Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion Using Triangular Titanium Implants vs Nonsurgical Management for Sacroiliac Joint Dysfunction: 12-Month Outcomes

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.

Clinical outcome measures following lateral versus posterior sacroiliac joint fusion: Systematic review and meta-analysis

Introduction

Sacroiliac joint fusion (SIJF) is indicated in patients with chronic Sacroiliac joint (SIJ) pain or instability and is usually performed using minimally invasive techniques through lateral or posterior approach.

Research question

Our study aims to compare the lateral approach to the posterior one in SIJF through meta-analysis of other studies. The outcome of each approach is measured using the visual analog scale (VAS), Oswestry disability index (ODI), or both.

Materials and methods

The study was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Articles were extracted using Pubmed advance search till February 27th, 2023. Articles included were those limited to either lateral, posterior or both approaches. Articles written in a non-English language, case reports and smaller-than-three case series were excluded from the study. Risk of bias was assessed using the Newcastle-Ottawa and Jadad scales. Stata-17 software program was used for statistical analysis and creation of forest plots.

Results

Forty-eight articles were available for the quantitative analysis, which represents a total of 2562 subjects. The average duration of postoperative follow-up was 21 months (3-72 months) and 17 months (6-72 months) for the VAS and ODI outcomes, respectively. The average percentage of improvement in the VAS was 57% (22-80%) in the lateral approach versus 58% (29-94%) in the posterior approach (p = 0.986). The average percentage of improvement in the ODI was 42% (11-75%) in the lateral approach versus 31% (11-65%) in the posterior one (p = 0.272). A trend towards performing posterior approaches more frequently was noted in studies published after 2017.

Discussion and conclusion

Approach selection for SIJF depends mainly on patient's characteristics and surgeon's experience. Our study demonstrated no difference in VAS outcome between lateral and posterior approach. Lateral approach appeared to be superior in ODI outcome although not statistically significant. The main limitation of the study is the selection-bias as the majority of articles included were observational. Therefore, randomized procedural trials are needed to validate these findings.

Minimally invasive lateral, posterior, and posterolateral sacroiliac joint fusion for low back pain: a systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate the therapeutic effects of minimally invasive lateral, posterior, and posterolateral sacroiliac joint fusion for low back pain through a meta-analysis.

METHODS

The PubMed, Web of Science, Embase, Cochrane Library, and ClinicalTrials.gov databases were comprehensively searched for studies up to 31 August 2024. Relevant studies using lateral, posterior, and posterolateral approaches were identified. Pooled outcomes and publication bias were assessed. The study was registered with PROSPERO (registration No. CRD42023451047).

RESULTS

A total of 48 studies were included: 32 focused on the lateral approach, 10 on the posterior approach, four on the posterolateral approach, and two compared the lateral and posterolateral approaches. The pooled effect analysis showed statistically significant improvements in the visual analog scale (VAS) scores for all three approaches at 6 and 12 months postoperatively. Although no between-approach comparisons were conducted, the pooled improvements in VAS scores at 6 and 12 months postoperatively were numerically similar across all three approaches, as were the pooled fusion rates. The pooled complication rate for the lateral approach was 9.2%, numerically higher than 1% for the posterior approach. The pooled revision rate for the lateral approach was 2.4%, also numerically higher than 0.6% for the posterior approach.

CONCLUSIONS

Although pain relief and fusion rates were similar across all approaches, the lateral approach might be associated with a higher risk of total complications and revision surgery.

Efficacy of Lateral Sacroiliac Joint Fusion With the Trident™ Screw System: A Retrospective Analysis

Background Chronic lower back pain is a significant global health issue, leading to disability and a substantial economic burden. A considerable number of cases are associated with the sacroiliac joint (SIJ), especially among patients with a history of lumbar fusions. Despite various treatments, persistent SIJ pain often requires surgical intervention, with minimally invasive techniques becoming the standard due to their benefits over open surgery. This study examines the clinical outcomes of a novel minimally invasive SIJ fixation technique using the Trident™ system. Methodology The study retrospectively reviewed 39 patients who underwent SIJ fusion with the Trident™ system across four surgical sites by a single surgeon. Strict inclusion and exclusion criteria ensured a homogeneous patient population. The procedure involved placing hollow fenestrated screws in a tri-pronged fashion across the SIJ to achieve fusion. The Oswestry Disability Index (ODI) was used to measure functional outcomes, and statistical analyses were conducted to assess the efficacy of the procedure. Results The study found statistically significant improvements in most ODI categories postoperatively. Subgroup analyses revealed that patients with bilateral SIJ fusions showed the greatest improvement, while those with unilateral fusions without prior lumbar surgery showed the least improvement, though still significant. The results suggest that the Trident™ system is effective in improving patient outcomes. Conclusions Evidence indicates that the novel SIJ fixation technique could influence future standards of care for SIJ-related chronic low back pain. The Trident™ Screw System's minimally invasive approach to SIJ fusion is effective in improving functional outcomes for patients with chronic SIJ-related lower back pain. The technique's efficacy, demonstrated through significant ODI improvements, supports its potential as a valuable treatment option.

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 Joint: Function, Pathology, Treatment, and Contribution to Outcomes in Spine and Hip Surgery

➢ Low back pain has a lifetime incidence of up to 84% and represents the leading cause of disability in the United States; 10% to 38% of cases can be attributed to sacroiliac joint (SIJ) dysfunction as an important pain generator.➢ Physical examination of the SIJ, including >1 provocation test (due to their moderate sensitivity and specificity) and examination of adjacent joints (hip and lumbar spine) should be routinely performed in all patients presenting with low back, gluteal, and posterior hip pain.➢ Radiographic investigations including radiographs, computed tomography, and magnetic resonance imaging with protocols optimized for the visualization of the SIJs may facilitate the diagnosis of common pathologies.➢ Intra-articular injections with anesthetic can be helpful in localizing the source of low back pain. Over-the-counter analgesics, physiotherapy, intra-articular injections, radiofrequency ablation, and surgery are all management options and should be approached from the least invasive to the most invasive to minimize the risks of complications.➢ Lumbar fusion surgery predisposes patients to more rapid SIJ degeneration and can also result in more rapid degenerative changes in the hip joints, especially with SIJ fusion.➢ Hip surgery, including hip arthroplasty and preservation surgery, is not a risk factor for SIJ degeneration, although reduced outcomes following hip surgery can be seen in patients with degenerative SIJ changes.

Trends in Sacroiliac Joint Fusion Costs and Utilization in the Privately Insured Population

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

Despite innovations in minimally invasive (MI) techniques for sacroiliac joint fusion (SIJF), trends in utilization and associated costs remain unclear. In this study, we assessed these trends and costs in a database of privately insured patients.

METHODS

Records of open and MI SIJFs were queried from the 2007-2021 MarketScan Databases with CPT codes. Net payments made by insurance carriers were identified, as were out-of-pocket payments made by patients for each encounter. Regression was used to model utilization, payments, and costs.

RESULTS

4124 SIJFs were identified, 1626 (39.4%) of which were MI SIJF. SIJF utilization increased by 1176.2% throughout the study period (P < .001). However, open SIJF utilization peaked in 2012. Open SIJF utilization was not significantly associated with time (P = .18). By contrast, the peak utilization for MI procedures occurred in 2021. Spine surgeons' volume of MI SIJF increased by 258% over the study period (P < .001), while nonsurgeon volume of MI SIJF increased by 990.9% (P < .001).

CONCLUSION

Privately insured patients have increasingly utilized SIJF over the past several years. This is predominantly due to the adoption of MI techniques by spine surgeons and nonsurgeons.

Surgical Treatment of Patients with Sacroiliac Joint Syndrome: Comparative Study of Two Implants

The treatment of patients with ISJ dysfunction is difficult due to the multifactorial causes of pain and various problems in clarification. Treatment includes physical therapy, corticosteroids, prolotherapy, radiofrequency denervation and sacroiliac joint fusion. A new option for the surgical treatment of ISG dysfunction is the Torpedo implant system. For a safe fusion, only 2 implants are needed, which are available in lengths of 30-50 mm. The new implant system has been tested in pilot studies for efficacy and biocompatibility with good results. For further documentation for the Torpedo implant system, a comparative study against the iFuse system was carried out.Two different implants were used: Group 1: Deltacor Torpedo, Group 2: iFuse implants (Si-Bone). The data generated during admission and subsequent check-ups (VAS, ODI, opioid use) were entered into an evaluation file set up for this purpose. Follow-up appointments were set at 1 month, 3, 6 and 12 months postoperatively.The data of 65 patients were evaluated comparatively. In all comparisons, only very small effect sizes were found with regard to the differences in the decrease in pain intensities, so that equivalent effectiveness of the two methods could initially be postulated from a clinical point of view. Most patients in both groups reported taking opioids to treat pain before surgery. According to the decrease in pain intensity, opioid treatment could be discontinued in some patients after the operation. After 12 months, the number of patients treated with opioids decreases to 23% in group 1 and to 17% in group 2. The success of the fusions with the two methods can also be proven by image documentation, from which the position of the implants can also be clearly recognised. In no case was there any loosening.Overall, the evaluation of this study allows the conclusion that both implant systems can be successfully used for the treatment of patients with ISJ syndrome. The present results should be confirmed in further comparative studies with the proposed evaluation methods.

Efficacy of manual therapy for sacroiliac joint pain syndrome: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

This study examined the efficacy of manual therapy for pain and disability measures in adults with sacroiliac joint pain syndrome (SIJPS).

METHODS

We searched six databases, including gray literature, on 24 October 2023, for randomized controlled trials (RCTs) examining sacroiliac joint (SIJ) manual therapy outcomes via pain or disability in adults with SIJPS. We evaluated quality via the Physiotherapy Evidence Database scale and certainty via Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Standardized mean differences (SMDs) in post-treatment pain and disability scores were pooled using random-effects models in meta-regressions.

RESULTS

We included 16 RCTs (421 adults; mean age = 37.7 years), with 11 RCTs being meta-analyzed. Compared to non-manual physiotherapy (i.e. exercise ± passive modalities; 10 RCTs) or sham (1 RCT) interventions, SIJ manual therapy did not significantly reduce pain (SMD: -0.88; 95%-CI: -1.84; 0.08, p = 0.0686) yet had a statistically significant moderate effect in reducing disability (SMD: -0.67; 95% CI: -1.32; -0.03, p = 0.0418). The superiority of individual manual therapies was unclear due to low sample size, wide confidence intervals for effect estimates, and inability to meta-analyze five RCTs with a unique head-to-head design. RCTs were of 'good' (56%) or 'fair' (44%) quality, and heterogeneity was high. Certainty was very low for pain and low for disability outcomes.

CONCLUSION

SIJ manual therapy appears efficacious for improving disability in adults with SIJPS, while its efficacy for pain is uncertain. It is unclear which specific manual therapy techniques may be more efficacious. These findings should be interpreted cautiously until further high-quality RCTs are available examining manual therapy against control groups such as exercise.

REGISTRATION

PROSPERO (CRD42023394326).

Sacroiliac joint pain: what treatment and when

INTRODUCTION

Spinal and non-spinal pathologies can cause low back pain. Non-spinal sources of low back pain include the sacroiliac joint (SIJ) and the hip. SIJ pain can be treated either conservatively or surgically. Current strategies for managing sacroiliac joint pain are debated, and limited evidence exists.

AREAS COVERED

The present expert opinion updates current evidence on conservative and surgical modalities for SIJ pain.

EXPERT OPINION

Surgical management for SIJ pain is effective. However, it exposes patients to surgery and, therefore, related complications. Conservative management may be implemented in patients with moderate SIJ pain, with less than six months of symptoms, or not eligible for surgery. Several noninvasive modalities are available, mostly centered on intra-articular injections. Corticosteroids, platelet-rich plasma, and stem cells have only midterm lasting effects, at most for nine months. Radiofrequency ablation is another methodology for pain relief. Both continuous and pulsatile radiofrequency ablation are associated with good outcomes. SIJ fusion can be performed using different techniques; however, a clear recommendation on the most appropriate modality for the management of SIJ pain is still debated.

Potential S1 Nerve Root Blocks Associated with Sacroiliac Joint Injections

Background

Sacroiliac (SI) joint dysfunction is a common cause of lower back pain. The diagnosis of SI joint pain remains challenging. Sacroiliac joint injection remains the gold standard of diagnosis of SI joint pain as well as providing therapeutic effect. One complication related to SI joint injection is temporary numbness and weakness of the leg.

Objectives

To evaluate the anatomy of the SI joint and the flow of the contrast in the sacroiliac joint and to understand how local anesthetic can affect the nerve roots and cause temporary weakness and numbness of the leg. Study Design. Retrospective case series. Setting. Academic medical center.

Methods

Patients who underwent SI joint injection with three-dimensional cone beam computed tomography with fluoroscopy (3D-CBCT) imaging were identified through retrospective review of two providers' case log from the electronic medical record. The cone beam CT images were reviewed to study the contrast spread and flow in the SI joint.

Results

27/32 patients with the mean age of 56 years (range 39-87 years), 20 females, and 7 males were included in this study. After reviewing cone beam CT images, 4/27 (14.8%) patients showed contrast spread in the SI joint and spread into the S1 posterior neuroforamen. The remainder 23/27 (85.2%) patients had contrast localized in the SI joint. Limitations. Small population size, retrospective review of medical records.

Conclusion

Our results indicate that the injection of lower concentration of local anesthetic with less volume may be necessary to decrease the risk of S1 nerve root block and epidural block. Furthermore, to improve the specificity of a diagnostic SI injection, an appropriate evaluation should be considered to rule out any S1 nerve pathology as a significant pain generator.

Navigated Simultaneous Lateral Minimally Invasive Tubular and Posterior Mini-Open Access for Removal and Revision of Triangular Sacroiliac Joint Implants: A Technical Note

BACKGROUND

Sacroiliac joint (SIJ) fusion, to treat back pain caused by SIJ dysfunction, can employ open or minimally invasive surgery (MIS) techniques and either cylindrical (screw-shaped) or triangular (wedge-shaped) implants. Fusion nonunion sometimes explains recurrent SIJ pain following fusion and occasionally requires hardware revision. MIS revision minimizes patient pain, infection, and disability, but due to the triangular implant size and form factor, implant removal can present challenges for MIS access during the explantation and achieving good bony purchase for reinstrumentation. Here, we report a prone single-position lateral MIS/posterior mini-open procedure for triangular-implant SIJ fusion revision.

METHODS

The patient is a 72-year-old female who underwent right SIJ fusion for lower back and leg pain sustained after a fall 2 years prior but experienced recurrent pain over the subsequent 2 years, with imaging findings of right SIJ peri-hardware lucencies and diagnostic injections confirming persistent right-sided sacroiliitis.

RESULTS

The patient underwent hardware removal using the lateral MIS incision with table-mounted tubular access and image-guided navigation to maintain exposure, plus simultaneous reinstrumentation using a navigated S2-alar-iliac screw and iliac bolt construct with connecting rod through the posterior mini-open incision made for the navigation reference frame spinous process clamp.

CONCLUSIONS

The use of navigation and MIS access can significantly decrease the complexity of lateral hardware removal, and mini-open navigated screw-and-rod constructs offer reinstrumentation options accessible to surgeons unfamiliar with specialized posterior SIJ systems.

Minimally invasive sacroiliac joint fusion secondary to lumbosacral fusion: Clinical and functional results at 2years of follow-up

INTRODUCTION

Degenerative sacroiliac (SI) joint syndrome is known to be more common after lumbosacral fusion. While this diagnosis is suspected based on various clinical criteria and diagnostic tests, it is confirmed with a diagnostic nerve block. If conservative treatment fails, SI joint fusion through a minimally invasive approach is a useful palliative approach for patients at a treatment crossroads. The aim of this study was to evaluate the clinical and functional results at 2years postoperative after minimally invasive SI joint fusion in patients with SI joint syndrome following lumbosacral fusion.

MATERIALS AND METHODS

We carried out a single-center retrospective study of patients operated between June 2017 and October 2020. Included were patients who had a confirmed diagnosis of SI joint syndrome after lumbosacral fusion surgery, who underwent SI joint fusion and had at least 2years' follow-up. The primary outcome was the improvement in lumbar and radicular pain on a numerical rating scale (NRS). The secondary outcomes were the functional scores (Oswestry and SF-12) along with the level of patient satisfaction. Our study population consisted of 54 patients (41 women, 13 men) with a mean age of 59years (27-88). Thirty-one of these patients were operated on both sides (85 fusions in all). The patients had undergone a mean of 3 lumbar surgeries (1-7) before the SI fusion.

RESULTS

The lumbar and radicular NRS were 8.4 (7-10) and 5.1 (2-10) preoperatively and 5.2 (0-8) and 3.0 (0-8) at 2years postoperatively, which was a reduction of 37% and 42% (p<0.001), respectively. The Oswestry score went from 69.4 (52-86) preoperatively to 45.6 (29-70) at 2years, which was a 33% improvement (p<0.001). Eighty-six percent of patients were satisfied or very satisfied with the surgery.

DISCUSSION

After minimally invasive SI joint fusion, the patients in this study had clear clinical and functional improvements. Previous publications analyzing the results of SI joint fusion found even more improvement, but those patients were relatively heterogenous; in our study, only patients who had a history of lumbosacral fusion were included.

CONCLUSION

Minimally invasive SI joint fusion helped patients who developed SI joint syndrome after lumbosacral fusion to improve clinically and functionally.

LEVEL OF EVIDENCE

IV, retrospective study.

Safety, Efficacy, and Durability of Outcomes: Results from SECURE: A Single Arm, Multicenter, Prospective, Clinical Study on a Minimally Invasive Posterior Sacroiliac Fusion Allograft Implant

Introduction

Research suggests that sacroiliac joint (SIJ) dysfunction is responsible for 15% to 30% of reported low back pain cases. Recently, there has been an increasing interest in SIJ fusion using minimally invasive surgery (MIS) due to safety. Initially, devices designed for MIS were intended for lateral approaches. A minimally invasive sacroiliac fusion implant for use with a posterior approach has been developed and is regulated for clinical use under the regulatory framework required for human cells, tissues, or cellular or tissue-based products (HCT/Ps).

Methods

A multi-center, prospective, single-arm study was launched after initial studies provided preliminary data to support safety, efficacy, and durability of this minimally invasive sacroiliac posterior fusion LinQ allograft implant (NCT04423120). Preliminary results were reported previously. Final results for the full participant cohort are presented here.

Results

One-hundred and fifty-nine (159) participants were enrolled across 16 investigational sites in the US between January 2020 and March 2022. One-hundred and twenty-two (122) participants were implanted. At the 1-month follow-up, 82 participants satisfied all criteria for the composite responder endpoint, representing 73.2% of the study cohort. These results stayed consistent across the remaining study timepoints with 66.0%, 74.4%, and 73.5% of participants classified as responders at the 3-, 6- and 12-month follow-up visits, respectively. VAS scores were significantly reduced (p < 0.0001) and ODI scores were significantly improved (p < 0.0001). All domains of the PROMIS-29 were also significantly improved (all p's <0.0001). Only one procedure-related serious AE was reported in the study.

Conclusion

These results suggest that the posterior approach LinQ Implant System is a safe and effective treatment for sacroiliac joint dysfunction at 12 months, with results that are favorable compared to outcomes reported for an FDA-cleared lateral approach.

Effect of revision sacroiliac joint fusion on unresolved pain and disability: a retrospective cohort study

PURPOSE

The sacroiliac (SI) joint is recognized as a source of low back pain in 15-30% of patients. Though randomized controlled trials have shown clinical improvement following SI joint fusion in 83.1% of patients, revision rates of 2.9% within 2 years have been reported. There is a paucity of literature reviewing this small yet significant population of patients requiring revision surgery.

METHODS

Following IRB approval, retrospective review of patients, who underwent a revision SI joint fusion from 2009 to 2021 was completed. Patient-reported outcomes were measured before and at each clinic visit after surgery with visual analoge scale (VAS) for back pain and Oswestry Disability Index (ODI). Patient characteristics (chronic opiate use and prior lumbar fusion) and surgical factors (operative approach, type/number of implants and use of bone graft) were recorded. Patient-reported outcomes were evaluated with Paired t and Wilcoxon signed rank tests. Univariate and multivariate logistic regression determined if patients met the minimally clinical important differences (MCID) for VAS-back pain and ODI scores at 1 year.

RESULTS

Fifty-two patients (77% female) with an average age of 49.1 (SD ± 11.1) years met inclusion criteria. Forty-four had single sided revisions and eight bilateral revisions. At 1 year follow-up there was no significant improvement in VAS-Back (p = 0.06) or ODI (p = 0.06). Patients with chronic opioid use were 8.5 times less likely to achieve the MDC for ODI scores (OR 0.118, p = 0.029). There was no difference in outcomes when comparing the different surgical approaches (p = 0.41).

CONCLUSION

Our study demonstrates patients undergoing revision surgery have moderate improvement in low back pain, however, few have complete resolution of their symptoms. Specific patient factors, such as chronic opiate use and female sex may decrease the expected improvement in patient-reported outcomes following surgery. Failure to obtain relief may be due to incorrect indications, lack of biologic fusion and/or presence of co-pathologies. Further clinical examination and consistent long-term follow-up, clarify the role revision surgery plays in long-term patient outcomes.

Treatment of an Impending Pathologic Sacral Fracture with a Novel Iliosacral Fusion Construct: A Case Report

CASE

A 49-year-old woman presented with left leg radiculopathy and posterior pelvic pain. Subsequent evaluation demonstrated metastatic multiple myeloma with an impending left S1 sacral fracture. Immediate posterior pelvic ring stabilization was recommended to prevent fracture and disruption of her oncologic recovery. This was performed percutaneously with computer-assisted navigation using a novel cannulated screw design.

CONCLUSION

The patient was treated with prophylactic percutaneous posterior pelvic ring fixation with a novel cannulated screw design that provided a durable construct for immediate weight-bearing. The fixation prevented a pathologic fracture and allowed immediate return to activity.

Minimally invasive sacroiliac joint fusion using triangular titanium implants versus nonsurgical management for sacroiliac joint dysfunction: a systematic review and meta-analysis

BACKGROUND

Minimally invasive sacroiliac joint (MISIJ) fusion is a surgical option to relieve SIJ pain. The aim of this systematic review and meta-analysis was to compare MISIJ fusion with triangular titanium implants (TTI) to nonoperative management of SIJ dysfunction.

METHODS

We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. We included prospective clinical trials that compared MISIJ fusion to nonoperative management in individuals with chronic low back pain attributed to SIJ dysfunction. We evaluated pain on visual analogue scale, Oswestry Disability Index (ODI) score, health-related quality of life (HRQoL) using the 36-Item Short Form Health Survey (SF-36) physical component (PCS) and mental component summary (MCS) scores, patient satisfaction, and adverse events.

RESULTS

A total of 8 articles representing 3 trials that enrolled 423 participants were deemed eligible. There was a significant reduction in pain score with MISIJ fusion compared with nonoperative management (standardized mean difference [SMD] -1.71, 95% confidence interval [CI] -2.03 to -1.39). Similarly, ODI scores (SMD -1.03, 95% CI -1.24 to -0.81), SF-36 PCS scores (SMD 1.01, 95% CI 0.83 to 1.19), SF-36 MCS scores (SMD 0.72, 95% CI 0.54 to 0.9), and patient satisfaction (odds ratio 6.87, 95% CI 3.73 to 12.64) were significantly improved with MISIJ fusion. No significant difference was found between the 2 groups with respect to adverse events (SMD -0.03, 95% CI -0.28 to 0.23).

CONCLUSION

Our analysis showed that MISIJ fusion with TTI shows a clinically important and statistically significant improvement in pain, disability score, HRQoL, and patient satisfaction with a similar adverse event profile to nonoperative management in patients with chronic low back pain attributed to SIJ dysfunction.

Biomechanics of sacroiliac joint fixation using lag screws: a cadaveric study

BACKGROUND

Iliosacral screw placement is ubiquitous and now part of the surgeon's pelvic trauma armamentarium. More recent evidence supports sacroiliac arthrodesis for treating sacroiliac joint (SIJ) dysfunction in select patients. Regardless of the surgical indication, there are currently no studies examining lag screw compression biomechanics across the SIJ. The objective of this biomechanical investigation was to quantify iliosacral implant compressive loads and to examine the insertion torque and compressive load profile over time.

METHODS

Eight human cadaveric pelvic specimens underwent SIJ fixation at S1 and S2 using 11.5 and 10.0 mm iFuse-TORQ Lag implants, respectively, and standard 7.3 mm trauma lag screws. Load decay analysis was performed, and insertion and removal torques were measured.

RESULTS

For both implants at S1 and S2 levels, the load relaxed 50% in approximately 67 min. Compressive load decay was approximately 70% on average occurring approximately 15 h post-insertion. Average insertion torque for the 11.5 mm TORQ implant at S1 was significantly greater than the trauma lag screw. Similarly, at S2, insertion torque of the 10.0 mm TORQ implant was greater than the trauma lag screw. At S1, removal torque for the 11.5 mm TORQ implant was higher than the trauma lag screw; there was no significant difference in the removal torque at S2.

CONCLUSIONS

In this study, we found that a novel posterior pelvic implant with a larger diameter, roughened surface, and dual pitch threads achieved improved insertion and removal torques compared to a standard screw. Load relaxation characteristics were similar between all implants.

Posterior oblique technique for sacroiliac joint fusion leads to greater pain relief and similar improvement in function compared to the lateral technique: A retrospective, comparative study

BACKGROUND

Management of chronic sacroiliac joint (SIJ) pain among patients who do not respond to nonsurgical treatment is increasingly turning toward minimally invasive SIJ fusion. There are different techniques available to perform this procedure, with the lateral technique being more commonly studied than the posterior oblique technique. This study examined the effects of these techniques on pain relief and functional improvement, both preoperatively and at a 12-month follow-up.

METHODS

This retrospective cohort study analyzed data from 45 patients who underwent SIJ fusion. Included patients were ≥50 years old, nonresponsive to conservative treatment. Subjects were divided into 2 cohorts based on the SIJ fusion technique. Primary outcomes were pain relief, measured by Visual Analog Scale (VAS), and functional improvement, determined by the Oswestry Disability Index (ODI); both were recorded and assessed at baseline, postoperative, and the change from pre- to postoperative. Additionally, data regarding patient demographics, previous lumbar fusion, operative time, and duration of hospital stay were collected and analyzed.

RESULTS

Baseline demographic and clinical variables exhibited no significant differences in distribution between groups. The posterior oblique cohort demonstrated a substantial reduction in operative time (over 50%) and duration of hospital stay compared to lateral cohort. Pain relief (postoperative VAS: lateral 3.5±1.7 vs. posterior oblique 2.4±1.5 [p=.02]) and functional improvement (postoperative ODI: lateral 29.6±7.3 vs. posterior oblique 21±5.7 [p≤.001]) were significantly better in the posterior oblique group. Pre- to postoperative improvement analysis indicated greater reduction in pain (VAS: lateral -4.4±1.9 vs. posterior oblique -6.1±1.5 [p=.002]) in the posterior oblique group.

CONCLUSIONS

Compared to the lateral technique group, patients undergoing minimally invasive SIJ fusion through the posterior oblique technique experienced greater pain relief and demonstrated a trend toward better functional improvement, with shorter operative times and duration of hospital stay. The posterior oblique technique may be more efficient and beneficial to manage patients suffering from chronic SIJ pain through joint fusion.

Evaluation of a New Treatment Strategy for Geriatric Fragility Fractures of the Posterior Pelvic Ring Using Sensor-Supported Insoles: A Proof-of-Concept Study

The incidence of fragility fractures of the pelvis (FFPs) is currently rising. Surgical treatment, which is performed using sacroiliac screws, is complicated by compromised bone quality, oftentimes resulting in implant failure. The iFuse implant system aims to improve attachment and durability with promising results for sacroiliac dysfunction, though data for its feasibility on FFPs are rare. Consequently, this study aims to evaluate the feasibility of the iFuse for FFPs. A total of 10 patients with FFPs were treated with the iFuse in this study. Pre- and postoperatively, both mobility using an established insole force sensor for an inpatient gait analysis and general well-being and pain using questionnaires were evaluated. When comparing pre- and postoperative findings, this study demonstrated a significant increase in the average (8.14%) and maximum (9.4%) loading (p < 0.001), a reduction in pain, as measured by the visual analog scale (VAS), from 4.60 to 2.80 at rest (p = 0.011) and from 7.00 to 4.40 during movement (p = 0.008), an increase in the Barthel Index by 20 points (p < 0.001) and an increase in the Parker Mobility Score by 2.00 points (p = 0.011). All this contributes to the possibility of early postoperative mobilization and improved general well-being, ultimately preventing the late consequences of postoperative immobilization and maintaining patients autonomy and contentment.

Radiomics for the Detection of Active Sacroiliitis Using MR Imaging

Detecting active inflammatory sacroiliitis at an early stage is vital for prescribing medications that can modulate disease progression and significantly delay or prevent debilitating forms of axial spondyloarthropathy. Conventional radiography and computed tomography offer limited sensitivity in detecting acute inflammatory findings as these methods primarily identify chronic structural lesions. Conversely, Magnetic Resonance Imaging (MRI) is the preferred technique for detecting bone marrow edema, although it is a complex process requiring extensive expertise. Additionally, ascertaining the origin of lesions can be challenging, even for experienced medical professionals. Machine learning (ML) has showcased its proficiency in various fields by uncovering patterns that are not easily perceived from multi-dimensional datasets derived from medical imaging. The aim of this study is to develop a radiomic signature to aid clinicians in diagnosing active sacroiliitis. A total of 354 sacroiliac joints were segmented from axial fluid-sensitive MRI images, and their radiomic features were extracted. After selecting the most informative features, a number of ML algorithms were utilized to identify the optimal method for detecting active sacroiliitis, leading to the selection of an Extreme Gradient Boosting (XGBoost) model that accomplished an Area Under the Receiver-Operating Characteristic curve (AUC-ROC) of 0.71, thus further showcasing the potential of radiomics in the field.

The effectiveness and safety of sacral lateral branch radiofrequency neurotomy (SLBRFN): A systematic review

Objective

To assess the effectiveness and safety of sacral lateral branch radiofrequency neurotomy (SLBRFN) in treating posterior sacroiliac joint complex (PSIJC) pain, stratifying results by patient selection criteria and technique.

Design

Systematic review.

Population

Adults over 18 years old with suspected PSIJC pain.

Intervention

SLBRFN with image guidance (including computed tomography, fluoroscopy, ultrasound).

Comparison

Any other treatment, sham, or no treatment.

Outcomes

The primary outcome was improvement in pain reported as continuous data or the proportion of patients obtaining ≥50% reduction in pain scores on either the visual analog scale (VAS) or numeric rating scale (NRS). Secondary outcomes included functional improvement, reported as continuous data or the proportion of patients obtaining ≥30% in function from baseline, and adverse events.

Methods

Six reviewers independently assessed publications prior to December 2022 in PubMed, EMBASE, Web of Science, and Google Scholar and utilized the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework to evaluate the overall quality of evidence.

Results

Of the 415 publications screened, 37 met the inclusion criteria, with 33 providing sufficient data regarding the effectiveness of SLBRFN. Of the included studies, there were four explanatory randomized controlled trials (RCTs), four pragmatic RCTs, 11 prospective cohort studies, 14 retrospective cohort studies, and four case reports describing adverse events. At 6 months, the proportion of patients with ≥50% pain relief ranged from 19 to 89%. Studies providing continuous data reported that patients achieved 40-60% pain relief sustained at 12 months. There was heterogeneity in reporting functional improvement, but most studies noted improvement. While all studies that reported categorical outcomes targeted the S1-3 sacral lateral branches, the majority also included RFN of the L5 dorsal ramus. Successful outcomes were reported in patients selected by the response to intra-articular blocks (single or dual) or sacral lateral branch blocks (single or dual). Twenty-nine total adverse events and three serious adverse events (SAE) were reported across 1367 patients. According to the GRADE system, there is moderate-quality evidence overall that SLBRFN effectively reduces pain and disability in a majority of patients with PSIJC pain at 1, 3, 6, and 12 months. When anatomically validated SLBRFN techniques are assessed, the level of evidence is upgraded to high quality.

Discussion/conclusion

Despite the variability in types of radiofrequency technology, technique, nerve targets, and study methodology, most studies found that substantial proportions of patients achieved ≥50% relief at 1, 3, 6, and 12 months following SLBRFN. When anatomically validated SLBRFN techniques are applied, there is a high level of confidence that the procedure effectively reduces pain and improves function in patients with PSIJC pain. Additional high-quality studies exploring the prognostic value of different block protocols and the relative effectiveness of the various SLBRFN procedure techniques are needed to further optimize the clinical outcomes of SLBRFN.

Posterior Oblique Approach for Sacroiliac Joint Fusion

Introduction Sacroiliac joint (SIJ) pain is a common source of low back pain. Though this condition can be treated with conservative measures, there is a subset of patients who fail to respond to conservative treatment. For them, surgical treatment using minimally invasive techniques could be considered. There are currently a number of SIJ fixation methods described. However, there is no case series reported on posterior oblique approach. Therefore, in this paper, the authors report their experience with the Sacrix system via the posterior oblique approach. Method In this series, 19 patients aged 44-84 years, with a median of 58 years, underwent SIJ fusion using this technique. This is a posterior oblique approach in which two screws are inserted into the ilium through the posterior part of the iliac crest and then advanced into the sacrum through the SIJ. Results The follow-up is between 7 and 30 months, with a median of 12 months. Eighteen patients had excellent pain relief. There was no complication from the procedure, and the blood loss was minimal. All eight patients who had follow-up radiographs showed solid fusion. Conclusion Posterior oblique approach for SIJ fusion is a minimally invasive procedure that proved to be effective and safe in this series. It also resulted in solid radiographic fusion, decreased pain, and improved function.

What You Need to Know About Sacroiliac Dysfunction

Low back pain is the leading cause of disability worldwide, and sacroiliac dysfunction is estimated to occur in 15%-30% of those with nonspecific low back pain. Nurses are in the unique position to support and provide education to patients who may be experiencing sacroiliac dysfunction or possibly apply this knowledge to themselves, as low back pain is a significant problem experienced by nurses. A patient's clinical presentation, including pain patterns and characteristics, functional limitations, common etiologies and musculoskeletal system involvement, current diagnostic tools, and realm of treatments, are discussed along with their respective efficacy. Distinction is made between specific diagnosis and treatment of joint involvement and that of sacroiliac regional pain, as well as other factors that play a role in diagnosis and treatment for the reader's consideration.

Double-center observational study of minimally invasive sacroiliac joint fusion for sacroiliac joint dysfunction: one-year results

BACKGROUND

For a substantial part of patients with chronic low back pain, the origin is located in the sacroiliac joint (SIJ). Minimally invasive sacroiliac joint fusion (MISJF) is increasingly being implemented as a treatment option in SIJ dysfunction. Despite remaining controversy, evidence continues to increase. This study evaluates the clinical results and safety of MISJF in a double-center consecutive case series in patients with SIJ dysfunction over a one-year observation period.

METHODS

SIJ complaints were diagnosed after history taking, physical examination and least a 50% reduction of SIJ pain 30-60 min following image-guided injection. Primary outcome measures were patient reported outcome measurements (PROMs), consisting of Visual Analogue Scale (VAS) pain score and EuroQol 5-dimensions 3-levels (EQ-5D-3L). Patients' perspectives on the effects of surgery were collected through questionnaires. Secondary outcome measures were implant positioning and (serious) adverse events ((S)AE's).

RESULTS

A total of 29 patients were included. In 44.8% of patients, SIJ dysfunction was of postpartum origin. The mean VAS-pain score improved from 7.83 (± 1.71) to 4.97 (± 2.63) postoperatively (p < 0.001). EQ-5D-3L score improved from 0.266 (± 0.129) to 0.499 (± 0.260) postoperatively (p < 0.001). Opioid consumption decreased from 44.8 to 24.1% postoperatively (p = 0.026). In 13.7% of patients, an (S)AE occurred.

CONCLUSION

MISJF appears to be an effective and safe procedure in this cohort. Statistically significant and clinically relevant improvements in pain and quality of life were observed one-year postoperatively. Future studies should focus on the long-term outcomes to further evaluate the safety and effectiveness of MISJF.

Relationship Between Sacroiliac Joint-related Pain and Spinopelvic Mobility

STUDY DESIGN

A case-control study.

OBJECTIVE

To evaluate the relationship between sacroiliac joint-related pain (SIJ-RP) and spinopelvic mobility.

SUMMARY OF BACKGROUND DATA

No specific radiological findings are available for the diagnosis of SIJ-RP. A previous study reported that a higher pelvic incidence and sacral slope (SS) values were significantly associated with sacroiliac joint pain. The concept of spinopelvic mobility, which is evaluated by the differences between SS in the standing and sitting positions, has been the focus of hip and spine surgeries in recent years.

MATERIALS AND METHODS

The SIJ-RP group comprised patients diagnosed with SIJ-RP based on physical findings and their response to analgesic injections. No other lumbar or hip joint diseases were observed. The non-SIJ-RP group comprised patients with lower back pain for reasons other than SIJ-RP. Radiographs of the lateral view of the pelvis in the standing and sitting positions were evaluated for all patients. We compared and analyzed the backgrounds, SS in the two positions, and difference in SS between the two positions in both groups.

RESULTS

In total, 245 patients were included in the study, with 49 and 196 patients in the SIJ-RP and non-SIJ-RP groups, respectively. More female patients experienced SIJ-RP than male patients ( P =0.0361). There were significant differences between the groups for SS in standing ( P =0.0076), sitting ( P =0.0005), and those with a difference between sitting and standing of <5° ( P =0.0278) in the univariate analyses. Logistic regression analyses, after adjustment for age and sex, revealed significant differences between the groups with an SS difference <5° ( P =0.0088; 95% confidence interval, 1.280-5.519), with an odds ratio of 2.7.

CONCLUSION

On evaluating spinopelvic mobility, we found that SIJ-RP was related to hypomobility of the sacrum, which could indicate the hypermobility of the sacroiliac joint.

The Impact of Intraoperative Image-Guidance Modalities and Neurophysiologic Monitoring in the Safety of Sacroiliac Fusions

STUDY DESIGN

Retrospective observational cohort.

OBJECTIVE

A review of efficiency and safety of fluoroscopy and stereotactic navigation system for minimally invasive (MIS) Sacroiliac (SI) fusion through a lateral technique.

METHODS

Retrospective analysis of an observational cohort of 96 patients greater than 18 years old, that underwent MIS SI fusion guided by fluoroscopy or navigation between January 2013 and April 2020 with a minimum of 3 months follow-up. Intraoperative neuromonitoring (IONM) with a variable combination of electromyography (EMG), somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) was also utilized.

RESULTS

The overall complication rate in the study was 9.4%, and there was no difference between the fluoroscopy (10.1%), and navigation groups (8%). Neurological complication rate was 2.1%, without a significant difference between both intraoperative guidance modality groups (p = 0.227). There was a significant difference between the modalities of IONM used and the occurrence of neurological injury (p = 0.01).The 2 patients who had a neurological complication postoperatively were monitored only with EMG and SSEP, but none of the patients (n = 76) in which MEPs were utilized had neurologic complication. The mean pain improvement 3 months after surgery was greater in the navigation group (2.44 ± 2.72), but was not statistically different than the improvement in the fluoroscopy group (1.90 ± 2.07) (p = 0.301).

CONCLUSIONS

No difference in the safety of the procedure was found between the fluoroscopy and the stereotactic navigation techniques. The contribution of the IONM to the safety of SI fusions could not be determined, but the data indicates that MEPs provide the highest level of sensitivity.

Minimally invasive sacroiliac joint fusion for chronic sacroiliac joint pain: a systematic review

BACKGROUND CONTEXT

Sacroiliac (SI) joint pain causes significant disability and impairment to quality of life (QOL). Minimally invasive SI joint fusion is increasingly used to relieve chronic SI joint pain among patients who do not respond to nonsurgical treatment.

PURPOSE

To systematically review the existing literature to assess the effectiveness and safety of minimally invasive SI joint fusion.

STUDY DESIGN/SETTING

Systematic review.

DATA SOURCES

PubMed, Embase, Cochrane, and a clinical trial registry from database inception to June 30, 2021.

STUDY SELECTION

Eligible studies were primary research studies published in the English language, enrolled adults with SI joint pain, and compared SI joint fusion to nonsurgical interventions or alternative minimally invasive procedures. We included randomized controlled trials (RCTs) or controlled cohort studies (CCSs) that reported effectiveness (pain, physical function, QOL, opioid use) or safety outcomes (adverse events [AEs], revision surgeries) and uncontrolled studies that reported safety outcomes.

DATA ABSTRACTION AND SYNTHESIS

Data were abstracted into structured forms; two independent reviewers assessed risk of bias using standard instruments; certainty of evidence was rated using GRADE.

RESULTS

Forty studies (2 RCTs, 3 CCSs, and 35 uncontrolled studies) were included. Minimally invasive SI joint fusion with the iFuse Implant System appeared to result in larger improvements in pain (two RCTs: mean difference in visual analog scale -40.5 mm, 95% CI, -50.1 to -30.9; -38.1 mm, p<.0001) and larger improvements in physical function (mean difference in Oswestry Disability Index -25.4 points, 95% CI, -32.5 to -18.3; -19.8 points, p<.0001) compared to conservative management at 6 months. Improvements in pain and physical function for the RCTs appeared durable at 1- and 2-year follow-up. Findings were similar in one CCS. The two RCTs also found significant improvements in QOL at 6 months and 1 year. Opioid use may be improved at 6 months and 1 to 2 years. AEs appeared higher in the fusion group at 6 months. The incidence of revision surgery varied by study; the highest was 3.8% at 2 years. Two CCSs compared the effectiveness of alternative minimally invasive fusion procedures. One CCS compared iFuse to the Rialto SI Fusion System and reported no differences in pain, function, QOL, and revision surgeries from 6 months to 1 year. One CCS compared iFuse to percutaneous screw fixation and reported significantly fewer revisions among iFuse participants (mean difference -61.0%, 95% CI, -78.4% to -43.5%). The 35 uncontrolled studies had serious limitations and reported heterogeneous safety outcomes. Two of the larger studies reported a 13.2% incidence of complications from minimally invasive SI joint fusion at 90 days using an insurance claims database and a 3.1% incidence of revision surgery over 2.5 years using a postmarket surveillance database.

CONCLUSIONS

Among patients meeting diagnostic criteria for SI joint pain and who have not responded to conservative care, minimally invasive SI joint fusion is probably more effective than conservative management for reducing pain and opioid use and improving physical function and QOL. Fusion with iFuse and Rialto appear to have similar effectiveness. AEs appear to be higher for minimally invasive SI joint fusion than conservative management through 6 months. Based on evidence from uncontrolled studies, serious AEs from minimally invasive SI joint fusion may be higher in usual practice compared to what is reported in trials. The incidence of revision surgery is likely no higher than 3.8% at 2 years. Limited evidence is available that compares different minimally invasive devices.

Advances in Pain Medicine: a Review of New Technologies

PURPOSE OF REVIEW

This narrative review highlights the interventional musculoskeletal techniques that have evolved in recent years.

RECENT FINDINGS

The recent progress in pain medicine technologies presented here represents the ideal treatment of the pain patient which is to provide personalized care. Advances in pain physiology research and pain management technologies support each other concurrently. As new technologies give rise to new perspectives and understanding of pain, new research inspires the development of new technologies.

Six Month Interim Outcomes from SECURE: A Single arm, Multicenter, Prospective, Clinical Study on a Novel Minimally Invasive Posterior Sacroiliac Fusion Device

INTRODUCTION

Sacroiliac joint disease is a prominent diagnosis across the world. A novel fixation technique employing a posterior approach, single point, bone allograft tranfixation has proven to be helpful anecdotally. The purpose of this is study is to investigate prospectively the safety and efficacy of this approach.

METHODS

A multicenter, prospective, single arm study was performed after patient identification and treatment with the novel posterior fusion, single-point transfixation system and followed for 24 months. Target enrollment is 100 patients. Interim results on the first 69 consecutive patients at 6 months is presented. Primary endpoint at 6-month analysis was Pain Intensity reduction by visual analogue scale and functional improvement by Oswestry Disability Index. Adverse events were assessed for safety analysis.

RESULTS

: 69 patients were identified for this analysis. At 6 months, a mean improvement of 34.9 was identified by a reduction in VAS and functional improvement was demonstrated by a mean reduction in ODI of 17.7. There were three adverse events, all unrelated to the device.

CONCLUSION

The posterior single point transfixation is safe and efficacious for the treatment of sacroiliac joint dysfunction with statistical improvements in pain and function.

Benefits and Harms of Interventions With Surgery Compared to Interventions Without Surgery for Musculoskeletal Conditions: A Systematic Review With Meta-analysis

OBJECTIVE

To estimate the benefits and harms of interventions with and without surgery for musculoskeletal (MSK) conditions.

DESIGN

Intervention systematic review with meta-analysis of randomized controlled trials (RCTs).

LITERATURE SEARCH

MEDLINE, EMBASE, CINAHL, Web of Science, and CENTRAL, all up to January 7, 2021.

STUDY SELECTION CRITERIA

RCTs (English, German, Danish, Swedish, and Norwegian) of interventions with and without surgery conducted in any setting for any non-fracture MSK condition in adults (mean age: 18+ years) evaluating the outcomes on a continuous (benefits) or count (harms) scale. Outcomes were pain, self-reported physical function, quality of life, serious adverse events (SAEs), and death at 1 year.

DATA SYNTHESIS

Random-effects metaanalyses for MSK conditions where there were data from at least 2 trials.

RESULTS

One hundred RCTs (n = 12 645 patients) across 28 different conditions at 9 body sites were included. For 9 out of 13 conditions with data on pain (exceptions include some spine conditions), 11 out of 11 for function, and 9 out of 9 for quality of life, there were no clinically relevant differences (standardized mean difference of 0.50 or above) between interventions with and without surgery. For 13 out of 16 conditions with data on SAEs and 16 out of 16 for death, there were no differences in harms. Only 6 trials were at low risk of bias.

CONCLUSION

The low certainty of evidence does not support recommending surgery over nonsurgical alternatives for most MSK conditions with available RCTs. Further high-quality RCTs may change this conclusion. J Orthop Sports Phys Ther 2022;52(6):312-344. doi:10.2519/jospt.2022.11075.

Minimally Invasive Sacroiliac Joint Fusion vs Conservative Management in Patients With Sacroiliac Joint Dysfunction: A Systematic Review and Meta-Analysis

BACKGROUND

The sacroiliac joint (SIJ) is affected in 14% to 22% in individuals presenting with chronic low back or buttock pain. This percentage is even higher in patients who underwent lumbar fusion surgery: 32% to 42%. Currently, there is no standard treatment or surgical indication for SIJ dysfunction. When patients do not respond well to nonsurgical treatment, minimally invasive sacroiliac joint fusion (MISJF) seems to be a reasonable option. This systematic review and meta-analysis evaluates the current literature on the effectiveness of MISJF compared to conservative management in patients with SIJ dysfunction.

METHODS

A systematic search of health-care databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were randomized controlled trials (RCTs) or prospective and retrospective comparative cohort studies that compared MISJF with conservative management. Primary outcome measures were pain, disability, and patient satisfaction measured by patient-reported outcome measures. Secondary outcomes were adverse events (AEs), serious AEs, financial benefits, and costs.

RESULTS

Two RCTs and one retrospective cohort study were included comparing MISJF and conservative management with regard to pain and disability outcome, encompassing 388 patients (207 conservative and 181 surgical). In a pooled mean difference analysis, MISJF demonstrated greater reduction in visual analog scale-pain score compared to conservative management: -37.03 points (95%CI [-43.91, -30.15], P < 0.001). Moreover, MISJF was associated with a greater reduction in Oswestry Disability Index outcome: -21.14 points (95% CI [-24.93, -17.35], P < 0.001). AEs were low among the study groups and comparable across the included studies. One cost-effectiveness analysis was also included and reported that MISJF is more cost-effective than conservative management.001). AEs were low among the study groups and comparable across the included studies. One cost-effectiveness analysis was also included and reported that MISJF is more cost-effective than conservative management.

CONCLUSIONS

This systematic review and meta-analysis suggest that MISJF, using cannulated triangular, titanium implants, is more effective and cost-effective than conservative management in reducing pain and disability in patients with SIJ dysfunction. Further well-powered, independent research is needed to improve the overall evidence.

LEVEL OF EVIDENCE: 1

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.

The Role of Diagnostic Injections in Spinal Disorders: A Narrative Review

Neck and back pain is increasingly prevalent, and has increased exponentially in recent years. As more resources are dedicated to the diagnosis of pain conditions, it is increasingly important that the diagnostic techniques used are as precise and accurate as possible. Traditional diagnostic methods rely heavily upon patient history and physical examination to determine the most appropriate treatments and/or imaging studies. Though traditional means of diagnosis remain a necessity, in many cases, correlation with positive or negative responses to injections may further enhance diagnostic specificity, and improve outcomes by preventing unnecessary treatments or surgeries. This narrative review aims to present the most recent literature describing the diagnostic validity of precision injections, as well as their impact on surgical planning and outcomes. Diagnostic injections are discussed in terms of facet arthropathy, lumbar radiculopathy, discogenic pain and discography, and sacroiliac joint dysfunction. There is a growing body of evidence supporting the use of diagnostic local anesthetic injections or nerve blocks to aid in diagnosis. Spinal injections add valuable objective information that can potentially improve diagnostic precision, guide treatment strategies, and aid in patient selection for invasive surgical interventions.

Sacroiliac joint fusion in patients with Ehlers Danlos Syndrome: A case series

Background

Sacroiliac joint dysfunction (SJD) is a known cause of lower back pain. SJD might be due to hypermobility in the Sacroiliac joint (SIJ) in patients with Ehlers Danlos Syndrome (EDS). Stabilization of the SIJ can be a highly successful treatment for lower back pain. No previous literature about EDS and SIJ fusion is available. The purpose of this study was to assess our mid-term results of SIJ fusion surgery in EDS patients suffering from SIJ dysfunction.

Methods

A case series of patients who underwent SIJ fusion for SIJ dysfunction due to EDS between January 2012 and December 2018 were analyzed in retrospect. Patients underwent surgery and the SIJ was stabilized with triangular implants bridging the joint. Pain and functional outcomes were assessed in nine agree/disagree questions and a satisfaction performance scale. Clinical data has been extracted from the patient files and in addition, we reassessed the position of the implants on the CT scans.

Results

A total of 16 patients with EDS completed the questionnaire and were available for analysis. The mean satisfaction score is 78.1 out of 100 and seven patients reported a 100% satisfaction score.

Conclusion

SIJ fusion is a safe and useful procedure to reduce pain and function levels in EDS patients with lower back pain due to SIJ dysfunction.

Sacroiliac Joint and Pelvic Dysfunction Due to Symphysiolysis in Postpartum Women

Pregnancy-related pain in the sacroiliac joint (SIJ), lumbosacral region, pubic symphysis, or in any combination of these joints has been coined as pelvic girdle pain (PGP) and has been estimated to affect almost half of all pregnant women. SIJ dysfunction in pregnancy is due to multiple biomechanical mechanisms, such as increased weight, change in posture, increased abdominal and intrauterine pressure, and laxity of the spine and pelvic structures. Moreover, when compared to men, women have increased SIJ mobility due to increased pubic angle and decreased SIJ curvature. These differences may assist in parturition where hormones, such as relaxin and estrogen, cause symphysiolysis. A retrospective review of the literature was conducted in the PubMed database using the search term “pregnancy-related sacroiliac joint pain.” All peer-reviewed studies were included. Around 8%-10% of women with PGP continue to have pain for one to two years postpartum. Patients that were treated with SIJ fusion show statistically significant improvement in pain scores when compared to patients that had non-operative treatment. Although we have a number of studies following patients after sacroiliac (SI) joint fusion for pelvic pain with SI joint dysfunction, further research is needed to study sacroiliac fusion for SI joint dysfunction in postpartum women to better tailor and optimize surgical outcomes for this patient population.

Biomechanics of a laterally placed sacroiliac joint fusion device supplemental to S2 alar-iliac fixation in a long-segment adult spinal deformity construct: a cadaveric study of stability and strain distribution

OBJECTIVE

S2 alar-iliac (S2AI) screw fixation effectively enhances stability in long-segment constructs. Although S2AI fixation provides a single transarticular sacroiliac joint fixation (SIJF) point, additional fixation points may provide greater stability and attenuate screw and rod strain. The objectives of this study were to evaluate changes in stability and pedicle screw and rod strain with extended distal S2AI fixation and with supplemental bilateral integration of two sacroiliac joint fusion devices implanted using a traditional minimally invasive surgical approach.

METHODS

Eight L1-pelvis human cadaveric specimens underwent pure moment (7.5 Nm) and compression (400 N) tests under 4 conditions: 1) intact (pure moment loading only); 2) L2-S1 pedicle screw and rod with L5-S1 interbody fusion; 3) added S2AI screws; and 4) added bilateral laterally placed SIJF. Range of motion (ROM), rod strain, and screw-bending moment (S1 and S2AI) were analyzed.

RESULTS

Compared with S1 fixation, S2AI fixation significantly reduced L5-S1 ROM in right lateral bending by 50% (0.11°, p = 0.049) and in compression by 39% (0.22°, p = 0.003). Compared with fixation ending at S1, extending fixation with S2AI significantly decreased sacroiliac joint ROM by 52% (0.28°, p = 0.02) in flexion, by 65% (0.48°, p = 0.04) in extension, by 59% (0.76°, p = 0.02) in combined flexion-extension, and by 36% (0.09°, p = 0.02) in left axial rotation. The addition of S2AI screws reduced S1 screw-bending moment during flexion (0.106 Nm [43%], p = 0.046). With S2AI fixation, posterior L5-S1 primary rod strain increased by 124% (159 μE, p = 0.002) in flexion, by 149% (285 μE, p = 0.02) in left axial rotation, and by 99% (254 μE, p = 0.04) in right axial rotation. Compared with S2AI fixation, the addition of SIJF reduced L5-S1 strain during right axial rotation by 6% (28 μE, p = 0.04) and increased L5-S1 strain in extension by 6% (28 μE, p = 0.02).

CONCLUSIONS

Long-segment constructs ending with S2AI screws created a more stable construct than those ending with S1 screws, reducing lumbosacral and sacroiliac joint motion and S1 screw-bending moment in flexion. These benefits, however, were paired with increased rod strain at the lumbosacral junction. The addition of SIJF to constructs ending at S2AI did not significantly change SI joint ROM or S1 screw bending and reduced S2AI screw bending in compression. SIJF further decreased L5-S1 rod strain in axial rotation and increased it in extension.

Self-Reported Female Orgasm Following Serial Sacroiliac Joint Injections

Sacroiliac joint (SIJ) dysfunction has been increasingly recognized as the underlying pathology responsible for a significant percentage of cases of chronic lower back pain and radiculopathy. Diagnosis of SIJ dysfunction involves multiple provocation tests followed by serial injections of anesthetic, with significant alleviation of pain indicating that the SIJ is the pain generator. One documented complication of SIJ injections is extravasation of injected material from the SIJ capsule, resulting in unintended symptoms. We report the case of a patient who reported experiencing an orgasm following each of her three diagnostic SIJ injections. We hypothesize that this unusual symptom was caused by extravasation of injected material ventrally to the nearby pudendal nerve, a nerve responsible for sensory innervation of the perineum and a mediator of sexual arousal and orgasm.

Biomechanical effects of a novel posteriorly placed sacroiliac joint fusion device integrated with traditional lumbopelvic long-construct instrumentation

OBJECTIVE

S2-alar-iliac (S2AI) screw fixation effectively ensures stability and enhances fusion in long-segment constructs. Nevertheless, pelvic fixation is associated with a high rate of mechanical failure. Because of the transarticular nature of the S2AI screw, adding a second point of fixation may provide additional stability and attenuate strains. The objective of the study was to evaluate changes in stability and strain with the integration of a sacroiliac (SI) joint fusion device, implanted through a novel posterior SI approach, supplemental to posterior long-segment fusion.

METHODS

L1-pelvis human cadaveric specimens underwent pure moment (7.5 Nm) and compression (400 N) tests in the following conditions: 1) intact, 2) L2-S1 pedicle screw and rod fixation with L5-S1 interbody fusion, 3) added S2AI screws, and 4) added bilateral SI joint fixation (SIJF). The range of motion (ROM), rod strain, and screw bending moments (S1 and S2AI) were analyzed.

RESULTS

S2AI fixation decreased L2-S1 ROM in flexion-extension (p ≤ 0.04), L5-S1 ROM in flexion-extension and compression (p ≤ 0.004), and SI joint ROM during flexion-extension and lateral bending (p ≤ 0.03) compared with S1 fixation. SI joint ROM was significantly less with SIJF in place than with the intact joint, S1, and S2AI fixation in flexion-extension and lateral bending (p ≤ 0.01). The S1 screw bending moment decreased following S2AI fixation by as much as 78% in extension, but with statistical significance only in right axial rotation (p = 0.03). Extending fixation to S2AI significantly increased the rod strain at L5-S1 during flexion, axial rotation, and compression (p ≤ 0.048). SIJF was associated with a slight increase in rod strain versus S2AI fixation alone at L5-S1 during left lateral bending (p = 0.048). Compared with the S1 condition, fixation to S2AI increased the mean rod strain at L5-S1 during compression (p = 0.048). The rod strain at L5-S1 was not statistically different with SIJF compared with S2AI fixation (p ≥ 0.12).

CONCLUSIONS

Constructs ending with an S2AI screw versus an S1 screw tended to be more stable, with reduced SI joint motion. S2AI fixation decreased the S1 screw bending moments compared with fixation ending at S1. These benefits were paired with increased rod strain at L5-S1. Supplementation of S2AI fixation with SIJF implants provided further reductions (approximately 30%) in the sagittal plane and lateral bending SI joint motion compared with fixation ending at the S2AI position. This stability was not paired with significant changes in rod or screw strains.

Novel Interventional Techniques for Chronic Pain with Minimally Invasive Arthrodesis of the Sacroiliac Joint: (INSITE, iFuse, Tricor, Rialto, and others)

Acute and chronic pain are public health issues that clinicians have been battling for years. Opioid medications have been a treatment option for both chronic and acute pain; however, they can cause unwanted complications and are a major contributor to our present opioid epidemic. The sacroiliac (SI) joint is a common cause of both acute and chronic low back pain. It affects about 15–25% of patients with axial low back pain, and up to 40% of patients with ongoing pain following lumbar fusion. Recent advances in the treatment of SI joint pain have led to the development of a wide variety of SI joint fusion devices. These fusion devices seek to stabilize the joints themselves in order that they become immobile and, in theory, can no longer be a source for pain. This is a minimally invasive procedure aimed to address chronic pain without subjecting patients to lengthy surgery or medications, including opioids with the potential for addiction and abuse. Minimally invasive SI fusion can be performed by a lateral approach (i.e., iFuse, Tricor) or posterior approach (i.e., CornerLoc, LinQ, Rialto). The posterior approach requires the patient to be in the prone position but allows for less disruption of muscles with entry. More data are necessary to determine which fusion system may be best for a particular patient. SI fusion devices are a promising way of treating chronic lower back pain related to the SI joint. This narrative review will discuss various types of SI fusion devices, and their potential use in terms of their safety and efficacy.

Perioperative Outcomes of Minimally Invasive Sacroilliac Joint Fusion Using Hollow Screws Through a Lateral Approach: A Single Surgeon Retrospective Cohort Study

Sacroiliac joint (SIJ) pain is a common cause of lower back pain and a significant source of disability in the United States. There is no consensus on the best surgical treatment for SIJ pain that is not responsive to conservative therapy. Minimally invasive fusion of the SIJ using hollow fenestrated screws from a lateral trajectory is a newer technique for SIJ fusion. This study presents perioperative and patient-reported outcomes amongst 62 patients who underwent SIJ fixation with hollow fenestrated screws. We find that mean disability on the Oswestry disability index improved from 52.2% to 34.9% at one-year post-op. Mean operative time was 34±9 minutes and blood loss was 22±35ml. Only six patients required overnight hospitalization. There were two cases of complications requiring operative intervention. We conclude that SIJ fixation using hollow fenestrated screws is a safe and effective procedure for the fixation of the SIJ. Further investigation is warranted to determine the best surgical treatment for SIJ pain.

CT Scan and Clinical Outcomes of Novel Lateral-Oblique Percutaneous Sacroiliac Joint (SIJ) Fixation: Technique and Literature Review

Purpose The sacroiliac joint (SIJ) is estimated to be a source of pain in 15%-30% of patients presenting for the evaluation of low back pain. The SIJ may develop symptoms in an estimated 43% of patients who have had previous lumbar fusion surgeries. With increased awareness of SIJ as a pain source and for those patients who have intractable pain and who fail nonoperative treatment, surgery to stabilize the SIJ is becoming more common. Thus multiple different technologies and techniques need to be evaluated. The purpose of this study is to report on the clinical and radiographic follow-up of percutaneous lateral-oblique sacroiliac joint fusion with a threaded compression screw performed in an outpatient ambulatory surgery center (ASC). Methods Three consecutive patients were chosen for this technique, and after completion, were followed for at least 24 months as part of a pilot study to see how they responded to the treatment. The medical charts of these patients were reviewed along with follow-up radiographs and computed tomography (CT) scans to assess for radiographic fusion designated as bridging bone across the SIJ with no signs of implant loosening such as haloes around the screws, change in position, or screw breakage. The SacroFuse (Sacrix LLC, Boston, MA) SIJ screws were 12 mm x 60 mm at S1 and 12 mm x 50 mm at S2 with threads for compressive fixation and cannulated for percutaneous placement over a guidewire. We evaluated patients' demographics, the pain visual analog scale (VAS) score, and the Oswestry Disability Index (ODI) preoperatively and postoperatively. Results Our first patient was a 51-year-old male body mass index (BMI) 33.3 kg/m² with a previous lumbar fusion. He underwent a two-staged SIJ fusion. The first surgery was done as an open direct lateral surgery, and the second stage was performed three months later using a direct percutaneous lateral-oblique technique for three months. The second and third patients, respectively, were 22-year-old female status prior L5-S1 anterior lumbar interbody fusion (ALIF) plus right posterior unilateral pedicle screws. She had a BMI of 38.3 kg/m². The third patient was a 41-year-old male with a BMI of 29.5 kg/m² who underwent lateral-oblique bilateral percutaneous SIJ fixation. The latest CT imaging of each patient demonstrated increased bone density adjacent and within implants with intra-articular osseous bridging. There were no implant failures or complications. Conclusion This pilot study demonstrated the feasibility and effectiveness of a new percutaneous lateral-oblique SIJ fusion technique with a threaded compression screw done safely in an ASC. Patients demonstrated early pain relief and long-term fusion of their SIJ. We introduced the Sacrix line as a key fluoroscopic landmark for the success of this percutaneous technique.

Minimally invasive sacroiliac joint fusion using a novel hydroxyapatite-coated screw: final 2-year clinical and radiographic results

Background

The proper diagnosis and treatment of sacroiliac joint (SIJ) pain remains a clinical challenge. Dysfunction of the SIJ can produce pain in the lower back, buttocks, and extremities. The present prospective clinical study is a follow-up report on a previous 1-year report on the use of a novel hydroxyapatite (HA)-coated titanium screw for the surgical treatment of SIJ dysfunction.

Methods

Data were prospectively collected on 32 consecutive patients who underwent minimally invasive SIJ fusion with a novel HA-coated screw. Clinical assessments and radiographs were collected and evaluated at 24 months postoperatively.

Results

Mean preoperative visual analog scale (VAS) back, left, and right leg pain scores decreased significantly to 20.0 (±18.4), 5.8 (±8.1), and 11.5 (±20.1) at 24-month follow-up, respectively. Oswestry Disability Index (ODI) scores significantly decreased to 27.5 (±18.8) points at 24 months (P<0.01). Two patients who required revision surgery reported improvement of their symptoms within 3 weeks and did not require subsequent surgery to be performed.

Conclusions

This study shows positive clinical and functional outcomes for patients who have undergone fusion using HA-coated screws for SIJ dysfunction. SIJ fusion using a HA-coated screw to treat SIJ dysfunction significantly decreased VAS back and leg pain and ODI scores at 2-year follow-up.

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.

A Review and Algorithm in the Diagnosis and Treatment of Sacroiliac Joint Pain

INTRODUCTION

The sacroiliac joint (SIJ) has been estimated to contribute to pain in as much as 38% of cases of lower back pain. There are no clear diagnostic or treatment pathways. This article seeks to establish a clearer pathway and algorithm for treating patients.

METHODS

The literature was reviewed in order to review the biomechanics, as well as establish the various diagnostic and treatment options. Diagnostic factors addressed include etiology, history, physical exam, and imaging studies. Treatment options reviewed include conservative measures, as well as interventional and surgical options.

RESULTS

Proposed criteria for diagnosis of sacroiliac joint dysfunction can include pain in the area of the sacroiliac joint, reproducible pain with provocative maneuvers, and pain relief with a local anesthetic injection into the SIJ. Conventional non-surgical therapies such as medications, physical therapy, radiofrequency denervation, and direct SI joint injections may have some limited durability in therapeutic benefit. Surgical fixation can be by a lateral or posterior/posterior oblique approach with the literature supporting minimally invasive options for improving pain and function and maintaining a low adverse event profile.

CONCLUSION

SIJ pain is felt to be an underdiagnosed and undertreated element of LBP. There is an emerging disconnect between the growing incidence of diagnosed SI pathology and underwhelming treatment efficacy of medical treatment. This has led to an increase in SI joint fixation. We have created a clearer diagnostic and treatment pathway to establish an algorithm for patients that can include conservative measures and interventional techniques once the diagnosis is identified.

The Pelvic Girdle Pain deadlock: 2. Topics that, so far, have remained out of focus

INTRODUCTION

In our preceding paper, we concluded that Pelvic Girdle Pain (PGP) should be taken seriously. Still, we do not know its causes. Literature reviews on treatment fail to reveal a consistent pattern, and there are patients who do not respond well to treatment. We designated the lack of progress in research and in the clinic as 'deadlock', and proposed a 'deconstruction' of PGP, that is to say, taking PGP apart into its relevant dimensions.

PURPOSE

We examine the proposition that PGP may emerge as local inflammation. Inflammation would be a new dimension to be taken into account, between biomechanics and psychology. To explore the consequences of this idea, we present four different topics that, so far, have remained out of focus. One: The importance of microtrauma. Two: Ways to counteract chronification. Three: The importance of sickness behaviour when systemic inflammation turns into neuroinflammation of the brain. And Four: The mainly emotional and cognitive nature of chronic pain, and how aberrant neuroinflammation may render chronic pain intractable. For intractable pain, sleep and stress management are promising treatment options.

IMPLICATIONS

The authors hope that the present paper helps to stimulate the flexible creativity that is required to deal with the biological and psychological impact of PGP. Measuring inflammatory mediators in PGP should be a research priority. It should be understood that the boundaries between biology and psychology are becoming blurred. Clinicians must frequently monitor pain, disability, and mood, and be ready to switch treatment whenever the patient does not improve.

iFuse Implant System for Treating Chronic Sacroiliac Joint Pain: A NICE Medical Technology Guidance

Treatment and management of sacroiliac joint pain is often non-surgical, involving packages of care that can include analgesics, physiotherapy, corticosteroid injections and radiofrequency ablation. Surgical intervention is considered when patients no longer respond to conservative management. The iFuse Implant System is placed across the sacroiliac joint using minimally invasive surgery, stabilising the joint and correcting any misalignment or weakness that can cause chronic pain. The iFuse system was evaluated in 2018 by the UK National Institute for Health and Care Excellence (NICE) as part of the Medical Technologies Evaluation Programme (MTEP). Clinical evidence for iFuse suggests improved pain, Oswestry disability index (ODI) and quality of life compared to non-surgical management. The company (SI-Bone^®) submitted two cost models indicating that iFuse was cost saving compared with open surgery and non-surgical management. Clinicians advised that non-surgical management was the most appropriate comparator and Cedar (a health technology research centre) made changes to the model to test the impact of higher acquisition and procedure costs. Cedar found iFuse to be cost incurring by approximately £560 per patient at 7 years. During the consultation period, the company reduced the cost of some iFuse consumables, and Cedar extended the time horizon to test the assumption that iFuse would become cost saving over time. These changes indicated that iFuse becomes cost saving at 8 years (approximately £129 per patient), after which the cost saving continues to increase. NICE published guidance in October 2018 recommending that the case for adoption of the iFuse system in the UK National Health Service (NHS) was supported by the evidence.