Inflammatory arthritis and chronic sacroiliac joint pain: What do we know?
“Arthur”, as my mother-in-law used to call the common type of joint pain caused by arthritis, is actually called “osteoarthritis” and is responsible for breaking down the cartilage in one’s joint resulting in pain. It is a mechanical breakdown of that glistening layer of slippery tissue that covers the ends of bones which allows them to slide on each other resulting in movement. This fragmentation or degeneration of cartilage, which has multiple causes, with the primary ones being the genetic way it is formed and all the stresses put on it by life’s adventures, results in the bone beneath this layer hurting. Most people can relate to the term “bone on bone” pain. In Inflammatory arthritis, though the bones also hurt, a different form of pathology is at work to make this happen.
Having inflammatory arthritis means having a condition that affects not only one or more joints, but much of the rest of the body as well. Some classic examples are rheumatoid arthritis (RA), lupus, and ankylosing spondylitis (AS). There are many others, and, in terms of the disease process, they can be very different in how they dole out their effects on recipient patients. The one entity these diseases have in common is how they go about attacking a joint and, in many cases, destroying it. Whereas osteoarthritis relies mainly on genetics and stresses on the body to do damage to a joint, inflammatory arthritis actually elicits and army of warrior cells to enter the joint and attack it with chemicals that destroy tissue and erode bone. These destructive cells not only damage cartilage and bone, but they work on soft tissue too like ligaments and tendons, which hold joints together. This is why inflammatory arthritis can result in severe and disabling deformities whereas osteoarthritis is not usually as deforming.
The sacroiliac joint is affected in different ways by inflammatory arthritis depending on its type. In my own experience with patients’ conditions like RA, the joint actually separated and became unstable, whereas AS caused cartilage destruction and erosions into the subchondral bone on which the cartilage was attached. Both conditions caused severe chronic disabling pain, which after failing long trials of conservative therapies required fusion surgery to relieve it. As I began my career as an orthopedic spine surgeon the only educational advice I had about the pathology that causes severe chronic sacroiliac joint pain was that the garden variety form of osteoarthritis, Arthur, caused it. When my first patient with RA and chronic sacroiliac joint pain presented to me in 1991, there was no textbook, no published articles and no formal knowledge base that I, as a surgeon, could tap into to tell me what to do. The same predicament happened when my first patient with AS and chronic sacroiliac joint pain appeared and so on with systemic lupus, psoriatic arthritis, and others. It was through my experiences with all these patients having inflammatory causes for their unrelenting and disabling sacroiliac joint pain that I was slowly able to string some educational messages together and learn some basics about how to best treat them and red flags to look out for.
In discussions with several doctors of physical therapy, they find patients having inflammatory causes for their severe sacroiliac joint pain a problem too. Likewise, there exists no definitive guidelines for them on treating this joint when intractable pain exists let alone in the context of inflammatory arthritis.
If you look at published literature in the field of rheumatology there is a lot of useful information for a clinician or surgeon dealing with chronic pain in these types of patients. Something that never came up in my very extensive orthopedic spine surgery education was that in RA the sacroiliac joint can become so unstable from the disease that it can actually separate or sublux. When you add osteoporosis to the diagnosis of inflammatory arthritis, which is very common, it can become a nightmare for a surgeon. The standard teaching in orthopedics is that the end result of sacroiliitis in AS is fusion of the joint. Based on that fact why would anyone want to formally fuse it together? What is not taught outside of rheumatology is that in women with AS the joint usually doesn’t fuse together and frequently results in bone erosions that can cause severe chronic pain. These patients frequently have osteopenia or osteoporosis accompanying their condition as well. This information is not being researched or taught in any institutions to primary care givers, physical therapists, or surgeons. Rheumatologists understand all this, but they usually aren’t the ones to refer these types of patients for conservative therapies or surgery. This leaves the thousands of patients (more women than men) who have inflammatory arthritis and severe chronic sacroiliac joint pain that is not improving with appropriate conservative therapies in a real bind. It also puts all the musculoskeletal clinicians and the surgeons, if they are needed, in a bind too.
I was recently contacted by a woman from South Africa through my BLOG (sijointpaingone.com) who was in this bind explaining her frustrations, with both the medical system there and her state insurance, resulting from no one understanding how her inflammatory arthritic condition affected her sacroiliac joint. Through a lot of correspondence and some industry donations she ultimately did have her sacroiliac joint fused, and she is doing well clinically. Her current issue is with her insurance, who, given the current state of education, is questioning a fusion surgery for a diagnosis of inflammatory arthritis. It certainly is not the insurance company’s fault by any means, especially if you look at the statement issued by the North American Spine Society (NASS) on when a fusion like this should or should not be performed. They state that a minimally invasive fusion surgery for sacroiliac joint pain should not be performed if …….” a systemic arthropathy, such as RA or AS, is present”. This statement is made with no scientific data or proof to support it.
This statement issued by NASS was concocted with the agenda of getting insurance companies to pay for the tens of thousands of minimally invasive sacroiliac joint surgeries that are performed each year that fall into the Federal Drug Administration (FDA) 510 (k) designation. The truth is that there has always been a payment code for fusion of the sacroiliac joint (I used it for 25 years to perform hundreds of these fusions), but it did not allow paying separately for the device or instrumentation used in the fusion process. If one looks closely at the NASS track record, they have nothing else to say about surgery for chronic pain in the sacroiliac joint. They have sponsored no research on this joint, there are no instructional course lectures for surgeons concerning this joint, they have provided no textbooks on this subject, and they have not supplied the American Board of Examiners with potential questions for surgeons to prove they are proficient in performing these complex surgeries that do have recognized complication rates. This statement was entirely for economic reasons to support the industries who manufacture these sacroiliac joint fusion devices and the surgeons for putting them in. At an average of $10,000 per device one can see how tens of thousands of these surgeries each year can really add up, and that doesn’t include the surgeon’s fee for inserting it.
The bottom line is there is no hard science to state that a fusion of the sacroiliac joint cannot help someone in pain having an inflammatory arthritis condition like RA or AS. We are truly at the mercy of anecdotal cases at this point in our history. Being one of those surgeons that has been involved in fusion surgery for the sacroiliac joint in both RA and AS, I have accumulated many of these anecdotal cases over two and a half decades. I know that good fusions in such joints can be literal life savers for many patients in terms of pain relief, but I do believe there are limits to this. The best results occurred in patients having one joint involved and not having to deal with generalized joint pain due to systemic symptoms. In each case a rheumatologist was involved who kept the systemic symptoms under control while attention could be entirely focused on the pain from the sacroiliac joint.
The take aways from this Blog are:
- If an inflammatory arthritis is affecting one sacroiliac joint, that has not auto fused, the individual is in severe disabling pain, and has failed all other forms of medical treatment and conservative care, that joint might be eligible for fusion surgery.
- Patients with both sacroiliac joints involved and having significant systemic symptoms from their disease may not do well in terms of pain relief after fusing these joints.
- The large surgical educational societies (e.g. NASS, AAOS, CNS, etc.) must get on board with research and education for the thousands of their surgeons now performing the tens of thousands of these sacroiliac joint fusions in America each year. Only then will they be able to make any definitive statements about sacroiliac joint fusion surgery, both in general and when inflammatory arthritis is involved.
Bruce E. Dall, MD
Orthopedic Spine Surgeon