Analysis of postmarket complaints database for the iFuse SI Joint Fusion System®: a minimally invasive treatment for degenerative sacroiliitis and sacroiliac joint disruption

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.

The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain

Introduction

Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety.

Objective

The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders.

Methods

The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented.

Results

After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain.

Conclusion

The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

Beyond the pedicle screw-a patent review

PURPOSE

This review provides an overview of the patent literature on posteriorly placed intrapedicular bone anchors. Conventional pedicle screws are the gold standard to create a fixation in the vertebra for spinal fusion surgery but may lack fixation strength, especially in osteoporotic bone. The ageing population demands new bone anchors that have an increased fixation strength, that can be placed safely, and, if necessary, can be removed without damaging the surrounding tissue.

METHODS

The patent search was conducted using a classification search in the Espacenet patent database. Only patents with a Cooperative Patent Classification of A61B17/70 or A61B17/7001 concerning spinal positioners and stabilizers were eligible for inclusion. The search query resulted in the identification of 731 patents. Based on preset inclusion criteria, a total of 56 unique patents on different anchoring methods were included, reviewed and categorized in this study.

RESULTS

Five unique fixation methods were identified; (1) anchors that use threading, (2) anchors that utilize a curved path through the vertebra, (3) anchors that (partly) expand, (4) anchors that use cement and (5) anchors that are designed to initiate bone ingrowth. Of the anchor designs included in this study, eight had a corresponding commercial product, six of which were evaluated in clinical trials.

CONCLUSION

This review provides insights into worldwide patented intrapedicular bone anchors that aim to increase the fixation strength compared to the conventional pedicle screw. The identified anchoring methods and their working principles can be used for clinical decision-making and as a source of inspiration when designing novel bone anchors.

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

Best Practices for Postoperative Management of Posterior Sacroiliac Joint Fusion

Sacroiliac joint (SIJ) pain is a common cause of low back pain. Traditionally, treatment for SIJ joint pain and dysfunction has consisted of physical therapy, medication management, SIJ injections, and SIJ ablations. Improved recognition of the SIJ as an etiology for back pain has led to advances in treatment options. Radiofrequency of the lateral sacral branches has been shown to be effective, though evidence is fraught with inconsistent patient selection, study design and procedural technique. It also does not directly address the mechanical dysfunction of the SIJ. In order to create a more enduring approach SIJ fusion has become an attractive option to reduce pain and to improve function. This method of SI joint treatment requires guidance in the perioperative phase of care from both the physicians and advanced practice providers (APP). In order to improve care and outcomes of those undergoing posterior SI joint fusion the American Society of Pain and Neuroscience appointed an expert panel of physicians and advanced practice providers to create a best practice for the post operative care of this approach. As with any best practice, the panel considered current peer reviewed literature and clinical expertise to create guidance today. This is intended to be a living document with modifications as additional evidence comes to light in data publication. The goals of this paper are to focus on (1) wound care, (2) medication use, (3) physical activity and (4) therapeutic exercises.

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.

Trends in Diagnosis and Treatment of Sacroiliac Joint Pathology Over the Past 10 Years: Review of Scientific Evidence for New Devices for Sacroiliac Joint Fusion

Sacroiliac (SI) joint pathology is a newly appreciated contributor to lower back pain. Sacroiliac joint fusion (SIJF) has grown rapidly in popularity in association with the advent of minimally-invasive surgical techniques. This has led to an explosion of new medical devices used for SIJF. The objective of this article is to outline clinical trends, summarize the current data, and categorize novel devices for SIJF. Trends in SI joint pathology and fusion were obtained via the Healthcare Cost and Utilization Project’s (HCUP) National Inpatient Sample (NIS) database and Web of Science. To review literature on devices for SIJF, PubMed was searched using the Boolean phrase “sacroiliac joint AND (fusion OR arthrodesis)” since 2010. To establish a list of SIJF devices not represented in the literature, searches were performed on the FDA 510(k), premarket approval, and de novo databases, as well as Google and LinkedIn. Literature review yielded 11 FDA-approved devices for minimally invasive SIJF. Database query yielded an additional 22 devices for a total of 33 devices. Twenty-one devices used the lateral transiliac approach, six posterior allograft approach, three posterolateral approach, and three combined the lateral transiliac and posterolateral approaches. The evidence for the lateral transiliac approach is the most robust. Many novel devices have been developed for minimally invasive SIJF over the past 10 years. Further randomized comparative trials are warranted to evaluate different surgical approaches and novel devices at this time.

International Society for the Advancement of Spine Surgery Policy 2020 Update-Minimally Invasive Surgical Sacroiliac Joint Fusion (for Chronic Sacroiliac Joint Pain): Coverage Indications, Limitations, and Medical Necessity

The index 2014 International Society for the Advancement of Spine Surgery Policy Statement-Minimally Invasive Surgical Sacroiliac Joint Fusion-was generated out of necessity to provide an International Classification of Diseases, Ninth Revision (ICD-9)-based background and emphasize tools to ensure correct diagnosis. A timely ICD-10-based 2016 update provided a granular threshold selection with improved level of evidence and a more robust and relevant database (Appendix Table A1). As procedures and treatment options have evolved, this 2020 update reviews and analyzes the expanding evidence base and provides guidance relating to differences between the lateral and dorsal surgical procedures for minimally invasive surgical sacroiliac joint fusion.

Minimally Invasive Sacroiliac Joint Fusion: The Current Evidence

Background

Fusion of the sacroiliac (SI) joint as a treatment for low back pain remains controversial. The purpose of this manuscript is to review the current literature and clinical outcomes of SI joint fusion surgery.

Methods

We conducted a literature review and included studies with the term "sacroiliac joint fusion" that had at least 12 months of clinical follow-up, reported on minimally invasive techniques, and included patient-reported outcome measures.

Results

Two approach types (dorsal and lateral) and numerous different implant manufacturers were identified. Most studies included level 4 data, with a small number of level 2 prospective cohort studies and 2 prospective level 1 studies. Every reviewed study reported clinical benefit in terms of improved pain scores or improvement in validated disability measures. Complication rates were low.

Conclusions

Minimally invasive SI joint fusion provides clinically significant improvement in pain scores and disability in most patients, across multiple studies and implant manufacturers.

Level of Evidence

5.

Clinical Relevance

Emerging evidence in support of SI joint fusion indicates that clinicians should examine the SI joint and include SI joint pain in their differential diagnosis for low back pain patients.

Effects on hip stress following sacroiliac joint fixation: A finite element study

For those patients who suffer from low back pain generated by the sacroiliac (SI) joint, fusion of the SI joint has proven to be an effective means of stabilizing it and reducing pain. Though it has shown promise, SI joint fusion raises clinical questions regarding its effect on neighboring joints such as the hip. As such, the purpose of this study was to determine the effects of SI joint fixation on the hip. A finite element spine-sacroiliac-hip (SSIH) model was developed and its functionality was verified against SI joint range of motion (ROM) and hip contact stress, respectively. The intact model was fixed in double leg stance at the distal femora, and loading was applied at the lumbar spine to simulate stance, flexion, extension, right and left lateral bending, and right and left axial rotation. Functionality was confirmed by measuring and comparing SI joint ROM and contact stress and area at the hip with data from the literature. Following verification of the intact SSIH model, both unilateral and bilateral SI joint fixation were modeled; hip contact stress and area were compared to the intact state. Average hip contact stress was ~2 MPa, with most motions resulting in changes less than 5% relative to intact; contact area changed less than 10% for any motion. Clinical significance: these results demonstrated that SI joint fixation with triangular titanium implants imparted little change in stress at the hip, which suggests that the risk of developing adjacent segment disease is likely low. Future clinical studies may be executed to confirm the results of this computational study.

The Safety Profile of Percutaneous Minimally Invasive Sacroiliac Joint Fusion

STUDY DESIGN

Literature review.

OBJECTIVES

Systematic review of the existing literature to determine the safety of minimally invasive (MI) sacroiliac (SI) joint fusion through the determination of the rate of procedural and device-related intraoperative and postoperative complications.

METHODS

All original studies with reported complication rates were included for analysis. Complications were defined as procedural if secondary to the MI surgery and device related if caused by placement of the implant. Complication rates are reported using descriptive statistics. Random-effects meta-analysis was performed for preoperative and postoperative Visual Analog Score (VAS) pain ratings and Oswestry Disability Index (ODI) scores.

RESULTS

Fourteen studies of 720 patients (499 females/221 males) with a mean follow-up of 22 months were included. Ninety-nine patients (13.75%) underwent bilateral SI joint arthrodesis resulting in a total of 819 SI joints fused. There were 91 reported procedural-related complications (11.11%) with the most common adverse event being surgical wound infection/drainage (n = 17). Twenty-five adverse events were attributed to be secondary to placement of the implant (3.05%) with nerve root impingement (n = 13) being the most common. The revision rate was 2.56%. MI SI joint fusion reduced VAS scores from 82.42 (95% confidence interval [CI] 79.34-85.51) to 29.03 (95% CI 25.05-33.01) and ODI scores from 57.44 (95% CI 54.73-60.14) to 29.42 (95% CI 20.62-38.21).

CONCLUSIONS

MI SI joint fusion is a relatively safe procedure but is not without certain risks. Further work must be done to optimize the procedure's complication profile. Possible areas of improvement include preoperative patient optimization, operative technique, and use of intraoperative real-time imaging.

Long-Term Prospective Clinical And Radiographic Outcomes After Minimally Invasive Lateral Transiliac Sacroiliac Joint Fusion Using Triangular Titanium Implants

BACKGROUND

Accumulating evidence supports the long-term safety and effectiveness of minimally invasive sacroiliac joint fusion (SIJF) for sacroiliac joint dysfunction.

OBJECTIVE

To report 5-year clinical and radiographic follow-up in patients undergoing SIJF using triangular titanium implants (TTI).

METHODS

One hundred and three subjects at 12 centers treated with SIJF using TTI in two prospective clinical trials (NCT01640353 and NCT01681004) were enrolled and followed in the current study (NCT02270203) with clinic visits at 3, 4 and 5 years. CT scans performed at 5 years were compared to prior CT scans (at 1 or 2 years) by an independent radiologist.

RESULTS

Compared to baseline scores, SIJ pain scores at 5 years decreased by a mean of 54 points, disability scores (Oswestry Disability Index) decreased by 26 points, and quality of life scores (EuroQOL-5D time trade-off index) increased by 0.29 points (0-1 scale) (all p<0.0001). Satisfaction rates were high and the proportion of subjects taking opioids decreased from 77% at baseline to 41% at 5-year follow-up. Independent radiographic analysis showed a high rate (98%) of bone apposition to implants on both the sacral and iliac sides of the SI joint, with a high rate of bony bridging (87%) and a low rate of radiolucencies suggestive of loosening (5%).

CONCLUSION

A 5-year follow-up showed continued excellent clinical responses in patients with SIJ pain treated with SIJF using triangular titanium implants along with a high rate (88%) of joint fusion.

LEVEL OF EVIDENCE

Level II.

Postmarket surveillance of 3D-printed implants for sacroiliac joint fusion

Background

Government regulations require postmarket surveillance for cleared/approved medical devices. Trend analysis of newly marketed devices may help to confirm device-related safety or uncover other device or procedure-related problems.

Methods

Complaints related to the use of 3D-printed triangular titanium implants for sacroiliac joint (SIJ) fusion were compared with those of the prior machined version of the device manufactured with a titanium plasma spray (TPS) coating. Event rates were calculated either by dividing event counts by numbers of surgeries or, for late events, using Kaplan–Meier survival analysis.

Results

Three types of complaints with nontrial frequencies were identified. Issues in instruments occurred at a low and constant rate (1.3%). Using Kaplan–Meier analysis, pain-related complaints occurred at a low and similar rate in both groups (<0.5%). The 1-year cumulative probability of surgical revision was low in both the 3D and machined versions of the device (1.5% for machined and 1% for 3D printed, P=0.0408 for difference). No implant breakages or migrations were identified in either group, and overall rates were similar to a previously published report.

Conclusion

The 3D-printed version of triangular titanium implant was associated with complaint and adverse event rates similar to those for the prior machined version of the device.

Revision of Minimally Invasive Sacroiliac Joint Fixation: Technical Considerations and Case Studies Using Decortication and Threaded Implant Fixation

BACKGROUND

Sacroiliac joint (SIJ) disease is increasingly recognized as a common source of low back pain. Arthrodesis of the SIJ has been shown to be clinically effective for this condition. In the last decade, minimally invasive (MI) SIJ fusion procedures have been developed to achieve the clinical effectiveness of open fusion procedures, with lower operative morbidity and faster recovery. However, SIJ fusion patients occasionally present with symptomatic nonunions necessitating revision.

METHODS

Four patients who previously underwent MI SIJ arthrodesis returned with complaints of SIJ related pain confirmed by examination. Radiographic assessment showed lucency after fixation with triangular titanium interference implants. Loose implants were removed, and the patients were revised with a different MI SIJ fusion system that utilizes decortication, placement of autograft and graft extender, and fixation with cannulated threaded implants. The trajectory of the revision implants was in a more ventral-to-dorsal and caudal-to-cranial trajectory to place the implants perpendicularly through the articular portion of the SIJ.

RESULTS

The triangular implants typically exhibited haloing lucency on radiographs and CT scans, and most were easily removed using the manufacturer's instrumentation; only one implant was left in place as it was well-fixed. The removed implants exhibited little or no bony ongrowth. Decortication of the SIJ was performed, followed by placement of local autograft and fixation with 12.5 mm or 14.5mm diameter implants, as required. A more ventral-todorsal and caudal-to-cranial trajectory was established for the revision implants through the center of the articular region of the joint in order to maximize implant purchase in residual bone stock and achieve bony fusion through the articular portion of the SIJ. By six to twelve months post-revision, the presenting symptoms were successfully resolved in all patients.

CONCLUSIONS

Patients demonstrating symptomatic pseudoarthrosis after SIJ fixation surgery can be successfully revised with decortication, grafting and fixation with threaded implants utilizing MI surgical techniques. Implant trajectory is an important consideration for primary or revision MIS SIJ fusion. Studies with longer-term follow-up of both primary and revision procedures are needed to further understand fusion rates for both primary and revision procedures utilizing both triangular and threaded implant systems.

Patient Reported Outcomes from Sacroiliac Joint Fusion

STUDY DESIGN

Retrospective, case series.

PURPOSE

The purpose of this study is to determine morbidity, complications, and patient reported outcomes from minimally invasive sacroiliac joint (SIJ) fusion.

OVERVIEW OF LITERATURE

Lumbar back pain emanating from the SIJ can be surgically treated via a percutaneous approach in the appropriately selected patient with minimal morbidity and acceptable functional outcomes.

METHODS

Patients diagnosed by >2 physical examination maneuvers and subjective relief from a computed tomography-guided lidocaine-bupivacaine-steroid injection underwent SIJ fusion after failing conservative management with a combination of oral anti-inflammatory medications, physical therapy, and pelvic belt stabilization. Perioperative data collected include estimated blood loss (EBL) and operative time. Oswestry disability index, 12-item short form health survey (SF-12), visual analogue score, and functional status were analyzed. All complications were noted.

RESULTS

The study cohort of 45 cases (69% female) achieved postoperative survey follow-up at 9.9 and 32.3 months. SF-12 physical component summary statistically improved while all other scores were equivalent. Mean EBL and operative time were 22 mL and 36 minutes, respectively. Initial survey showed that 64% of patients discontinued narcotics (29/45), 71% do not use an assistive device (32/45), and 15.6% do not work due to pain (7/45). 73% of patients stated they would have the surgery again (33/45). For the second survey, 65% of patients discontinued narcotics (26/40), 70% did not use an assistive device (28/40), and 17.5% did not work due to pain (7/40). A history of thoracolumbar instrumentation (16/45) did not significantly affect outcomes. Three complications described by screw malposition with neurologic deficit (6.7%) were treated with screw repositioning (1 case) and removal of a single superior implant (2 cases) with time to revision of 2.2 months. All three ultimately had resolution of radicular pain.

CONCLUSIONS

Percutaneous SIJ fusion offers minimal morbidity and acceptable functional outcomes. While women and those with a prior history of lumbar instrumentation may be at increased risk of having SIJ dysfunction requiring surgical intervention, it was not found to affect postoperative functional outcomes when compared to the non-instrumented group.

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.

Sacroiliac Joint Fusion Using Triangular Titanium Implants vs. Non-Surgical Management: Six-Month Outcomes from a Prospective Randomized Controlled Trial

BACKGROUND

Sacroiliac (SI) joint pain is a prevalent, underdiagnosed cause of lower back pain. SI joint fusion can relieve pain and improve quality of life in patients who have failed nonoperative care. To date, no study has concurrently compared surgical and non-surgical treatments for chronic SI joint dysfunction.

METHODS

We conducted a prospective randomized controlled trial of 148 subjects with SI joint dysfunction due to degenerative sacroiliitis or sacroiliac joint disruptions who were assigned to either minimally invasive SI joint fusion with triangular titanium implants (N=102) or non-surgical management (NSM, n=46). SI joint pain scores, Oswestry Disability Index (ODI), Short-Form 36 (SF-36) and EuroQol-5D (EQ-5D) were collected at baseline and at 1, 3 and 6 months after treatment commencement. Six-month success rates, defined as the proportion of treated subjects with a 20-mm improvement in SI joint pain in the absence of severe device-related or neurologic SI joint-related adverse events or surgical revision, were compared using Bayesian methods.

RESULTS

Subjects (mean age 51, 70% women) were highly debilitated at baseline (mean SI joint VAS pain score 82, mean ODI score 62). Six-month follow-up was obtained in 97.3%. By 6 months, success rates were 81.4% in the surgical group vs. 23.9% in the NSM group (difference of 56.6%, 95% posterior credible interval 41.4-70.0%, posterior probability of superiority >0.999). Clinically important (≥15 point) ODI improvement at 6 months occurred in 75% of surgery subjects vs. 27.3% of NSM subjects. At six months, quality of life improved more in the surgery group and satisfaction rates were high. The mean number of adverse events in the first six months was slightly higher in the surgical group compared to the non-surgical group (1.3 vs. 1.0 events per subject, p=0.1857).

CONCLUSIONS

Six-month follow-up from this level 1 study showed that minimally invasive SI joint fusion using triangular titanium implants was more effective than non-surgical management in relieving pain, improving function and improving quality of life in patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruptions.

CLINICAL RELEVANCE

Minimally invasive SI joint fusion is an acceptable option for patients with chronic SI joint dysfunction due to degenerative sacroiliitis and sacroiliac joint disruptions unresponsive to non-surgical treatments.

One-year outcomes after minimally invasive sacroiliac joint fusion with a series of triangular implants: a multicenter, patient-level analysis

Background

Sacroiliac joint (SI) pain is an often-overlooked cause of lower-back pain, due in part to a lack of specific findings on radiographs and a symptom profile similar to other back-related disorders. A minimally invasive surgical (MIS) approach to SI joint fusion using a series of triangular, titanium plasma spray-coated implants has shown favorable outcomes in patients with SI joint pain refractory to conservative care. The aim of this study was to provide a multicenter experience of MIS SI joint fusion using a patient-level analysis.

Patients and methods

We report a patient-level analysis from 144 patients with a mean of 16 months postoperative follow-up. Demographic information, perioperative measures, complications, and clinical outcomes using a visual analog scale for pain were collected prospectively. Random-effects regression models were used to account for intersite variability.

Results

The mean age was 58 years, 71% of patients were female, and 62% had a history of lumbar spinal fusion. Mean (95% confidence interval [CI]) operative time was 73 minutes (25.4–118), blood loss was minimal, and hospital stay was 0.8 days (0.1–1.5). At follow-up, mean (95% CI) visual analog scale pain scores improved by 6.1 points (5.7–6.6). Substantial clinical benefit, defined as a decrease in pain by >2.5 points or a score of 3.5 or less, was achieved in 91.9% of patients (95% CI 83.9%–96.1%), and 96% (95% CI 86.3%–98.8%) of patients indicated they would have the same surgery again.

Conclusion

When conservative measures fail to relieve symptoms resulting from degeneration or disruption of the SI joint, MIS SI joint fusion using a series of triangular, porous, titanium plasma spray-coated implants is a safe and effective treatment option.

Comparison of the costs of nonoperative care to minimally invasive surgery for sacroiliac joint disruption and degenerative sacroiliitis in a United States commercial payer population: potential economic implications of a new minimally invasive technology

Introduction

Low back pain is common and treatment costly with substantial lost productivity and lost wages in the working-age population. Chronic low back pain originating in the sacroiliac (SI) joint (15%–30% of cases) is commonly treated with nonoperative care, but new minimally invasive surgery (MIS) options are also effective in treating SI joint disruption. We assessed whether the higher initial MIS SI joint fusion procedure costs were offset by decreased nonoperative care costs from a US commercial payer perspective.

Methods

An economic model compared the costs of treating SI joint disruption with either MIS SI joint fusion or continued nonoperative care. Nonoperative care costs (diagnostic testing, treatment, follow-up, and retail pharmacy pain medication) were from a retrospective study of Truven Health MarketScan^® data. MIS fusion costs were based on the Premier’s Perspective™ Comparative Database and professional fees on 2012 Medicare payment for Current Procedural Terminology code 27280.

Results

The cumulative 3-year (base-case analysis) and 5-year (sensitivity analysis) differentials in commercial insurance payments (cost of nonoperative care minus cost of MIS) were $14,545 and $6,137 per patient, respectively (2012 US dollars). Cost neutrality was achieved at 6 years; MIS costs accrued largely in year 1 whereas nonoperative care costs accrued over time with 92% of up front MIS procedure costs offset by year 5. For patients with lumbar spinal fusion, cost neutrality was achieved in year 1.

Conclusion

Cost offsets from new interventions for chronic conditions such as MIS SI joint fusion accrue over time. Higher initial procedure costs for MIS were largely offset by decreased nonoperative care costs over a 5-year time horizon. Optimizing effective resource use in both nonoperative and operative patients will facilitate cost-effective health care delivery. The impact of SI joint disruption on direct and indirect costs to commercial insurers, health plan beneficiaries, and employers warrants further consideration.

Management of sacroiliac joint disruption and degenerative sacroiliitis with nonoperative care is medical resource-intensive and costly in a United States commercial payer population

Introduction

Low back pain is common and originates in the sacroiliac (SI) joint in 15%–30% of cases. Traditional SI joint disruption/degenerative sacroiliitis treatments include nonoperative care or open SI joint fusion. To evaluate the usefulness of newly developed minimally-invasive technologies, the costs of traditional treatments must be better understood. We assessed the costs of nonoperative care for SI joint disruption to commercial payers in the United States (US).

Methods

A retrospective study of claim-level medical resource use and associated costs used the MarketScan® Commercial Claims and Encounters as well as Medicare Supplemental Databases of Truven Healthcare. Patients with a primary ICD-9-CM diagnosis code for SI joint disruption (720.2, 724.6, 739.4, 846.9, or 847.3), an initial date of diagnosis from January 1, 2005 to December 31, 2007 (index date), and continuous enrollment for ≥1 year before and 3 years after the index date were included. Claims attributable to SI joint disruption with a primary or secondary ICD-9-CM diagnosis code of 71x.xx, 72x.xx, 73x.xx, or 84x.xx were identified; the 3-year medical resource use-associated reimbursement and outpatient pain medication costs (measured in 2011 US dollars) were tabulated across practice settings. A subgroup analysis was performed among patients with lumbar spinal fusion.

Results

The mean 3-year direct, attributable medical costs were $16,196 (standard deviation [SD] $28,592) per privately-insured patient (N=78,533). Among patients with lumbar spinal fusion (N=434), attributable 3-year mean costs were $91,720 (SD $75,502) per patient compared to $15,776 (SD $27,542) per patient among patients without lumbar spinal fusion (N=78,099). Overall, inpatient hospitalizations (19.4%), hospital outpatient visits and procedures (14.0%), and outpatient pain medications (9.6%) accounted for the largest proportion of costs. The estimated 3-year insurance payments attributable to SI joint disruption were $1.6 billion per 100,000 commercial payer beneficiaries.

Conclusion

The economic burden of SI joint disruption among privately-insured patients in the US is substantial, highlighting the need for more cost-effective therapies.

Safety and 6-month effectiveness of minimally invasive sacroiliac joint fusion: a prospective study

Background

Sacroiliac (SI) joint pain is an often overlooked cause of low back pain. SI joint arthrodesis has been reported to relieve pain and improve quality of life in patients suffering from degeneration or disruption of the SI joint who have failed non-surgical care. We report herein early results of a multicenter prospective single-arm cohort of patients with SI joint degeneration or disruption who underwent minimally invasive fusion using the iFuse Implant System®.

Methods

The safety cohort includes 94 subjects at 23 sites with chronic SI joint pain who met study eligibility criteria and underwent minimally invasive SI joint fusion with the iFuse Implant System® between August 2012 and September 2013. Subjects underwent structured assessments preoperatively, immediately postoperatively, and at 1, 3, and 6 months postoperatively, including SI joint and back pain visual analog scale (VAS), Oswestry Disability Index (ODI), Short Form-36 (SF-36), and EuroQoL-5D (EQ-5D). Patient satisfaction with surgery was assessed at 6 months. The effectiveness cohort includes the 32 subjects who have had 6-month follow-up to date.

Results

Mean subject age was 51 years (n=94, safety cohort) and 66% of patients were women. Subjects were highly debilitated at baseline (mean VAS pain score 78, mean ODI score 54). Three implants were used in 80% of patients; two patients underwent staged bilateral implants. Twenty-three adverse events occurred within 1 month of surgery and 29 additional events occurred between 30 days and latest follow-up. Six adverse events were severe but none were device-related. Complete 6-month postoperative follow-up was available in 26 subjects. In the effectiveness cohort, mean (± standard deviation) SI joint pain improved from a baseline score of 76 (±16.2) to a 6-month score of 29.3 (±23.3, an improvement of 49 points, P<0.0001), mean ODI improved from 55.3 (±10.7) to 38.9 (±18.5, an improvement of 15.8 points, P<0.0001) and SF-36 PCS improved from 30.7 (±4.3) to 37.0 (±10.7, an improvement of 6.7 points, P=0.003). Ninety percent of subjects who were ambulatory at baseline regained full ambulation by month 6; median time to full ambulation was 30 days. Satisfaction with the procedure was high at 85%.

Conclusion

Minimally invasive SI joint fusion using the iFuse Implant System® is safe. Mid-term follow-up indicates a high rate of improvement in pain and function with high rates of patient satisfaction.

Comparison of the costs of nonoperative care to minimally invasive surgery for sacroiliac joint disruption and degenerative sacroiliitis in a United States Medicare population: potential economic implications of a new minimally-invasive technology

INTRODUCTION

The economic burden associated with the treatment of low back pain (LBP) in the United States is significant. LBP caused by sacroiliac (SI) joint disruption/degenerative sacroiliitis is most commonly treated with nonoperative care and/or open SI joint surgery. New and effective minimally invasive surgery (MIS) options may offer potential cost savings to Medicare.

METHODS

An economic model was developed to compare the costs of MIS treatment to nonoperative care for the treatment of SI joint disruption in the hospital inpatient setting in the US Medicare population. Lifetime cost savings (2012 US dollars) were estimated from the published literature and claims data. Costs included treatment, follow-up, diagnostic testing, and retail pharmacy pain medication. Costs of SI joint disruption patients managed with nonoperative care were estimated from the 2005-2010 Medicare 5% Standard Analytic Files using primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes 720.2, 724.6, 739.4, 846.9, or 847.3. MIS fusion hospitalization cost was based on Diagnosis Related Group (DRG) payments of $46,700 (with major complications - DRG 459) and $27,800 (without major complications - DRG 460), weighted assuming 3.8% of patients have complications. MIS fusion professional fee was determined from the 2012 Medicare payment for Current Procedural Terminology code 27280, with an 82% fusion success rate and 1.8% revision rate. Outcomes were discounted by 3.0% per annum.

RESULTS

The extrapolated lifetime cost of treating Medicare patients with MIS fusion was $48,185/patient compared to $51,543/patient for nonoperative care, resulting in a $660 million savings to Medicare (196,452 beneficiaries at $3,358 in savings/patient). Including those with ICD-9-CM code 721.3 (lumbosacral spondylosis) increased lifetime cost estimates (up to 478,764 beneficiaries at $8,692 in savings/patient).

CONCLUSION

Treating Medicare beneficiaries with MIS fusion in the hospital inpatient setting could save Medicare $660 million over patients' lifetimes.

Minimally invasive sacroiliac joint fusion: one-year outcomes in 18 patients

Background

Sacroiliac joint (SI) pain is an often-overlooked cause of low back pain due, in part, to lack of specific findings on radiographs and symptoms mimicking other back-related disorders. We report our experience with minimally invasive (MIS) SI joint arthrodesis using a series of triangular, titanium plasma spray (TPS) coated implants in patients refractory to conservative care.

Methods

We report outcomes from 18 patients with 12 months of postoperative follow-up.

Demographics, complications, and clinical outcomes using visual analog scale (VAS) for pain, Oswestry Disability Index (ODI) for back function and SF-12 for quality of life were collected preoperatively and at 3, 6 and 12 months post-operatively.

Results

Mean age was 64 years and 67% of patients were female. There were no intraoperative complications and one explant at three months for malposition.

All patient-reported outcomes showed both clinically and statistically significant improvement at 12 months (p < 0.001 for each of the following): VAS improved by 6.6 points, ODI scores improved by −37.5 points. One year SF-12 physical and mental component (PCS, MCS) scores approximated population normal scores for both physical and mental functioning. Patient satisfaction with outcomes was high at 95%; 89% said would have the same surgery again.

Conclusions

MIS SI joint fusion using a series of triangular porous TPS coated titanium implants is a safe and effective procedure for patients with SI joint disorders who have failed conservative care.