The lower back pain that is commonly misdiagnosed
Lower back pain is a common and painful condition that affects over 31 million patients in the United States patients per year. It is the most common cause of job-related disability and a leading contributor to missed workdays. Pregnancy could also play a major role in low back pain, according to orthopedic surgeon Dr. Robere J. Missirian who shared information about the diagnosis and treatment of the sacroiliac joint (SI) at the recent Grand Bahama Medical and Dental Association’s 17th Annual Scientific Educational Conference.
According to the doctor, chronic low back pain, and specifically the sacroiliac joint is a common source of low back pain that is frequently misdiagnosed and under-treated.
The lower back supports the weight of the upper body and provides mobility for everyday motions such as bending and twisting. Most acute low back pains result from injury to the muscles, ligaments, joints and discs.
“In fact, 80 percent of the population, at some point in their life, will experience low back pain. And at any one time, and at any moment, about 10 to 15 percent of the population is experiencing low back pain,” said the orthopedic surgeon who founded Vital Orthopedic & Spine Institute, and who has been treating injured patients for over 18 years with a multi-modality clinical approach.
Sacroiliac joint pain presents as lower back pain and weakness, while pelvic, buttock, hip and groin pain may occur during sudden movements such as laying to sitting and sitting to standing.
“One of the causes of sacroiliac joint pain which can be traumatic or non-traumatic is actually pregnancy, and or childbirth. When a woman is pregnant, hormones are released that weaken or loosen the sacroiliac ligaments that hold the sacroiliac joint together, and the act of the child coming through the birth canal stretches the sacroiliac joints further to allow the child to pass through.
“And in 25 percent of women after delivery, they have some type of pelvic girdle pain, which can be caused by the Sacroiliac joint. Other causes can be leg length discrepancy — people who have one leg longer than the other or shorter than the other; people who already had joint replacements; people who have scoliosis. If somebody already has a fusion of the lumbar spine, where the lack of motion at one segment forces the motion to be transferred to another segment and that can cause problems, and obviously arthritis of the joint can cause pain.”
The doctor believes that patient care begins with conservative, non-surgical treatment consisting of physical therapy, rehabilitation, medications, trigger point injections and bracing, followed by more invasive treatment such as pain management and surgery when appropriate.
Missirian said musculoskeletal conditions are the most common cause of disability, and make up 50 percent of the cause of disability of all patients, including people with heart disease, diabetes and cancer.
“You add all that up, they don’t surpass musculoskeletal conditions as a source of disability,” said the doctor who said that traditionally, low back pain was treated as a problem with the discs of the lumbar spine, and that before the 1930s, low back pain was commonly thought to be coming from the Sacroiliac joint, until a paper in 1934 which said that the discs were the cause of low back pain.
The doctor said in 25 to 33 percent of patients, one quarter to a third of those patients who have chronic low back pain, the cause is not lumbar spine, but the sacroiliac joint; and that it is commonly missed by doctors, including orthopedic surgeons.
“The problem is they are so close to each other — within less than an inch, that is easy to misdiagnose and mistreat,” said Missirian.
He said most acute low back pain, about 60 to 70 percent of the time, gets better within six weeks. But that it’s the people with the chronic pain that need treatment, and that conservative treatments work for most patients.
“About two-thirds of patients get better with physical therapy, rehabilitation, activity modification and medication; and the ones that don’t respond are in the minority, which is about one-third and those are the ones who will need further treatment such as the injections, or more rehab, and ultimately surgery in the cases where they don’t respond.”
Consequence of misdiagnosis
The consequence of misdiagnosis could mean a patient having to undergo a surgery off their lumbar spine, like a disc surgery or a fusion, and ending up with screws in the back and rods and plates — and the pain doesn’t go away.
“You have what is called a failed back syndrome — someone with chronic back pain who has had multiple surgeries who still complains of back pain.”
According to the doctor, there is an overlap of symptoms between someone with a herniated disc, someone with a facet pain, which are the joints that connect the lumbar spine together as well as the remainder of the spine, and hip arthritis and sacroiliac joint dysfunction which has to be differentiated.
He said a patient could get referred pain that mimics.
“With facet pain, people get lower back pain that can radiate all the way down the back of the thigh to the knee. With a herniated disc, someone can get lower back pain radiating to the buttocks, down to the back of the thigh, down the calf and into the foot. With sacroiliac pain someone can get lower back pain, radiating from the back of the buttocks, down the thigh, down the calf into the foot sometimes as well. And with sacroiliac pain, you can get groin pain which mimics hip arthritis, so there are ways to differentiate these.”
In most instances, he said patients will point to the back of their pelvis to show where the pain is, in the area called the posterior superior iliac spine, which is the back of the pelvis. He said the majority of the time it is the point of maximum pain and is about half-an-inch within that posterior superior iliac spine.
“Patients will often complain of difficulty with prolonged sitting, prolonged walking, transitional movements like rolling over in bed, or going from a sitting to a standing position, or the lying down to the standing position — these are common complaints.”
He said physicians have five specific tests that they do, which are a good diagnostic tool to differentiate the sacroiliac joint. He said a positive three-out-of-five result is ascertained, then they can be certain that the pain is from the joint. They would then do a diagnostic injection under fluoroscopic control in which a numbing medication is injected into the joint and the patient re-examined 15 minutes after injection to see if there is any pain left along the posterior superior iliac spine.
Medical practitioners redo the five tests again, to see if they feels better, and how much better they feel.
“If the patient states that they feel 50, 60, 70, 80 percent better, or sometimes 90 or 100 percent better, that gives you a pretty good diagnosis that the problem is coming in large part from the sacroiliac joint. With chronic low back pain, about 25 to 35 percent of most patients, that is most of their pain. And if they already had back fusion, 42 to 45 percent from the time it is coming from the sacroiliac joint.”
The orthopedic surgeon says a correct diagnosis means a person will not have the wrong surgery for their back.
He says treatment for sacroiliac joint is different, and is effective if a person has the right diagnosis, and does the correct treatment.
Non-surgical treatment options include oral pain medications, SI belting, physical therapy and therapeutic SI joint injections. If a patient is experiencing ongoing or recurring pain, Missirian said this may be due to a disruption of the sacroiliac ligaments causing instability of the joint or damage to the articular cartilage, which causes arthritis. Additionally, for chronic postpartum pelvic pain lasting more than six months due to SI joint dysfunction, fusion of the Sacroiliac joint may be an option.
Patients’ refractory to non-surgical management, he said, may benefit from a minimally invasive surgical fusion of the SI joint. The implant used at Vital Orthopedic and Spine Institute has produced unparalleled clinical results and has demonstrated that treatment improved pain, patient function and quality of life.
Missirian can be reached at 1-877-848-2507 or visit us at www.vitalortho.com.