SI joint pain

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facets

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I have a patient, 55 year old female with severe SI joint pain on the left side. No specific trauma except perhaps being bumped on the thigh by a large dog running by. This has been going on for 6 months and steadily gotten worse. Plain films, MRIs show moderate arthritis of the facets and SI joints, hips clear, right side is just is bad on x ray but no pain there. Moving from sitting to standing is excruciating, as is getting out of bed. She is ordinarily athletic, no interest in disability and this has totally devestated her quality of life and she is desperate for relief. "Sucking it up" is not an option, this is a US Army veteran who can take a needle without a flinch. Physical therapy, chiropractic, every topical agent, stretching, lyrica, has been tried. NSAID are contraindicated due to a GI bleed. SI joint injections, facet injections, radiofrequency at L4 L5 S1 S2 S3 has not helped. The pain is in the buttock and lateral thigh, severe gripping vise like with a severe stabbing pain when motion is attempted. PRP is planned next. Small doses of opoids do work, no addiction history but she does not like the feeling that she gets from narcotics, does not like the "high" feeling and is asking about a pump her reasoning being that this should deliver pain relief without making her feel like she is drugged. She has also asked about a SCS but this does not appear to be radicular. She will do anything to be relieved of this and is and is willing to pay cash if the insurance company will not cover the treatment. She is really desperate. Any suggestions?
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Try supartz series x 3, one week apart. I have had success with this when steroid has failed.
 
may be a good butrans or low dose nucynta patient as well.
 
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facets said:
I have a patient, 55 year old female with severe SI joint pain on the left side. No specific trauma except perhaps being bumped on the thigh by a large dog running by. This has been going on for 6 months and steadily gotten worse. Plain films, MRIs show moderate arthritis of the facets and SI joints, hips clear, right side is just is bad on x ray but no pain there. Moving from sitting to standing is excruciating, as is getting out of bed. She is ordinarily athletic, no interest in disability and this has totally devestated her quality of life and she is desperate for relief. "Sucking it up" is not an option, this is a US Army veteran who can take a needle without a flinch. Physical therapy, chiropractic, every topical agent, stretching, lyrica, has been tried. NSAID are contraindicated due to a GI bleed. SI joint injections, facet injections, radiofrequency at L4 L5 S1 S2 S3 has not helped. The pain is in the buttock and lateral thigh, severe gripping vise like with a severe stabbing pain when motion is attempted. PRP is planned next. Small doses of opoids do work, no addiction history but she does not like the feeling that she gets from narcotics, does not like the "high" feeling and is asking about a pump her reasoning being that this should deliver pain relief without making her feel like she is drugged. She has also asked about a SCS but this does not appear to be radicular. She will do anything to be relieved of this and is and is willing to pay cash if the insurance company will not cover the treatment. She is really desperate. Any suggestions?
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gluteus medius tendinopathy? Ultrasound guided evaluation and treatment. PRP sounds like a decent option. Hows the hip? Any groin pain?
 
Possible gluteus tendinopathy or iliopsoas bursitis. Did she get temporary relief with the local during the SI joint injection? If so, then SI joint fusion is a possibility as the RF only addresses the dorsal innervation and not the ventral innervation. If not, try iliopsoas bursa steroid injection or TPI into painful region along with stretching exercises.
 
Women in this age group get gluteus medius origin tendonopathy and bursitis s LOT. I don't know why. I suspect wider pelvis and aging weakening tendons unable to bear the load sny longer. I've had good success with PRP if the SIJ if needed, as long as there is hypermobility.
 
Thanks for the responses so far. She has a good ROM of the hip and the hip joint is clear on X Ray. No tenderness over the medial tendon the pain is all in the buttock and outer thigh. I was thinking low dose Nucynta or butrans also because the opoids do work but she is active and does not want to feel drugged. Would a muscle relaxent help with the severe gripping pain she gets when she moves? I have heard some PMR docs (I'm anesthesia based) say low dose Klonopin works for muscle pain like the gripping pain she is describing but she does not like to feel drugged and is on low dose opoids and there would be the opoid /benzo mix problem. A pump with baclofen/ Morphine? She will do anything
 
piriformis syndrome for buttock pain?

i do use low dose Nucynta ER - although patients even on this low a dose of 50 mg bid will complain of opioid related side effects such as sedation.

have you thought about tramadol ER?

id still have her see a pain psychologist for cognitive therapy. explore all options. self-hypnosis, biofeedback...
 
I still dont see the harm in ultrasound guided eval and treatment with a peritendon injection of glut med tendon if indicated. You can try ryzolt or lorzone (to try to mitigate sedative side effects). I wouldnt pump this person until all else is tried.
 
She is on Cymbalta and had a seizure from tramadol so that is out. Have you had good results with Lorzone?
 
Ducttape said:
piriformis syndrome for buttock pain?
.
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That's kinda what I was thinking.



Just had a guy cone to me from neurosurg with buttock pain radiating down the leg (little if any back pain). Had a cyst pushing on L5 removed, had numerous hip studies/injections, had ESIs/TFs, with no relief. The guy was suffering bad, 9 months of severe pain. He wanted no part of daily opiates. Did a piriformis injection and got 100% relief and still 70% relief of pain at 2 months.

The guy is going around telling people I performed a "miracle" on him. He's off all opiates.
 
facets said:
Thanks for the responses so far. She has a good ROM of the hip and the hip joint is clear on X Ray. No tenderness over the medial tendon the pain is all in the buttock and outer thigh. I was thinking low dose Nucynta or butrans also because the opoids do work but she is active and does not want to feel drugged. Would a muscle relaxent help with the severe gripping pain she gets when she moves? I have heard some PMR docs (I'm anesthesia based) say low dose Klonopin works for muscle pain like the gripping pain she is describing but she does not like to feel drugged and is on low dose opoids and there would be the opoid /benzo mix problem. A pump with baclofen/ Morphine? She will do anything
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When you say buttock and outer thigh pain I think either piriformis, gluteus medius, referred disk or radicular pain. I typically think of SIJ pain as being worse over the sacral sulcus with referral into the posterior hip/buttock region but the worst pain should be over the sacral sulcus
 
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1-Agree with US guided injection/eval of glut med/piriformis
2-Recommend reeval by a physical therapist with post-graduate training in manipulation. Check out AOOMPT or NAIOMPT for someone with that level of training in your area.
3- Recommend repeat diagnostic left L5, S1-S3 block. If this is produces significant relief, then your previous SIJ ablation didn't take, which is common given the variable depth and path of SIJ innervation. What RF technique was used? Synergy? Simplicity? Bipolar lesions? Repeat RF with different technique, particularly synergy, may be helpful.
4-IF 1-3 fail then I would consider SIJ ligament PRP and SIJ joint synvisc injection.
5- IF 1-4 failed then I would consider referral for SIJ fusion for this patient.
 
Agree with above except before fusion you can try peripheral stim with 2 octads. I have experience with 2 so far when nothing else worked with great results.
 
She has arthritic facets are they sagitally oriented? Does she have a degen. spondy at L4-5, I would check lateral flexion extension views looking for hypermobility causing radicular irritation when she moves ("sitting to standing") Sometimes spondy's are not seen until you get x-rays because some people will reduce when supine for there MRI scan and arthiritc facets predispose.

Any significant neuroforaminal stenosis? Any numbness?

Poorly localizable buttock pain with thigh pain first thing I think is radicular irritation.

But agree with all other posts as well with there respective differential diagnoses
 
NEA said:
Agree with above except before fusion you can try peripheral stim with 2 octads. I have experience with 2 so far when nothing else worked with great results.
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How do you get that paid for now that field stim isn't paid for?

Do you call it laminectomy syndrome (in case of L5-S1 fusion)?
Just code as SIJ pain otherwise? Does medicare pay for that?

Do you lay the octads paralleling the SIJ on either side or do you place them across the joint?
 
Im telling you guys, if you think it is SI, consider supartz/viscosupplementation. Insurance will not pay for supartz for SI injections, so you need to have samples on hand from your rep or write script for patient and they have to pay. Worth a consideration if you are sure its SI and your other SI interventions have failed. If its gluteus medius tendonopathy or ischial bursitis, by all means treat that. But I can safely say I have had 15-20 patients over the past several years do quite well.
 
She has had intermittent numbness in the leg since the radiofrequency. No stenosis was noted on MRI just moderate arthritis of the facets. She got extreme anxiety with the steroids (bad enough to medicate with Ativan) used for the RF and also has premature osteoporosis and early diabetes so steroids should be avoided. She will pay for PRP, supartz and even a pump/stimulator, the pain is really bad,
 
consider sending her for fusion of SI joint if all else fails
 
facets said:
She has had intermittent numbness in the leg since the radiofrequency. No stenosis was noted on MRI just moderate arthritis of the facets. She got extreme anxiety with the steroids (bad enough to medicate with Ativan) used for the RF and also has premature osteoporosis and early diabetes so steroids should be avoided. She will pay for PRP, supartz and even a pump/stimulator, the pain is really bad,
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I'd pull back from aggressive interventions. Let's delve into her Psychological and Psychiatric background. But you can put the US to her head while asking about the former husband/boyfriend/crazy uncle in clown suit.

Intermittent numbness inleg since RF is not organic pathology. Nonstandard responses to standard treatments needs further assessment.

1. Willing to pay cash.
2. Prior military female (not pointing fingers here)
3. Discordant imaging for anything but age appropriate findings.
4. Unresponsive to standard treatments
5. SCS in a runner? And I thought positional stim was bad.

GO back over the MRI and look around the spine, post pics of axial cuts at L4-5.
 
lobelsteve said:
I'd pull back from aggressive interventions. Let's delve into her Psychological and Psychiatric background.
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You aren't going to fix this with a needle or scapel. You are treating a psych problem here.
 
No she absolutely is not nuts, no history of abuse and not all women who have served in the military are whack jobs. You guys really have to work on assuming that all women without easy to define patholgy are nuts, you sound like Sigmond Freud attributing hysteria to a "wandering womb" How many times have you found facet syndrome and SI joint pain in joints that are "normal for age" and how many times have you seen RF fail in the SI joints? She is willing to pay cash because this is ruining her active life style and she has the money to get a solution besides being gorked for the rest of her life. The numbness is primarily over the skin of the back which you would expect, but some is in the leg which may be coincidental to a missed stenosis. I swore I would have recieved different suggestions if I identified her as male. Next you guys will be suggesting a vibrator. You really need to work on your sexism
 
facets said:
No she absolutely is not nuts, no history of abuse and not all women who have served in the military are whack jobs. You guys really have to work on assuming that all women without easy to define patholgy are nuts, you sound like Sigmond Freud attributing hysteria to a "wandering womb" How many times have you found facet syndrome and SI joint pain in joints that are "normal for age" and how many times have you seen RF fail in the SI joints? She is willing to pay cash because this is ruining her active life style and she has the money to get a solution besides being gorked for the rest of her life. The numbness is primarily over the skin of the back which you would expect, but some is in the leg which may be coincidental to a missed stenosis. I swore I would have recieved different suggestions if I identified her as male. Next you guys will be suggesting a vibrator. You really need to work on your sexism
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I'm criticizing YOU, not her. Atraumatic, idiopathic, disabling, ass pain. That's not something any of us can fix but you can get rich trying.

Don't you ever have reason to pause when a patient's symptoms vastly exceed any identifyable pathology? Well you've reached that point here.
 
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This case sounds familiar. She has a marked curvature to the same side at L4-5 I bet...and the RF missed it because it was L5-S1 and below. Disk and facet at L4-5 refers to the lateral buttock/hip. The hip has pain with ROM I suspect as well. Chronic pain has her sensitive to the post-RF neuritis. She is not nuts. Quite highly functioning, actually.
 
Yes, you and I have seen the same person. Care to give US guided tramell for the facets and supartz for the SI joint? I'll send her back to you. I agree the SCS/ pump would be a final act of desperation but you know how miserable she is.
 
facets said:
No she absolutely is not nuts, no history of abuse and not all women who have served in the military are whack jobs. You guys really have to work on assuming that all women without easy to define patholgy are nuts, you sound like Sigmond Freud attributing hysteria to a "wandering womb" How many times have you found facet syndrome and SI joint pain in joints that are "normal for age" and how many times have you seen RF fail in the SI joints? She is willing to pay cash because this is ruining her active life style and she has the money to get a solution besides being gorked for the rest of her life. The numbness is primarily over the skin of the back which you would expect, but some is in the leg which may be coincidental to a missed stenosis. I swore I would have recieved different suggestions if I identified her as male. Next you guys will be suggesting a vibrator. You really need to work on your sexism
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lobelsteve's overall direction should not be discounted on any patient with chronic pain (well, maybe the way he presented it ahould). it seems like you are focused purely on a cure, when she has tried multiple procedures, injections, medications, et al for her chronic pain without benefit. you are now delving into procedures with little solid evidence-based medicine to support them, and at least 2 seemingly excellent pain physicians with years of solid clinical experience have not found a simple and/or reasonable explanation (i was reminded of Ockham's Razor today in an audiobook.)

assisting her in pain management should also include behavioral medicine, cognitive therapy, coping mechanisms, etc in addition to sticking more needles or probes or catheters into her back. this is not to say that she is nuts or has an underlying psychiatric issue.


your ultimate best intervention may be to help her come to the realization that she can still have a high quality of life, even if it is not as active as it was prior to when her pain started.
 
The way presented by Lobel was sexist as Hel%, "If I can't figure it out in 2 minutes, she must be crazy after all she is a female Army veteran who does not want drugs and is willing to pay cash for treatment." That remark never would have been made in regard to a male patient.
To give you some degree of the pain she goes through, imagine your testicles being squeezed in a vise, then have someone ask you about you crazy uncle (who didn't exist) or "assisting her in pain management including behavioral medicine, cognitive therapy, coping mechanisms, etc" by the time her fist comes off your face I'm sure YOU would have a psychiatric diagnosis thereby "proving the commentaters above correct, she is crazy"
PMR -she is scheduled for PRP this week if that does not work then I will send her back to you for the supartz in the SI and some tramell in the facets, maybe some tramell into the gluteus med. with that fancy us gizmo of yours :)
 
bedrock said:
How do you get that paid for now that field stim isn't paid for?

Do you call it laminectomy syndrome (in case of L5-S1 fusion)?
Just code as SIJ pain otherwise? Does medicare pay for that?

Do you lay the octads paralleling the SIJ on either side or do you place them across the joint?
Click to expand...

Well both of those cases were workmen's comp so payment wasn't an issue and I laid the octads parallel to the joint line on either side.
 
facets said:
She is on Cymbalta and had a seizure from tramadol so that is out. Have you had good results with Lorzone?
Click to expand...

Lorzone works well. Ive used it on a few patients without underlying psych issues that is :naughty:
 
facets said:
To give you some degree of the pain she goes through, imagine your testicles being squeezed in a vise, then have someone ask you about you crazy uncle (who didn't exist) or "assisting her in pain management including behavioral medicine, cognitive therapy, coping mechanisms, etc" by the time her fist comes off your face I'm sure YOU would have a psychiatric diagnosis thereby "proving the commentaters above correct, she is crazy"
Click to expand...


so now you are trying to legitimize her pain. tell me, what makes her pain any different or more real than the pain of someone with a failed back syndrome, or CRPS after minimal trauma, or idiopathic neuropathy?

do you not tell these other patients about bmed, cognitive therapy, learning coping techniques? how is this patient different, or have you developed some level of attachment to this patient above and beyond what would be expected of a traditional doctor-patient relationship?

or are you just a needle jockey and care only about what shot/injection/procedure will make the patient happy? in which case....
 
facets said:
To give you some degree of the pain she goes through, imagine your testicles being squeezed in a vise, then have someone ask you about you crazy uncle (who didn't exist) or "assisting her in pain management including behavioral medicine, cognitive therapy, coping mechanisms, etc" by the time her fist comes off your face I'm sure YOU would have a psychiatric diagnosis thereby "proving the commentaters above correct, she is crazy"
Click to expand...

Too many of your posts sound like you are an enabler.
 
facets said:
The way presented by Lobel was sexist as Hel%, "If I can't figure it out in 2 minutes, she must be crazy after all she is a female Army veteran who does not want drugs and is willing to pay cash for treatment." That remark never would have been made in regard to a male patient.
To give you some degree of the pain she goes through, imagine your testicles being squeezed in a vise, then have someone ask you about you crazy uncle (who didn't exist) or "assisting her in pain management including behavioral medicine, cognitive therapy, coping mechanisms, etc" by the time her fist comes off your face I'm sure YOU would have a psychiatric diagnosis thereby "proving the commentaters above correct, she is crazy"
PMR -she is scheduled for PRP this week if that does not work then I will send her back to you for the supartz in the SI and some tramell in the facets, maybe some tramell into the gluteus med. with that fancy us gizmo of yours :)
Click to expand...

Man. Woman. Child. Doesn't matter. Keep plugging away with those needles. I'm sure you'll cure her. Maybe provide more history. Or did you not take one as you were too busy billing her insurance and ramming her with needles? I enjoy how much you are in touch with her pain. But since you haven't made her better yet and you were asking for advice....try a caudal. Or three.
 
lobelsteve said:
Man. Woman. Child. Doesn't matter. Keep plugging away with those needles. I'm sure you'll cure her. Maybe provide more history. Or did you not take one as you were too busy billing her insurance and ramming her with needles? I enjoy how much you are in touch with her pain. But since you haven't made her better yet and you were asking for advice....try a caudal. Or three.
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I'm pretty sure she wasn't doing the ramming.
 
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In our field, EVERYONE with chronic pain is crazy until proven otherwise.
 
101N said:
Including a lot of us who purport to treat it.
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Unfortunately, our job often requires attempting to treat the physical manifestation of psychiatric illness. I cant tell you how many times I see the commercial for cymbalta in my head while Im listening to these people comlain..."where does depression hurt..."
 
Dr. Ice said:
Unfortunately, our job often requires attempting to treat the physical manifestation of psychiatric illness. I cant tell you how many times I see the commercial for cymbalta in my head while Im listening to these people comlain..."where does depression hurt..."
Click to expand...

I've been around the block long enough to know this. But, some of us continue to fatten their walets while doing the job.

It's not just a matter of having the balls to call the crazy when you see it, but also turning away the money that comes with continuing the chrade.
 
The cymbalta has not done anything for the pain but the commercial says it helps :) I forget to mention that her hobby is training big personal protection dogs (red flag for Steve, she's really crazy) so large dogs have a tendency to run past her occasionally hitting her in the thigh, sometimes knocking her over. She THINKs what happened is her thigh was raised to correct a dog and the dog rammed her thigh out and back and jammed the SI joint. But this was type of thing was an everyday event until her pain stopped her from this hobby so an exact history is difficult. That is one of the reasons I have discounted physical manifestation of neurosis, another is she has absolutely no secondary gain issues and does not have widespread achy whiney FMS pain. Just pain in the left side of the butt, down the outer thigh, but primarily in the "butt dimple".
So she is scheduled for PRP this week.I will consider low dose Nucynta or butrans. If that does not do it PMRMD you are IT ( to the folks on here we are in the same town, I am anesthesia based, he is PMR so we exchange patients) you have that high tech US machine and maybe she would benefit from gluteus medius and iliopsoas injections, piriformis syndrome is a good thought also. Supartz into the SI joint would be a good option. I'll leave the lorzone up to you (never even heard of it) Maybe she should stop training dogs for good, duh, why don't YOU tell her that.
If everybody is in agreement that a pump /stim is not appropriate I will nix that idea and find some meds to help her without making her feel gorked.
Thanks everyone for your input. If none of the above helps I'll send her to Georgia so Steve can talk to her about her crazy uncle :) Steve I ordinarily respect your views but I believe that you are jaded from being around too many whiney southern belles
 
facets said:
The cymbalta has not done anything for the pain but the commercial says it helps :) I forget to mention that her hobby is training big personal protection dogs (red flag for Steve, she's really crazy) so large dogs have a tendency to run past her occasionally hitting her in the thigh, sometimes knocking her over. She THINKs what happened is her thigh was raised to correct a dog and the dog rammed her thigh out and back and jammed the SI joint. But this was type of thing was an everyday event until her pain stopped her from this hobby so an exact history is difficult. That is one of the reasons I have discounted physical manifestation of neurosis, another is she has absolutely no secondary gain issues and does not have widespread achy whiney FMS pain. Just pain in the left side of the butt, down the outer thigh, but primarily in the "butt dimple".
So she is scheduled for PRP this week.I will consider low dose Nucynta or butrans. If that does not do it PMRMD you are IT ( to the folks on here we are in the same town, I am anesthesia based, he is PMR so we exchange patients) you have that high tech US machine and maybe she would benefit from gluteus medius and iliopsoas injections, piriformis syndrome is a good thought also. Supartz into the SI joint would be a good option. I'll leave the lorzone up to you (never even heard of it) Maybe she should stop training dogs for good, duh, why don't YOU tell her that.
If everybody is in agreement that a pump /stim is not appropriate I will nix that idea and find some meds to help her without making her feel gorked.
Thanks everyone for your input. If none of the above helps I'll send her to Georgia so Steve can talk to her about her crazy uncle :) Steve I ordinarily respect your views but I believe that you are jaded from being around too many whiney southern belles
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You are just way off base. THe pathology on imaging is nil, just age appropriate. THe pain is way out of proportion to the alleged/reported injury. You just have the wrong diagnosis and are treating it overly aggressively without knowing what you are treating. How about CT abd/pelvis and some blood work to ty and get the right diagnosis first. Just cause you are wrong, does not mean she is crazy, but your responses to the posts here makes me question your practice. You selectively quoted me for something I never said. And you keep harping about how much pain she is in- so find out why, stop treating and begin diagnosing. Or turf to PMR so he can get you the right answer. But injections are not the answer to all cases, and especially this one.
 
Its so crazy but so far today I have already seen two women in their 40s, athletic, runners with buttock pain, minimal axial low back discomfort with occasional radiation into the hamstring/thing. Flex/ext xrays normal. Getting MRI lumbar spine...uncanny!
 
Dr. Ice said:
Its so crazy but so far today I have already seen two women in their 40s, athletic, runners with buttock pain, minimal axial low back discomfort with occasional radiation into the hamstring/thing. Flex/ext xrays normal. Getting MRI lumbar spine...uncanny!
Click to expand...

runners with buttock pain = poor stride with a heel-strike gait, rather than landing on mid-foot or fore-foot. this is especially if they have pain at the ischial tubes /insertion of the hamstrings.

they need to use minimalist shoes or lean forward when they run.

if they are a bit chunky, the glut med tendonitis is more likely.
 
Interesting..

So if she's a high functioning logical person, pain should be curable with the right treatment.

If she's a hysterical female, pain is forever and we need to teach her to cope and manage her chronic pain.
 
Jitter Bug said:
Interesting..

So if she's a high functioning logical person, pain should be curable with the right treatment.

If she's a hysterical female, pain is forever and we need to teach her to cope and manage her chronic pain.
Click to expand...

Um...well...yes :laugh:

We all do our due dilligence to treat what we can though...of course...
 
Dr. Ice said:
Um...well...yes :laugh:

We all do our due dilligence to treat what we can though...of course...
Click to expand...

Ha Ha. My point is that sometimes even rational intelligent patients cannot be cured, and then we have to focus treatment on coping strategies rather than going too far down the interventional path. In this case I think there are a few good ideas that seem reasonable but I wouldn't drag this on for too long. Not all pains have an organic cause.
 
Jitter Bug said:
Interesting..

So if she's a high functioning logical person, pain should be curable with the right treatment.

If she's a hysterical female, pain is forever and we need to teach her to cope and manage her chronic pain.
Click to expand...

Did you do a fellowship?
99% of chronic pain is central.
And 1% inspiration...

Invention, my dear friends, is 93% perspiration, 6% electricity, 4% evaporation, and 2% butterscotch ripple.
 
Jitter Bug said:
Interesting..

So if she's a high functioning logical person, pain should be curable with the right treatment.

If she's a hysterical female, pain is forever and we need to teach her to cope and manage her chronic pain.
Click to expand...

Ding ding ding. We have a winner.
 
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