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Polly DW. The Sacroiliac Joint: A Current State-of-the-Art Review. JBJS Rev 2024; 12:01874474-202402000-00001. [PMID: 38315777 DOI: 10.2106/jbjs.rvw.23.00151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
» The sacroiliac joint (SIJ) is a common cause of low back pain and should be included in the differential diagnosis.» Nonoperative treatment of sacroiliac pain is always the first line of therapy; however, when it is unsuccessful and becomes chronic, then recurrent nonoperative treatment becomes expensive.» Surgical treatment is cost-effective in appropriately selected patients. High-quality clinical trials have demonstrated statistically and clinically significant improvement compared with nonsurgical management in appropriately selected patients.» Spinal fusion to the sacrum increases degeneration of the SIJ and frequency of SIJ pain.
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Affiliation(s)
- David W Polly
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
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Sayed D, Amirdelfan K, Hunter C, Raji OR. Posterior intra-articular fixation stabilizes both primary and secondary sacroiliac joints: a cadaveric study and comparison to lateral trans-articular fixation literature. J Orthop Surg Res 2023; 18:406. [PMID: 37270508 PMCID: PMC10239050 DOI: 10.1186/s13018-023-03886-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 05/28/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Posterior and lateral techniques have been described as approaches to sacroiliac joint arthrodesis. The purpose of this study was to compare the stabilizing effects of a novel posterior stabilization implant and technique to a previously published lateral approach in a cadaveric multidirectional bending model. We hypothesized that both approaches would have an equivalent stabilizing effect in flexion-extension and that the posterior approach would exhibit better performance in lateral bending and axial rotation. We further hypothesized that unilateral and bilateral posterior fixation would stabilize both the primary and secondary joints. METHODS Ranges of motion (RoMs) of six cadaveric sacroiliac joints were evaluated by an optical tracking system, in a multidirectional flexibility pure moment model, between ± 7.5 N-m applied moment in flexion-extension, lateral bending, and axial rotation under intact, unilateral fixation, and bilateral fixation conditions. RESULTS Intact RoMs were equivalent between both samples. For the posterior intra-articular technique, unilateral fixation reduced the RoMs of both primary and secondary joints in all loading planes (flexion-extension RoM by 45%, lateral bending RoM by 47%, and axial RoM by 33%), and bilateral fixation maintained this stabilizing effect in both joints (flexion-extension at 48%, lateral bending at 53%, and axial rotation at 42%). For the lateral trans-articular technique, only bilateral fixation reduced mean RoM of both primary and secondary sacroiliac joints, and only under flexion-extension loads (60%). CONCLUSION During flexion-extension, the posterior approach is equivalent to the lateral approach, while producing superior stabilization during lateral bend and axial rotation.
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Affiliation(s)
- Dawood Sayed
- The University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
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Sayed D, Amirdelfan K, Naidu RK, Raji OR, Falowski S. A Cadaver-Based Biomechanical Evaluation of a Novel Posterior Approach to Sacroiliac Joint Fusion: Analysis of the Fixation and Center of the Instantaneous Axis of Rotation. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2021; 14:435-444. [PMID: 34949942 PMCID: PMC8691588 DOI: 10.2147/mder.s347763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/09/2021] [Indexed: 12/27/2022] Open
Abstract
Purpose The purpose of this study was to assess the stabilizing effect of a posterior joint fixation technique using a novel cortical allograft implant in unilateral and bilateral fixation constructs. We hypothesize that fixation would reduce the joint's range of motion during flexion-extension, axial rotation, and lateral bending loads. We also hypothesize that fixation would shift the center of the instantaneous axis of rotation during the predominant flexion-extension motions towards the implant's location, and that this shift would be correlated with the reduction in flexion-extension range of motion. Materials and Methods Six cadaveric sacroiliac joint specimens were tested under intact, unilateral fixation, and bilateral fixation conditions. The total range of motion (ROM) of the sacroiliac joint in flexion-extension, lateral bending, and axial rotation were evaluated by an optical tracking system, in a multidirectional flexibility pure moment model, between ± 7.5 Nm applied moment loads. The centers of the instantaneous axis of rotation (cIAR) of the sacroiliac joint were evaluated during flexion-extension loading. A correlation analysis was performed between the ROM reduction in flexion-extension upon implantation and shift of the cIAR to the graft implantation site. Results Unilateral and bilateral fixations generated sacroiliac joint ROM reductions in flexion-extension, lateral bending, and axial rotation motions. Fixation shifted the cIAR to the graft implantation site. Reduction in the total range of motion had a moderate correlation with the shift of the cIAR. Conclusion Our novel posterior approach presents a multifaceted mechanism for stabilizing the joint: first, by the reduction of the total range of motion in all planes of motion; second, by shifting the centers of the instantaneous axis of rotation towards the implant's location in the predominant plane of motion, ensuring little to no motion at the implantation site, thus promoting fusion in this region.
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Affiliation(s)
- Dawood Sayed
- The University of Kansas Medical Center, Kansas City, KS, USA
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Intra-Articular Sacroiliac Joint Injection: Technical Guide. Clin Spine Surg 2021; 34:14-16. [PMID: 32433098 DOI: 10.1097/bsd.0000000000001010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 02/17/2020] [Indexed: 11/26/2022]
Abstract
Sacroiliac (SI) joint pathology has been an increasingly discussed pathology as a potential etiology for significant low back and lower extremity pain. While patient history and examination maneuvers can assist with identifying the SI joint as a potential cause of pain, an intra-articular SI joint injection is critical to properly diagnose the SI joint as a clinically relevant pain generator. In addition to the diagnostic information from the injection, SI joint intra-articular injections can be performed for therapeutic benefit as part of a multi-modal, conservative treatment approach for SI joint pathology. We discuss our technique for safe and effective SI joint intra-articular injections as a both diagnostic and therapeutic aid for SI joint pathology.
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Polly DW, Holton KJ. Minimally Invasive Sacroiliac Joint Fusion: A Lateral Approach Using Triangular Titanium Implants and Navigation. JBJS Essent Surg Tech 2020; 10:ST-D-19-00067. [PMID: 33204578 PMCID: PMC7665262 DOI: 10.2106/jbjs.st.19.00067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Minimally invasive sacroiliac (SI) joint fusion is indicated for low back pain from the SI joint that is due to degenerative sacroiliitis and/or sacroiliac joint disruption. This technique is safe and effective in relieving pain uncontrolled by nonoperative management1-4. There is some controversy, but there continues to be increasing evidence of effectiveness. Description: This procedure is performed, with the patient under general anesthesia and in the prone position, using fluoroscopy or 3-dimensional (3D) navigation such as cone-beam computed tomographic (CT) imaging. After navigation setup, a navigated probe is used to approximate the desired location of each implant and trajectory. These positions are marked on the skin, and the skin is incised. A 3 to 5-cm lateral incision is made. The gluteal fascia is bluntly dissected to the outer table of the ilium. A guide pin is passed across the SI joint and into the center of the sacrum lateral to the neural foramina, which is confirmed with imaging. This is then drilled and broached. Triangular titanium rods are placed. Typically, 3 implants are placed, 2 in S1 and 1 in S2. Multiplanar postplacement imaging of the pelvis is obtained. The wound is irrigated and closed in layers. Alternatives: Nonsurgical alternatives have been reported to include pharmacological therapies, such as nonsteroidal anti-inflammatory drugs, therapeutic SI joint blocks5, and physical therapy, such as core stabilization, orthotics (SI belts), and radiofrequency ablation1,2,6-8. The surgical alternative is an open anterior or posterior approach with SI joint arthrodesis. The anterior approach differs by the resection of the SI joint cartilage, the use of a plate or screws across the joint for stabilization, and the packing of bone graft to facilitate fusion9. These are more morbid and have a much longer recovery. Rationale: Conservative management for SI joint pain is inadequate for all patients. Having 3 of 5 positive physical examination maneuvers7, having confirmatory diagnostic block(s)10, and ruling out the hip or spine as the pain generator provide a success rate of >80%. These patients have early and sustained clinically important and significantly improved outcomes across varying measures compared with conservative treatment1-4,11,12. Expected Outcomes: Patients can expect to experience decreased pain, reduced disability, increased daily function, and improved quality of life soon after the procedure is performed. These patients typically have an improvement of ≥50% in the Oswestry Disability Index score and a clinically significant decrease in visual analog pain scores13. The procedure appears durable through at least 5 years14. Complete pain relief is rare, but clinically important improvement is typical. Important Tips: Proper setup of the navigation system or fluoroscopy is needed to ensure accurate starting points. For 3D navigation, use a reference pin in the contralateral posterior superior iliac spine. Although navigation is used, radiographic images are made periodically to confirm proper placement of guide pins and implants. Images provide the greatest benefit when establishing navigation, after guide-pin placement when an outlet view allows for evaluation of pin depth, and after implant placement to confirm proper placement. Blood loss is generally low, but care should be taken to avoid vascular injury. Although rare, improper placement has led to injury of the superior gluteal artery15 and iliac artery16. This can be avoided by staying in bone. Proper placement of the implant is imperative in this procedure. There is the potential for nerve injury with improper placement of the implant: an L5 nerve injury if the implant is too ventral or an S1 or S2 nerve injury if the implant is too deep and into the foramen. Revision surgery is commonly due to nerve root impingement and/or malpositioning. Preoperative 3D imaging is indicated when it is necessary to rule out differential diagnoses that mimic SI joint pain. This enables the surgeon to rule out intrapelvic pathology, assess sacral bone density17, and identify dysmorphic sacra or transitional vertebrae.
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Affiliation(s)
- David W Polly
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Kenneth J Holton
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
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Kim YH, Ha KY, Chang DG, Park HY, Jeon WK, Park HC, Kim SI. Relationship between iliac screw loosening and proximal junctional kyphosis after long thoracolumbar instrumented fusion for adult spinal deformity. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:1371-1378. [DOI: 10.1007/s00586-020-06366-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 02/07/2020] [Accepted: 03/07/2020] [Indexed: 12/16/2022]
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Abstract
Pain is often the initial complaint for which patients seek medical care, presenting both a diagnostic and therapeutic challenge to the primary care provider. The appreciation of pain is not merely the result of abnormal sensory stimulation causing an unpleasant sensation but rather a combination of the recognition of the somatic discomfort in association with an emotional response to that discomfort. The perception of pain and the extent of distress and disability can vary depending on previous experience, cultural background, situational factors, and comorbid psychiatric disease. Though acute pain is usually the result of tissue damage, this is not always the case, as evidenced by primary headache disorders. Chronic pain may be the result of an injury, irreversible underlying disease, or clinical conditions such as fibromyalgia for which the mechanism remains unclear. Treatment of the underlying cause will usually effect a resolution or improvement in the pain, but when the discomfort persists, a consultation with a neurologist or pain management specialist should be considered.
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Affiliation(s)
- Victor C Wang
- Department of Neurology, Department of Anesthesia, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - William J Mullally
- Graham Headache Center, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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Hodges PW, Cholewicki J, Popovich JM, Lee AS, Aminpour P, Gray SA, Cibulka MT, Cusi M, Degenhardt BF, Fryer G, Gutke A, Kennedy DJ, Laslett M, Lee D, Mens J, Patel VV, Prather H, Sturesson B, Stuge B, Vleeming A. Building a Collaborative Model of Sacroiliac Joint Dysfunction and Pelvic Girdle Pain to Understand the Diverse Perspectives of Experts. PM R 2019; 11 Suppl 1:S11-S23. [PMID: 31169360 DOI: 10.1002/pmrj.12199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Pelvic girdle pain (PGP) and sacroiliac joint (SIJ) dysfunction/pain are considered frequent contributors to low back pain (LBP). Like other persistent pain conditions, PGP is increasingly recognized as a multifactorial problem involving biological, psychological, and social factors. Perspectives differ between experts and a diversity of treatments (with variable degrees of evidence) have been utilized. OBJECTIVE To develop a collaborative model of PGP that represents the collective view of a group of experts. Specific goals were to analyze structure and composition of conceptual models contributed by participants, to aggregate them into a metamodel, to analyze the metamodel's composition, and to consider predicted efficacy of treatments. DESIGN To develop a collaborative model of PGP, models were generated by invited individuals to represent their understanding of PGP using fuzzy cognitive mapping (FCM). FCMs involved proposal of components related to causes, outcomes, and treatments for pain, disability, and quality of life, and their connections. Components were classified into thematic categories. Weighting of connections was summed for components to judge their relative importance. FCMs were aggregated into a metamodel for analysis of the collective opinion it represented and to evaluate expected efficacy of treatments. RESULTS From 21 potential contributors, 14 (67%) agreed to participate (representing six disciplines and seven countries). Participants' models included a mean (SD) of 22 (5) components each. FCMs were refined to combine similar terms, leaving 89 components in 10 categories. Biomechanical factors were the most important in individual FCMs. The collective opinion from the metamodel predicted greatest efficacy for injection, exercise therapy, and surgery for pain relief. CONCLUSIONS The collaborative model of PGP showed a bias toward biomechanical factors. Most efficacious treatments predicted by the model have modest to no evidence from clinical trials, suggesting a mismatch between opinion and evidence. The model enables integration and communication of the collection of opinions on PGP.
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Affiliation(s)
- Paul W Hodges
- The University of Queensland, NHMRC Centre of Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, Brisbane, Australia
| | - Jacek Cholewicki
- MSU Center for Orthopedic Research, Department of Osteopathic Surgical Specialties, Michigan State University, East Lansing, MI
| | - John M Popovich
- MSU Center for Orthopedic Research, Department of Osteopathic Surgical Specialties, Michigan State University, East Lansing, MI
| | - Angela S Lee
- MSU Center for Orthopedic Research, Department of Osteopathic Surgical Specialties, Michigan State University, East Lansing, MI
| | - Payam Aminpour
- Department of Community Sustainability, Michigan State University, Natural Resource Building, East Lansing, MI
| | - Steven A Gray
- Department of Community Sustainability, Michigan State University, Natural Resource Building, East Lansing, MI
| | | | - Mel Cusi
- School of Medicine, Sydney, University of Notre Dame Australia, Darlinghurst, Australia
| | | | - Gary Fryer
- College of Health & Biomedicine, Victoria University, Melbourne, Australia
| | - Annelie Gutke
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, University of Göteborg, Göteborg, Sweden
| | - David J Kennedy
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Mark Laslett
- Health and Rehabilitation Research Institute, AUT University, Auckland, New Zealand; Southern Musculoskeletal Seminars, New Zealand
| | - Diane Lee
- Diane Lee & Associates, South Surrey, Canada
| | - Jan Mens
- Department of Rehabilitation Medicine & Physical Therapy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Vikas V Patel
- Department of Orthopaedic Surgery, University of Colorado, Denver, CO
| | - Heidi Prather
- Departments of Orthopaedic Surgery and Neurology, Washington University School of Medicine, St Louis, MO
| | - Bengt Sturesson
- Department of Orthopedics, Aleris, Ängelholm Hospital, Ängelholm, Sweden
| | - Brit Stuge
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Andry Vleeming
- Department of Anatomy, Medical Osteopathic College of the University of New England, Biddeford, ME.,Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, Ghent University, Belgium
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