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

Management of sacroiliac joint pain: current concepts

INTRODUCTION

Managing sacroiliac joint (SIJ) pain is challenging and unpredictable. There are no internationally accepted recommendations. In light of the lack of global consensus and guidelines and the ongoing advancements in management options, a widely accepted treatment algorithm remains absent. This systematic review updates and evaluates the existing evidence on strategies for managing SIJ pain.

METHODS

This study followed the guidelines defined in the 2020 PRISMA statement. All clinical studies concerning the clinical management of SIJ pain were considered. Web of Science, PubMed, and Embase were accessed in January 2025 without additional filters or temporal constraints. The risk of bias evaluation and statistical analysis followed the guidelines described in the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Fifteen randomised controlled trials, 13 clinical trials, and 10 retrospective studies were included. Data from 2666 patients (1429 women) were retrieved. The mean length of follow-up was 14.7 ± 15.2 months. The mean age was 54.0 ± 5.8 years, and the mean BMI was 28.5 ± 2.5 kg/m2. Non-surgical options primarily focus on physical therapy to relieve discomfort. Different medications aim to decrease inflammation and pain at the SIJ. Fluoroscopically guided SIJ injections allow for directly administering steroids or mesenchymal stem cells into the joint. Radiofrequency denervation is frequently used to address SIJ pain, while surgical fusion is usually reserved for cases where conservative treatment is ineffective.

CONCLUSION

Managing SIJ pain is challenging due to limited and inconsistent evidence. Treatment progresses from conservative options, physiotherapy, lifestyle changes, and non-steroidal anti-inflammatory drugs to more invasive approaches like injections, radiofrequency denervation, and, in severe cases, surgical management. Research limitations include small sample sizes, short follow-ups, and inconsistent methodologies. Future high-quality studies are needed to establish clear diagnostic and treatment guidelines, compare techniques, and explore new therapies like regenerative medicine.

Biomechanical study and preliminary application of percutaneous retrograde sacral alar-iliac screw for fixation of sacroiliac joint with low bone density

BACKGROUND

The Sacral alar-iliac screw (SAIS) has stronger stability for sacroiliac joint fixation compared to the classical sacroiliac screw, making it particularly suitable for osteoporotic patients. However, the spinous process can hinder its percutaneous implantation. To address this, we developed a percutaneous retrograde SAIS (RSAIS) technique. This study aimed to explore the stability and preliminary application effects of percutaneous RSAIS for fixation of sacroiliac joint with low bone density.

METHODS

A Tile type C fracture was simulated in fifteen artificial pelvises with low bone density and assigned to three groups. Each group received posterior fixation using one of the following: one sacroiliac screw (SIS) on each side, one transsacral-transiliac screw (TSTIS) on both sides, or one RSAIS on each side. Axial stiffness and maximum load to failure were analyzed. Additionally, two patients with sacroiliac joint pain (SIJP) and three patients with Tile type C pelvic fractures were treated with percutaneous RSAIS fixation. Four males and one female, aged 56 to 68 years with a T-value of -1.6 to -2.5 SD. The study observed screw insertion time, X-ray fluoroscopy time, screw position (Smith criterion), pain (VAS), and functional recovery (ODI and Majeed scores).

RESULTS

RSAIS stiffness and maximum load were significantly greater than those of TSTIS and SIS (p < 0.05). The average insertion time was 30 min, intraoperative bleeding averaged 16 ml, and fluoroscopy time was 55 s per RSAIS placement. There were no surgery-related complications, and all screw positions were excellent. At 7-20 months postoperative follow-up, the VAS score recovered from preoperative 5.6-1.6, the ODI improved from 50.4 to 17, and the Majeed score for patients with pelvic fractures recovered from 59.7 to 81. No screw loosening was observed.

CONCLUSION

RSAIS fixation stability for sacroiliac joints with low bone density is superior to SIS and TSTIS. The screw placement is simple, safe, and provides satisfactory therapeutic effects, making it suitable for patients with low bone density.

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.

Injective Treatments for Sacroiliac Joint Pain: A Systematic Review and Meta-analysis

Background

The most effective injective treatment approach for sacroiliac joint (SIJ) pain remains unclear. Aim of this study was to quantify the safety and effectiveness of the available injective strategies to address SIJ pain.

Methods

A systematic review and meta-analysis of the literature was conducted on PubMed, Scopus, and Embase databases from inception until January 2023. Inclusion criteria were studies written in English, comparative and non-comparative studies regardless of the minimum follow-up, and case series on SIJ injections. Safety and efficacy of the different injection therapies for the SIJ were quantified. A meta-analysis was conducted on the available data of the documented injective therapies. The "Checklist for Measuring Quality" by Downs and Black was used to assess the risk of bias and the quality of papers.

Results

The literature search retrieved 43 papers (2431 patients): 16 retrospective case series, 2 retrospective comparative studies, 17 prospective case series, 3 prospective comparative studies, and 5 randomized controlled trials. Of the selected studies, 63% examined the effect of steroid injections, 16% of PRP injections, while 21% reported other heterogeneous treatments. The failure rate was 26% in steroid injections and 14% in PRP injections. The meta-analysis showed a statistically significant reduction in pain with the VAS score for both steroids and PRP: steroids improvement at mid-term 3.4 points (p < 0.05), at long-term 3.0 (p < 0.05), PRP improvement at mid-term 2.2 (p = 0.007), at long-term 2.3 points of the VAS pain scale (p = 0.02).

Conclusions

Steroids are the most documented injective approach, with studies showing an overall safety and effectiveness. Still, the high number of failures underlined by some studies suggest the need for alternative procedures. Early PRP data showed promise, but the limitations of the current literature do not allow to clearly define the most suitable injective approach, and further studies are needed to identify the best injective treatment for SIJ patients.

Comparative Efficacy of Clinical Interventions for Sacroiliac Joint Pain: Systematic Review and Network Meta-analysis With Preliminary Design of Treatment Algorithm

OBJECTIVE

We aimed to identify the most effective clinical treatment method for sacroiliac joint (SIJ)-related pain based on the systematic review and network meta-analysis (NMA) to evaluate the comparative efficacy of clinical interventions for sacroiliac joint pain by pooling the randomized controlled trials (RCTs).

METHODS

Our team conducted a systematic review and NMA of RCTs to determine the most effective clinical treatment for SIJ-related pain. We searched the PubMed (MEDLINE), Web of Science, Cochrane Library, and Scopus databases for RCTs until February 2023. The PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines were followed. Pairwise and network meta-analyses were conducted using a random effects model.

RESULTS

Based on the search strategy and inclusion criteria, our systematic review and NMA included 9 randomized studies with 652 participants. Research has mainly focused on various radiofrequency sources, but their number is still low. In the network analysis, according to the NMA and mean ranking probabilities for the improvement of pain intensity (PI) and quality of life (QoL), sacroiliac joint fusion and cooled radiofrequency were associated with high treatment rank for improving PI and QoL in patients with sacroiliac joint pain.

CONCLUSION

This NMA suggest that SIJ fusion and cooled radiofrequency could be potential options for improving the QoL and relieving pain in patients with SIJ-related pain. Comparison studies of outcomes between these 2 procedures with solid methodology and a low risk of bias would be very beneficial to identify the optimal treatment option for this challenging disease.

Sacroiliac joint degeneration in degenerative lumbar spondylolisthesis and related risk factors: a retrospective study

OBJECTIVE

This study was performed to evaluate the degree of radiological sacroiliac joint (SIJ) degeneration in patients with degenerative lumbar spondylolisthesis (DLS). The related risk factors for SIJ degeneration were also investigated.

METHODS

We retrospectively analyzed the lumbar and pelvic computed tomography (CT) scans of 303 patients with DLS admitted from January 2018 to December 2021. One hundred and fifty-six age-, gender-, and body mass index-matched patients without lumbar anomality who underwent lower abdominal or pelvic computed tomography scans were included in the control group. Sagittal parameters were measured on full-length lateral radiographs. Two protocols (Backlund's grade and Eno's classification) were used to assess SIJ degeneration. Univariate analysis and bivariate and multivariate regression analysis were performed to identify the factors affecting SIJ degeneration in patients with DLS.

RESULTS

According to Backlund's grade and Eno's classification, SIJ degeneration was more severe in the DLS group than in the control group (P < 0.001). Multi-segment degenerative changes (P = 0.032), two-level DLS (P = 0.033), a history of hysterectomy (P < 0.001), lower extremity pain (P = 0.016), and pelvic pain (P = 0.013) were associated with more significant SIJ degeneration as assessed by Backlund's grade. The results of Pearson's correlation analysis showed positive correlation between the sagittal vertical axis and SIJ degeneration (r = 0.232, P = 0.009). The multivariate linear regression analysis showed that a history of hysterectomy was significantly correlated with SIJ degeneration in patients with DLS (r = 1.951, P = 0.008).

CONCLUSIONS

SIJ degeneration was more severe in patients with than without DLS. We should take SIJ degeneration into consideration when diagnosing and treating DLS especially those who had undergone previous hysterectomy or showed sagittal malalignment.

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.