Sacroiliac joint fusion for low back pain: a systematic review and meta-analysis

Utility of minimally invasive percutaneous arthrodesis of the sacroiliac joint for the treatment of low back pain: systematic review of the literature

BACKGROUND

The surprising increase observed in recent years in the use of minimally invasive sacroiliac joint arthrodesis techniques as a treatment for low back pain justifies an objective review of this results.

PURPOSE

carry out a systematic review of the literature to evaluate the clinical results of patients with low back pain treated with percutaneous arthrodesis of the SIJ.

STUDY DESIGN

Systematic review.

METHODS

Systematic search of the medical literature. The words used in the Search were: "Hollow screw system", "percutaneous sacroiliac joint stabilization", "sacroiliac joint", "minimally invasive", "sacroiliac pain", "sacroiliac dysfunction". With logical connectors such as "and", "not" and "or".

DATABASES

Pubmed, Scopus, Embase, Ovid, EBSCO host and google scholar. The search extended from the beginning of the databases until September 2024. The "Rayyan" program was used to collect the information and facilitate the analysis process.

INCLUSION CRITERIA

Systematic review from the literature, clinical trials, observational studies and case series. They followed PRISMA principles.

RESULTS

661 articles were found, of which 108 articles were duplicates. The criteria (Inclusion/Exclusion) were applied to the 553 articles identified based on the independent reading of the summaries by each of the authors on the Rayyan platform and 434 articles were excluded. The 119 selected articles were completely reviewed to finally obtain 102 articles included in the review. Epidemiological data were extracted into an Excel table, methodological and related to clinical results and safety of procedures made. The Prisma checklist for systematic reviews was applied in each article. The epidemiological quality of the articles was evaluated based on the checklists STROBE and CONSORT. The results regarding clinical improvement were overwhelming. However, most of the studies were sponsored by industry and with a limited population and follow-up not always prolonged.

CONCLUSIONS

Although the clinical results regarding the effectiveness of SIJ fusion are forceful for their effectiveness, we recommend considering some aspects for their analysis and especially long-term studies.

Phase-specific changes in hip joint loading during gait following sacroiliac joint fusion: Findings from a finite element analysis

BACKGROUND

Low back pain affects over 80 % of adults, with sacroiliac joint dysfunction accounting for 15-30 % of these cases. Sacroiliac fusion is a surgical procedure for refractory joint pain. While the biomechanics of the joint and its fusion relative to the spinal column are well-known, the hip-spine relationship post-fusion remains unclear. Understanding the biomechanical state following fusion can enhance patient recovery and optimize surgical outcomes. This study uses finite element analysis to assess hip joint biomechanics following sacroiliac joint fusion.

METHODS

CTs of a 55-year-old male were used to create a biomechanical model, validated against a cadaveric study. Three triangular titanium alloy implants were placed across the sacroiliac joint in a unilateral and bilateral configuration. The model, loaded with pelvis and hip joint kinematics during a gait cycle, calculated joint reaction forces, contact stress and area on the hip joint across various gait phases.

FINDINGS

Hip joint contact stresses varied with fixation configurations and gait phases. Unilateral right fusion reduced joint reaction forces by 2 % but increased contact stress by 3.7 %. Bilateral fusion increased joint reaction forces by 6.7 % and contact stress by 3.25 %, with higher stress during foot flat and heel off phases compared to unilateral fixation.

INTERPRETATION

Fusion alters hip loading patterns during specific gait phases, with bilateral fusion producing the highest stresses during foot flat and heel off. These findings may suggest the need for fusion-specific rehabilitation protocols and warrants further investigation of long-term joint health outcomes.

Clinical outcomes for minimally invasive sacroiliac joint fusion with allograft using a posterior approach

BACKGROUND

Sacroiliac joint (SIJ) dysfunction can occur as a result of injury, degeneration, or inflammation. This dysfunction presents symptoms of pain at various locations, including the low back, hips, buttocks, and legs. The diagnosis of SIJ dysfunction is challenging and cannot be achieved solely with imaging studies such as X-rays, MRI, or CT. The current gold standard diagnostic modality is intra-articular SIJ blocks using two differing local anesthetics. Current treatments for SIJ dysfunction may be beneficial for short-term relief but lack long-term efficacy. The purpose of our study was to examine the outcomes of patients who underwent minimally invasive, posterior SIJ fusion using allograft at a single center.

METHODS

This was a retrospective study which received exemption from the WCG IRB. Data regarding preoperative and postoperative pain levels, surgical time, complications, and medication usage were obtained retrospectively from patient electronic medical records and prescription drug monitoring program reports. No mapping was completed prior to the procedure. Pain was assessed with the 11-point (0-10) Visual Analogue Scale (VAS) and medication usage was assessed using Morphine Milligram Equivalents (MME). Patients were included if they had been diagnosed with SIJ dysfunction using two intra-articular diagnostic blocks that resulted in at least an 80% decrease in pain and had failed conservative management. Patients with sacral insufficiency fractures were excluded.

RESULTS

VAS scores reduced from 8.26 (SD = 1.09) at baseline to 2.59 (SD = 2.57), 2.55 (SD = 2.56), 2.71 (SD = 2.88), and 2.71 (SD = 2.88) at 3, 6, 9, and 12 months, respectively. MME reduced from 78.21 mg (SD = 51.33) to 58.95 mg (SD = 48.64), 57.61 mg (SD = 47.92), 61.71 mg (SD = 45.64), and 66.29 mg (SD = 51.65) at 3, 6, 9, and 12 months, respectively. All reductions in VAS scores and MME were statistically significant. No adverse events occurred, and the average operating room time was 40.16 min (SD = 6.27).

CONCLUSION

Minimally invasive, posterior SIJ fusion using allograft is a safe and efficacious method for managing SIJ dysfunction.

Sacroiliac dysfunction and minimally invasive sacroiliac joint fusion

The sacroiliac joint (SIJ) is the largest diarthrodial joint in the human body and accounts for approximately 20% of all low back pain, which is commonly seen in patients with lumbosacral fusions. Despite this, SIJ dysfunction often poses a challenging diagnosis depending on clinical evaluation, imaging, and image-guided joint injection. SIJ fusion is an effective and safe method of treatment, with minimally invasive approaches fitting well within the armamentarium of interventional radiologists treating chronic pain and other musculoskeletal conditions. Contemporary technical approaches and clinical considerations are discussed.

Mobility and anthropometry of the sacroiliac joint: range of motion and morphological characteristics

Purpose

The sacroiliac joint (SIJ), a synovial joint with irregular surfaces, is crucial for stabilizing the body and facilitating daily activities. However, recent studies have reported that 15-30% of lower back pain can be attributed to instability in the SIJ, a condition collectively referred to as sacroiliac joint dysfunction (SIJD). The aim of this study is to investigate how the morphological characteristics of the auricular surface may influence the SIJ range of motion (ROM) and to examine differences in SIJ ROM between females and males, thereby contributing to the enhancement of SIJD diagnosis and treatment.

Methods

We measured SIJ ROM using motion-analysis cameras in 24 fresh cadavers of Korean adults (13 males and 11 females). Using three-dimensional renderings of the measured auricular surface, we investigated the correlations between the morphological characteristics of the auricular surface and the ROM of the SIJ.

Results

The SIJ ROM was between 0.2° and 6.7° and was significantly greater in females (3.58° ± 1.49) compared with males (1.38° ± 1.00). Dividing the participants into high-motion (3.87° ± 1.19) and low-motion (1.13° ± 0.62) groups based on the mean ROM (2.39°) showed no significant differences in any measurements. Additionally, bone defects around the SIJ were identified using computed tomography of the high-motion group. In the low-motion group, calcification between auricular surfaces and bone bridges was observed.

Conclusion

This suggests that the SIJ ROM is influenced more by the anatomical structures around the SIJ than by the morphological characteristics of the auricular surface.

The sacroiliac dysfunction and pain is associated with history of lower extremity sport related injuries

BACKGROUND

The purpose of this study was to examine the association of sacroiliac joint (SIJ) dysfunction and pain with overuse and acute lower limb and pelvic girdle injuries of Iranian basketball players.

METHODS

In this cross-sectional study, basketball-related injury data were collected during 2019-2020 from 204 basketball players of the Iranian league using the online Information Retrospective Injury Questionnaire. A researcher then performed ten clinical tests to assess SIJ dysfunction and pain (five tests for dysfunction and five tests for pain). Data analysis was performed by logistic regression at the confidence interval of 95%.

RESULTS

Within our sample (n = 204), injury rates were calculated across sub-groups of athletes that had only SIJ pain (n = 19), only SIJ dysfunction (n = 67), both SIJ pain and dysfunction (n = 15) or no SIJ complaints (n = 103). Across these groups, a total of 464 injuries were reported. SIJ pain group reported 80 injuries (17.2%), SIJ dysfunction group reported 210 injuries (45.2%), both SIJ pain and dysfunction group reported 58 injuries (12.5%, and the no SIJ pain or SIJ dysfunction group reported 116 injuries (25.0%). Participants with SIJ pain were more likely to report previous pelvic girdle injuries (overuse: odds ratio (OR): 0.017; 95% CI: 0.005-0.56; p < 0.001 and acute: OR: 0.197; 95%CI: 0.101-0.384; p < 0.001) and also lower limb injuries (overuse: OR: 0.179, 95%CI: 0.082-0.392, p < 0.001). Participants with SIJ dysfunction only were likely to report acute pelvic girdle injuries (OR: 0.165; 95%CI: 0.070-0.387; p < 0.001) and acute lower limb injuries (OR: 0.165; 95%CI: 0.030-0.184; p < 0.001).

CONCLUSION

The presence of SIJ dysfunction and pain is associated with a history of acute and overuse injuries in the pelvic girdle and lower limb. Thus, SIJ dysfunction and pain should be specifically evaluated and addressed when designing rehabilitation programs for sports-related injuries.

Rotational-motion measurement of the sacroiliac joint using upright MRI scanning and intensity-based registration: is there a sex difference?

PURPOSE

The sacroiliac joint (SIJ) has attracted increasing attention as a source of low back and groin pain, but the kinematics of SIJ against standing load and its sex difference remain unclear due to the difficulty of in vivo load study. An upright magnetic resonance imaging (MRI) system can provide in vivo imaging both in the supine and standing positions. The reliability of the mobility of SIJ against the standing load was evaluated and its sex difference was examined in healthy young volunteers using an upright MRI.

METHOD

Static (reliability) and kinematic studies were performed. In the static study, a dry bone of pelvic ring embedded in gel form and frozen in the plastic box was used. In the kinematic study, 19 volunteers (10 males, 9 females) with a mean age of 23.9 years were included. The ilium positions for the sacrum in supine and standing positions were measured against the pelvic coordinates to evaluate the mobility of the SIJ.

RESULTS

In the static study, the residual error of the rotation of the SIJ study was < 0.2°. In the kinematic study, the mean values of SIJ sagittal rotation from supine to standing position in males and females were - 0.9° ± 0.7° (mean ± standard deviation) and - 1.7° ± 0.8°, respectively. The sex difference was statistically significant (p = 0.04). The sagittal rotation of the SIJ showed a significant correlation with the sacral slope.

CONCLUSION

The residual error for measuring the SIJ rotation using the upright MRI was < 0.2°. The young healthy participants showed sex differences in the sagittal rotation of the SIJ against the standing load and the females showed a larger posterior rotation of the ilium against the sacrum from the supine to standing position than the males. Therefore, upright MRI is useful to investigate SIJ motion.

Outcomes After Minimally Invasive Sacroiliac Joint Fusion: A Scoping Review

BACKGROUND

Sacroiliac joint (SIJ) dysfunction is a significant contributor to lower back pain. Although open surgical treatment for persistent pain has long been the standard, it is associated with significant surgical morbidity, high complication rates, and variable patient satisfaction. Minimally invasive SIJ fusion (MISJF) is a promising and effective approach. This scoping review was carried out to map the available evidence on outcomes after MISJF.

METHODS

This review was conducted in accordance with the PRISMA guidelines. Inclusion criteria were all full-text articles reporting on functional, clinical, and quality-of-life outcomes after MISJF. Exclusion criteria consisted of studies including patients with traumatic sacroiliac injuries or congenital spinal abnormalities, and procedures involving multiple spinal fusions or an open approach to SIJ fusion.

RESULTS

A total of 1305 studies were identified across 6 databases. After duplicate removal and further screening, 33 independent studies were included in our review. Regarding pain management, 21 studies reported visual analog scale scores, and all showed significant (>50%) reductions in pain at multiple time points postoperatively. Six studies reported on quality-of-life outcomes and showed significant increases, especially compared with nonsurgical treatment.

CONCLUSIONS

This study highlights the existing literature regarding outcomes after MISJF. MISJF provides favorable responses in quality-of-life metrics, pain scores, and overall postoperative outcomes in select patients. Although outcomes have been widely studied, more studies, especially prospectively designed and those without industry influence, should be performed to elucidate the optimal management of patients with intractable SIJ pain.

The efficacy of primary sacroiliac joint fusion for low back pain caused by sacroiliac joint pathology: a systematic review and meta-analysis

PURPOSE

Conduct a systematic review to quantify the effect of primary sacroiliac joint fusion (SIJF) for the treatment of sacroiliac (SI) joint pathology on patient reported outcomes.

METHODS

Medline, Embase, Cochrane, PubMed, and Scopus databases were searched prior to August 18th, 2020 for all English-Language studies involving the treatment of SIJ pathology through SIJF and/or conservative management (CM). The quality of included studies was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Primary outcome measure was the Visual Analogue Scale (VAS) for low back pain. Secondary outcome measure was the Oswestry Disability Index (ODI) and the incidence of adverse reactions.

RESULTS

A total of 564 patients and six studies were included. The overall quality of evidence analyzed by this review was low (GRADE = 0). Five out of the six studies were industry funded. The VAS standardized mean difference (SMD) between SIJF and CM at three months and six months follow-up was - 1.4 [95% confidence interval - 2.3, - 0.6] and - 1.5 [95% CI - 1.8, - 1.1]. The ODI SMD between SIJF and CM scores at three months and 6 months follow-up was - 0.9 [95% CI - 1.1, - 0.7] and - 1.1 [95% CI - 1.6, - 0.5]. The odds ratio of adverse reactions due to SIJF compared to CM was 1.9 [95% CI 0.1, 42.8].

CONCLUSION

Based on the limited number of independent trials with long-term follow-up, SIJF shows potential as a surgical treatment option for SIJ pathology.

PROSPERO REGISTRATION

CRD42020206149 (25th September 2020).

Surgical and clinical efficacy of minimally invasive sacroiliac joint fusion surgery: a meta-analysis protocol

INTRODUCTION

Sacroiliac joint (SIJ) dysfunction has been shown to cause significant morbidity. Current treatment includes conservative management and surgical intervention. Previously published data reporting clinical and surgical outcomes reached conflicting conclusions. This protocol aims to conduct a meta-analysis to determine fusion rates and patient-reported outcomes of minimally invasive (MIS) SIJ fusions compared with conservative treatment.

METHODS AND ANALYSIS

We drafted our protocol according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We will search PubMed, Embase and the Cochrane Library, supplemented by manual search when necessary. Two independent reviewers will screen for eligibility by title/abstract, then full text, arbitrated by a third reviewer if necessary. The two reviewers will carry out a risk of bias assessment using the Cochrane Collaboration Risk of Bias tool for randomised controlled trial and the Methodological Index for Non-Randomised Studies tool for observational cohort studies. A third reviewer will arbitrate any disagreement. We will perform data synthesis using Review Manager (RevMan for Windows, V.5.4.1, The Cochrane Collaboration, 2020) and Comprehensive Meta-Analysis (V.3.3.070). Meta-bias will be evaluated and confidence determined using the Grading of Recommendations, Assessment, Development and Evaluation guidelines.

ETHICS AND DISSEMINATION

Ethical approval for this review will not be required as no patient data is being collected. The results of this study will be submitted for publication in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42021273481.

First clinical results of a novel minimally-invasive fusion system for the sacroiliac joint

BACKGROUND

Sacroiliac joint (SIJ) painful dysfunction is a common source of low back pain (LBP). Several surgical treatment options for SIJ fusion were described. A promising treatment option with demonstrated clinical improvement is the minimally-invasive SIJ fusion.

OBJECTIVE

The aim of this case study was to document the effectiveness and safety of the new SIJ system (Torpedo®) over a period of 6 months after the minimally invasive implantation.

METHODS

Patients with failed conservative treatment of painful SIJ dysfunction were enrolled successively in two centers. The Diagnosis was made by positive response to SIJ-injection with local anesthetic and at least by two positive SIJ provocation tests. The Torpedo® Implant system was used for the implantation. This workpiece made of titanium alloy is characterized by a helical profile geometry (CST: chronical spinal turn) with a hydrophilic surface. The evaluated endpoints LBP and grade of disability were assessed using a 0-10 numerical rating scale (NRS), and Oswestry Disability Index (ODI) preoperatively and at one, three and six months postoperatively.

RESULTS

15 patients (10 female, 5 male; mean age 59 ± 13 years) were operated on one after the other. The pain intensity decreased in all 15 patients. After 6 months, a decrease in the median values of 70% (quartiles 1-3: 65-79%) was calculated. The median values of the Oswestry Disability Index after 6 months were 62% (quartiles 1-3: 53-67) lower than before the operation. Before surgery, 13 patients (87%) were taking opioids for pain management. Six months after the operation, opioids were only needed by 3 patients (20%). Implant malpositioning was not detected on plain radiograph. No surgical site infections or perioperative complications occurred.

CONCLUSIONS

The clinical improvement in early follow up and the absence of surgery related complications demonstrate a high grade of device-related safety and effectiveness of the treatment with a novel minimally-invasive SIJ fusion system.

Instrumentation of the sacroiliac joint with cylindrical threaded implants: A detailed finite element study of patient characteristics affecting fixation performance

The sacroiliac joint (SIJ) is a known pain generator that, in severe cases, may require surgical fixation to reduce intra-articular displacements and allow for arthrodesis. The objective of this computational study was to analyze how the number of implants affected SIJ stabilization with patient-specific characteristics such as the pelvic geometry and bone quality. Detailed finite element models were developed to account for three pelvises of differing anatomy. Each model was tested with a normal and low bone density (LD) under two types of loading: compression only and compression with flexion and extension moments. These models were instrumented with one to three cylindrical, threaded and fenestrated implants through a posterior oblique trajectory, requiring less muscle dissection than the more common lateral trajectory used with triangular implants. Compared with the noninstrumented pelvis, the change in range of motion (ROM) and stress distribution were used to characterize joint stabilization. Noninstrumented mobility ranged from 0.86 to 2.55 mm and from 1.37° to 6.11°. Across patient-specific characteristics, the ROM reduction with one implant varied from 3% to 21% for vertical and 15% to 47% for angular displacements. With two implants, the ROM reduction ranged from 12% to 41% for vertical and from 28% to 61% for angular displacements. Three implants, however, did not further improve the joint stability (14% to 42% for vertical and 32% to 63% for angular displacements). With respect to patient characteristics, an LD led to a decreased stabilization and a higher volume of stressed bone (>75% of yield stress). A better understanding of how patient characteristics affect the implant performance could help improve surgical planning of sacroiliac arthrodesis.

Impact of diagnosis and type of sacroiliac joint fusion on postoperative complications

PURPOSE

Two main surgical approaches are available for fusing the sacroiliac joint (SIJ): an open or minimally invasive (MIS) approach. The purpose of this study was to analyze the associated total hospital charges and postoperative complications of the MIS and open approach.

METHODS

Using the 2016 and 2017 National Readmission Database, we conducted a retrospective cohort analysis of 2521 patients who received a SIJ fusion with an open (N = 1990) or MIS (N = 531) approach for diagnosed sacrum pain, sacroiliitis, sacral instability, or spondylosis. Each cohort was analyzed for postoperative complications.

RESULTS

We identified 604 patients diagnosed with sacrum pain, 1142 with sacroiliitis, 315 with spondylosis, and 288 with sacral instability. Patients who received the open approach for sacrum pain had significantly higher rates of novel post-procedural pain (p = 0.045) and novel lumbar pathology (p = 0.015) within 30 days. On 30-day follow-up, patients with sacroiliitis treated with open SIJ fusion had significantly higher rates of novel postprocedural pain compared to those treated with MIS fusion (p = 0.045). Patients who received the open approach for spondylosis resulted in significantly higher rates of non-elective readmission within 30 days compared to the MIS approach (p < 0.0001). In addition, the open technique for spondylosis resulted in significantly higher rates of non-elective readmissions for infection within 30 days (p = 0.014). On 30-day follow-up, patients with sacral instability treated with open SIJ fusion had significantly higher rates of UTI (p = 0.045).

CONCLUSION

Our study suggests that there exist unique postoperative complications that arise after SIJ fusion specific to preoperative diagnosis and surgical approach.

[Minimally invasive arthrodesis of the sacroiliac joint (SIJ)]

OBJECTIVE

Pain reduction and improvement in quality of life with sacroiliac joint (SIJ) fusion.

INDICATIONS

Chronic SIJ-associated pain; positive response to SIJ injection with local anesthetic; positive SIJ provocation tests; failed conservative therapy over 6 months.

CONTRAINDICATIONS

Non-SIJ-associated pain; tumor/infection/unstable fracture in the implantation area; malformations; tumor or osteolysis of the sacrum or ilium bone; active infection at the implantation site; allergy to metal components; secondary gain from illness, request for a pension; inadequately treated osteoporosis.

SURGICAL TECHNIQUE

Transarticular placement of Kirschner's wires through the SI joint via minimally invasive lateral approach. Guided preparation of implant site over Kirschner's wires and implantation of 3 triangular, transarticular titanium implants for SIJ fusion.

POSTOPERATIVE MANAGEMENT

Deep vein thrombosis prophylaxis. 3 weeks partial weight-bearing and then moving on to full weight-bearing. X‑ray controls at defined intervals. Physiotherapy.

RESULTS

We enrolled 26 patients who were followed up over the period of 4 years. The evaluated endpoints were low back pain on the visual analog scale (VAS 0-10), grade of disability with the Oswestry Disability Index (ODI) and quality of life with the EuroQOL-5D. At 4 years, mean low back pain improved compared to preoperative (VAS preoperative 8.4, VAS 4 years postoperative 4.6). Mean improvements in ODI (ODI preoperative 58.1, ODI 4 years postoperative 32.1) and EQ-5D (preoperative 0.5, after 4 years 0.7) could be evaluated over the long-term period of 4 years. Satisfaction rates were high and the proportion of subjects taking opioids decreased at the 4‑year follow-up (preoperative 82%, postoperative 39%). Implant loosening could not be detected on plain radiograph.

Infra-adjacent Segment Disease After Lumbar Fusion: An Analysis of Pelvic Parameters

STUDY DESIGN

Cross-sectional observational cohort study.

OBJECTIVE

The aim of this study was to determine the incidence and risk factors associated with the development of sacroiliac joint (SIJ) dysfunction following lumbosacral fusion.

SUMMARY OF BACKGROUND DATA

Adjacent segment degeneration to both proximal and distal areas of spinal fusion is a postoperative complication of lumbar fusion. Various studies examined supra-adjacent degeneration following lumbar fusion, but few focused on infra-adjacent degeneration. In lumbosacral fusion, fusion extends to the sacrum, placing increased stress on the SIJ.

METHODS

A total of 2069 sequential patients who underwent lumbosacral fusion surgery from 2008 to 2018 at a single academic medical center were retrospectively reviewed. Patients who subsequently developed SIJ dysfunction were identified. SIJ dysfunction was defined as patients who met the diagnostic criteria with physical examination and received an SIJ injection with clinical evidence of improvement. Controls, without subsequent SIJ dysfunction, were matched with cases based on levels of fusion, age, sex, and body mass index. Pre-and postoperative pelvic parameters were measured, including pelvic incidence, pelvic tilt (PT), sacral slope, lumbar lordosis, lumbosacral angle, L4 incidence and L5 incidence.

RESULTS

Of 2069 patients who underwent lumbosacral fusion, 81 patients (3.9%) met criteria for SIJ dysfunction. Measurements were made for 47 of 81 patients who had SIJ dysfunction, that had both pre- and post-operative imaging. Measurements for 44 matched controls were taken. Postoperative PT was significantly lower in SIJ dysfunction patients compared to controls (20.82° ± 2.19° vs. 27.28° ± 2.30°; P < 0.05), as was L5 incidence (28.64° ± 3.38° vs. 37.11° ± 3.50°; P < 0.05).

CONCLUSION

Incidence of the SIJ dysfunction after lumbosacral fusion surgery was 3.9% and these patients had a significantly lower PT and L5 incidence compared to the control group. Significantly low PT may be derived from weak hamstring muscles, predisposing a patient to SIJ dysfunction. Therefore, hamstring muscle strengthening exercise for patients with decreased PT after lumbosacral fusion may decrease the incidence of SIJ dysfunction.Level of Evidence: 3.

A Current Update on Pelvifemoral Conditions That Should be in the Differential Diagnosis for Patients With Lower Extremity Radiculopathy

Patients presenting to an outpatient spine clinic frequently report symptoms of low back pain with associated buttock, groin, and lower extremity pain. While many of these individuals suffer from lumbar spine radiculopathy, a number of different orthopedic pathologies can mimic these symptoms. Management depends substantially on a detailed history and physical examination, in addition to working from a broad list of differential diagnoses when evaluating these patients. It is imperative that spine practitioners have a comprehensive understanding of the differential diagnoses that may mimic those originating from the lumbar spine, especially when a patient's symptoms are atypical from classic radicular pain. Misdiagnosis can lead to unnecessary testing and treatment, while delaying an accurate clinical assessment and treatment plan. This review highlights common orthopedic diagnoses that may present similar to lumbar spine pathologies and the evidence-based evaluation of these conditions.

Sacroiliac joint degeneration is common in patients with end-stage hip osteoarthritis secondary to unilateral developmental dysplasia of the hip: Factors associated with its severity and laterality

BACKGROUND

The etiology of sacroiliac joint (SIJ) degeneration has not been fully elucidated, and there has been almost no report on the relevance between SIJ degeneration and hip osteoarthritis secondary to developmental dysplasia of the hip (DDH). We investigated factors associated with SIJ degeneration, specifically its laterality in patients with end-stage hip osteoarthritis secondary to unilateral DDH.

METHODS

We included 152 patients with end-stage unilateral hip osteoarthritis secondary to DDH who underwent primary THA between January 2008 and November 2015. SIJ degeneration was classified (type 0, no degenerative change, to type 3, ankyloses) using preoperative axial computed tomography. SIJ degeneration of the DDH (shorter leg) and contralateral (longer leg) sides was compared; differences in patient demographics and radiological parameters between SIJ degeneration of type 0 or 1 versus type 2 or 3 for the shorter and longer leg sides were analyzed.

RESULTS

SIJ on the longer leg side showed more degenerative changes (p < 0.001). Substantial SIJ degeneration or ankylosis (type 2 or 3) was observed on 62.5% of longer leg sides and 33.6% of shorter leg sides. Factors significantly associated with SIJ degeneration severity were percent hip subluxation and leg length discrepancy for the longer leg side and body weight and body mass index (BMI) for the shorter leg side. Patients with worse degeneration on the shorter leg side (9.9%) had significantly larger BMI and longer sagittal vertical axis, whereas patients with worse degeneration on the longer leg side (46.7%) had significantly longer leg length discrepancy.

CONCLUSION

Severe SIJ degeneration was common in patients with end-stage hip osteoarthritis secondary to unilateral DDH. Patients with worse SIJ degeneration on the longer leg side had more hip subluxation, whereas patients with worse SIJ degeneration on the shorter leg (DDH) side tended to have sagittal spinal imbalance and greater body weight with larger BMI.

International Society for the Advancement of Spine Surgery Policy 2020 Update-Minimally Invasive Surgical Sacroiliac Joint Fusion (for Chronic Sacroiliac Joint Pain): Coverage Indications, Limitations, and Medical Necessity

The index 2014 International Society for the Advancement of Spine Surgery Policy Statement-Minimally Invasive Surgical Sacroiliac Joint Fusion-was generated out of necessity to provide an International Classification of Diseases, Ninth Revision (ICD-9)-based background and emphasize tools to ensure correct diagnosis. A timely ICD-10-based 2016 update provided a granular threshold selection with improved level of evidence and a more robust and relevant database (Appendix Table A1). As procedures and treatment options have evolved, this 2020 update reviews and analyzes the expanding evidence base and provides guidance relating to differences between the lateral and dorsal surgical procedures for minimally invasive surgical sacroiliac joint fusion.

Sacroiliac joint fusion VS conservative management for chronic low back pain attributed to the sacroiliac joint: A protocol for systematic review and meta analysis

INTRODUCTION

Low back pain (LBP) is high prevalent and it is the leading cause of years lived with disability in both developed and developing countries. The sacroiliac joint (SIJ) is a common reason that caused LBP. At present, the treatment of chronic LBP attributed to SIJ is mainly conservative treatment and surgical treatment. However, there are still controversies between the 2 treating methods, and there is no recognized standard of treatment or surgical indications. Recent publications indicated that minimally invasive sacroiliac joint arthrodesis was safe and more effective improving pain, disability, and quality of life compared with conservative management in 2 years follow-up, which re-raise the focus of sacroiliac joints fusion. This paper will systematically review the available evidence, comparing the effectiveness of sacroiliac joint fusion and conservative therapy for the treatment of gait retraining for patients suffered from LBP attributed to the sacroiliac joint.

METHOD AND ANALYSIS

A systematic review and meta-analysis of relevant studies in Pubmed, Embase, SCOPUS, and Cochrane Library will be synthesized. Inclusion criteria will be studies evaluating clinical outcomes (i.e., changes to pain and/or function) comparing sacroiliac joint fusion and conservative therapy in populations sacroiliac join related LBP; studies with less than 10 participants in total will be excluded. The primary outcomes measured will be pain score, Oswestry Disability Index (ODI), and adverse events during treatment. Review Manager (Revman; Version 5.3) software will be used for data synthesis, sensitivity analysis, meta-regression, subgroup analysis, and risk of bias assessment. A funnel plot will be developed to evaluate reporting bias and Begg and Egger tests will be used to assess funnel plot symmetries. We will use the Grading of Recommendations Assessment, Development and Evaluation system to assess the quality of evidence.

ETHICS AND DISSEMINATION

Our aim is to publish this systematic review and meta-analysis in a peer-reviewed journal. Our findings will provide information comparing the efficacy and safety comparing sacroiliac joint fusion and non-surgical treatment for patients with LBP attributed to the sacroiliac joint. This review will not require ethical approval as there are no issues about participant privacy.

Biomechanics of the Sacroiliac Joint: Surgical Treatments

BACKGROUND

Fixation is one of the most common surgical techniques for the treatment of chronic pain originating from the sacroiliac joint (SIJ). Many studies have investigated the clinical outcomes and biomechanics of various SIJ surgical procedures. However, the biomechanical literature points to several issues that need to be further explored, especially for the devices used in minimally invasive surgery of the SIJ. This study (part II) aims to assess biomechanical literature to understand the existing information as it relates to efficacies of the surgical techniques and the gaps in the knowledge base. Part I reviewed basic anatomy and mechanics of the SIJ joint, including difference between males and females, and causes of pain emanating from these joints.

METHODS

A thorough literature review was performed pertaining to studies related to SIJ fixation techniques and the biomechanical outcomes of the surgical procedures.

RESULTS

Fifty-five studies matched the search criteria and were considered for the review. These articles predominantly pertained to the biomechanical outcomes of the minimally invasive surgery with different instrumentation systems and surgical settings.

CONCLUSIONS

The SIJ is one of the most overlooked sources of lower back pain. The joint is responsible for the pain in 15% to 30% of people suffering from lower back pain. Various studies have investigated the clinical outcomes of different surgical procedures intended to improve the pain and quality of life following surgery. The data show that these techniques are indeed effective. However, clinical studies have raised several issues, like optimal number and positioning of implants, unilateral versus bilateral placements, adjacent segment disease, implant designs, and optimal location of implants with respect to variations in bone density across the SIJ. Biomechanical studies using in vitro and in silico techniques have addressed some of these issues. Studies also point out the need for additional investigations for a better understanding of the underlying mechanics for the improved long-term surgical outcomes. Further long-term clinical follow-ups are essential as well. This review presents pertinent findings.

Biomechanical analysis of two insertion sites for the fixation of the sacroiliac joint via an oblique lateral approach

BACKGROUND

The sacroiliac joint is an important source of low back pain. In severe cases, sacroiliac joint fusion is used to reduce pain, but revision rates can reach 30%. The lack of initial mechanical stability may lead to pseudarthrosis, thus not alleviating the patient's symptoms. This could be due to the damage induced to the interosseous ligament during implant insertion. Decoupling instrumentation steps (drilling-tapping and implant insertion) would allow verifying this hypothesis. Moreover, no biomechanical studies have been published on sacroiliac joint fixation with an oblique lateral approach, while it has important clinical advantages over the direct lateral approach.

METHODS

Eight cadaveric human pelves with both ischia embedded were tested in three sequential states: intact, drilled-tapped and instrumented with one cylindrical threaded implant with an oblique lateral trajectory. Specimens were assigned one of two insertion sites (distal point; near the posterior superior iliac spine, and proximal point; anterosuperior to the distal point) and tested in compression and flexion-extension. Vertical and angular displacements of the sacroiliac joint were measured locally using digital image correlation methods.

FINDINGS

In compression, instrumentation significantly reduced vertical displacements (17% (SD 22%), P = 0.04) but no difference was found for angular displacements or flexion-extension loads (P > 0.05). Drilling-tapping did not change the stability of the sacroiliac joint (P > 0.05); there was no statistical difference between the insertion sites (P > 0.05).

INTERPRETATIONS

Insertion of one implant through either the distal or proximal insertion site with an oblique lateral approach significantly reduced vertical displacements of the sacroiliac joint in compression, a predominant load of this joint.

RESEARCH ETHICS COMMITTEE

Polytechnique Montreal: CÉR-1617-30.

Inaccuracies in the Use of the Majeed Pelvic Outcome Score: A Systematic Literature Review

OBJECTIVES

To evaluate the accuracy with which the Majeed Pelvic Score has been reported in the English literature.

DATA SOURCES

Databases used to search for literature were PubMed, Embase, and Ovid, restricted to English language from inception to October 2, 2018.

STUDY SELECTION

Search words used were: Majeed, pelvis, and outcome.

DATA EXTRACTION

Articles were assessed for descriptions of scoring and proper reporting of Majeed Pelvic Outcome Score.

DATA SYNTHESIS

Descriptive statistics were used to report the outcome of our findings.

CONCLUSIONS

Ninty-two English articles were identified. Twenty-four (26%) articles were identified as including methodology related to the use and scoring of the Majeed Pelvic score. The remaining 68 presented mean Majeed scores with no methodological information. None (0/92) discussed how the range of possible scores for the most severe function was applied. Six (7%) reported adjusted scores for patients not working. Three (3%) included a discussion of the scores as adjusted for patients working before injury compared with those not working. Ten (11%) addressed the categorization of scores by excellent to poor describing what raw scores defined those categories. We observed poor accuracy and notable inconsistency in the use and reporting of the Majeed Pelvic Outcome Score in the literature. These data demonstrate that interpretation and comparison of research reporting this score should be done cautiously. Future studies should include specific information as to how the Majeed instrument calculated to allow for verification of the presented scores and subsequent conclusions.

Biomechanics of the Sacroiliac Joint: Anatomy, Function, Biomechanics, Sexual Dimorphism, and Causes of Pain

BACKGROUND

The sacroiliac joints (SIJs), the largest axial joints in the body, sit in between the sacrum and pelvic bones on either side. They connect the spine to the pelvis and thus facilitate load transfer from the lumbar spine to the lower extremities. The majority of low back pain (LBP) is perceived to originate from the lumbar spine; however, another likely source of LBP that is mostly overlooked is the SIJ. This study (Parts I and II) aims to evaluate the clinical and biomechanical literature to understand the anatomy, biomechanics, sexual dimorphism, and causes and mechanics of pain of the SIJ leading to conservative and surgical treatment options using instrumentation. Part II concludes with the mechanics of the devices used in minimal surgical procedures for the SIJ.

METHODS

A thorough review of the literature was performed to analyze studies related to normal SIJ mechanics, as well as the effects of sex and pain on SIJ mechanics.

RESULTS

A total of 65 studies were selected related to anatomy, biomechanical function of the SIJ, and structures that surround the joints. These studies discussed the effects of various parameters, gender, and existence of common physiological disorders on the biomechanics of the SIJ.

CONCLUSIONS

The SIJ lies between the sacrum and the ilium and connects the spine to the pelvic bones. The SIJ transfers large bending moments and compression loads to lower extremities. However, the joint does not have as much stability of its own against the shear loads but resists shear due the tight wedging of the sacrum between hip bones on either side and the band of ligaments spanning the sacrum and the hip bones. Due to these, sacrum does not exhibit much motion with respect to the ilium. The SIJ range of motion in flexion-extension is about 3°, followed by axial rotation (about 1.5°), and lateral bending (about 0.8°). The sacrum of the female pelvis is wider, more uneven, less curved, and more backward tilted, compared to the male sacrum. Moreover, women exhibit higher mobility, stresses/loads, and pelvis ligament strains compared to male SIJs. Sacroiliac pain can be due to, but not limited to, hypo- or hypermobility, extraneous compression or shearing forces, micro- or macro-fractures, soft tissue injury, inflammation, pregnancy, adjacent segment disease, leg length discrepancy, and prior lumbar fusion. These effects are well discussed in this review. This review leads to Part II, in which the literature on mechanics of the treatment options is reviewed and synthesized.

A biomechanical investigation of the sacroiliac joint in the setting of lumbosacral fusion: impact of pelvic fixation versus sacroiliac joint fixation

OBJECTIVE

The sacroiliac joint (SIJ) is a known source of low-back pain. Randomized clinical trials support sacroiliac fusion over conservative management for SIJ dysfunction. Clinical studies suggest that SIJ degeneration occurs in the setting of lumbosacral fusions. However, there are few biomechanical studies to provide a good understanding of the effect of lumbosacral fusion on the SIJ. In the present study, researchers performed a biomechanical investigation to discern the effect of pelvic versus SIJ fixation on the SIJ in lumbosacral fusion.

METHODS

Seven fresh-frozen human cadaveric specimens were used. There was one intact specimen and six operative constructs: 1) posterior pedicle screws and rods from T10 to S1 (PS); 2) PS + bilateral iliac screw fixation (BIS); 3) PS + unilateral iliac screw fixation (UIS); 4) PS + UIS + 3 contralateral unilateral SIJ screws (UIS + 3SIJ); 5) PS + 3 unilateral SIJ screws (3SIJ); and 6) PS + 6 bilateral SIJ screws (6SIJ). A custom-built 6 degrees-of-freedom apparatus was used to simulate three bending modes: flexion-extension (FE), lateral bending (LB), and axial rotation (AR). Range of motion (ROM) was recorded at L5-S1 and the SIJ.

RESULTS

All six operative constructs had significantly reduced ROM at L5-S1 in all three bending modes compared to that of the intact specimen (p < 0.05). In the FE mode, the BIS construct had a significant reduction in L5-S1 ROM as compared to the other five constructs (p < 0.05). SIJ ROM was greatest in the FE mode compared to LB and AR. Although the FE mode did not show any statistically significant differences in SIJ ROM across the constructs, there were appreciable differences. The PS construct had the highest SIJ ROM. The BIS construct reduced bilateral SIJ ROM by 44% in comparison to the PS construct. The BIS and 6SIJ constructs showed reductions in SIJ ROM nearly equal to those of the PS construct. UIS and 3SIJ showed an appreciable reduction in unfused SIJ ROM compared to PS.

CONCLUSIONS

This investigation demonstrated the effects of various fusion constructs using pelvic and sacroiliac fixation in lumbosacral fusion. This study adds biomechanical evidence of adjacent segment stress in the SIJ in fusion constructs extending to S1. Unilateral pelvic fixation, or SIJ fusion, led to an appreciable but nonsignificant reduction in the ROM of the unfused contralateral SIJ. Bilateral pelvic fixation showed the greatest significant reduction of movement at L5-S1 and was equivalent to bilateral sacroiliac fusion in reducing SIJ motion.

Technical variation of trans-articular sacroiliac joint (SIJ) fusion using three screws considering the effects of sacral dysplasia in patients with non-traumatic SIJ pain

Background

This study evaluated the technical adequacy of trans-articular sacroiliac joint (SIJ) fusion using three screws for non-traumatic SIJ pain, considering different grades of sacral dysplasia.

Methods

Cadaveric CT data of unilateral sacropelvic complexes for 72 individuals (53.4 ± 8.4 years) were selected. A 3D model was reformatted into the plain lateral radiograph to mark the articular surface of the SIJ. Subjects were classified into dysplastic (DYS) and non-dysplastic sacrum (NDS) groups. Proximal (PS), middle (MS), and distal screws (DS) with 10-mm diameter were virtually introduced to the iliac bone and the SIJ on the lateral image with a 5-mm safety margin. On a corresponding axial image, each screw was advanced vertically to the sagittal plane with the same safety margin. The entry points for each screw to the endplate of S1 (S2) and to the corresponding anterior sacral margin on the lateral image were measured, along with the maximal screw lengths on the axial image. Whether each screw passed through the SIJ was determined. Different types of sacral dysplasia and screws were compared statistically.

Results

Thirty-eight (26.4%) cases were DYS, and 106 (73.6%) were NDS. The entry points of all screws were significantly more distal in DYS than in NDS groups. The PS and MS screw lengths differed significantly between the 2 groups. Incidences of short sacral fixation (< 10 mm) were significantly higher for the DS in both NDS (38.7%) and DYS (39.5%) groups. Incidences of screw pass were lowest for the MS in both NDS (43.4%) and DYS (47.4%) groups.

Conclusions

Sacral dysplasia locates the SIJ more distally and therefore affects the entry point locations and screw lengths for all screws in trans-articular SIJ fusion, compared with a non-dysplastic sacrum. Moreover, three-screw fixation risks the development of unstable DS fixation and a high extra-articular fixation rate in MS.

Re-examining the Spectrum of Lumbosacral Transitional Dysmorphisms: Quantifying Joint Asymmetries and Evaluating the Anatomy of Screw Fixation Corridors

Objective

Although a wide range of sacral dysmorphisms has been documented with lumbosacral transitional vertebrae (LSTV) variations, quantitative characterization of the upper segment morphology and articular anatomy across the array of lumbosacral transitions are hardly found in the literature. This study presents LSTV anomalies as a series of sequential morphological changes (the LSTV spectrum) and quantitatively compares 6 LSTV subtypes with normative sacral dimensions including the anatomy at the upper sacral segments used for percutaneous sacroiliac screw insertion.

Methods

Seven linear dimensions were measured from LSTV subtypes and normal sacral variants from dried adult sacral specimens. The auricular, superior articular and facet surface areas were quantified. Obliquity and thickness of osseous corridors used for sacroiliac screw fixation were measured. Data were statistically compared within and between LSTV subtypes and the normal variants.

Results

LSTVs presented a wide range of morphometric differences in comparison to the normal bones. Grouping LSTV according to auricular surface positions (high, normal, and low) demonstrated significant between-group differences in the obliquity and thickness at the S1 and S2 segmental corridors.

Conclusion

Frequent occurrence of LSTV in the general population may require evaluation of anatomical parameters in these variations for safe sacroiliac instrumentation around this region.

Predictors of Outcome in Conservative and Minimally Invasive Surgical Management of Pain Originating From the Sacroiliac Joint: A Pooled Analysis

STUDY DESIGN

A pooled patient-level analysis of two multicenter randomized controlled trials and one multicenter single-arm prospective trial.

OBJECTIVE

The aim of this study was to identify predictors of outcome of conservative and minimally invasive surgical management of pain originating from the sacroiliac joint (SIJ).

SUMMARY OF BACKGROUND DATA

Three recently published prospective trials have shown that minimally invasive SIJ fusion (SIJF) using triangular titanium implants produces better outcomes than conservative management for patients with pain originating from the SIJ. Due to limitations in individual trial sample size, analyses of predictors of treatment outcome were not conducted.

METHODS

We pooled individual patient data from the three trials and used random effects models with multivariate regression analysis to identify predictors for treatment outcome separately for conservative and minimally invasive surgical treatment. Outcome was measured using visual analogue scale (VAS), Oswestry Disability Index (ODI), and EuroQOL-5D (EQ-5D).

RESULTS

We included 423 patients assigned to either nonsurgical management (NSM, n = 97) or SIJF (n = 326) between 2013 and 2015. The reduction in SIJ pain was 37.9 points larger [95% confidence interval (95% CI) 32.5-43.4, P < 0.0001] in the SIJF group than in the NSM group. Similarly, the improvement in ODI was 18.3 points larger (95% CI 14.3-22.4), P < 0.0001). In NSM, we found no predictors of outcome. In SIJF, a reduced improvement in outcome was predicted by smoking (P = 0.030), opioid use (P = 0.017), lower patient age (P = 0.008), and lower duration of SIJ pain (P = 0.028).

CONCLUSIONS

Our results support the view that SIJF leads to better treatment outcome than conservative management of SIJ pain and that a higher margin of improvement can be predicted in nonsmokers, nonopioid users, and patients of increased age and with longer pain duration.

LEVEL OF EVIDENCE

1.

The Assessment of Fusion Following Sacroiliac Joint Fusion Surgery

Sacroiliac joint fusions (SIJF) have been the subject of many research studies. The technical success of an SIJF is in part determined by whether osseous bridging occurs across the sacroiliac joint (SIJ). However, no validated SIJF assessment method has been described. Our objective was to document previously described SIJF assessment methods and define and validate a detailed assessment system for SIJF. Our results are only intended to establish computed tomography (CT)-based guidelines for SIJF to be used in a subsequent large clinical study to correlate them with clinical outcomes.

The SIJF literature was reviewed to document previous descriptions of SIJF assessments. A detailed system was then developed for assessing SIJF from CT exams. To provide data that can be used to address a range of research questions, the system included assessing bridging bone relative to the SIJ anatomy, bridging bone immediately adjacent to the threaded implants crossing the joint, as well as bridging bone close to but not immediately adjacent to the implants. The system was applied to assessing SIJF from thin-slice CT exams in 19 patients 12 months following surgery. Two experienced radiologists implemented the assessment system, and in the event of a disagreement, an adjudicator was used.

Most prior studies provide very little detail about how SIJF was assessed. Using the new assessment system, the agreement between the primary readers was substantial (0.67 using Gwet’s AC1 statistic). Bridging bone representing a fusion of the SIJ was identified in most patients both immediately adjacent to the threaded implants crossing the joint, as well as distant to the implants.

A detailed radiographic assessment system proved to be applicable to SIJF. The assessment system includes explicit language describing the location and extent of bridging bone across the SIJ. Standardization of the assessment of the SIJFs may allow for a more meaningful comparison of data between studies.

Emerging Techniques in Degenerative Thoracolumbar Surgery

There continue to be incremental advances in thoracolumbar spine surgery techniques in attempts to achieve more predictable outcomes, minimize risk of complications, speed recovery, and minimize the costs of these interventions. This paper reviews recent literature with regard to emerging techniques of interest in the surgical treatment of lumbar spinal stenosis, fusion fixation and graft material, degenerative lumbar spondylolisthesis, and thoracolumbar deformity and sacroiliac joint degeneration. There continue to be advances in minimal access options in these areas, although robust outcome data are heterogeneous in its support. The evidence in support of sacroiliac fusion appears to be growing more robust in the properly selected patient.

Patient Reported Outcomes from Sacroiliac Joint Fusion

STUDY DESIGN

Retrospective, case series.

PURPOSE

The purpose of this study is to determine morbidity, complications, and patient reported outcomes from minimally invasive sacroiliac joint (SIJ) fusion.

OVERVIEW OF LITERATURE

Lumbar back pain emanating from the SIJ can be surgically treated via a percutaneous approach in the appropriately selected patient with minimal morbidity and acceptable functional outcomes.

METHODS

Patients diagnosed by >2 physical examination maneuvers and subjective relief from a computed tomography-guided lidocaine-bupivacaine-steroid injection underwent SIJ fusion after failing conservative management with a combination of oral anti-inflammatory medications, physical therapy, and pelvic belt stabilization. Perioperative data collected include estimated blood loss (EBL) and operative time. Oswestry disability index, 12-item short form health survey (SF-12), visual analogue score, and functional status were analyzed. All complications were noted.

RESULTS

The study cohort of 45 cases (69% female) achieved postoperative survey follow-up at 9.9 and 32.3 months. SF-12 physical component summary statistically improved while all other scores were equivalent. Mean EBL and operative time were 22 mL and 36 minutes, respectively. Initial survey showed that 64% of patients discontinued narcotics (29/45), 71% do not use an assistive device (32/45), and 15.6% do not work due to pain (7/45). 73% of patients stated they would have the surgery again (33/45). For the second survey, 65% of patients discontinued narcotics (26/40), 70% did not use an assistive device (28/40), and 17.5% did not work due to pain (7/40). A history of thoracolumbar instrumentation (16/45) did not significantly affect outcomes. Three complications described by screw malposition with neurologic deficit (6.7%) were treated with screw repositioning (1 case) and removal of a single superior implant (2 cases) with time to revision of 2.2 months. All three ultimately had resolution of radicular pain.

CONCLUSIONS

Percutaneous SIJ fusion offers minimal morbidity and acceptable functional outcomes. While women and those with a prior history of lumbar instrumentation may be at increased risk of having SIJ dysfunction requiring surgical intervention, it was not found to affect postoperative functional outcomes when compared to the non-instrumented group.

ISASS Policy 2016 Update - Minimally Invasive Sacroiliac Joint Fusion

The index 2014 ISASS Policy Statement - Minimally Invasive Sacroiliac Joint Fusion was generated out of necessity to provide an ICD9-based background and emphasize tools to ensure correct diagnosis. A timely ICD10-based 2016 Update provides a granular threshold selection with improved level of evidence and a more robust, relevant database.

Six-month outcomes from a randomized controlled trial of minimally invasive SI joint fusion with triangular titanium implants vs conservative management

PURPOSE

To compare the safety and effectiveness of minimally invasive sacroiliac joint fusion (SIJF) using triangular titanium implants vs conservative management (CM) in patients with chronic sacroiliac joint (SIJ) pain.

METHODS

103 adults with chronic SIJ pain at nine sites in four European countries were randomly assigned to and underwent either minimally invasive SIJF using triangular titanium implants (N = 52) or CM (N = 51). CM was performed according to the European guidelines for the diagnosis and management of pelvic girdle pain and consisted of optimization of medical therapy, individualized physical therapy (PT) and adequate information and reassurance as part of a multifactorial treatment. The primary outcome was the difference in change in self-rated low back pain (LBP) at 6 months. Additional endpoints included quality of life using EQ-5D-3L, disability using Oswestry Disability Index (ODI), SIJ function using active straight leg raise (ASLR) test and adverse events. NCT01741025.

RESULTS

At 6 months, mean LBP improved by 43.3 points in the SIJF group and 5.7 points in the CM group (difference of 38.1 points, p < 0.0001). Mean ODI improved by 26 points in the SIJF group and 6 points in the CM group (p < 0.0001). ASLR, EQ-5D-3L, walking distance and satisfaction were statistically superior in the SIJF group. The frequency of adverse events did not differ between groups. One case of postoperative nerve impingement occurred in the surgical group.

CONCLUSIONS

In patients with chronic SIJ pain, minimally invasive SIJF using triangular titanium implants was safe and more effective than CM in relieving pain, reducing disability, improving patient function and quality of life.