Columbus orthopedic surgeon Fred Flandry says sometimes the source of severe back pain can't be found because the problem is not in the spine.
The trouble, he said, can be with the sacroiliac joint, but every doctor doesn't check for that possibility.
Sacroiliac joint dysfunction accounts for as much as 25 percent of all chronic lower back pain.
Flandry said that it is not something that an X-ray, MRI or CT scan is very effective in discovering.
Sacroiliac joint dysfunction involves the deterioration of the two joints on each side of the lower spine that connect it to the pelvis. The joint transfers weight and forces between the upper body and legs. It is an essential component for shock absorption to prevent impact forces during walking from reaching the spine.
It is stabilized by a network of ligaments and muscles that limit motion.
If there is joint or ligament degeneration and the joint becomes unstable, it can produce pain similar to that of a ruptured disc or sciatica.
"It can be just a small instability," Flandry said, which brings pain all the way down a leg.
The instability may be caused by a trauma such as a fall.
An inflammation of the ligaments, perhaps, as a result of arthritis, can also produce great discomfort.
One way to determine whether the joint is the problem is for a physician to inject an anesthetic into the joint and see if it is effective against the pain.
Flandry said if the sacroiliac joint is determined to be the problem, then his treatment plan is conservative, first using medicine and physical therapy rather than rushing into surgery.
Flandry, who works with the Hughston Clinic, said if surgery is needed, it is not as traumatic as it used to be because of the iFuse Implant System, which allows for minimally invasive surgery.
SI-BONE, a medical device company, produces the titanium implants Flandry uses to stabilize the joint.
The company received clearance in November 2008 from the Food and Drug Administration to market the joint fusion system. It is available in the United States and Europe.
The entire procedure is performed through a small incision, approximately 2 to 3 centimeters long, alongside the side of the buttock.
"The incision used to be much larger," Flandry said.
There was a massive amount of tissue exposed.
During the procedure, a fluoroscope gives the surgeon live imaging to facilitate proper placement of the implants.
Normally, three implants are inserted across the sacroiliac joint.
Flandry said titanium encourages bone growth.
"Everything must be precise so we don't hit nerves," he said of the process of inserting the implants.
Flandry said that surgery recovery with the iFuse system is a couple of weeks rather than the six months with traditional surgery.
Flandry said people have come in for years with the problem but doctors didn't make the right diagnosis and some needless spinal fusions were done.
Of sacroiliac joint dysfunction, he said, "We were not seeing it but it was seeing us."
Flandry said it would not upset him if a patient were to suggest sacroiliac joint dysfunction as their problem.
"A good doctor is not afraid for anyone making a suggestion," he said.