Successful Diagnosis of Sacroiliac Joint Dysfunction

Evolving Trends in the Use of Sacroiliac Fusion From 2015 to 2020

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

To assess the evolution of patients undergoing sacroiliac (SI) fusion with minimally invasive surgery (MIS) relative to open approaches.

SUMMARY OF BACKGROUND DATA

The SI joint can be a contributor to lumbopelvic symptoms. The MIS approach to SI fusion has been shown to have fewer complications compared with the open approach. Recent trends and evolved patient populations have not been well-characterized.

MATERIALS AND METHODS

Data were abstracted from the large, national, multi-insurance, administrative 2015-2020 M151 PearlDiver database. The incidence, trends, and patient characteristics of MIS, as well as open, SI fusions for adult patients with degenerative indications, were determined. Univariable and multivariable analyses were then performed to compare the MIS relative to open populations. The primary outcome was to assess the trends of MIS and open approaches for SI fusions.

RESULTS

In total, 11,217 SI fusions were identified (of which 81.7% were MIS), with a clear increase in numbers over the years from 2015 (n=1318, 62.3% of which were MIS) to 2020 (n=3214 86.6% of which were MIS). Independent predictors of MIS (as opposed to open) SI fusion included: older age (odds ratio [OR] 1.09 per decade increase), higher Elixhauser-Comorbidity Index (OR 1.04 per two-point increase), and geographic region (relative to South, Northeast OR 1.20 and West OR 1.64). As might be expected, 90-day adverse events were lower for MIS than open cases (OR 0.73).

CONCLUSION

The presented data quantify the increasing incidence of SI fusions over the years, with the increase being driven by MIS cases. This was largely related to an expanded population (those who are older and with greater comorbidity), fitting the definition of disruptive technology with lesser adverse events than open procedures. Nonetheless, geographic variation highlights the differential adoption of this technology.

A literature review of biomechanical studies on physiological and pathological sacroiliac joints: Articular surface structure, joint motion, dysfunction and treatments

BACKGROUND

Sacroiliac joints are affected by mechanical environments; the joints are formed under mechanical stimulation, receive impact of walking between the upper and lower parts of the bodies and can be a cause of pain due to non-physiological loads. However, there are so far very few studies that reviewed biomechanics of physiological and pathological sacroiliac joints. This review article aims to describe the current sacroiliac joint biomechanics.

METHODS

Previous original papers have been summarized based on three categories: articular surface structure, sacroiliac joint motion and sacroiliac joint dysfunction and treatments.

FINDINGS

Although the articular surface morphologies vary greatly from individual to individual, many researchers have tried to classify the joints into several types. It has been suggested that the surface morphologies may not change regardless of joint dysfunction, however, the relationship between the joint structure and pain are still unclear. The range of sacroiliac joint motion is demonstrated to be less than 1 mm and there is no difference between physiological and pathological joints. The sacroiliac joint absorbs shock within the pelvis by the joint structures of pelvic morphology, ligaments and fat tissues. The morphology and motion of the sacroiliac joints may be optimized for upright bipedal walking.

INTERPRETATION

There is no doubt that pelvic mechanical environments affect pain induction and treatment; however, no one has yet provided a concrete explanation. Future research could help develop treatments based on sacroiliac joint biomechanics to support joint function.

Sacroiliac Joint Denervation-A Novel Approach to Target Sacral Lateral Branches: A Practical Approach

INTRODUCTION

Sacroiliac joint (SIJ) pain is a relatively common cause of low back pain. Percutaneous radiofrequency (RF) techniques for SIJ are limited to ablation of the posterior SIJ innervation. Different techniques have been described for SIJ radiofrequency ablation, including conventional thermal, cooled RF, pulsed RF, bipolar RF, and specialized tip RF needle (i.e., multi-tined); however, additional costs may limit these applications.

METHODS

This new technique for SIJ denervation uses anatomical landmarks and a single RF cannula. Two spinal needles are placed lateral to the posterior S1 and S2 sacral foramina; then, with caudal tilt we get a coaxial view of the sacral bone, we advance an 18-G curved 15-mm active tip RF cannula just lateral to the aligned finder needles. Ablation is performed, and then the RF cannula is retracted 2 cm and ablation is repeated for a total of four lesions.

RESULTS

The two spinal needles placed lateral to the posterior sacral foramina S1 and S2 guide the final needle in the posterior aspect of the sacrum, lateral to the sacral foramina, where the lateral sacral branches are located.

CONCLUSION

We introduce a cost and time efficient technique to perform radiofrequency ablation of the sacral lateral branches using a single RF needle. This technique utilizes the sacrum's reliable anatomy and angulation and maximizes the surface area of the active tip lesioning. This technique creates a strip lesion lateral to the sacral foramina and reduces time and cost efficacy compared to several of the other techniques and/or commercially available special devices designed for sacroiliac denervation.

Interventional treatments for low back pain due to sacroiliac joint dysfunction: a systematic review of the literature

PURPOSE

This systematic review aimed to report the current evidence in the literature about the efficacy of interventional treatments in the management of low back pain (LBP) due to sacroiliac joint dysfunction.

METHODS

A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Medline, EMBASE, Scopus, CINAHL, Cochrane Library, and CENTRAL bibliographic databases were searched. The search was performed from October to December 2021, and articles from the inception of the database to December 2021 were searched.

RESULTS

Fourteen studies were included for qualitative synthesis. Five studies used the traditional radiofrequency approach (tRF), five studies used cooled radiofrequency approach (cRF), one study used botulinum toxin (BT), two studies used steroid injection, triamcinolone (TA) and local anesthetics injections, and one study used pulsed radiofrequency (PRF) denervation. Two studies used sham as a comparator.

CONCLUSIONS

Cooled radiofrequency seems to be the most effective treatment in improving pain and functionality, while intra-articular injections are helpful only as diagnostic tools. However, due to the lack of high-quality studies, it was not possible to draw significant conclusions.

A systematic review and update on diagnosis and treatment of new onset sacroiliac joint dysfunction after lumbar fusion

BACKGROUND

Sacroiliac joint dysfunction (SIJD) after lumbar/lumbosacral fusion has become increasingly recognized as the utilization of lumbar fusion has grown. Despite the significant morbidity associated with this condition, uncertainty regarding its diagnosis and treatment remains. We aim to update the current knowledge of the etiology, diagnosis, and treatment of post-lumbar surgery SIJD.

METHODS

PRISMA guidelines were used to search the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, and OVID databases for literature published in the last 10 years. The ROBIS tool was utilized for risk of bias assessment. Statistical analyses were performed using the R foundation. A Fisher's exact test was performed to determine the risk of SIJD based on operative technique, gender, and symptom onset timeline. Odds ratios were reported with 95% confidence intervals. A p-value [Formula: see text] 0.05 was considered statistically significant.

RESULTS

Seventeen publications were included. The incidence of new onset SIJD was 7.0%. The mean age was 56 years, and the follow-up length was 30 months. SIJD was more common with fixed lumbar fusion vs floating fusion (OR = 1.48 [0.92, 2.37], p = 0.083), fusion of [Formula: see text] 3 segments (p < 0.05), and male gender increased incidence of SIJD (OR = 1.93 [1.27, 2.98], p = 0.001). Intra-articular injection decreased the Visual Analogue Scale (VAS) score by 75%, while radiofrequency ablation (RFA) reduced the score by 90%. An open approach resulted in a 13% reduction in VAS score versus 68 and 29% for SIJ fixation using the iFuse and DIANA approaches, respectively.

CONCLUSIONS

Lumbar fusion predisposes patients to SIJD, likely through manipulation of the SIJ's biomechanics. Definitive diagnosis of SIJD remains multifaceted and a newer modality such as SPECT/CT may find a future role. When conservative measures are ineffective, RFA and SIJ fixation using the iFuse System yield the greatest improvement VAS and ODI.

Effect of sacroiliac fusion on gait, standing balance, and pelvic mobility for unilateral sacroiliac joint dysfunction

Background

Sacroiliac joint fusion (SIF) has been shown to effectively alleviate pain and improve functional deficits associated with sacroiliac joint dysfunction (SIJD). Previous studies have demonstrated significant improvements in gait function, however, none have reported both over-ground walking and quiescent standing, and additionally, none have included analysis of pelvic kinematics which may contain important information regarding pain avoidant compensatory behaviors. The purpose of this study was to identify objective functional differences between symptomatic and asymptomatic sides of unilateral sacroiliac joint dysfunction (SIJD) patients and to demonstrate the effectiveness of unilateral sacroiliac fusion (SIF) to improve gait and balance function compared to matched controls.

Methods

Thirteen unilateral SIJD patients were evaluated before and 6 months after SIF and were compared to matched asymptomatic controls. Pain and disability were assessed using visual analog scales and the Oswestry disability index respectively. Over ground walking and standing balance were assessed using 3D joint kinematics and kinetic ground reaction force analyses.

Results

Preoperatively, SIJD patients reported high levels of pain and disability and exhibited significant deficits in gait including elevated step width, reduced hip flexion/extension, and elevated pelvic motion as well as elevated center of pressure sway characteristics during standing. After unilateral SIF, patients reported significant reductions in pain and demonstrated significant improvements in gait including normalization of step width between sides and improved hip motion however elevated pelvic obliquity and rotation motion remained. Improvements in standing balance included reduced coronal sway characteristics and normalization of loading symmetry between sides.

Conclusion

Unilateral SIF resulted in significant improvements in both gait and balance function among SIJD patients to levels comparable to matched controls, however elevated pelvic motion remained. These findings help inform surgeons on the effectiveness of SIF for unilateral SIJD and provide important information regarding interpretation of functional outcomes.

Nationwide Analysis of Sacroiliac Joint Fusion Trends: Regional Variations in Utilization and Population Characteristics

STUDY DESIGN/SETTING

Retrospective cohort analysis.

OBJECTIVES

This study evaluates utilization and demographic trends for sacroiliac joint (SIJ) fusions across the United States (US).

METHODS

Patients who underwent SIJ fusion from 2010-2021 were identified within the PearlDiver national database using International Classification of Disease (ICD-9, ICD-10) and Current Procedural Terminology (CPT) codes. Indications for trauma, malignancy, or infection were excluded. Demographic, clinical, and procedure characteristics were recorded along with annual utilization rates. Annual percent change (APC) was calculated to identify increasing or decreasing utilization from prior years. Negative binomial regression was performed to project subsequent utilization for 2022-2028. Chi-squared analysis followed by post-hoc comparisons were used to compare differences in diagnostic indications and clinical features associated with SIJ fusion across regions. Bonferroni adjustments were applied to P-values for pairwise analyses.

RESULTS

Overall, 18 032 patients (69.8% female, mean age = 51.0 + 13.4 years) underwent SIJ fusion between 2010 and 2021. Annual utilization increased by 33.5% on average. The South comprised the largest proportion of cases (48.9%). Projections for 2022-2028 predict continued growth in procedures, with an overall increase of 1100% from 1350 cases in 2021 to 16 195 by end of 2028. Spondyloarthropathy-induced sacroilitis was the most prevalent diagnostic indication nationwide (51%). Of patients undergoing SIJ fusion, 18% had a prior lumbar fusion, and only 45% received a preoperative diagnostic SIJ injection.

CONCLUSION

As SIJ fusion is increasingly utilized to treat refractory SIJ-based pain, establishing evidence-based guidelines, improving diagnostic strategies, and defining indications are imperative to support growing applications within clinical practice.

Challenges in treating juvenile idiopathic arthritis

PURPOSE OF REVIEW

Juvenile idiopathic arthritis (JIA) diagnosis and classification is currently still based on clinical presentation and general laboratory tests. Some joints such as the temporomandibular joint (TMJ) and sacroiliac (SI) are hard to assess and define as actively inflamed based on clinical examination. This review addresses these difficult to assess joints and provides the latest evidence for diagnosis and treatment.

RECENT FINDINGS

Recommendations on clinical examination and radiological examination are available. Recent 2021 ACR recommendations were made for TMJ arthritis and in 2019 for sacroiliitis.

SUMMARY

New evidence to guide clinical suspicion and need for further investigations are available for these hard to assess joints. These guidelines will help healthcare providers in diagnosis and treatment assessment.

Application of platelet-rich plasma in spinal surgery

With the aging of the population and changes in lifestyle, the incidence of spine-related diseases is increasing, which has become a major global public health problem; this results in a huge economic burden on the family and society. Spinal diseases and complications can lead to loss of motor, sensory, and autonomic functions. Therefore, it is necessary to identify effective treatment strategies. Currently, the treatment of spine-related diseases includes conservative, surgical, and minimally invasive interventional therapies. However, these treatment methods have several drawbacks such as drug tolerance and dependence, adjacent spondylosis, secondary surgery, infection, nerve injury, dural rupture, nonunion, and pseudoarthrosis. Further, it is more challenging to promote the regeneration of the interstitial disc and restore its biomechanical properties. Therefore, clinicians urgently need to identify methods that can limit disease progression or cure diseases at the etiological level. Platelet-rich plasma (PRP), a platelet-rich form of plasma extracted from venous blood, is a blood-derived product. Alpha granules contain a large number of cytokines, such as platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), epidermal growth factor, platelet factor 4 (PF-4), insulin-like growth factor-1 (IGF-1), and transforming growth factor-β (TGF-β). These growth factors allow stem cell proliferation and angiogenesis, promote bone regeneration, improve the local microenvironment, and enhance tissue regeneration capacity and functional recovery. This review describes the application of PRP in the treatment of spine-related diseases and discusses the clinical application of PRP in spinal surgery.

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.

Sacroiliitis: A Review on Anatomy, Diagnosis, and Treatment

Introduction

Sacroiliitis is an inflammation of one or both of the sacroiliac (SI) joints, most often resulting pain in the lower back that can extend down the legs. Pain arising from the SI joint can be difficult to diagnose and treat due to the intricate surrounding ligamentous structure, nerve innervation, and its role in transferring weight from the upper body to the lower limbs. SI joint dysfunction accounts for up to 25% of cases of lower back pain and has a debilitating effect on patient functionality. This review aims to provide comprehensive coverage of all aspects of SI joint pain, with a specific focus on differential diagnosis and treatment.

Methods

Current literature on SI joint pain and inflammation, other etiologies of lower back pain, and new treatment options were compiled using the databases PubMed and Cochrane and used to write this comprehensive review. There were no restrictions when conducting the literature search with regard to publication date, study language, or study type.

Results

The diagnosis protocol of SI joint pain arising from sacroiliitis usually begins with the presentation of lower back pain and confirmatory diagnostic testing through fluoroscopy joint block. Reduction in pain following the anesthetic is considered the golden standard for diagnosis. The treatment begins with the conservative approach of physical therapy and analgesics for symptom relief. However, refractory cases often require interventional methods such as corticosteroid injections, prolotherapy, radiofrequency ablation, and even SI joint fusion surgery.

Conclusion

SI joint pain is a complex problem that can present with varying patterns of pain due to uncertainty regarding its innervation and its prominent surrounding structure. It is therefore especially important to obtain a thorough history and physical on top of diagnostic tests such as a diagnostic block to properly identify the source of pain. Conservative treatment options with physical therapy and analgesics should be attempted first before interventional strategies such as ablation, injections, and prolotherapy can be considered. SI joint fusion surgery is a solution to cases in which previous methods do not provide significant relief.

Biomechanical analysis of sacroiliac joint motion following oblique-pulling manipulation with or without pubic symphysis injury

Background: Oblique-pulling manipulation has been widely applied in treating sacroiliac joint (SIJ) dysfunction. However, little is known about the biomechanical mechanism of the manipulation. This study aims to analyze the SIJ motion under oblique-pulling manipulation, in comparison with compression and traction loads.

Methods/Study Design: A total of six specimens of embalmed human pelvis cadavers were dissected to expose the SIJ and surrounding ligaments. Through a servo-hydraulic testing system, biomechanical tests were performed on the stable pelvis and the unstable pelvis with pubic symphysis injury (PSI). A three-dimensional (3D) photogrammetry system was employed to determine the separation and nutation in three tests: axial compression (test A), axial traction (test B), and oblique-pulling manipulation (test C).

Results: After applying the testing loads, the range of nutation was no more than 0.3° (without PSI) and 0.5°(with PSI), separately. Except for test B, a greater nutation was found with PSI (p < 0.05). Under both conditions, nutation following test A was significantly greater than that of other tests (p < 0.05). SIJ narrowed in test A and separated in tests B and C, where the range of motion did not exceed 0.1 mm (without PSI) or 0.3 mm (with PSI) separately. Under both conditions, the separation of SIJ in test C was not as apparent as the narrowness of SIJ in test A (p < 0.05). Compared to SIJ, a more significant increasing displacement was found at the site of the iliolumbar ligament (p < 0.05). Nevertheless, when the force was withdrawn in all tests, the range of nutation and separation of SIJ nearly decreased to the origin.

Conclusion: Pubic symphysis is essential to restrict SIJ motion, and the oblique-pulling manipulation could cause a weak nutation and separation of SIJ. However, the resulting SIJ motion might be neutralized by regular standing and weight-bearing load. Also, the effect on SIJ seems to disappear at the end of manipulation. Therefore, the stretching and loosening of surrounding ligaments need to be paid more attention to.