Unlike the rather stationary sacroiliac joint, the newest member of the SI-BONE team is on the move. The company has announced that Steven R. Garfin, Professor and Chairman of Orthopedics Department at University of California, San Diego, has been named Chair of the SI-BONE Medical Advisory Board. Dr. Garfin, a past President of the North American Spine Society and Cervical Spine Research Society, is a prolific scientist and author, with nine books, 123 book chapters, 255 peer-reviewed journal articles, and 132 abstracts to his name.
Dr. Garfin chaired the recently held 3rd SI Joint Diagnostic Summit—sponsored by SI-BONE—where notables in the spine world came together to determine a best consensus algorithm for evaluation of symptomatic patients with SI Joint pathology. “The SI joint has been thought by many to be relatively unimportant as related to the cause of low back symptoms, including pain and disability, ” said Dr. Garfin, in the news release. “The initial research presented by surgeons and other clinicians at the Summit strongly suggests it is a real cause and may be a contributor to low back complaints and disability. The SI joint supports essentially all the weight of the spine.”
Dr. Garfin provided OTW with the following points involved with the algorithm:
- Physical Exam (PE) has been thoroughly evaluated and only provocative pain tests are of use. Motion and Position tests have been discarded.
- PE – rule out neurologic signs (If neurologic signs are positive, the focus is on the lumbar spine).
- Provocative Tests (Need minimum 3 out of 5 to be + to have sufficient data to proceed to further SI joint workup). These tests include:
– Distraction test,
– FABER test,
– Compression test,
– Thigh Thrust (POSH),
– Sacral Thrust test,
– Gaenslen’s (pelvic torsion) test.
- If PE points to the SI joint, (i.e., the pain is below L-5, and the ROM of the spine does not elicit the patient’s pain) it is responsible to assume that the pain generator is the SI joint.
- If any doubt is present, then proceed with a lumbo-sacral MRI. It is the preference of some physicians to include the SI joint in lumbar MRI.
- Patients may have 2 pain generators, one from the back and the other from SI joint (or even hip).
– If PE points to SI joint, presence of chronic disc or facet changes, which do not elicit pain with motion, may be red herrings.
- Next step is fluoroscopic or CT guided SI joint injection with pain MD or radiologist. Details of pain relief or lack of should be documented.
- The diagnostic gold standard of SI joint disease diagnosis is either:
– One injection that alleviates at least 75% of pain, or
– 2 injections that both alleviate at least 50% of pain.
- Prior to the injection, it may be helpful to ask the patient to repeatedly do whatever aggravates the back pain.
– Alleviation of pain may be clearer to patient under these conditions.
- Most physicians are comfortable with a conservative approach at first to SI joint pathology.
– Either pelvic belts, chiropractic manipulations, or physical therapy, combined with NSAIDS / muscle relaxants may effect the pain.
- It is probable that after injections and conservative treatment have run their course, the patient will probably require SI joint fusion.
A champion of life in the lab, Dr. Garfin explained in the news release that his acceptance of the SI-BONE Medical Advisory Board leadership position demonstrates his commitment to guiding the clinical research process. “It will be a process that will yield new insights, understanding, and strategies for spine surgeons seeking to deal with unresolved, chronic low back symptoms that may be related to SI joint pathology. The lower back can be vulnerable to many pain-causing injuries or disorders related to SI joint pathology because it carries much of the body weight and is subject to the most force and stress from the spine.”
The company indicates that due to an increasing awareness of SI joint dysfunction as a debilitating symptom generator, they developed and patented an intramedullary implant—iFuse—to treat the SI joint. iFuse is in use throughout the U.S.; SI-BONE will also conduct a post-market multicenter study to determine the effect of iFuse over time on SI joint pathology and on symptoms associated with SI joint dysfunction.
With regard to educating surgeons on SI joint dysfunction (SIJD), a company representative told OTW, “Surgeons are typically not taught to diagnose SIJD, but SI-BONE has partnered with thought leaders and created a SIJD Working Group, with the effort chaired by Steve Garfin. This group is writing and publishing papers and doing presentations at major spine meetings to help educate surgeons on SIJD. SI-BONE is supporting efforts to communicate the Working Group Algorithm to surgeons through papers, presentations, meetings and seminars. The company is also supporting publications of experience and case studies with the iFuse Implant System as the MIS solution for SIJD.”
