History and development of sacroiliac joint surgery in patients with chronic low back pain

R.J.H. Knoef1,2 W.C. Verra3 J.M. Nellensteijn3 1Orthopaedic resident, Department of Orthopaedics, Isala Clinics, The Netherlands

2Orthopaedic resident, Department of Orthopaedics, Medical Spectrum Twente, The Netherlands

3Orthopaedic surgeon, Department of Orthopaedics, Medical Spectrum Twente, The Netherlands

Corresponding author: R.J.H. Knoef, r.j.h.knoef@isala.nl

More and more sacroiliac joint (SIJ) dysfunction is acknowledged as a pain generator and cause of buttock and lower back pain (LBP). Chronic disabling pain caused by the SIJ is currently often underdiagnosed and undertreated due to lack of recognition and formal education of care providers. SIJ dysfunction can have a severe impact on a patients’ quality of life. Therefore, correct diagnosis is essential and adequate treatment is desirable. Adequate knowledge of SIJ related problems, of diagnostic and physical tests and possible treatment options are essential. Surgical treatment of the SIJ gained considerable popularity in recent years. Insights into the surgical options for SIJ related LBP complement the skillset of every caretaker treating patients with LBP. In this article we give an overview of the history of SIJ surgery, patient selection and diagnostic work-up and the current state of operative treatment options for SIJ dysfunction.

The sacroiliac joint The SIJ is the articulation between the sacrum and the iliac bones of the pelvis which are connected by some of the human body’s strongest ligaments. The SIJ is a true diarthrodial joint consisting of an anterior sacroiliac ligament, a synovial part lined with cartilage, and a posterior ligamentous section (figure 1). With a surface area of 17.5 cm² on average, the SIJ is the largest spinal articulation in the human body.1 There is an enormous anatomical variation in the composition of the joint. The shape and surface of the joint can be influenced by pathophysiological processes and aging.2,3 Although its main function involves providing stability and managing forces between the spine and pelvis, the SIJ also offers a very limited degree of mobility with a few degrees of nutation, rotation and translation.4,5 The SIJ forms an isolated anatomical structure with its own nociceptive innervation in which pain can be induced by provocation.6 This means the joint is a potential pain generator within the LBP spectrum. The innervation is provided mainly by the sacral nerves S1 to S4 on the dorsal side and the L4 and L5 branches ventrally.6,7 In the second half of the 19th century SIJ ‘disease’ was first desribed.8,9 Nowadays it is generally known that dysfunction of the SIJ can lead to LBP and buttock pain.10 LBP is one of the most common health problems worldwide and its burden to society has enormous impact on global health and economy.11,12 It appears that of patients presenting with LBP, in 15-30% the SIJ is involved as origin of the pain.10,13-15

Figure 1. Anatomy of the sacroiliac joint.1

Sacroiliac joint dysfunction Pain originating from the SIJ may be the result of pathologic changes, caused by either intra- or extra-articular processes. Inflammatory response and arthritis are commonly found intra-articular causes. Extra-articular sources include enthesopathy, fractures, ligamentous injury, and myofascial pain.10 Known risk factors for SIJ dysfunction are: post traumatic, leg length discrepancy, gait abnormalities, prolonged vigorous exercise, scoliosis, previous lumbosacral fusion or lumbar spine fusion, pregnancy, tumour, spondyloarthropathies and hypermobility syndrome.16-24 Patients predominantly complain of LBP and pain in the buttock, localized below L5 around the posterior superior iliac spine (PSIS) overlying the SIJ. Sometimes groin pain, symphysial pain or pain radiating down the S1 dermatome is described. Pain is mainly present during weight bearing. Sometimes patients complain about instability of the pelvis.10 Various clinical tests have been validated in diagnosing SIJ dysfunction. Relevant physical examination manoeuvres include the Fortin Finger test (the patient localizes pain with one finger pointed inferomedial to the PSIS) and five SIJ provocation tests.25-27 Combining these tests results in adequate sensitivity, specificity and predictive values.27-29 Other physical examination tests are pain provoked by single leg stance and straight leg raise test. In practice the clinical diagnosis of SIJ dysfunction is based on the combination of a typical patient history, positive Fortin finger test and SIJ pain incitement on at least three of five established physical examination provocative tests (figure 2). Patients who meet these criteria are selected to perform a diagnostic SIJ injection.

Figure 2. SI joint exam: provocative tests.76

Radiographic anomalies of the SIJ are common findings but are not necessarily predictive for SIJ dysfunction.30 In typical practice, plain X-ray imaging of the pelvis and lumbar spine are performed to rule out other pathology that could explain pain in the buttock or groin.1 Imaging modalities, such as CT, MRI, and radionuclide imaging, all seem to have poor sensitivities.10 The gold standard is therefore physical examination, followed by a confirmatory diagnostic injection. At least a 50% and preferably 75% reduction in pain after intra-articular injection with local anaesthetic is considered a positive test and strongly indicated the SIJ as a pain generator (figure 3)15,31.

Figure 3. Flowchart for identification of patients eligible for surgical treatment of SIJ dysfunction.

Treatment of patients with sacroiliac joint dysfunction Initial treatment for SIJ dysfunction should be nonsurgical in nature. Common treatment options include pain medication, bracing, activity modification, physical therapy, manual therapy, chiropractic manipulation, corticosteroid injections, and radio frequent denervation.10,15 Surgical stabilization of the SIJ is considered when a patient failed conservative management, has persistent severe pain and functional impairment. The main goal in the surgical treatment of SIJ related pain is stabilization of the joint. However, the anatomical location and geometry makes it a challenge to approach the joint and achieve a true arthrodesis without causing extensive tissue damage.32,33 Open approach for sacroiliac joint surgery In 1907 Charles Painter, an orthopaedic surgeon from Boston (USA), was the first to publish about the operative treatment of the SIJ.32 Painter described a case in which a 33-year-old male presented with post traumatic SIJ-related LBP. Conservative therapy by taping and a plaster corset only offered temporary relief. After testing various approaches and techniques on cadavers, the SIJ was exposed by a posterior open approach. Access to the joint was obtained through an osteotomy of the illum after which the cartilage of the SIJ was worked with a chisel. The joint was closed using the decorticated osteotomy bone flap. Recovery consisted of bed rest for over a month and a special belt had to be worn. After a two-month postoperative follow-up, the patient was reported free of complaints and ready to return to work. In 1921 Smith-Petersen proposed a similar but less invasive approach using a smaller bone flap.34-35 In a case series study SIJ fusion was seen in 95% (21/23), and 96% (22/23) of all patients made a complete recovery. These results were supported by similar studies during that time and the procedure was further refined.36-39 Through a minimal open approach Bloom accessed the joint using a cylindrical saw to create a bone plug. After decortication the plug was reinserted. Patients were allowed to mobilize after just two weeks. Despite the developments and positive results of SIJ arthrodesis, interest in the SIJ as a pain generator faded with the publication of new medical research. In 1934 Mixter and Barr and later Verbiest published their work on lumbar disc hernia and neurogenic claudication, based on spinal and foraminal stenosis. These novel diagnosis of LBP became widely accepted.40,41 For a long time SIJ dysfunction and operative treatment of the SIJ remained in obscurity but regained attention by the 1970’s.42-46 Often used for post-traumatic pelvic ring stabilization, SIJ fixation techniques evolved rapidly after 1980.47-49 In 1984 an external fixator was first used on a patient with chronic SIJ dysfunction, a technique proven successful in unstable pelvic fractures.50-52 Under pelvic compression, a trapezoid frame was placed for 5-14 days during which patients were allowed to mobilize. Radiostereometric analysis demonstrates a significant reduction in the mobility of the SIJ after fixation.51,53 Walheim reported a decrease in pain and an increase in functional outcomes in 92% (11/12) of the patients.52 Slätis found similar positive results in seven out of ten female patients using the pelvic ring stabilization.51 When external fixation was successful but pain symptoms recurred after removal of the frame, an open anterior SIJ arthrodesis was considered. This operation was performed in seven patients, after which five patients became free of symptoms. Minimal invasive sacroiliac joint surgery It was not until 1987 that the minimal invasive work of Smith-Peterson was continued with a modified minimal open approach in which additional ceramic blocks were placed bridging the SIJ.54 At a 30-month follow-up, treatment was successful in 70% (15/21) of the patients. This work marked the beginning of modern-day diagnostics and operative treatment, now referred to as SIJ fusion, for SIJ related LBP. Moore first used Intra-articular injections as a diagnostic tool for SIJ dysfunction.55 Under growing interest in SIJ fusion, multiple modified versions of existing procedures were published. Anterior approach to the SIJ, followed by arthrodesis and plate fixation.56,57 Posterior fixation by means of transiliac bars, cobra plates, tension band plates/transiliac reconstruction plates and iliosacral lag screws.57-62 Though fusion rates in the described series were high, in all cases significant disadvantages and complications were emphasized, most of which related to the surgical exposure of the joint and implant placement. Percutaneous sacroiliac joint surgery In recent years, minimally invasive percutaneous approaches have become the most widely used methods for SIJ fusion.63-70 Today there are over 25 different systems for SIJ fusion commercially available, mostly using a lateral or posterior approach, all providing their own specific advantages. Some techniques utilize allograft bone plugs to bridge the joint and induce arthrodesis, often using one or two implants. Some systems use single or multiple screw fixation with specially designed implants, often fenestrated for bone impaction and covered in an osteoconductive coating.71 Screw placement provides the added possibility to provide compression over the joint. Currently the most often used implants worldwide are triangular titanium implants bridging the SIJ using a lateral approach. The golden standard is placement of three joint bridging implants.66-67 The triangular shape provides stability and minimizes rotation while the porous titanium surface allows for bony ingrowth in both sacrum and ilium. Patients can fully mobilize after a short period of partial weight bearing (figure 4).

Results after SI stabilization While previous studies were mainly of a retro- or prospective nature, in recent years two large multicentre randomized controlled trails (RCT) were published.66,67,72 These industry sponsored trials compared SIJ fusion to conservative treatment in patients with SIJ dysfunction. Both studies included strict, standardized diagnostic criteria, including at least a 50% reduction in pain after intra-articular injection with an anaesthetic. SIJ fusion was performed according to a fixed protocol of percutaneous placement of triangular, SIJ-bridging, titanium implants. A total of 251 patients were included between both studies and the first results were published after 12 months of follow-up. Both studies showed success in the operated group was significantly higher compared to the control group. The functional outcomes (Oswestry Disability Index) were also significantly better in the SIJ fusion group. After six months crossover for the patients in the control group was possible. Patients choosing to do so, achieved the same results as the primary SIJ fusion group (figure 5).

Figure 5. Mean SIJ pain by visit (top). Dark thick lines are those assigned to NSM or SIJF. Dotted line indicates NSM subjects who crossed over to surgery. Thin grey line indicates those who did not cross over to surgery. Mean Oswestry Disability Index by visit (bottom) is shown similarly.72

Adverse events after SIJ fusion The procedure of fusing the SIJ is not without risks. As the SIJ is a complex three-dimensional structure, placement of implants crossing the joint poses a technical challenge. As medical technology and imaging modalities improve, the safety during implant placement increases. However neurological impairment after incorrect placement is still a known and serious complication requiring additional surgery. Also, with suboptimal positioning of the implant’s fractures of the ilium of sacrum can occur leading to increased postoperative pain. Other adverse events of SIJ fusion are pain (in various forms), infection of the wound or the underlying bone and/or joint, bleeding or hematoma, deep venous thrombosis, pulmonary embolism, vascular injury, gastrointestinal injury, and genitourinary injury. Migration, loosening, breakage or failure of the implants can also occur.73 A retrospective database study of 469 patients who received minimally invasive SI fusion between 2007 and 2014 showed an overall complication rate of 16.4% at 6 months postoperatively.74 These results are in good agreement with findings in similar studies.66,75 Future challenges in SIJ fusion As promising as the developments in the treatment of SIJ mediated LBP may seem, there are still challenges to consider. The key to the success of SIJ fusion is adequate patient selection. Even though tested and proven measures have been developed to differentiate SIJ mediated LBP from other specific physical causes and non-specific back pain, diagnosis remains challenging. Patients often present with non-specific symptoms, have seen multiple health care professionals and underwent different forms of conservative and surgical treatment before SIJ dysfunction is considered. As LBP is a multifactorial problem not all patients who meet the criteria for SIJ dysfunction will be pain free after SIJ fusion. Conclusion SIJ dysfunction as a cause of LBP and buttock pain is often underdiagnosed and undertreated. Surgical treatment of SIJ dysfunction is a controversial topic. However, history shows positive outcomes of SIJ fusion in well selected patients. Since the first procedure described in 1907, many have focused on perfecting the SIJ fusion technique. Though despite increasing interest and a growing number of publications there is still a hiatus in long term results of SIJ fusion using modern techniques. Next to adequate surgical performance, patient selection appears to be one of the most important pillars in determining the success of this treatment. In current practice indication for surgical treatment is made according to a clear diagnostic model. The latest minimally invasive percutaneous surgical techniques ensure shorter operating times, less tissue damage, minimal aftercare, a decrease in complications and a faster recovery. Care providers should be aware of the indication, possibilities, and success rate of this surgical treatment for SIJ related LBP. Disclosure Nothing to disclose.

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