Nonoperative Treatment Options for Patients With Sacroiliac Joint Pain

Efficacy of manual therapy for sacroiliac joint pain syndrome: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

This study examined the efficacy of manual therapy for pain and disability measures in adults with sacroiliac joint pain syndrome (SIJPS).

METHODS

We searched six databases, including gray literature, on 24 October 2023, for randomized controlled trials (RCTs) examining sacroiliac joint (SIJ) manual therapy outcomes via pain or disability in adults with SIJPS. We evaluated quality via the Physiotherapy Evidence Database scale and certainty via Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Standardized mean differences (SMDs) in post-treatment pain and disability scores were pooled using random-effects models in meta-regressions.

RESULTS

We included 16 RCTs (421 adults; mean age = 37.7 years), with 11 RCTs being meta-analyzed. Compared to non-manual physiotherapy (i.e. exercise ± passive modalities; 10 RCTs) or sham (1 RCT) interventions, SIJ manual therapy did not significantly reduce pain (SMD: -0.88; 95%-CI: -1.84; 0.08, p = 0.0686) yet had a statistically significant moderate effect in reducing disability (SMD: -0.67; 95% CI: -1.32; -0.03, p = 0.0418). The superiority of individual manual therapies was unclear due to low sample size, wide confidence intervals for effect estimates, and inability to meta-analyze five RCTs with a unique head-to-head design. RCTs were of 'good' (56%) or 'fair' (44%) quality, and heterogeneity was high. Certainty was very low for pain and low for disability outcomes.

CONCLUSION

SIJ manual therapy appears efficacious for improving disability in adults with SIJPS, while its efficacy for pain is uncertain. It is unclear which specific manual therapy techniques may be more efficacious. These findings should be interpreted cautiously until further high-quality RCTs are available examining manual therapy against control groups such as exercise.

REGISTRATION

PROSPERO (CRD42023394326).

First clinical results of a novel minimally-invasive fusion system for the sacroiliac joint

BACKGROUND

Sacroiliac joint (SIJ) painful dysfunction is a common source of low back pain (LBP). Several surgical treatment options for SIJ fusion were described. A promising treatment option with demonstrated clinical improvement is the minimally-invasive SIJ fusion.

OBJECTIVE

The aim of this case study was to document the effectiveness and safety of the new SIJ system (Torpedo®) over a period of 6 months after the minimally invasive implantation.

METHODS

Patients with failed conservative treatment of painful SIJ dysfunction were enrolled successively in two centers. The Diagnosis was made by positive response to SIJ-injection with local anesthetic and at least by two positive SIJ provocation tests. The Torpedo® Implant system was used for the implantation. This workpiece made of titanium alloy is characterized by a helical profile geometry (CST: chronical spinal turn) with a hydrophilic surface. The evaluated endpoints LBP and grade of disability were assessed using a 0-10 numerical rating scale (NRS), and Oswestry Disability Index (ODI) preoperatively and at one, three and six months postoperatively.

RESULTS

15 patients (10 female, 5 male; mean age 59 ± 13 years) were operated on one after the other. The pain intensity decreased in all 15 patients. After 6 months, a decrease in the median values of 70% (quartiles 1-3: 65-79%) was calculated. The median values of the Oswestry Disability Index after 6 months were 62% (quartiles 1-3: 53-67) lower than before the operation. Before surgery, 13 patients (87%) were taking opioids for pain management. Six months after the operation, opioids were only needed by 3 patients (20%). Implant malpositioning was not detected on plain radiograph. No surgical site infections or perioperative complications occurred.

CONCLUSIONS

The clinical improvement in early follow up and the absence of surgery related complications demonstrate a high grade of device-related safety and effectiveness of the treatment with a novel minimally-invasive SIJ fusion system.

[Minimally invasive arthrodesis of the sacroiliac joint (SIJ)]

OBJECTIVE

Pain reduction and improvement in quality of life with sacroiliac joint (SIJ) fusion.

INDICATIONS

Chronic SIJ-associated pain; positive response to SIJ injection with local anesthetic; positive SIJ provocation tests; failed conservative therapy over 6 months.

CONTRAINDICATIONS

Non-SIJ-associated pain; tumor/infection/unstable fracture in the implantation area; malformations; tumor or osteolysis of the sacrum or ilium bone; active infection at the implantation site; allergy to metal components; secondary gain from illness, request for a pension; inadequately treated osteoporosis.

SURGICAL TECHNIQUE

Transarticular placement of Kirschner's wires through the SI joint via minimally invasive lateral approach. Guided preparation of implant site over Kirschner's wires and implantation of 3 triangular, transarticular titanium implants for SIJ fusion.

POSTOPERATIVE MANAGEMENT

Deep vein thrombosis prophylaxis. 3 weeks partial weight-bearing and then moving on to full weight-bearing. X‑ray controls at defined intervals. Physiotherapy.

RESULTS

We enrolled 26 patients who were followed up over the period of 4 years. The evaluated endpoints were low back pain on the visual analog scale (VAS 0-10), grade of disability with the Oswestry Disability Index (ODI) and quality of life with the EuroQOL-5D. At 4 years, mean low back pain improved compared to preoperative (VAS preoperative 8.4, VAS 4 years postoperative 4.6). Mean improvements in ODI (ODI preoperative 58.1, ODI 4 years postoperative 32.1) and EQ-5D (preoperative 0.5, after 4 years 0.7) could be evaluated over the long-term period of 4 years. Satisfaction rates were high and the proportion of subjects taking opioids decreased at the 4‑year follow-up (preoperative 82%, postoperative 39%). Implant loosening could not be detected on plain radiograph.

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.