Minimally Invasive Sacroiliac Joint Fusion

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 management 1 - 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 blocks 5 , and physical therapy, such as core stabilization, orthotics (SI belts), and radiofrequency ablation 1 , 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 fusion 9 . 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 maneuvers 7 , 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 treatment 1 - 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 ...

Presentation, Diagnosis, and Treatment of Sacroiliac Joint Dysfunction

“…Both cohorts demonstrated improvement in outcomes throughout the follow-up period 48. A major possible complication of MI SI joint fusion is nerve damage of L5-S2, often because the implant was malpositioned 49. Consequently, nerve impingement is a common indication for revision surgery 49.…”

“…48 A major possible complication of MI SI joint fusion is nerve damage of L5-S2, often because the implant was malpositioned. 49 Consequently, nerve impingement is a common indication for revision surgery. 49 One retrospective study of robotic guidance and neuronavigation suggested improved accuracy of percutaneous screw placement compared with fluoroscopic guidance.…”

“…49 Consequently, nerve impingement is a common indication for revision surgery. 49 One retrospective study of robotic guidance and neuronavigation suggested improved accuracy of percutaneous screw placement compared with fluoroscopic guidance. 50 These techniques warrant further study, as they may help to improve implant positioning and decrease the revision rates of MI SIJ fusion in the future.…”

Pelvic ring injuries

“…The EQ-5D is a 5-item questionnaire that measures health-related quality of life based on five dimensions of health: mobility, self-care, daily activities, pain/discomfort and anxiety/depression (76). Patients can use the dimensions to delineate to what extent they experience problems, scoring from 1 (no problems) up to 5 (extreme problems).…”

“…Compared to 2D-assisted conventional techniques, there is subsequent evidence that 3D-assisted techniques can reduce screw malposition rate (73), operating time (73)(74)(75) and fluoroscopy frequency (75). Moreover, promising outcomes of long lasting effects of decreased pain, reduced disability as well as increased daily function and improved QoL in patient that require SI joint fusion can be expected (76). Also, 3D-fluoroscopy can possibly suffice as a post-operative control examination with accuracies similar to that of post-operative CT (72,77), reducing radiation exposure to the patient.…”