By Prue Salasky, email@example.com
6:20 PM EDT, May 3, 2014
They're on top of the world. They feel reborn. They have their lives back. The typical sacroiliac joint fusion patient has suffered debilitating pain for a decade or more, and been subject to numerous procedures and back surgeries.
For those who qualify — and they're a select group — sacroiliac (SI) joint fusion, a 20-minute "minimally invasive" surgery, in which a joint in the pelvis is fused, can offer instant relief from pervasive pain.
"So far, so wonderful," said Judy Thomas, 74, a few days after orthopedic surgeon John Aldridge of Hampton Roads Sports & Orthopaedic Medicine, operated on her right sacroiliac joint at Bon Secours Mary Immaculate Hospital in Newport News.
"Where I used to have constant pain in my back on the right side, it's gone," she reported. Thomas had minimized all activity over the past few years and gave up cooking 15 years ago because she was unable to stand in one place long enough.
"I'm fixed. It's an amazing relief," said Williamsburg resident Susan Carden, 52, a former police officer who found her life turned upside down from constant pain she attributed to years of wearing a gun belt. She had been unable to find a comfortable position, either resting or moving.
Her pet parrots learned to mimic her moaning, she said.
After outpatient surgery last year by TPMG spine specialist Jeff Moore, Carden instantly discovered greater stability, stopped limping, and was able to come off pain meds that had her "in the ozone."
With a genetic history of back problems, she's had multiple surgeries. "It's the first thing I've ever had done to my back that's worked," she said.
Moore and Aldridge are the only two surgeons on the Peninsula to perform the iFuse surgery, a technique and implements that were developed in 2008. Prior to that, the surgery was worse than the complaint, said Dr. Moore, who did his first iFuse surgery four years ago.
"It's a good advancement of technology. It's an outpatient procedure," Moore said. "It works very well for people who have the right diagnosis. It can dramatically change their life."
The problem can be particularly difficult to diagnose as it usually doesn't show up on X-rays or CT scans. Only 15 percent of SI problems are isolated — most have had prior lumbar fusions — and many can be treated without surgery, said Moore.
"You should never find a surgeon who does a lot. It's a very isolated thing." And because it's low-volume and highly technical, requiring a surgeon to manipulate instruments through a tiny incision while following their course on three screens arrayed above the patient, it has not been widely adopted, he said. "It takes a lot of practice."
During the procedure, three titanium rods, between 4 and 7 mm diameter and 30 to 70 mm in length, are used to immobilize the joint and cause bone to grow, or fuse, over six months.
The SI joint, designed to expand during childbirth, has minimal movement, but causes disproportionate pain. It can mimic sciatica, running through the buttocks and down the leg. It's most often diagnosed by patient history in conjunction with a physical exam and an injection to test for pain relief.
For Thomas, the injection provided instant, short-term relief. "I could have been queen of the prom. There's my pot of gold," she said.
The surgeon was running late. Two representatives of SI-Bone, the iFuse system, paced the hall with a plexiglass model of a pelvis. It showed where the three rods are placed through the sacroiliac joint. Stuart Lackey and Mike Francesca chorused the surgery's benefits. The titanium plasma coating is a tried-and-true material long used for hips, said Francesca.
Lackey attributed 25 percent of lower back pain to the SI joint; "it's a less invasive way of dealing with an under-diagnosed problem," he said.
In the chilled operating room, Thomas, the patient, lay on her stomach, completely draped, with just the surgical site showing. The clock read 13.01 p.m. A buzz of people, nine in all — including a circulating nurse, physician's assistant, surgical assistant, two radiologic technicians, and the company reps — readied for the procedure. The reading of the patient's name, the procedure and the side, known as a "surgical timeout," signaled the start.
"The hard part is getting the X-ray images set up," explained one attendant, as three screens captured fluoroscopic X-ray images from different angles with two large C-arms maneuvering overhead.
Aldridge, the surgeon, watched the screens as he made a short incision before inserting a tool to position the guidewire. There were light tapping and hammering sounds before he called repeatedly for "stimulation," or electric current. Tense moments followed when the response was an unexpected positive. "Do you have it set up right? I'm not anywhere near any nerves," he said, repeating the call.
Then came the reply he wanted: "No response, nothing." The use of nerve monitoring has eliminated any problems with misplacement of the implants causing nerve pain, Aldridge explained after the surgery. "It's a weird-shaped anatomy. You're looking from the side and it can be overlapping," he said.
The next few minutes were spent drilling out the bone and using a rasp to create space, then hammering in the first implant, followed by the second and third, all through the same 2-to-3-inch incision. He used a different angle for each.
"The first one is the hardest," said Aldridge, observing the rods that appeared like little torpedoes on the screen, while a small trickle of blood oozed from the wound.
At 13:25 p.m., he pronounced, "All done."
If her recovery continues on schedule, Thomas plans to get her left side done next month.
For Mark Makowski of Yorktown who had surgery with Aldridge earlier this year, first on his right side, then on his left, the two operations have been life-changers. "I'm feeling great. I'm feeling saved," he said. Just as with the other patients he had not been offered the option before.
When he learned about it, "it seemed like it was talking directly to me," Makowski said, and subsequent diagnostic testing showed he was the perfect candidate. He's back at work and able to walk in the neighborhood with his wife and dog.
"Every day I'd wake up with pain that was with me all day. It's a remarkable difference," he said.
Salasky can be reached by phone at 757-247-4784.
See a video of the surgery at http://www.dailypress.com.
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