"Overlooked" Back Pain Has New Minimally Invasive Surgical Option

UH Clinical Update | November 2023

People with chronic lower back pain who’ve tried medication, physical therapy and steroid injections, without relief, have a new minimally invasive surgical option from the UH Spine Institute.

Dustin Donnelly, MD, PhD

The I-Fuse implant system, now available at joint venture Southwest General, addresses sacroiliac joint (SI) dysfunction. Studies show that the SI joint may be the source of low back pain in 15 to 30 percent of patients, but it can be overlooked in the complexity of making a diagnosis.

Reducing pain and frustration: UH spine surgeon Dustin Donnelly, MD,PhD, is trained on the new minimally invasive surgical system and has many SI dysfunction patients in his practice. He can attest to the significant pain and frustration they feel.

“SI joint dysfunction patients can often point directly to a single spot just below the belt and to the right or left of midline near the dimple as the primary location of pain,” he says. “They can present with sciatica-like symptoms, or have pelvis, buttock, hip or groin pain. They have problems with prolonged sitting on the affected side, and may have trouble walking, getting up from a chair or have disturbed sleep patterns. To further complicate things, people can struggle to establish a diagnosis for years and years and years, and they go back for epidural steroid injections. They do physical therapy time and time again, but it's not tailored to that.

People often just give up because they're not thinking about this as a diagnostic possibility.”

Who can benefit: Dr. Donnelly names three broad groups of patients who can benefit from minimally invasive SI joint fusion surgery:

• Patients with unexplained pain in the back of their hip after undergoing conservative therapy with medications, physical therapy and injections
• Patients with scoliosis and also hip pain: “Because of the biomechanics, they tend to present with SI dysfunction,” he says.  In some cases, he adds, a scoliosis patient facing an extensive surgery with a six-month recovery can instead have a minimally invasive SI fusion to address their pain and be home the same day.
• Patients who’ve had multi-level lumbar fusions – removal of the disc and fusion of the lower vertebrae with a bone graft to achieve stability of the spinal segment and eliminate motion. “With any fusion, you have to worry about adjacent segment disease, and people usually look higher up at the next level above, but you have to look at the level below,” Dr. Donnelly says. “The next mobile segment is actually the sacroiliac joint. Their back pain's gone. Their leg pain's gone. But they got this new pain in the back of their hip. Most of the time I can just refer them out for an injection. But sometimes, if that lingers, then we can do a minimally invasive fusion.”

What patients can expect: Minimally invasive SI joint fusion surgery is usually performed under general anesthesia, but it is an outpatient, same-day discharge procedure. Before patients get to that point, however, they must complete several steps.

“It's a lot of work getting them ready for surgery,” Dr. Donnelly says. “You have to have two sets of injections, six weeks apart. You have to have physical therapy, ideally targeting the SI joint, and you need to have shown by imaging of the lumbar spine and the pelvis that there's no other reason that they could be having pain in the back of the hip. But once you establish all those diagnostic checks, you can be very, very confident. I've never done an SI joint fusion where the patient didn't feel better.”

Increasing awareness: Dr. Donnelly says he hopes the new I-Fuse implant system available to UH patients will increase awareness of SI dysfunction as a possible diagnosis – among both patients and providers.

“If patients have chronic low back pain that doesn't really seem to be over the midline, if it tends to be more out to the side, or it's on both sides but not in the midline, don't discount the fact that it could be SI dysfunction,” he says.