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Chronic Symptomatic Symphyseal Instability M.L. Chip Routt, Jr., M.D. Patient #1 • • • • • • • • • • • 28 yo Female G1P1 2.5 Years after NSVD of Term Baby Son Anterior and Posterior Chronic Pain Unable to Walk > 100 ft Unable to Lift/Carry Son Dyspareunia & Stress Urinary Incontinence Employed-Sedentary Job-Computer Work-Fulltime “Relatively Comfortable” Sitting 45-60 Minute Intervals Takes No Medications – “Nothing Works, Why Take Them?” Pelvic Instability on Compression Exam, Causes Pain Presentation Pelvic Films • AP Presentation Pelvic Films • Alternating LE Standing Films Pelvic CT Scan • In Binder Pelvic CT Scan • Axials @ S1 & S2 • SI Joints Surgery • • • • • • Supine Pfannenstiel Unstable Symphysis Compressive Reduction Clamped Symphyseal Plating – Frail Bone Perc Upper and 2nd Sacral Segment IS Screws Postop CT Imaging Postop CT Imaging • Axials @ S1 & S2 Levels Rehabilitation • 1st 6 Weeks - Bed or Chair Restricted and Isometrics • “Marginally Compliant” Due to “Comfort” • 2nd 6 Weeks - Tandem Bilateral Protected WB, Stretching, Strengthening Program, Aquatic Program • Non-Compliant Due to “Comfort” 4 Months After Surgery • Plain Films • Notable Plate Segmental Breakage 4 Months After Surgery • • • • • • No Pain Complaints Normal Gait without Distance Limit Lifts/Carries Son “Normal” Sexual Activity No GU Complaints Still Working FT Patient #2 • • • • • • • • • • • • 51yo Male Was D1 College Baseball Player “back in the day” Remained Fit & Active Executive - Employed FT 8-12+ Years Progressive Pelvic-Groin-Back Pain Anterior Pelvic “Grinding” Bilateral Posterior Pelvic Pain Worsened By Essentially Any Activities Antalgic Gait Dyspareunia (But Fights Thru It!) Has Had Spinal Injections Without Relief – Body MRI In Hand ? Pelvic Instability on Exam Plain Films • Inlet-Outlet Initial Plain Films • Single LE Alternating Stance Films Pelvic CT Imaging • SI Joints Surgery • • • • • • Supine Pfannenstiel Fluid Filled “Cyst” Around Unstable Symphysis Compressive Reduction Clamped Symphyseal Plating Perc Bilat IS Screws at Upper Sacral Segment Postop Imaging • CT Scan Rehabilitation • 1st 6 Weeks - Bed or Chair Restricted and Isometrics • 2nd 6 Weeks - Tandem Bilateral Protected WB, Stretching, Strengthening Program, Aquatic Program • “Very” Compliant Due to “Fear of Pain Return” 3 Months After Surgery • • • • • • Left Adductor Sporadic “Cramping” No Prior Pelvic & Low Back Symptoms “Slowly Evolving Normal-Pareunia” “Scared and Cautious Recoverer” Back to Work Durable Implants Thus Far 3 Months After Surgery • Plain Films • No Implant Breakage….Yet!
