ISASS policy statement - minimally invasive sacroiliac joint fusion

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

PROSPERO REGISTRATION

CRD42020206149 (25th September 2020).

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

PROSPERO REGISTRATION NUMBER

CRD42021273481.

Sacroiliitis in cancer patients: a review of current literature

The sacroiliac (SI) joint can be directly jeopardized by malignancy and indirectly by ergonomic changes of pelvic obliquity that introduces uneven weight distribution. Cancer treatment can exacerbate preexisting arthritis and cause diffuse arthropathies, but these are unlikely to be isolated to the SI joint. The cancer population is exposed to unique stressors that might facilitate development of SI joint pain that includes cancer itself and therapy-related complications. Like the general population, cancer patients are subject to aging and BMI and musculoskeletal structural changes that affect symmetric body functioning and posturing. No frank association between sacroiliitis and cancer has been identified. Therefore, we believe there is a need to characterize any relationship between cancer and SI joint dysfunction and pain.

Two-year clinical results of patients with sacroiliac joint syndrome treated by arthrodesis using a triangular implant system

BACKGROUND

Sacroiliac joint (SIJ) syndrome can cause various symptoms and may also be one reason for persistent low back pain, especially in patients with prior spinal fusions. If conservative treatments fail to improve symptoms, arthrodesis surgery can be considered. Minimally invasive approaches have emerged recently providing a good alternative to conventional methods. A novel triangular implant system (iFuse) can achieve an arthrodesis of the SIJ without the use of additional screws or bone material.

OBJECTIVE

Aim of the present study was an evaluation of short-term safety and efficacy of the implant system.

METHODS

Twenty-four patients were included in the study and treated with the iFuse system. In addition to demographic data, pain intensity (visual analogue scale) and functional impairment (Oswestry-disability index) were assessed prior to surgery and 1 month, 3 months, 6 months, 12 months and 24 months thereafter. During surgery and the follow up period all adverse events were documented and the correct implant position was controlled via plain radiographs.

RESULTS

VAS scores and ODI improved significantly directly after surgery from 84.3 ± 9.2 mm to 40.7 ± 9.2 mm and from 76.8 ± 9.2% to 40.7 ± 9.2 % (p < 0.001). The ODI improved further to 31 ± 5.4% after 24 months whereas the VAS improved until the 3 months examination and ten stayed constant between 27.7 mm and 26.5 mm to 27 ± 6.6 mm at 24 months. No adverse events, intraoperative complications, implant malpositioning or loosening could be recorded at any time.

CONCLUSIONS

The iFuse system is an effective and safe treatment for minimally invasive surgical arthrodesis of the SIJ. Pain and functional impairment can be significantly improved. However, in addition to this case series, further controlled studies are necessary, particularly in terms of a previous spinal fusion history.

Emerging Techniques in Degenerative Thoracolumbar Surgery

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

Postoperative complications in patients undergoing minimally invasive sacroiliac fusion

BACKGROUND CONTEXT

Minimally invasive sacroiliac (SI) joint fusion has become increasingly relevant in recent years as a treatment for SI joint pathology. Previous studies have found minimally invasive SI fusion to be an effective and safe treatment option for chronic SI joint pain. However, these studies have been primarily single-center, case-based, or manufacturer-sponsored investigations, and as such their findings are limited to their sample populations.

PURPOSE

The aim of this study was to investigate the safety of minimally invasive SI fusion using a large nationwide sample group to more accurately identify complication rates of this increasingly popular procedure.

STUDY DESIGN/SETTING

This is a retrospective database study.

PATIENT SAMPLE

The sample includes patients within the orthopedic subset of Humana database who underwent minimally invasive SI fusion between 2007 and 2014.

OUTCOME MEASURES

Complications and novel lumbar and nerve pathology were the outcome measures.

METHODS

Patients undergoing minimally invasive SI fusion from 2007 to 2014 were identified using the Pearl Diver patient record database (Pearl Diver Technologies, West Conshohocken, PA, USA) from the nationwide private insurance provider Humana Inc. This approach provided access to records of over 18 million patients in every major geographic region of the country. Using the ICD-9 diagnosis codes (International Classification of Diseases 9th edition), data from patient records were analyzed to reveal incidence of postoperative infection, pain, osteomyelitis, joint derangement, urinary tract infection, and novel lumbar and nervous system pathology.

RESULTS

Four hundred sixty-nine patients (305 female; 164 male) within the Humana insurance database received minimally invasive SI fusion between 2007 and 2014. Data from these patients showed a substantial increase in the use of the procedure over this 7-year period. Among these patients, an overall complication rate of 13.2% (n=62) was seen at 90 days postoperatively and 16.4% (n=77) at 6 months. The number of patients receiving a first time diagnosis of lumbar pathology following minimally invasive SI fusion in the sample population was also analyzed. The incidence of novel lumbar pathology in this population was 3.6% (n=17) at 90 days postoperatively and 5.3% (n=25) at 6 months. Men experienced diagnoses of novel lumbar pathology at higher rates than women within both 90 days (men=6.7%; women≤3.3%) and 6 months (men=9.1%; women≤3.3%) of the procedure (p<.01).

CONCLUSIONS

The results of this study show that minimally invasive SI joint fusion could possibly carry higher risks of complications than previously stated. These findings are useful for physicians and patients when considering treatment for chronic SI joint pain.

ISASS Policy 2016 Update - Minimally Invasive Sacroiliac Joint Fusion

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

A systematic review of minimally invasive sacroiliac joint fusion utilizing a lateral transarticular technique

BACKGROUND

A number of studies have been published regarding minimally invasive surgical (MIS) fusion of the sacroiliac (SI) joint using a lateral transarticular approach. Herein we report a systematic review and meta-analysis to summarize operative measures and clinical outcomes reported in published studies of MIS SI joint fusion.

METHODS

The systematic review was done according to PRISMA standards. PubMed and EMBASE were searched using the terms sacroiliac joint AND fusion. Original peer-reviewed articles in the English language that reported clinical outcomes on at least 5 cases of MIS SI joint fusion using a lateral transarticular approach were included. Random effects meta-analysis (RMA) was performed on selected variables using the DerSimonian and Laird method, including operative measures, VAS SI joint pain ratings (0-10 scale) and Oswestry Disability Index (ODI). Mean and 95% confidence intervals (CI) were calculated and heterogeneity was assessed. Other findings were summarized qualitatively.

RESULTS

A total of 18 articles met the inclusion criteria. After accounting for overlapping cohorts, 12 unique cohorts from 4 countries were extracted for a total of 432 subjects. The RMA mean (range) was 59 minutes (27-78) for procedure time, 36.9cc (10-70) for estimated blood loss and 1.7 days (range 0-7) for length of stay (LOS). The RMA mean [95% CI] pain score dropped by 5.2 points at 6 months and 5.3 points at 12 months (baseline score of 8.1 [7.8-8.4], 12-month score of 2.7 [2.1-3.3]), and a 24-month score of 2.0(1.4-2.5). ODI decreased by 31 points at 12 months (baseline score of 56.2 [51.0-61.5], 6-month score of 30.7 [21.8-39.6], and 12-month score of 25.1 [12.3-37.9]). Some estimates showed significant variation across studies and between the types of implants used. Other reported outcomes were supportive of the positive effects of SI joint fusion.

CONCLUSION

Published studies of MIS SI joint fusion using a lateral transarticular approach confirm its minimally invasive characteristics with minimal blood loss and short operating room times, and show consistent, rapid, sustained and clinically important improvements in patient reported SI joint pain, disability and quality of life scores.