Sacroiliac joint pain: is the medical world aware enough of its existence? Why not considering sacroiliac joint fusion in the recalcitrant cases?
Editorial Commentary

Sacroiliac joint pain: is the medical world aware enough of its existence? Why not considering sacroiliac joint fusion in the recalcitrant cases?

Vicente Vanaclocha-Vanaclocha1, Nieves Sáiz-Sapena2, Leyre Vanaclocha3

1Department of Neurosurgery, 2Department of Anesthesiology, Hospital 9 de Octubre, Valencia, Spain; 3Medical School, University College London, London, UK

Correspondence to: Vicente Vanaclocha-Vanaclocha, MD. Consorcio Hospital 9 de Octubre, Avenida Valle de la Ballestera 59, 46015 Valencia, Spain. Email: vvanaclo@hotmail.com.

Provenance: This is an invited article commissioned by the Section Editor Ai-Min Wu (Department of Spine Surgery, Zhejiang Spine Surgery Centre; Orthopaedic Hospital, the Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University; The Key Orthopaedic Laboratory in Zhejiang Province, Wenzhou Medical University, Wenzhou, China).

Comment on: Dengler J, Kools D, Pflugmacher R, et al. Randomized Trial of Sacroiliac Joint Arthrodesis Compared with Conservative Management for Chronic Low Back Pain Attributed to the Sacroiliac Joint. J Bone Joint Surg Am 2019;101:400-11.


Submitted Jun 18, 2019. Accepted for publication Jun 27, 2019.

doi: 10.21037/jss.2019.06.11


Sacroiliac joint (SIJ) pain is a common contributor to low back pain, present in 10–30% of patients with chronic low back pain (1-5). SIJ pain impairs quality of life similarly to other spine conditions (6,7). Non-surgical treatments, such as physical therapy, chiropractic, intraarticular SIJ steroid injections and prolotherapy have minimal evidentiary support. Two small trials of periarticular corticosteroids (8,9) and radiofrequency neurotomy of sacral nerve root branches (10,11) suggest short-term therapeutic benefit. No published high-quality studies support long-term effectiveness of any non-surgical treatment for SIJ pain.

Open fusion of the SIJ, first described in the early 1900s (12,13), may provide benefits (14), but its use is less common in the era of minimally invasive surgery (15), almost certain due to its invasive nature and prolonged recovery. Minimally invasive fusion of the sacroiliac joint (SIJF) is an increasingly accepted surgical option for SIJ dysfunction. Multiple devices and approaches are currently available, including devices for lateral transiliac fixation/fusion of the joint and devices placed through a posterior approach. The device with the most published clinical evidence is triangular titanium implants (TTI) with a porous surface. Evidence for this device to support improvements in pain, disability and quality of life derives from 3 prospective clinical trials (16-18), numerous case series (19-24) and comparative case series (25-27).

iMIA is a recently published prospective multicenter randomized controlled trial from Europe (28). In this study, patients with carefully diagnosed SIJ pain were assigned at random (1:1 ratio) to either non-surgical management, comprised mainly of physiotherapy, or immediate SIJ fusion with TTI. Treated subjects returned to clinic for evaluations at 3, 6, 12 and 24 months after treatment initiation. Authors assessed multiple measures, including self-reported outcomes (pain, disability, quality of life, satisfaction, walking distance, ambulatory and work status, global comparison to baseline), physical function and opioid use. The study showed marked improvement in all measures in the surgical group with only minor changes in the non-surgical group. The proportions of subjects with clinically important improvements in pain and disability were far higher in the surgical group compared to the non-surgical group (79% vs. 22% for a change of at least 20 points in leg pain and 64% vs. 24%). Other advantages of the study were use of a semi-objective functional test (active straight leg raise test) (29), which showed large differences in support of surgery and speaks to concerns that most other outcomes reported were subjective in nature. Consistent with positive findings in support of surgery, opioid use decreased in the surgical group but was unchanged in the non-surgical group. From a safety perspective, the incidence of postoperative outcomes in the surgery group was low, with a low rate of revision surgery (1 case of nerve root impingement due to device misplacement). Clinical outcomes were supported by radiographic evaluation by an independent assessor, which showed no implant breakages or migrations and high rates of bone apposition to the device. Somewhat disappointingly, intraarticular fusion was not commonly observed. It is possible that intraarticular fusion may take up to 5 years (30); in the meantime, clinical responses at 24 months appeared in this study to be sustained.

The findings of this study are consistent with our experience, in which surgical treatment using the same device was associated with large improvements in pain and disability, along with marked decreases in opioid use, where as non-surgical treatment was associated with poor clinical outcomes, worsened job status and increased opioid use (31). The diagnostic algorithm we use to diagnose SIJ pain is identical to that used in Dengler et al. Using this approach, we observed a very high rate of positive responses to surgery.

It is our common experience that surgeons do not recognize pain arising from the SIJ (32). I have seen dozens of patients with easily diagnosed SIJ pain that went for years (and with multiple visits to other surgeons) without a diagnosis. Of great concern is that the frequency of lumbar fusion in this patient population is high; in our experience, most patients diagnosed with SIJ pain who underwent previous lumbar fusion derived no benefit from the fusion. Rather, they were exposed only to its risks. To improve surgical outcomes in the care of patients with chronic low back pain, the practicing surgeon must make efforts to recognize SIJ pain. Typical symptoms include inability to sit for prolonged periods, pain during driving over bumps, and pain on turning over in bed at night. Patients often present in the clinic sitting on the unaffected buttock cheek or standing. Physical examinations for SIJ pain are easily performed and shown to be highly predictive of the reference standard, intraarticular joint block (33). The publication of long-term results from a high-quality study should provide inspiration to surgeons to learn more about SIJ pain and become familiar with its diagnosis and treatment.


Acknowledgments

To Daniel Cher for his help, assistance and support.


Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.


References

  1. Sembrano JN, Polly DW. How often is low back pain not coming from the back? Spine 2009;34:E27-32. [Crossref] [PubMed]
  2. Bernard TN, Kirkaldy-Willis WH. Recognizing specific characteristics of nonspecific low back pain. Clin Orthop 1987.266-80. [PubMed]
  3. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995;20:31-7. [Crossref] [PubMed]
  4. Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996;21:1889-92. [Crossref] [PubMed]
  5. Irwin RW, Watson T, Minick RP, et al. Age, Body Mass Index, and Gender Differences in Sacroiliac Joint Pathology. Am J Phys Med Rehabil 2007;86:37-44. [Crossref] [PubMed]
  6. Cher D, Polly D, Berven S. Sacroiliac Joint pain: burden of disease. Med Devices (Auckl) 2014;7:73-81. [Crossref] [PubMed]
  7. Cher DJ, Reckling WC. Quality of life in preoperative patients with sacroiliac joint dysfunction is at least as depressed as in other lumbar spinal conditions. Med Devices (Auckl) 2015;8:395-403. [Crossref] [PubMed]
  8. Luukkainen R, Nissilä M, Asikainen E, et al. Periarticular corticosteroid treatment of the sacroiliac joint in patients with seronegative spondylarthropathy. Clin Exp Rheumatol 1999;17:88-90. [PubMed]
  9. Luukkainen RK, Wennerstrand PV, Kautiainen HH, et al. Efficacy of periarticular corticosteroid treatment of the sacroiliac joint in non-spondylarthropathic patients with chronic low back pain in the region of the sacroiliac joint. Clin Exp Rheumatol 2002;20:52-4. [PubMed]
  10. Cohen SP, Hurley RW, Buckenmaier CC, et al. Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology 2008;109:279-88. [Crossref] [PubMed]
  11. Patel N, Gross A, Brown L, et al. A randomized, placebo-controlled study to assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint pain. Pain Med 2012;13:383-98. [Crossref] [PubMed]
  12. Painter CF. Excision of the Os Innominatum; Arthrodesis of the Sacro-Iliac Synchondrosis. Boston Med Surg J 1908;159:205-8. [Crossref]
  13. Smith-Petersen MN. Arthrodesis of the sacroiliac joint. A new method of approach. J Bone Jt Surg 1921;3:400-5.
  14. Buchowski JM, Kebaish KM, Sinkov V, et al. Functional and radiographic outcome of sacroiliac arthrodesis for the disorders of the sacroiliac joint. Spine J Off J North Am Spine Soc 2005;5:520-8; discussion 529.
  15. Lorio MP, Polly DW Jr, Ninkovic I, et al. Utilization of Minimally Invasive Surgical Approach for Sacroiliac Joint Fusion in Surgeon Population of ISASS and SMISS Membership. Open Orthop J 2014;8:1-6. [Crossref] [PubMed]
  16. Polly DW, Swofford J, Whang PG, et al. Two-Year Outcomes from a Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion vs. Non-Surgical Management for Sacroiliac Joint Dysfunction. Int J Spine Surg 2016;10:28. [Crossref] [PubMed]
  17. Sturesson B, Kools D, Pflugmacher R, et al. Six-Month Outcomes from a Randomized Controlled Trial of Minimally Invasive SI Joint Fusion with Triangular Titanium Implants vs. Conservative Management. Eur Spine J 2017;26:708-19. [Crossref] [PubMed]
  18. Duhon BS, Bitan F, Lockstadt H, et al. Triangular Titanium Implants for Minimally Invasive Sacroiliac Joint Fusion: 2-Year Follow-Up from a Prospective Multicenter Trial. Int J Spine Surg 2016;10:13. [Crossref] [PubMed]
  19. Rudolf L. Sacroiliac Joint Arthrodesis-MIS Technique with Titanium Implants: Report of the First 50 Patients and Outcomes. Open Orthop J 2012;6:495-502. [Crossref] [PubMed]
  20. Rudolf L. MIS Fusion of the SI Joint: Does Prior Lumbar Spinal Fusion Affect Patient Outcomes? Open Orthop J 2013;7:163-8. [Crossref] [PubMed]
  21. Sachs D, Capobianco R. One year successful outcomes for novel sacroiliac joint arthrodesis system. Ann Surg Innov Res 2012;6:13. [Crossref] [PubMed]
  22. Sachs D, Capobianco R. Minimally invasive sacroiliac joint fusion: one-year outcomes in 40 patients. Adv Orthop 2013;2013:536128. [Crossref] [PubMed]
  23. Cummings J Jr, Capobianco RA. Minimally invasive sacroiliac joint fusion: one-year outcomes in 18 patients. Ann Surg Innov Res 2013;7:12. [Crossref] [PubMed]
  24. Schroeder JE, Cunningham ME, Ross T, et al. Early Results of Sacro-Iliac Joint Fixation Following Long Fusion to the Sacrum in Adult Spine Deformity. HSS J 2014;10:30-5. [Crossref] [PubMed]
  25. Smith AG, Capobianco R, Cher D, et al. Open versus minimally invasive sacroiliac joint fusion: a multi-center comparison of perioperative measures and clinical outcomes. Ann Surg Innov Res 2013;7:14. [Crossref] [PubMed]
  26. Ledonio CGT, Polly DW, Swiontkowski MF. Minimally invasive versus open sacroiliac joint fusion: are they similarly safe and effective? Clin Orthop 2014;472:1831-8. [Crossref] [PubMed]
  27. Ledonio CG, Polly DW Jr, Swiontkowski MF, et al. Comparative effectiveness of open versus minimally invasive sacroiliac joint fusion. Med Devices (Auckl) 2014;7:187-93. [Crossref] [PubMed]
  28. Dengler J, Kools D, Pflugmacher R, et al. Randomized Trial of Sacroiliac Joint Arthrodesis Compared with Conservative Management for Chronic Low Back Pain Attributed to the Sacroiliac Joint. J Bone Joint Surg Am 2019;101:400-11. [Crossref] [PubMed]
  29. Mens JM, Vleeming A, Snijders CJ, et al. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine 2001;26:1167-71. [Crossref] [PubMed]
  30. Rudolf L, Capobianco R. Five-year clinical and radiographic outcomes after minimally invasive sacroiliac joint fusion using triangular implants. Open Orthop J 2014;8:375-83. [Crossref] [PubMed]
  31. Vanaclocha V, Herrera JM, Sáiz-Sapena N, et al. Minimally Invasive Sacroiliac Joint Fusion, Radiofrequency Denervation, and Conservative Management for Sacroiliac Joint Pain: 6-Year Comparative Case Series. Neurosurgery 2018;82:48-55. [Crossref] [PubMed]
  32. Vanaclocha-Vanaclocha V, Herrera JM, Sáiz-Sapena N, et al. High frequency of lumbar fusion in patients denied surgical treatment of the sacroiliac joint. Br J Neurosurg 2019;33:12-6. [Crossref] [PubMed]
  33. Petersen T, Laslett M, Juhl C. Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews. BMC Musculoskelet Disord 2017;18:188. [Crossref] [PubMed]
Cite this article as: Vanaclocha-Vanaclocha V, Sáiz-Sapena N, Vanaclocha L. Sacroiliac joint pain: is the medical world aware enough of its existence? Why not considering sacroiliac joint fusion in the recalcitrant cases? J Spine Surg 2019;5(3):384-386. doi: 10.21037/jss.2019.06.11