Pain physicians treat the signal, surgeons treat the structure, and insurers evaluate the cost. Patients experience all three.
The Elephant in the Room
There is an old parable about several blind men examining an elephant. One touches the trunk and declares the animal must be a snake. Another grasps a leg and insists it is a tree. A third holds the ear and describes a fan. Each man is certain he understands the animal. Each man is correct—yet only partially.
Sacroiliac (SI) joint pain in modern spine care often resembles this parable. Pain physicians and spine surgeons frequently encounter the same problem but interpret it through fundamentally different frameworks. Each perspective is grounded in legitimate training and experience. Yet the conclusions can appear irreconcilable.
The patient, meanwhile, encounters both realities at once.
The Pain Physician’s Elephant
For the interventional pain physician, the SI joint is primarily a generator of nociceptive signaling. The clinical task is pragmatic: identify the pain source, interrupt the signal, and restore function. Diagnostic blocks, steroid injections, radiofrequency ablation, and other interventions are designed to modulate pain and improve quality of life.
Within that framework, the SI joint becomes one component of a larger pain landscape. The objective is not necessarily permanent structural correction but reduction of the patient’s pain experience. Stabilizing the joint chemically or mechanically for several months may reduce inflammation and neural irritation long enough to restore meaningful function.
Temporary relief is not viewed as failure. Relief lasting three to six months may represent meaningful progress in a chronic pain condition.
Temporary interventions may help identify pain generators, guide patient selection, and delay—or in some cases avoid—surgery in selected patients. Yet they may also, in others, merely postpone recognition of structural instability, allowing recurrent and sometimes crippling pain to persist when the joint ultimately fails to unite.
From this perspective, even a nonunion may be clinically acceptable. The pain physician does not perform the intervention with the primary intent of achieving arthrodesis. The objective is mitigation of suffering.
Through this lens, the elephant is primarily a signal. Treat the signal, and the patient improves.
The Surgeon’s Elephant
Spine surgeons encounter the SI joint through a different clinical lens.
Surgeons frequently encounter sacroiliac pain after lumbar fusion. The SI joint becomes the next mobile segment in a spinal construct whose motion has been intentionally altered. In that setting, SI pain is not merely another pain generator but a biomechanical consequence of the original operation.
As many surgeons quietly acknowledge, “the SI joint is often the first structure asked to compensate for the rigidity we create upstream.”
What insurers ultimately prioritize in their quarterly calculus is less clear. What is clear is that lumbar fusion has become a significant contributor to secondary sacroiliac dysfunction.
In many patients, sacroiliac dysfunction represents the distal expression of prior spinal surgery, where the pelvis becomes the final mobile interface asked to absorb the mechanical forces created by rigid lumbar stabilization.
For surgeons trained in structural mechanics, instability demands correction. Motion where stability should exist represents pathology. The problem therefore appears fundamentally mechanical.
Within this framework, temporary modulation of pain does not address the underlying problem. The joint itself remains unstable. For the surgeon, the logical solution becomes structural stabilization—typically through fusion intended to permanently eliminate pathological motion.
The surgeon’s intent—supported by years of intense and highly focused training—is biomechanical stabilization achieved through arthrodesis. In that context, a nonunion is not simply a technical detail but a failure of the intended mechanical solution.
To the surgeon, the elephant is not a signal but a structural failure.
Three Different Definitions of Success
Part of the confusion surrounding sacroiliac disease arises because three different actors approach the problem with three different definitions of success.
For the pain physician, the goal is mitigation of suffering. Interventional procedures are not performed with the expectation of structural fusion but rather with the intention of interrupting nociceptive signaling and restoring function for a period of time. If a procedure reduces pain for several months, it may reasonably be judged successful within the framework of pain medicine.
The surgeon approaches the same anatomy from a fundamentally different perspective. Surgical training emphasizes structural mechanics, load transfer, and long-term stability. When surgeons intervene, the intent is not temporary modulation of pain but biomechanical correction. Arthrodesis—true fusion—represents the endpoint of that philosophy.
Payers operate under yet another framework. Coverage decisions are guided less by anatomy or professional philosophy than by financial risk and return on investment measured over fiscal quarters. If a procedure is perceived as quick, safe, reproducible, and capable of reducing downstream expenditures, coverage may follow. When outcomes appear inconsistent or failure rates become visible, scrutiny inevitably increases.
This dynamic can be seen across several areas of spine care. Nonunion after sacroiliac interventions may raise questions about durability. Likewise, the well-recognized phenomenon of adjacent segment degeneration following lumbar fusion has contributed to payer reluctance to broadly authorize fusion procedures in the absence of clear instability. In many cases insurers demonstrate a preference for simpler decompression procedures rather than fusion constructs when mechanical instability is not clearly demonstrated.
None of these perspectives are entirely wrong. Each reflects the priorities of the system in which the actor operates.
The challenge is not choosing one perspective over another, but recognizing that each reflects a different definition of success.
The difficulty arises when these three frameworks intersect in the care of a single patient.
The Patient Sees the Whole Elephant
Patients experience the situation differently.
They do not distinguish between nociceptive signaling and biomechanical instability. They experience only the consequences: pain when sitting, pain when standing, pain when walking.
To them, the debate between temporary modulation and definitive correction is secondary to the simple desire to regain normal life.
Yet patients inevitably encounter the professional divide. One specialist may recommend injections. Another may recommend surgery. Both recommendations may be rational within their respective frameworks. Yet to the patient they can appear contradictory.
In truth, they represent two partial views of the same condition.
Patients do not live inside professional frameworks. They live inside bodies that hurt.
The patient, perhaps, is the only one who truly feels the entire elephant.
Seeing the Whole Elephant
The ancient parable of the blind men and the elephant is often told to illustrate disagreement, but its deeper lesson is about incomplete perception.
Each observer describes what he feels. None are lying. Yet none are seeing the entire animal.
In sacroiliac disease, the pain physician feels the signal of suffering and seeks to quiet it. The surgeon feels the motion of an unstable joint and seeks to stabilize it. The payer feels the pressure of financial risk and seeks to control it.
Each interpretation contains truth. Each also reflects the priorities of the observer.
The difficulty arises when these partial truths collide in the care of a single patient whose experience cannot be neatly divided into categories of signal, structure, or quarterly return.
Patients do not live inside professional frameworks. They live inside bodies that hurt.
The challenge for modern spine care is therefore not to decide which observer is correct, but to recognize that each is touching only part of the elephant.
Because the elephant, after all, is still standing in the room—and the patient is the one living with its weight.
