Documentation of outcomes for sacroiliac joint fusion: does prior spinal fusion influence the outcome?

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.

Minimally Invasive Sacroiliac Fusion-a Review

PURPOSE OF REVIEW

Sacroiliac dysfunction is an important cause of low back pain with significant impact on quality of life and daily activities. Minimally invasive sacroiliac joint fusion (MIS SI fusion) is an effective treatment for patients who failed non-surgical strategies. The purpose of this article is to review the clinical outcomes and complications of this surgical technique.

RECENT FINDINGS

For patients with SI joint dysfunction, MIS SI fusion reduced pain and disability as measured by Visual Analog Scale and Oswestry Index and improved quality of life as measured by Short-Form 36 and EuroQol-5D questionnaires. Satisfaction rates were higher in the SI fusion group when compared to the conservative management. In recent clinical trials, adverse events occurred with a similar rate in the first 6 months for patients assigned in the conservative management versus patients assigned to MIS SI fusion. MIS SI fusion is an effective and safe procedure for patients with sacroiliac dysfunction who failed non-surgical strategies. This procedure provides rapid as well as sustained pain relief, improvement in back function, high patient satisfaction, with low rate of complications.

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.

Sacroiliac Joint Fusion: Approaches and Recent Outcomes

The sacroiliac joint may be a primary source of pain in patients complaining of low back and/or buttock pain. Nonsurgical treatment of sacroiliac joint pain typically includes structured core and pelvic muscle flexibility and strengthening; pharmaceutical management through oral and injectable medication; and ablation procedures. For patients who do not improve with comprehensive, nonoperative treatment, surgical fusion of the sacroiliac joint is an option with overall good reported outcomes and high patient satisfaction. Minimally invasive surgery (MIS) approaches have been shown to have lower morbidity and earlier recovery than traditional open approaches. To date, the majority of published clinical studies on MIS sacroiliac joint fusion are industry-sponsored and predominantly using one system (ingrowth triangular titanium rods). These include two level 1 randomized controlled trials comparing MIS sacroiliac joint fusion to nonoperative management, with results favoring surgery.

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.

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.

Five-year clinical and radiographic outcomes after minimally invasive sacroiliac joint fusion using triangular implants

Object :

Previous reports of minimally invasive (MIS) sacroiliac (SI) joint fusion for low back, SI joint, and buttock pain secondary to SI joint disorders have shown favorable short- and mid-term outcomes. Herein we present 5-year clinical and radiographic outcomes after MIS SI joint fusion using a series of triangular porous titanium plasma spray (TPS) coated implants.

Methods :

Consecutive patients treated with MIS SI joint fusion for degenerative sacroiliitis and/or sacroiliac joint disruptions between October 2007 and March 2009 were evaluated. Pain on VAS, an SI joint specific survey and Oswestry Disability Index (ODI) were administered. X-ray and CT scans were obtained to assess the implants.

Results :

Of 21 patients treated, 17 were available for the study. Mean age was 58 years (range 36-85), 77% were female and 47% had prior lumbar spinal fusion. Pain on VAS improved from 8.3 at baseline to 2.4 at 5 years; 88% of patients reached Substantial Clinical Benefit. Mean ODI score at 5 years was 21.5 (SD 22.7). Patient satisfaction achieved at 12 months was maintained for 5 years (82%). A qualitative review of x-ray and CT imaging showed increased bone density immediately adjacent to all implants, intra-articular osseous bridging in 87% of patients and no evidence of implant loosening or migration.

Conclusion :

Long-term clinical and radiographic outcomes after MIS SIJ fusion are favorable. Clinical improvements observed at 12 months postoperatively were maintained at 5 years. There was no evidence of long-term complications, implant loosening or migration. Patients who did not achieve large improvements were affected by multiple severe concomitant degenerative conditions of the lumbar spine, pelvis, and/or hip.

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.

Comparative effectiveness of open versus minimally invasive sacroiliac joint fusion

Background

The mainstay of sacroiliac joint disruption/degenerative sacroiliitis therapy has been nonoperative management. This nonoperative management often includes a regimen of physical therapy, chiropractic treatment, therapeutic injections, and possibly radiofrequency ablation at the discretion of the treating physician. When these clinical treatments fail, sacroiliac joint fusion has been recommended as the standard treatment. Open and minimally invasive (MIS) surgical techniques are typical procedures. This study aims to compare the perioperative measures and Oswestry Disability Index (ODI) outcomes associated with each of these techniques.

Methods

A comparative retrospective chart review of patients with sacroiliac joint fusion and a minimum of 1 year of follow-up was performed. Perioperative measures and ODI scores were compared using the Fisher’s exact test and two nonparametric tests, ie, the Mann–Whitney U test and the Wilcoxon signed-rank test. The results are presented as percent or median with range, as appropriate.

Results

Forty-nine patients from two institutions underwent sacroiliac joint fusion between 2006 and 2012. Ten patients were excluded because of incomplete data, leaving 39 evaluable patients, of whom 22 underwent open and 17 underwent MIS sacroiliac joint fusion. The MIS group was significantly older (median age 66 [39–82] years) than the open group (median age 51 [34–74] years). Surgical time and hospital stay were significantly shorter in the MIS group than in the open group. Preoperative ODI was significantly greater in the open group (median 64 [44–78]) than in the MIS group (median 53 [14–84]). Postoperative improvement in ODI was statistically significant within and between groups, with MIS resulting in greater improvement.

Conclusion

The open and MIS sacroiliac joint fusion techniques resulted in statistically and clinically significant improvement for patients with degenerative sacroiliitis refractory to nonoperative management. However, the number of patients reaching the minimal clinically important difference and those showing overall improvement were greater in the MIS group.

Minimally invasive versus open sacroiliac joint fusion: are they similarly safe and effective?

BACKGROUND

The sacroiliac joint has been implicated as a source of chronic low back pain in 15% to 30% of patients. When nonsurgical approaches fail, sacroiliac joint fusion may be recommended. Advances in intraoperative image guidance have assisted minimally invasive surgical (MIS) techniques using ingrowth-coated fusion rods; however, how these techniques perform relative to open anterior fusion of the sacroiliac joint using plates and screws is not known.

QUESTIONS/PURPOSES

We compared estimated blood loss (EBL), surgical time, length of hospital stay (LOS), and Oswestry Disability Index (ODI) between patients undergoing MIS and open sacroiliac joint fusion.

METHODS

We retrospectively studied 63 patients (open: 36; MIS: 27) who underwent sacroiliac joint fusion with minimum 1-year followup at our institution from 2006 to 2011. Of those, 10 in the open group had incomplete records. All patients had sacroiliac joint dysfunction confirmed by image-guided intraarticular anesthetic sacroiliac joint injection and had failed nonoperative treatment. Patients were matched via propensity score, adjusting for age, sex, BMI, history of spine fusion, and preoperative ODI scores, leaving 22 in each group. Nine patients were not matched. We reviewed patient medical records to obtain EBL, length of surgery, LOS, and pre- and postoperative ODI scores. Mean followup was 13 months (range, 11-33 months) in the open group and 15 months (range, 12-26 months) in the MIS group.

RESULTS

Patients in the open group had a higher mean EBL (681 mL versus 41 mL, p < 0.001). Mean surgical time and LOS were shorter in the MIS group than in the open group (68 minutes versus 128 minutes and 3.3 days versus 2 days, p < 0.001 for both). With the numbers available, mean postoperative ODI scores were not different between groups (47% versus 54%, p = 0.272).

CONCLUSIONS

EBL, surgery time, and LOS favored the MIS sacroiliac fusion group. With the numbers available, ODI scores were similar between groups, though the study size was relatively small and it is possible that the study was underpowered on this end point. Because the implants used for these procedures make assessment of fusion challenging with available imaging techniques, we do not know how many patients' sacroiliac joints successfully fused, so longer followup and critical evaluation of outcomes scores over time are called for.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Open versus minimally invasive sacroiliac joint fusion: a multi-center comparison of perioperative measures and clinical outcomes

Background

Sacroiliac (SI) joint pain is an under diagnosed source of low back pain due in part to lack of visible pathology on radiographs and symptoms mimicking other back-related disorders. Open SI joint fusion has been performed since the 1920s. This technique has fallen out of favor with the introduction of minimally invasive options. To date there has been no direct comparison between open and MIS SI joint fusion.

Methods

We conducted a multi-center, retrospective comparative cohort study of patients who underwent SI joint fusion using either an open surgical (OS) technique using a combination of screws and cages or a minimally invasive surgical (MIS) technique with a series of titanium plasma spray (TPS) coated triangular implants. Operative measures including surgical operating time, length of hospitalization and estimated blood loss (EBL) were collected along with demographics and medical history, surgical complications, and 12- and 24-month pain scores. Improvements in pain were compared after matching for age and gender and controlling for a history of lumbar spine fusion using repeated measures analysis of variance.

Results

Data were available for 263 patients treated by 7 surgeons; 149 patients treated with OS and 114 treated with MIS SI joint fusion. Compared to OS patients, MIS patients were on average 10 years older (mean age 57 vs. 46) and 69% of all patients were female. MIS operative measures of EBL, operating time and length of hospitalization were significantly lower than open surgery (p < 0.001). Pain relief, measured as change from baseline to 12 months in VAS pain rating, was 3.5 points lower in the MIS vs. OS group (-6.2 vs. -2.7 points, p < 0.001). When matched for age, gender and a history of prior lumbar spinal fusion, postoperative pain scores were on average 3.0 points (95% CI 2.1 – 4.0) lower in MIS vs. OS (rANOVA p < 0.001).

Conclusions

In this multi-center comparative study, patients who underwent either OS or MIS SI joint fusion showed postoperative improvements in pain score. Compared to OS patients, patients who underwent MIS SI joint fusion had significantly greater pain relief and more favorable perioperative surgical measures.