“We can achieve long-term pain relief”

Low back pain can often be traced back to a pathology of the sacroiliac joint (SI joint). The treatment is all about stabilizing and relieving the joint. Spine expert Prof. Dr. Dr. Nikolai Rainov, Specialist in Neurosurgery and Special Pain Therapy at MVZ Wirbelsäulenzentrum Munich-Taufkirchen spine center in Germany, explains his approach to conservative treatment and the minimally invasive fusion method he uses for surgical cases.

“Due to its non-specific symptoms and practitioners’ excessive focus on the spine, the SI joint used to be an unpopular field for a long time. But given the number of patients with SI joint problems visiting my office, it’s definitely relevant,” says Prof. Nikolai Rainov describing the situation. The two sacroiliac joints that connect the alae of the ilium with the sacral bone on the right and left distribute the forces exerted on the pelvis and relieve the lumbosacral junction. With only a few degrees of mobility (nutation), the narrow joint spaces feature irregular surfaces which can cause painful rubbing or tilting/blockages.

This can have various causes: degenerative changes in the cartilage layer based on age-related wear, trauma or incorrect posture. If the spinal function is impaired, for example because of spinal fusions, pressure on the SI joint¹ increases automatically. Too much mobility of the joint can be another reason. This happens particularly frequently in women several years after one or more natural births, where the pelvis has been severely widened. That is why there are three to five times more women than men among SI joint patients.

“Patients can never work out themselves where their problems are coming from,” Prof. Rainov explains. “And depending on the physician’s expertise, it can often be a long journey to finding the correct diagnosis because other causes, such as problems with the intervertebral disks or sciatica, are initially deemed responsible for the ongoing symptoms. That’s why my diagnostic process always starts with a thorough clinical examination.”

Using functional and challenge tests where the expert applies pressure on the joint, he narrows down his suspicions. Imaging, such as X-ray or MRI scans, cannot give an indication of an instability and, because of the extremely small joint space, only provide limited information regarding osteoarthritis. This is the reason why Prof. Rainov first carries out an infiltration as a functional test. “If the pain recurs repeatedly after one to two days, this is a clear indication of an SI joint problem,” the spine expert explains.

25 percent of back pain originates in the sacroiliac joints²

Conservative internal and external stabilization

There are several options to treat pain. Prof. Rainov believes it is important to explore all conservative methods first before considering surgery. In addition to infiltration, manual therapy and pharmaceutical treatment, tailored training and physiotherapy are central elements of the treatment plan to increase internal muscular stabilization of the pelvis. The neurosurgeon also believes in external stabilization using pelvic braces, preferring especially the SacroLoc. “A pelvic brace is always part of the treatment regime. Once we have given patients our prescription, they will be provided with advice and their product in the nearby medical retail store.” If the pain gets better straight away from wearing the brace, this is another confirmation of the diagnosed instability. “It is these patients in particular who benefit from a brace. We observe that relieving the sacroiliac joints during sitting, but also during all types of physical strain, can lead to pain reduction,” Prof. Rainov reports.

Proven effectiveness of the SacroLoc

The SacroLoc surrounds the pelvis with elastic mesh material. Tightening the straps creates circular compression around the pelvic girdle which straightens the sacral bone. This reduces the nutation movement in the SI joint and has been proven to relieve the ligaments. In two studies performed by N. Hammer and F. Sichting et al. at Leipzig University and Chemnitz Technical University – internationally published in 2014 and 2015³ – the effectiveness of the brace on the SI joints was confirmed. The straps are also used for the precise positioning of the viscoelastic pads on the sacroiliac joints. During everyday movements, the pads’ frictional nubs exert a targeted massage on trigger points and on the insertions of the stabilizing ligaments and muscles. These neuromuscular and myoligamentous effects were empirically proven by Soisson et al. in 2015⁴. Patients who had worn the SacroLoc for six weeks reported reduced pain, loosened tension and improved mobility. This perception was substantiated by a measurement that confirmed gait improvement with a higher cadence (number of steps per minute) and step speed compared with the control group.

Prof. Rainov has been using the SacroLoc for about a year now: “I wasn’t aware of any brace specifically designed for the SI joint before this one. The SacroLoc is also very lightweight, and we can see that patients like to wear it because of that.” Equipped with this brace, patients undergo SI joint-specific physiotherapy for about four to six weeks, with the main goal of reducing the pain when sitting or walking to a very low level. Depending on the intensity of the discomfort and the activity level of the affected patient, this can be achieved successfully – at least temporarily.

SI joint fusion as a helpful option

If the symptoms cannot be managed in the long term using pain medication, physiotherapy, external stabilization and infiltration, Prof. Rainov will also consider surgery, initially for one joint. “It used to be common to immobilize the joint in one major surgery. The disadvantage is that quite a lot of soft tissue is damaged and it will take a long time to heal. These days, we perform minimally invasive fusion of the SI joint,” Prof. Rainov explains. During a procedure lasting about half an hour, titanium implants are inserted laterally into the sacral bone via the ala of the ilium. This approach results in quick fusion and therefore immediate immobilization of the SI joint.

“We perform surgery only on about one of ten patients who come to see us for persistent SI joint problems. But in 95 percent of these cases, the outcome is excellent,” Prof. Rainov emphasizes. MVZ Wirbelsäulenzentrum Munich-Taufkirchen spine center offers its patients a holistic infrastructure. Its clients not only include national but also international patients who cannot have repeated multiple appointments simply because of the long journeys. That is why the experts must offer quick and comprehensive care. In addition to orthopedists, neurologists and neurosurgeons, the center also features imaging equipment as well as a clinic for invasive procedures, such as imaging-guided infiltration or CT scans, to ensure an efficient patient journey. This comprehensive treatment is complemented by a medical supply retailer nearby that provides the required medical products in coordination with the treating physicians. Prof. Rainov: “Patients visit us with a problem, and we make sure the plan they receive to solve it will fit their lifestyle. Our consultation is centered the patient’s needs and perspective, and we first explore all conservative options. Only when the required quality of life can no longer be achieved with this approach will the patient decide whether they want surgery.”

“Patients visit us with a problem, and the plan they receive to solve it will always fit their lifestyle.”

Prof. Dr. Dr. Nikolai Rainov

Minimally invasive procedures as a game changer

For surgical procedures, Prof. Rainov uses a tried-and-tested, evidence-based surgical technique using the triangular iFuse 3D® implants provided by SI-BONE. “SI joint problems have always existed. But my experience has been that screw-based joint fusion will eventually loosen again. Fusion using triangular implants has been available for about ten years. The way we’re using the iFuse 3D implants these days is a real game changer. We’ve already been able to successfully treat more than 800 patients with this procedure,” Prof. Rainov points out. During this minimal access surgery, an incision of two to three centimeters is made in the skin to insert three small titanium implants into the ala of the ilium and the sacral bone using the press-fit technique. “The triangular shape prevents twisting and provides immediate rotational stability, which eliminates the cause of the pain,” the neurosurgeon explains. “The grid structure and the porous surface allow the implant to grow into the bone quickly. We have observed macroscopically that bone cells may grow around the implant in all directions, which is why the iFuse 3D implants can also be used in the elderly as well as those suffering from osteoporosis, rheumatism or weak bone stock.” According to the specialist, contraindications mainly include an intolerance to general anesthesia and blood clotting disorders. “Surgery is performed close to major nerves, such as the sciatic nerve, and large blood vessels. The challenge of this procedure is therefore to translate two-dimensional scans into three-dimensional surgery. Special characteristics of the patient’s condition and the soft tissue mass must also be taken into account,” says Prof. Rainov explaining his approach. “My experience and the general feedback of my patients reflect the clinical effectiveness of the iFuse 3D implants evaluated in studies. Even on the day of their procedure, most patients can get up and start mobilization. After a few days, they can get back to their everyday activities.”

Post-operative management

Following the stabilization of one side, the actual SI joint pain will disappear in the majority of patients immediately after the procedure. However, it can take four to six weeks until the pain caused by the surgery reduces. During that time, Prof. Rainov recommends continuing to wear the SacroLoc even after the surgery to provide improved support to the surrounding body tissue. Since the load exerted on the pelvic girdle is appropriately distributed, it is often sufficient to stabilize only one SI joint with implants. About 15 to 25 percent percent of patients will later decide to have the other SI joint fused as well. This may become necessary if the pain shifts or no sufficient long-term effect can be achieved with unilateral stabilization. With the exceptionally low revision rate of 2.64 percent, Professor Rainov puts the chances of success in a nutshell: “It enables us to achieve long-term pain relief.”

SacroLoc: targeted relief

The SacroLoc stabilizes the pelvis and relieves the sacroiliac joints as well as the lumbosacral junction. The brace consists of elastic mesh material and a patented tensioning strap system. Thanks to their dual deflection, the two straps can be used to create a good level of tension around the pelvic girdle. This straightens the sacral bone, which relieves the local ligaments. In addition, the straps precisely position two dorsal pads. The pads massage trigger points during everyday movement and have an effect on the stabilizing ligaments and muscles. This alleviates pain, releases tension, and further enhances the relief provided. The lightweight brace has a narrow, low-profile abdominal fastening and can be worn inconspicuously under outer clothing. You can receive further information from your local Bauerfeind Sales Representative or from International Customer Service, email: export@bauerfeind.com.

iFuse 3D®: secure fusion

iFuse 3D by SI-BONE has been designed specifically for the stabilization and fusion of the sacroiliac joint. In a minimally invasive procedure, the titanium implant creates a secure connection between the alae of the ilium and the sacral bone. The unique triangular prism profile minimizes rotation (more than six times the rotational resistance of a screw) and stabilizes the joint, while the porous surface supports long-term fusion. The grid structure with its 3D-printed trabecular surface mimics the natural trabecular bone and enhances osseointegration. iFuse 3D is available in different sizes, and its design enables bony ingrowth, through-growth and intra-articular fusion. Thanks to the self-harvesting technology, iFuse 3D collects the bone material during the implanting process. The fenestrated structure of the implant body can be pre-packed with the body’s own material or foreign material.
Further information is available at: www.si-bone.de

SI-BONE is a company that has no business or sales relationship whatsoever with Bauerfeind AG. The statements about SI-BONE products and their use in this text were reviewed and approved by SI-BONE. They are the responsibility of SI-BONE.

Images: Bauerfeind, Conny Kurz, SI-Bone

1. Ivanov AA, Kiapour A, Ebraheim NA, Goel V. Lumbar fusion leads to increases in angular motion and stress across sacroiliac joint: a finite element study. Spine (Phila Pa1976). 2009; 34: 162-169. doi: 10.1097/BRS.0b013e3181978ea3 ↩︎
2. Cohen SP. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesth Analg 2005; 101: 1440-1453. ↩︎
3. Sichting F, Rossol J, Soisson O, Klima S, Milani T, Hammer N. Pain Physician. 2014 Jan–Feb; 17 (1): 43–51. Pelvic belt effects on sacroiliac joint ligaments: a computational approach to understand therapeutic effects of pelvic belts. Soisson O, Lube J, Germano A, Hammer K-H, Josten C, Sichting F, Winkler D, Milani T, Hammer N. PLOS ONE10.1371/journal.pone.0116739. Published 17 Mar 2015. Pelvic belt effects on pelvic morphometry, muscle activity and body balance in patients with sacroiliac joint dysfunction. www.plosone.org ↩︎
4. Soisson O, Lube J, Germano A, Hammer K-H, Josten C, Sichting F, et al. (2015) Pelvic Belt Effects on Pelvic Morphometry, Muscle Activity and Body Balance in Patients with Sacroiliac Joint Dysfunction. PLoS ONE 10(3): e0116739. https://doi.org/10.1371/journal.pone.0116739 ↩︎