22: Why understanding this number is paramount for those with chronic low back pain
Twenty-two percent of people with low back pain, or a little more than one in five, have the source of that pain coming either all or in part from their sacroiliac joint(s). Everyone has at least heard the term “sacroiliac” as it is even in popular songs from well-known singers with lyrics like “I got a pain in my sacroiliac”. Although its verbal use frequently does suggest pain in the back or butt, most people would find it hard to describe where this joint is on their body and what it’s there for. There are two of these joints in everyone’s body, and they connect the base of the entire spine to the pelvic bones. They are largest joints in the body and susceptible to all the pathologic processes that can affect major joints like the spine, hip and knee. The alarming fact is that most primary care doctors (except for osteopaths), orthopedic surgeons, or neurosurgeons would not even look for this joint as a potential source of the pain if someone shows up in their office complaining of pain in their low back. Since this 22% number is a valid and well documented one, it seems that most everyone would know about the pain this joint can cause, and it would be at least the third item on the list, after muscle strain and herniated disc, of possible causes for low back pain. In reality, it is not something that primary care doctors or surgeons, both orthopedic and neurosurgical, know much about. The result is that it is not on their radar when that new low back pain patient walks through the door.
There are some doctors and clinicians who do know how to diagnose this joint as a pain generator and have entire arsenals of treatments with which to treat this condition. These are osteopaths, chiropractors, pain doctors (physiatrists and anesthesiologists), and physical therapists. What each of these clinicians have in common is that they use differing methods to make the diagnoses and conservative measures to treat pain in this joint. These treatments include manipulation, exercise and injections. The other common thread linking them together is that none of them operate on or surgically treat this joint. Although there is no official success rate published using all of these modalities to treat this condition I believe most experts in all these fields would agree that at least 75-80% of patients do have successful outcomes with these conservative measures. However, if one considers that millions of people do suffer with low back pain, then it is not unreasonable to consider that tens of thousands are not successfully treated with conservative measures and fall into the “unresolved low back pain” category in which many of those are condemned to live a life of suffering and misery.
Surgeries for severe chronic and disabling sacroiliac joint pain are available and were started long ago by orthopedic surgeons. We know from almost a century of literature on surgery for this joint, coming mostly from self-taught surgeons who could think outside the box, that most all the surgical procedures published to fuse this joint together when all else has failed to cure the pain have been at least 75% successful in reliving the pain. The logical question that follows is, why aren’t these people, who fail conservative treatments, referred to surgeons for a 75% chance of a cure? That is the million-dollar question, and it doesn’t have a simple straight forward answer. Surgery for the painful dysfunctional sacroiliac joint is not taught in medical schools, surgical residency programs, or spinal fellowships. There are no instructional courses on this subject in the major orthopedic or neurosurgical educational societies, and there are no questions on this subject on board examinations for these surgeons as well. It’s not like this information is not in the medical/surgical literature as the first surgical paper on fusing the painful arthritic sacroiliac joint was published in the 1920s in one of our most prestigious surgical journals. Dozens of articles and clinical studies have been published since with that number on an exponential rise today. In America today, if a surgeon understands that this joint can be a disabling pain generator and performs surgery for it, that surgeon either is self-taught or taught by another surgeon, who has been taught by industry, how to do this. That surgeon was not taught by anyone within the medical educational system in America, and no one is testing their proficiency for performing it.
The big question then becomes how many of these surgeries are currently being performed in our country each year, and who’s looking out for the patient? If we consult Becker’s Spine Review, a leading source of data analysis for orthopedic surgeries, thousands of these surgeries to fuse the sacroiliac joint are being performed each year in America. They predict that up to 50,000 of these surgeries will be performed annually by the year 2020. That is less than two years away. The current surgical literature for the procedure being performed most often in the United States today carries a 1-17% complication rate. These complications most frequently involve blood vessels, nerves and bone, and can result in repeat surgeries, lasting morbidities and continued chronic pain.
If our major surgical educational and testing entities aren’t teaching and evaluating all these surgeons, who is? Who is taking the responsibility to teach surgeons how to diagnose this condition, provide the most appropriate conservative treatments for that 75-80% chance of success, properly select surgical candidates, learn the multiple ways that this surgery can be performed and the anatomical concerns for each, perform these complex procedures, properly rehabilitate their patient after surgery, look for and recognize all the potential complications that can and do occur, treat the complications, teach methods to avoid complications from happening in the first place, and verify the proficiency of each surgeon in accomplishing these tasks?
The teachers of the surgeons are the surgical device manufacturing industry and the entrepreneurial surgeons working for them. There is a simple reason for this. With the devices used in a surgical fusion of the sacroiliac joint costing approximately $10,000 for each surgery, there is a considerable profit to be made. Just multiply 10,000 by Becker’s Spine Review’s 50,000 and what business people refer to as the “blue ocean”, or unlimited profits, starts looking like a possible reality. In America, if industry and entrepreneurs are making money they are considered successful by those who evaluate them, and their shares on the stock market start to soar.
Let’s consider what is happening to the individual patient with the diagnosis of a painful disabling sacroiliac joint. If they happen to go to their primary care doctor or an orthopedic or neurosurgeon first they are at risk for being whisked into surgery by one of the thousands of surgeons now trained by industry possibly not even having the opportunity to have a chance at improving with appropriate conservative treatments. Since surgeons are not trained in the potential complications lurking in the critical anatomy surrounding this joint, complications from the surgeries have a chance of going unrecognized and subsequently untreated or if recognized poorly treated. With every type of orthopedic or neurosurgery there are standards for rehabilitation after such surgeries; not so with sacroiliac joint fusion surgery. If the surgery fails or the device fails there is frequently no page 2 or follow-up strategy to fix it. In these situations, either another company with another device comes to the rescue with their trained surgeon, or the patient just sucks it up and lives with the poor result, which could be continued chronic pain or even a lasting morbidity.
One might ask where the Federal Drug Administration (FDA) is in all of this. After all they are the ones charged to provide for the safety and well-being of patients when it comes to industry and the devices they manufacture that go into people. Because industry has found a way to circumvent the FDA by obtaining a 510 (k) designation for their devices, which in this case could be the subject for another editorial, the FDA literally maintains a “blind-eye” to all that happens surrounding current fusion surgery for this joint. So, the bottom line is that no official entity in America is looking out for these patients to make sure they have been properly diagnosed, had proper conservative treatment, are truly appropriate surgical candidates, or provide for evaluation of their outcomes and the proficiency of the surgeons performing these operations. Despite the fact that it seems that no laws are being broken this is potentially a very dangerous situation for patients.
Since industry and entrepreneurial surgeons are completely controlling surgical treatment for the painful dysfunctional sacroiliac joint what can be done to protect those individuals having disabling pain from this joint to ensure they receive an accurate diagnosis, the conservative care they deserve, and, if surgery is the best option, a safe journey through this experience all while keeping them more sacred than the goal of profitability?
It is here that the burden lies completely with each patient as currently they are not going to be helped in any way by the medical/surgical educational institutions, the American surgical board examiners, or the government. The first thing those suffering with low back pain need to do is to understand that the sacroiliac joint may be the problem or one of the problems. They need to realize that if they have the diagnosis of a painful sacroiliac joint, and they are stuck in what I call the “revolving door of conservative therapy”, whether it is manipulation, exercise, injections or other, they should be enquiring about a possible surgical solution. There are good surgeons who currently are learning about this joint on their own and, of course from industry, and do perform excellent surgery. This is where the Internet can help people find surgeons who have a true interest in this joint and understand the whole realm of treatments, conservative and surgical, for it. These surgeons give lectures on the subject, write books on it and do valid research on the sacroiliac joint. Patients need to ask their doctors, primary physicians or surgeons, if their sacroiliac joint could be the cause of their pain. Beware that industry pays greatly for ads and the location of them to Google and other search engines, to promote their devices to anyone with sacroiliac joint pain so people need to approach their investigations by looking for those who are not trying to sell you something.
For those suffering with low back pain this is one area in people’s individual health care that it is not wise to go into uneducated, uninformed and without advocates if they can’t be their own.