Impact of sacropelvic fixation on the development of postoperative sacroiliac joint pain following multilevel stabilization for degenerative spine disease

Randomized Trial of Augmented Pelvic Fixation in Patients Undergoing Thoracolumbar Fusion for Adult Spine Deformity: Initial Results from a Multicenter Randomized Trial

BACKGROUND

The optimal configuration for spinopelvic fixation during multilevel spine fusion surgery for adult spine deformity remains unclear. Postoperative sacroiliac (SI) joint pain, S2AI screw loosening and implant breakage could be related to continued motion of the SI joint with use of only a single point of fixation across the SI joint.

METHODS

Prospective, international, multicenter randomized controlled trial of 222 patients with adult spine deformity scheduled for multilevel (4 or more levels) spine fusion surgery with pelvic fixation. Subjects were randomized to sacroalar (S2) iliac (S2AI) screws alone for pelvic fixation or S2AI + triangular titanium implants placed cephalad to S2AI screws. Quad rod techniques were not allowed or used. Baseline spinal deformity measures were read by an independent radiologist. Site-reported perioperative adverse events were reviewed by a clinical events committee. Quality of life questionnaires and other clinical outcomes are in process with planned 2-year follow-up.

RESULTS

One hundred thirteen participants were assigned to S2AI and 109 to S2AI + titanium triangular implants (TTI). 35/222 (16%) of all subjects had a history of SI joint pain or were diagnosed with SI joint pain during preoperative workup. Three-month follow-up was available in all but 4 subjects. TTI placement was successful in 106 of 109 (98%) subjects assigned to TTI. In 2 cases, TTI could not be placed due to anatomical considerations. Three TTI ventral iliac breaches were observed, all of which were managed non-surgically. One TTI subject had a transverse sacral fracture and 1 TTI subject had malposition of the implant requiring removal.

CONCLUSIONS

SI joint pain is common in patients with adult spinal deformity who are candidates for multilevel spine fusion surgery. Concurrent placement of TTI parallel to S2AI screws during multilevel spine fusion surgery is feasible and safe. Further follow-up will help to determine the clinical value of this approach to augment pelvic fixation.

A New Approach to the Treatment of Sacroiliac Joint Pain and First Patient-Reported Outcomes Using a Novel Arthrodesis Technique for Sacroiliac Joint Fusion

Purpose

To report the development of a new sacroiliac joint (SIJ) arthrodesis system that can be used for isolated fusion of the SIJ and, unlike known implant systems, in combination with lumbar instrumentation or as an alternative to existing sacropelvic fixation (SPF) methods, and the patient-reported outcomes in two cases.

Materials and Methods

After a comprehensive review of 207 pelvic computed tomography (CT) datasets, an implant body was designed. Its shape was modeled based on the SIJ recess. A screw anchored in the ilium secures the position of the implant and allows connection to lumbar instrumentation. Two patients with confirmed SIJ syndrome underwent surgery with the anatomically adapted implant. They were evaluated preoperatively, 6 months, and 12 months postoperatively. Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), Million Visual Analogue Scale (MVAS), Roland Morris Score (RMS), reduction of SIJ/leg pain, and work status were assessed. Bony fusion of the SIJ was evaluated by radiographs and CT 12 months after the procedure.

Results

Analysis of pelvic CT data revealed a wedge-shaped implant body in four different sizes. In the two patients, VAS decreased from 88 to 33 points, ODI improved from 67 to 35%, MVAS decreased from 80 to 36%, and RMS decreased from 18 to 9 points 12 months after surgery. SIJ pain reduction was 80% and 90%, respectively. Follow-up CT and radiographs showed solid bony integration.

Conclusion

The implant used takes into account the unique anatomy of the SIJ and also meets the requirements of a true arthrodesis. Initial results in two patients are promising. Biomechanical and clinical studies will have to show whether the considerable theoretical advantages of the new implant system over existing SIJ implants - in particular the possibility of connection to a lumbar stabilization system - and SPFs can be put into practice.

Sacroiliac Joint Degeneration and Pain After Spinal Arthrodesis: A Systematic Review

STUDY DESIGN

This was a systematic review.

OBJECTIVE

The present study aims to review the available literature concerning sacroiliac joint (SIJ) pain and degeneration after lumbosacral fixation to identify the prevalence and potential risk factors.

SUMMARY OF BACKGROUND DATA

Although numerous factors can predispose patients to SIJ degeneration and pain various clinical studies indicate lumbosacral arthrodesis as a major cause.

MATERIALS AND METHODS

The PubMed-MEDLINE, Cochrane Central Registry of Controlled Trials, and Embase Biomedical database were searched. Peer-reviewed comparative studies, cohort studies, case series studies and case control studies, conducted either in a retrospective or prospective design, that registered data about SIJ pain and degeneration after lumbosacral fixation were included.

RESULTS

Twenty-one studies including 2678 patients met the inclusion criteria. The percentage of SIJ pain after lumbosacral fixation diagnosed with injections and physical examination varied widely, from 3% to 90%. Among patients who underwent spinal fusion, SIJ pain prevalence was higher when arthrodesis was fixed compared with floating fusions (59% vs. 10%, P -value >0.05). The prevalence of SIJ degenerative changes at computed tomography scan was more frequent in patients who underwent spinal arthrodesis than in those who did not (75% vs. 38.2%, P -value ≤0.05).

CONCLUSION

According to current evidence, patients who received lumbosacral fixation are at risk of SIJ pain. Number of fused levels, involvement of pelvis or sacrum in the arthrodesis area, inadequate lumbosacral sagittal alignment, and site of bone graft harvesting could be possible risk factor leading to sacroiliac degeneration and pain after lumbar spine fixation that should be investigated by physicians. However, there is a lack of homogeneity of the studies that address the problem, therefore, further prospective comparative studies, with a homogeneous architecture and cohorts are needed.

LEVEL OF EVIDENCE

Level III.

Incidence of sacroiliac joint pain after lumbosacral spine fusion: A systematic review

OBJECTIVES

To determine the incidence of sacroiliac joint (SIJ) pain after lumbosacral spinal fusion.

BACKGROUND

Persistent low back pain is a potential source of disability and poor outcomes following lumbar spine fusion. The SIJ has been described as a potential source. However, there is a paucity of data concerning its importance.

METHODS

This is a PROSPERO registered systematic review. A systematic search of the English literature was performed in Medline, Embase and Cochrane Library databases. MeSH terms such as Lumbar vertebrae, Sacrum, Spinal Fusion, Pain, Sacrum, Ligaments, Sacroiliac Joint were utilized for the search. Key words such as "sacroiliac dysfunction.mp." and "sacroiliac complex.mp." were utilized for the search. Two independent reviewers reviewed articles to determine eligibility for final review and analysis. The Newcastle-Ottawa Scale was used to appraise the quality of all nonrandomized observational studies. Inverse variance weighting with random effects was used to pool data. The GRADE approach, PRISMA workflow and checklists was performed.

RESULTS

Twelve studies were included. All studies were observational and of moderate to low quality. The pooled incidence of sacroiliac joint pain was 15.8%. The pooled incidence of SIJ pain for patients without fusion extending to the sacrum was 15.8%. The pooled incidence of SIJ pain for patients with fusion extending to the sacrum was 32.9%. There was high heterogeneity.

CONCLUSION

SIJ pain is a potential cause of persistent pain after lumbar spine surgery. The current literature of poor quality. Patients presenting with pain after lumbosacral spine fusion should be evaluated for SIJ related pain.

Cost-Utility Analysis of Sacroiliac Joint Fusion in High-Risk Patients Undergoing Multi-Level Lumbar Fusion to the Sacrum

Purpose

Multi-level lumbar fusion to the sacrum (MLF) can lead to increased stress and angular motion across the sacroiliac joint (SIJ), with an incidence of post-operative SIJ pain estimated at 26–32%. SIJ fusion (SIJF) can help obviate the need for revisions by reducing range of motion and screw stresses. We aimed to evaluate the cost-utility of MLF + SIJF compared to MLF alone among high-risk patients from a payer perspective, where high risk is defined as high body mass index and high pelvic incidence.

Methods

A Markov process decision-analysis model was developed to evaluate cumulative 5-year costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) of MLF + SIJF compared to MLF alone using published data; costs from Medicare claims data analyses and health state utility values (derived from EQ-5D) informed by three prospective, multicenter, clinical trials. The base case assumed a reduction in post-operative SIJ pain from 30% to 10% (relative risk reduction [RRR] of 67%). Costs and utilities were discounted 3% annually. The ICER is reported in 2020 US dollars. One-way, multi-way, and probabilistic sensitivity analyses were performed.

Results

With an assumed 30% incidence of SIJ pain after MLF alone, stabilizing with SIJF was associated with an additional 5-year cost of $2421 and a gain of 0.14 QALYs, resulting in an ICER of $17,293 per QALY gained (similar to total knee arthroplasty and more favorable than open discectomy). ICERs were most sensitive to the RRR of post-operative SIJ pain conferred by SIJF, time horizon, and probability of successful treatment with MLF alone. At a willingness-to-pay threshold of $50,000/QALY gained, MLF + SIJF has a 97.7% probability of being cost-effective in the target patient population.

Conclusion

Fusing the SIJ in high-risk patients undergoing MLF was cost-effective when the incidence of post-operative SIJ pain after MLF alone exceeds approximately 25%, providing value-based healthcare from a payer perspective.

Sacroiliac Joint Degeneration After Lumbopelvic Fixation

STUDY DESIGN

Retrospective Study.

OBJECTIVES

Sacroiliac buttress screws (SBS) and S2 alar iliac screws (SAI) are used as distal screws in cases with long fusion to the pelvis. Distal fixation ends, whether exceeding the sacroiliac joint (SIJ), may affect postoperative degenerative changes in the SIJ. The aim of this study was to investigate SIJ degeneration after lumbosacral and lumbopelvic fixation, using SBS and SAI in degenerative spine diseases, respectively.

METHODS

This study included 70 patients aged ≥50 years with lumbosacral fusion (>3 levels). They were divided into 2 groups (SBS 20 and SAI 50 cases) based on the type of distal screws. Radiographical and clinical data were reviewed with a minimum 2-year follow-up. Radiographical SIJ degeneration was analyzed using computed tomography; clinical outcomes were evaluated using visual analog scale (VAS) and Japanese Orthopaedic Association Back Pain Questionnaire (JOABPEQ).

RESULTS

No significant differences were observed in patients' preoperative characteristics between the 2 groups. The incidence of SIJ degeneration, including osteophyte formation (30.0% and 8.0%, p = 0.03), intraarticular air (75.0% and 16.0%, p < 0.001), and subchondral cyst (20.0% and 2.0%. p = 0.02) in SBS and SAI groups, respectively, at the follow-up, was significantly higher in the SBS group. Although SIJ degenerative changes were significantly different between the SBS and SAI groups, there was no significant difference in VAS and JOABPEQ scores between the groups at 2 years post-surgery.

CONCLUSIONS

Lumbosacral fusion can cause SIJ degeneration, which is more frequent when SBS are used in fixation to the sacrum.

The Comparison of Spinopelvic Parameters, Complications, and Clinical Outcomes After Spinal Fusion to S1 with or without Additional Sacropelvic Fixation for Adult Spinal Deformity: A Systematic Review and Meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

The purpose of the study was to compare the outcomes and after spinal fusion with or without iliac screw (IS) insertion for patients with adult spinal deformity (ASD).

SUMMARY OF BACKGROUND DATA

The number of patients undergoing multilevel spinal stabilization for the treatment of ASD is growing. However, the selection of spinopelvic fixation for ASD patients with long fusion is controversial.

METHODS

A comprehensive literature search was performed without time restriction according to the guidelines from the Cochrane Collaboration in May 2020 using PubMed, EMBASE, and the Cochrane Library. The comparison of the two types of fixation was evaluated by spinopelvic parameters, incidence rate of complications, rate of revision, and clinical outcomes at the last follow-up.

RESULTS

The literature search identified 422 records, of which eight studies were included for meta-analysis with a total of 439 patients. All the included studies provided level III evidence. There was no significant difference in the sagittal vertical axis, pelvic incidence, the proximal junctional kyphosis rates, the pseudarthrosis rates, the revision rates, and the clinical outcomes at the last follow-up between those who receive sacrum fixation and sacropelvic fixation. Nevertheless, greater lumbar lordosis (LL) (weighted mean difference [WMD], 4.15; 95% confidence interval [CI] 2.46-5.84, P < 0.01), greater sacral slope (SS) (WMD, 2.32; 95% CI 1.21-3.43, P < 0.01), and lower rate of the distal instrumentation instability (odds ratio, 0.25; 95% CI 0.10-0.61, P = 0.002) were observed in IS group between the comparison.

CONCLUSION

The clinical outcomes in the IS group were similar to those in the non-IS group, but the application of the IS significantly restored LL, prevented decompensation, and reduced the occurrence of the distal instrumentation instability. Therefore, the IS may be a good choice for the operative treatment of ASD patients with sagittal malalignment and other risks of lumbosacral fracture, metal breakage, and screw pullout.Level of Evidence: 3.

Simultaneous Robotic Single Position Oblique Lumbar Interbody Fusion With Bilateral Sacropelvic Fixation in Lateral Decubitus

Single position lateral fusion reduces the need for a secondary surgery and robotic guidance allows for potentially higher accuracy of screw placement. We expand the role of robotics with a simultaneous workflow where 2 surgeons can work in single position surgery and discuss the technical feasibility of placement of S2-alar-iliac (S2AI) screws in the lateral position. A 70-year-old male presented with chronic back pain and bilateral leg pain with the left side worse than the right. He subsequently underwent an L3–S1 oblique lumbar interbody fusion (OLIF) with a minimally invasive L3-ilium robotic posterior spinal fixation simultaneously in single lateral position with S2AI screws. The software planning requisite of robotics allowed for a preoperative plan where lumbar cortical screws were used to line up with bilateral S2AI screws. Intraoperatively, the OLIF was performed anterior to the patient which allowed for a second surgeon to perform the posterior stage of screw placement simultaneously in overlapping fashion during OLIF exposure. Once all screws were placed, the OLIF discectomy and cage placement were completed. As the OLIF incision is closed, rodding proceeds posteriorly with subsequent closure simultaneously as well. Operative time from skin incision to skin closure was 3 hours and 47 minutes. We present here a novel technical report on the recommended workflow of simultaneous robotic single position surgery OLIF and demonstrate the feasibility of placement of sacroiliac fixation in the lateral decubitus position. We believe this technique to be minimally invasive, effective, with the benefit of shortening valuable operating room case time.

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.

The use of triangular implants to enhance sacropelvic fixation: a finite element investigation

BACKGROUND CONTEXT

Long thoracolumbar fixation and fusion have become a consolidated treatment for severe spinal disorders. Concomitant sacropelvic fixation with S2 alar-iliac (S2AI) screws is frequently performed to limit instrumentation failure and pseudarthrosis at the lumbosacral junction.

PURPOSE

This study explored the use of triangular titanium implants in different configurations in which the implants supplemented standard sacropelvic fixation with S2AI screws in order to further increase the stability of S2AI fixation.

STUDY DESIGN

Finite element study.

METHODS

Four T10-pelvis instrumented models were built: pedicle screws and rods in T10-S1 (PED); pedicle screws and rods in T10-S1, and bilateral S2 alar-iliac screws (S2AI); pedicle screws and rods in T10-S1, bilateral S2AI screws, and triangular implants inserted bilaterally in a sacral alar-iliac trajectory (Tri-SAI); pedicle screws and rods in T10-S1, bilateral S2AI screws and two bilateral triangular titanium implants inserted in a lateral trajectory (Tri-Lat). The models were tested under pure moments of 7.5 Nm in flexion-extension, lateral bending and axial rotation.

RESULTS

SIJ motion was reduced by 50% to 66% after S2AI fixation; the addition of triangular titanium implants in either a SAI or a lateral trajectory further reduced it. S2AI, Tri-SAI, and Tri-Lat resulted in significantly lower stresses in S1 pedicle screws when compared to PED. Triangular implants had a protective effect on the maximal stresses in S2AI screws, especially when placed in the SAI trajectory. Sacropelvic fixation did not have any protective effect on the posterior rods.

CONCLUSIONS

Supplementing S2AI screws with triangular implants had a protective effect on the S2AI screws themselves, as well as the S1 pedicle screws, in the tested model.

CLINICAL SIGNIFICANCE

Triangular implants can substantially reduce the residual flexibility of the SIJ with respect to S2AI fixation alone, suggesting a possible role in patients needing reinforced fixation. In vivo investigation is needed to determine if these in vitro effects translate into clinically important differences.

A comprehensive biomechanical analysis of sacral alar iliac fixation: an in vitro human cadaveric model

In BriefIn this in vitro investigation, we compared the multidirectional flexibility properties of sacral alar iliac fixation with conventional methods of sacral and sacroiliac fixation using nondestructive and destructive investigative methods. The study demonstrated that S1-2 sacral fixation alone significantly increases sacroiliac motion under all loading modalities, while sacral alar iliac fixation reduced motion in axial rotation at the sacroiliac joint and offers potential advantages of a lower instrumentation profile and ease of assembly compared to conventional sacroiliac screw instrumentation.

Sacropelvic Fixation With S2 Alar Iliac Screws May Prevent Sacroiliac Joint Pain After Multisegment Spinal Fusion

STUDY DESIGN

A retrospective study.

OBJECTIVE

To examine the postoperative incidence of sacroiliac joint pain (SIJP) at the lower fusion level following multisegment fusion.

SUMMARY OF BACKGROUND DATA

Recently, multisegment fusion is being increasingly performed. While proximal junctional kyphosis (PJK) commonly develops following multisegment fusion, SIJP also commonly occurs following this surgery. In surgery for adult spinal deformity, fixation is often extended to the pelvis to include the sacroiliac joint. Therefore, the question of whether SIJP occurs in such cases is interesting. Here, we examined postoperative incidence of SIJP at the lower fusion level, including the incidence of PJK, and postoperative lumbopelvic alignment.

METHODS

Participants included 77 patients who underwent corrective fusion (≥3 segments). Patients were divided into three groups based on the lower fixation end: L5 (L5), S (sacrum), and P (pelvis). In the P group, an S2 alar iliac screw was used. Postoperative incidence of SIJP and PJK in each group was examined along with lumbopelvic parameters.

RESULTS

SIJP incidence was 16.7%, 26.1%, and 4.2% in the L5, S, and P groups, respectively, indicating the highest value in the S group and a significantly lower value in the P group. PJK incidence was 23.3%, 30.4%, and 29.2% in the L5, P, and S groups, respectively, with no significant differences. Regarding postoperative lumbopelvic parameters, there was no significant difference between the groups; however, lumbar lordosis tended to be better in the P group.

CONCLUSION

SIJP incidence was extremely high with fixation to the sacrum, and in the group with fixation to the pelvis, there was hardly any SIJP. Sacropelvic fixation using S2 alar iliac screws could prevent SIJP onset following multisegment fusion.

LEVEL OF EVIDENCE

3.

Incidence, diagnosis and management of sacroiliitis after spinal surgery: a systematic review of the literature

The sacroiliac joint (SIJ) is a possible source of persistent or new onset pain after lumbar or lumbosacral fusion. The aim of this paper is to systematically review and analyze the available literature related to the incidence, diagnosis and management of sacroiliitis after spinal arthrodesis. The authors independently screened the titles and abstracts of all articles identified concerning sacroiliac joint pain after lumbar or lumbosacral fusion, to assess their suitability to the research focus. The average incidence of sacroiliitis after lumbar or lumbosacral arthrodesis was found to be 37 ± 28.48 (range 6-75), increasing directly to the number of fused segments involved, especially when the sacrum is included. The most accurate evaluation is the image-guided injection of anesthetic solutions in the joint. Surgery treatment may be considered when conservative therapy fails, with open surgery or with minimally invasive SIJ fusion. Although the risk of developing SIJ degeneration is unclear, the results indicate that pain and degeneration of SIJ develop more often in patients undergoing lumbosacral fusion regardless of the number of melting segments. The treatment of sacroiliitis appears to be independent of his etiology, with or without previous instrumentation on several levels.