral maps upon applying a new injection/arthrography technique  Part I: Asymptomatic Volunteers  Spine 1994;19:1475-82.

14.  Fortin JD, April CN, Ponthieux B, Pier J.  Sacroiliac joint: Pain referral maps upon applying a new injection/arthrography technique  Part II: Clinical evaluation  Spine1994;19:1483-9.

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• Image notations

Image 1, coronal CT of normal sacrum showing irregularity and asymmetry of joint surface with prominent S3 axis of rotation.

Image 2, Egyptian Pelvis, 2400 BC, with pathologic fused left SIJ of probable infectious etiology, British Royal Museum, London, England

Image 3, Fluoroscopic-guided contrast-confirmed intraarticular sacroiliac joint injection. Needle placed in inferior pole of joint demonstrating arthrogram with inferior pole redundant joint capsule filling and irregular surfaces in this normal arthrogram.

In Progress

An alternative approach to sacroiliac joint dennervation

ABSTRACT:

Objective: Establishment of safety and primary evaluation of an alternative method of L5S1 facet and superior pole SIJ dennervation

Design: prospective cohort

Setting: community spine/pain clinic within ambulatory surgery center

Participants: 14 patients, 8men 6 women ages 43-78 average 62

Intervention: Non-pulsed radiofrequency lesioning of S1, S2 lateral branches and L5 medial branch with fluoroscopic-guided contrast-confirmed ethanol infiltration into the S1 medial and lateral branch regions

Main Outcome measures: Oswestry Disability Index, visual analog scale, patient satisfaction, neurologic examination

Results: all 8 patients self-reported significant relief and stated they were glad they had it done and would do it again. One patient, reported pain flare that spontaneously resolved on post-injection day 12. No complications occurred.

Conclusions: the use of dehydrated ethanol to target L5 and S1 medial and lateral brances at the superior pole of the SIJ is a safe alternative/adjunctive radiofrequency neurolysis

Keywords: SIJ pain; interventional pain management; Neurolytic agents

Introduction:

The SIJ is studies (  ref) have shown a variable pattern of innervation in this region

The sacroiliac joint (SIJ) has been a contentious point within the spine and pain community as a potential etiology of low back pain. The clinical scenario progresses to such a point where radiodennervation of the joint has been selected as a treatment option.  Inherent differences innnervation have been reported (ref from waldman photo).  While it is widely accepted that the inferior portion of the SIJ is innervated by S3 S4 lateral branches the upper pole is more varied and is often a source of technical difficulty for even experienced practicing pain interventionalists. Little argument is heard at international conferences regarding the arduousness and technical difficulty in posterior injection of ?????????.  in long term  The problem with this model is that it fails to take ligamentous pain into consideration

Can be difficult and complicated even in the most experienced hands.

All patients had received physical therapy, topical agents, oral medications, 6 had prior Transcutaneous electrical stimulation
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