(upbeat music)
- Welcome, my friends, to the Bob and Brad Podcast,
produced by Bob and Brad,
the two most famous physical therapists on the internet.
I am Bob and I exactly one half of the Bob and Brad team.
Today is truly an honor to be joined once again
by Dr. Hamid Abbasi, a neurosurgeon, means he's smart,
and we've had him on before
to talk about a minimally invasive surgery
he does for the lumbar spine,
but this one is a minimally invasive surgery
for the sacroiliac joint.
And you're gonna find out that you don't,
maybe your back pain is coming from your sacroiliac.
We'll discuss all that today,
along with what the procedure is, where it's at,
how to get it, and it'll be worth your time to watch
and listen to the show.
Welcome to the show, Dr. Abbasi.
Thank you so much again for joining us
and we're gonna talk about a new topic today.
We're gonna jump right in.
We're talking about sacroiliac joint dysfunction.
Why don't we start with someone comes in,
you suspect SI pain,
what are the common tests that you're gonna do?
- Now, some of the thing I learned
and I teach to many surgeon now,
is that include that in your differential diagnosis.
- [Bob] Sure. - Again, chameleon joint.
If anybody has not,
if the prevalence of that was like 0.1%,
we usually don't include that
in out our differential diagnosis.
But with prevalence of 22%,
I think it absolutely need to get included
in any kind of differential diagnosis
of the lower back pain.
Now, many times there are other indication,
like we talked about young female runners
waking up in the night and they even,
they do activities, go stairs up and down,
pain goes from side to side and so on.
The history's very important.
- [Bob] Yes.
- You have to start, many of the specialists,
we become, like, so involved and so concentrating
on the pictures, on the million dollar machine
to give us a dance.
Whereas patient has the most advanced kind of sensory
inside of them.
They can give you all those information.
You should just talk to your patient
and put your hand on the patient and examine them.
Many of these patients,
they put their finger on sacroiliac joint,
but you just have to bother, let them stand up,
let them turn around that you can look at the back
and you ask them to put their finger on the back
where the pain is.
And often they put the finger on where the pain is,
where is the sacroiliac joint.
We are doctors.
I am not expecting everybody knows
what the sacroiliac joint is,
but I'm expecting everybody who has gone
through the med school to understand
where the sacroiliac joint is.
Now, and we have even name for that.
We called it Fortin test, after Dr. Fortin,
who figured out if they point to the location of the pain
and within an inch, always they point to the same place,
there's a high likelihood that the sacroiliac joint
is the problem.
Another thing that I think is important is in some of them,
not many of them, but at least half of the patient,
the other side of the sacroiliac joint, Bob,
is all groin.
They say, "I have pain in the back."
Sometimes they tell you.
Sometime if you ask them, they say, "Oh yes, yes.
Sometimes I do have pain in my groin,"
because the other side of the sacroiliac joint is all groin.
And then the activities, you know,
like going stairs up and down, all those help you to...
- [Bob] It makes sense.
- Good picture of what, if the pain
is in the sacroiliac joint,
then if it hints in that direction,
the next action on the surgeon side
is to provoke that joint.
But I know you're a physical therapist, right?
- Yes and I wanted to ask you about the test
that you developed.
- Yeah.
- I know you don't want to call it your name,
the Abbasi test, you should.
- Medicine, you love names, no.
I always tend to call, like, I have a device that makes
something in the surgery much easier
and people asked me to call it Abbasi,
but that doesn't say, a new person,
a new surgeon, what that is.
- Right.
- Calling that facet decorticator,
every surgeon hears the name, they know what that does.
- What it does, right.
- Decorticate the surface of the facet joint in our spine,
every surgeon just, he need to hear the name.
So I'm more, all more for making teaching and learning easy,
rather than put my name on devices and tests.
- It almost seemed to me that, and maybe I'm wrong,
because I don't know what your test is for sure,
but it seems like someone could almost do it on themselves.
I mean, they could...
- They could. They could.
- I mean, first off, if they can't,
you want to describe it, but if they can't even do it,
that's part of the test, right, itself?
- Yes. Generally, yes.
To certain point, you can do it yourself,
but it has be that, you know, you have to be passive.
Somebody active...
- [Bob] Sure.
- Because guess what?
Try to stick a needle in yourself.
Then you see how tense you become.
- [Bob] Right.
- This is same mechanism.
This is one of those tests is better somebody else
can do it for you.
It's a provocation test.
What I learned over many years,
do you know who is the best person to do that test?
Physical therapist.
- [Bob] Sure.
- They are the best people to do this test,
because they understand the joint,
they know how to perform those tests,
and the idea of the sacroiliac provocation test,
there is anything that put pressure on it.
Now, the fact is that this joint
is in middle of our body.
There are lots of ligament attached to that.
Sometimes, you cannot provoke enough force
to provoke this joint.
So for that reason, most of the time you use your pelvis
and femur as a full crew, like, like a wrench,
like a crowbar, to magnify a force to provoke the joint.
But the idea, I'm not going to go through
the individual kind of test, because...
- Right, you don't need to.
- I think for the populace, it's really...
- Yeah, I would like you to describe yours though,
because that would be helpful.
- Now, many times, I think, many of these tests,
they use your femur, your pelvis, to provoke the test.
- [Bob] Right.
- So and you remember, we talked about that
when many of these patients in the middle of the night,
they wake up, because when they turn from side to side,
it's something that's really trivial.
And people don't know that,
but every 15 to 20 minute in your sleep,
even when you are sleeping,
you automatically turn from side to side.
That is why you don't wake up in the morning
having pressure sores, broken skin,
because you automatically do that.
Now these poor people, every time they do that,
the pain wakes them up.
- And that's not surprising to me,
because we find instability in the lumbar spine,
the same thing, they'll wake up with pain.
- Yeah, exactly.
Now, the test that I developed puts, make it easier,
because to do those tremendous tests,
you have to put the patient on the bed,
you have to yank their femur,
take their pelvis and push it back and forth.
Sometimes you need a place to start before you do those.
Because if you do that with everybody,
it's going to be tremendously cumbersome.
But if you want to do a quick test,
and then if it's positive, do the proper test,
you just ask the person to,
and I'm going back a little to show on my own for here,
you ask them to put one leg over the other one.
Sometimes they cannot do that.
That's already provoking their pain.
- Yes.
- And then if you gently start pushing down
on the knee down,
practically, you are distracting
and extending the sacroiliac joint
and almost everybody who has a sacroiliac joint
at one or the other level described to you,
this action extremely painful.
And I'm just going to call it sacroiliac combined test.
- All right.
- Because that tell everybody that you're
practically putting densling test, faber test
and distraction test together.
- All together.
- One easy test, without putting the patient
on a stretcher or a bed.
But then, if positive, then you still go
and do those provocation tests.
- And then you were, I'm sorry, I cut you off,
but you were about ready to talk about the next step
to diagnose is provoking the joint.
- So now once the history fits and the provocation test fit,
you just have to make sure that that
is where the pain is coming from.
And the way I describe it to my patient,
I tell them, when you go to the dentist,
he numbs up your gum on the right side
and start drilling on the right side.
- Right.
- If he numbs up the right side
and start on drilling on the left side,
that numbing will have no proper action.
It's useless.
It only works if the pain is produced on the same side,
that if you numb it up, that pain goes away.
And guess what?
Sacroiliac joint, it's a very confined place,
and there is a very specific protocol to that,
which by the way, has been nationally standardized.
Like, you have to do it in a certain way
from certain angle in certain part of the joint
with certain amount of medication.
So you don't want to numb everything,
but if you do it properly and patient come back
and tell you 75% of their symptoms gone away,
and sometimes we ask them to go out and do things
that are usually painful
and surprisingly, they can come and tell you,
"Yes, 85% of my pain was gone, 90% of my pain was gone,"
but you have to tell them, I'm just numbing up the joint,
so pain will return.
As a matter of fact, sometimes patient don't understand
what a diagnostic test is.
- [Bob] Right.
- This is not a therapeutic test. This is a diagnostic test.
Sometimes they come and tell me that,
"Doctor, it didn't help me at all.
After three days, pain came back even worse."
But then my question is,
how was it in that three days before the pain come back?
"Oh yeah, it was great for two days."
(Bob laughing)
But this is the idea of a diagnostic test.
- And obviously, I think you talked about, too,
that you gotta make sure it's, well,
in the joint and not the ligaments.
- Yes.
No, no, what we do is generally we want to be sure
that they didn't get better just because of placebo effect
or they had a good day or some other things.
But I do that test three times,
meaning that I inject the joint three times.
If every time I inject that joint, 75% of the pain goes away
for a very short period of time, obviously,
then you're sure this is where the pain is generated.
We call that pain generator.
Then we are sure that the sacroiliac joint
is the pain generator.
- So three separate occasions?
- Three separate occasion, preferably two weeks apart,
but at least waiting until the pain is back.
Now, there is a caveat here.
This is not an easy joint to inject,
because bone is on bone, the space is very narrow,
and because this joint has no function,
nature allows lots of variations,
sometimes in the same patient,
right and the left sacroiliac joint look different.
For that reason, it's not easy joint to inject,
but we can do it, if you're trained properly.
You just have to go to somebody who has done it enough
and knows how to do that,
because it is unlike other joint,
is harder than other joint to inject.
But the caveat is once your needle is there,
there's no reason not to put a little steroid there.
About one fourth to one third of my patient,
after three injections, they come back and say,
"Hey, doctor, I'm actually good.
I don't want anything else."
I say, "Great. I helped you without the surgery."
I send them out and unfortunately though,
after two, three years, some of them still come back
and the joint cause them problem,
but now we know what the problem is.
So this injection, even though it's diagnostic,
by us adding a little bit of a steroid to that,
we can as well combine it,
making it therapeutic injection at the same time.
- Very good.
- The beauty of that and what patient needs to know
is that it doesn't interfere with the diagnostic part,
and the reason for that is local anesthetic,
which work for the diagnostic part, works right away.
Within two days, it's completely gone.
As a matter of fact,
when you go to your dentist, Bob,
and they numb up your gum in your,
how long do you feel the numbness?
- Well, usually that day, I mean.
- Yeah, six hours. Six, eight hours.
- [Bob] Right.
- Yeah, but because your gum is well perfused
and washed it out.
Sacroiliac joint is not well perfused,
so the local anesthetic realistic can stay 1, 2, 3 days,
but nothing more than that.
- You need assistance as far as far as video
to guide you into the right spot or do you just do it?
- Yeah, we used either a CAT scan, CT, or a fluoroscope.
Most of the time we use a fluoroscope, a live x-ray,
to practically guide us to be in the right place.
And then once we put the local anesthetic
and we put the steroid, the effect of the steroid
is just the first day or two.
Steroids start working four, five, six or seven days
after the injection.
So they don't, it doesn't confuse you to use
both diagnostic and therapeutic injection.
- Gotcha, yeah. Makes sense.
Okay, again, we'll have his website down below
in the comments, as well as the links
for the previous presentations on the lumbar spine.
So thanks again, Dr. Abbasi.
- Always my pleasure.
- [Bob] Yep, take care.
Thank you. Buh-bye.
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