Buttock Pain After Lumbar Fusion

Fusion of the lumbar spine is commonly performed for low back and leg pain. Pain relief varies from minor to moderate.  Unfortunately  fusion of the lumbar spine can result in complications or the development of a new type of pain.

 EB is a case in point.  EB is a 50y/o patient who underwent two level fusion for severe lower back and leg pain which was refractory to conservative therapy.  While her leg pain improved her lower back pain remained unchanged and she developed new buttock pain which was constant in duration, progressive in nature, localized deep in her buttock with radiations into the posterior thigh.  Physical examination was significant for tenderness over the PSIS and a  positive Patrick’s test. EB  had developed sacroiliac joint dysfunction as a result of her lumbar fusion.

The sacroiliac Joint (SI) is the joint in the bony pelvis between the sacrum and the ilium.  It functions as a major shock absorpter for the spine.  Removal of some of the shock absorbers of the spine puts additional forces and strain on the SI jont leading to pain and dysfunction.

The SI joint, its anatomy, physiology and clinical significance is well documented.

Symptoms: Unilateral pain which if severe enought can refer into hip, groin and down the posterior thigh.

Engineeers have demonstrated increased stresses and motion in SI joint following lumbar fusion.

Katz demonstrated that SI joint dysfunction was a cause of pain in 32% of patients with low back pain after lumbar fusion.

At the Centeno-Schultz Clinic EB underwent x-ray guided injections of the prolotherapy into the joint and supporting ligaments with greater than 75% benefit.   Patients unresponsive to prolotherapy have undergone SI injections with Regenexx SCP, Regenexx SD and Regenexx PL with good success.

Stem Cell Therapy for Sacroiliac Joint Pain

The sacroiliac joint is common source of pain.  It is a cartilaginous joint between the base of the spine (sacrum) and the waist bone (ilium).   

SI joint pain can occur in patients who have undergone lumbar fusion due to the increased biomechanical forces or following trauma. Conservative therapy includes physical therapy, core stabilization, prolotherapy and intra-articular joint injections with low dose cortisone .

BM is a talented athlete who hit a tree after going over a cliff on his snowboard.  He struck his left back and buttock injuring his SI joint.  He underwent extensive therapy directed at both his lumbar spine and SI joint which included PT, chiropractic care, lumbar facet injections, lumbar facet radiofrequency ablation, steroid injection in the SI joint and  40 sessions of prolotherapy without significant relief.

 Surgery was the next option which BM declined.  Instead he opted to undergo the Regenexx procedure which allowed him to use his own mesenchyml stem  cells. The SI joint and associated ligaments were injected with stem cells.  Yesterday, patient returned to clinic, 4 months post stem cell therapy reporting 90% improvement in pain.  He is very excited about the results and is in training for the upcoming session.

Mesenchymal stem cells can differentiate into ligaments, bone, cartilage and tendons.  Stem cell therapy allowed BM to avoid surgery, significantly reduced his pain and to return to his passion.

MISLEADING MRI: The picture does not tell the whole story

In a previous blog, I have discussed the limitations of MRI’s in identifying the source of a given patient’s pain.  A clinical evaluation today illustrates this point.

35y/o athletic patient presented with a 4 year history of lower back pain, constant in duration, 6/10 in severity, progressive in nature, localized in left lower back and buttock area without any radiations into his leg.  Pain which was aching in character was aggravated by prolonged sitting, standing and twisting.

Treatment to date had included massage, chiropractic care, physical therapy, trial of anti-inflammatory agents, narcotics and a surgical evaluation.

Physical examination was significant for tenderness in the left lower spine and buttocks with no neurologic abnormalities.  Direct pressure applied to the mid-buttock was painful.

MRI of the lumbar spine was significant for advanced degeneration of the L5/S1 disc and bone swelling.

The patient was convinced that his pain was arising from the degenerative lumbar disc.  Family members, his primary care physician and surgeon endorsed this view.  The surgeon had recommended lumbar fusion to relieve his pain.

Low back pain can arise from many structures including muscle, ligament, facet, disc and sacro-illac joint (SI). Evaluation to determine the source of the pain had not been performed.  At the Centeno-Schultz Clinic this is achieved by injecting a small volume of local anesthetic under x-ray into a specific targeted tissue.  If the pain is significantly relieved from the injection, the pain generator has been identified and an appropriate treatment plan can be created.  Often without such diagnostic evaluations, the source of a given patient’s pain cannot be established and therefore the patient is at risk for incorrect diagnosis and therapy.

Treatment of Sacroiliac Joint Pain with Prolotherapy

The sacrolilac joint is the joint between the sacrum, the base of the spine, and the ilium of the pelvis.

It can be a common source of pain in patients who have had lumbar fusions and traumatic injuries.

Diagnosis is made by injection of a small amount of local anesthetic into the joint.  Insertion of a needle into the SI Joint can be challenging.  Confirmation of accurate placement is achieved through the injection of contrast which  fills the joint.  This is illustrated below with yellow dashed circle. 

Prolotherapy at the Centeno-Schultz Clinic involves injecting into joint as well as the surrounding ligaments.  A very important ligament for the  succesful treatment of the SI joint pain is the iliolumbar ligament.  The ligament is illustrated in blue.  It attaches to the L5 transverse process.

Maximal results from prolotherapy of the SI joint includes accurate placement of the injectate, as confirmed by contrast, as well as treatment of all ligaments.  This is the standard of care at the Centneo-Schultz Clinic.