THE SACROILIAC JOINT:To fuse or not to fuse

Azam Basheer MDHenry Ford Neurosurgery

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Disclosures

None

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60 y/o F with LBP and neurogenic claudications

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L3-5 lumbar lami and fusion. Pain alleviated

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1 year later, she presents with left lower back pain radiating to her groin with point tendernesss over the SI joint

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- Diagnosed with left SI joint pain

- Sent to the pain clinic for SI joint injection which relieves the pain for 3 months and then returns again with the same symptoms.

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Anatomy

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AnatomyAnatomy

• Bony articulation Bony articulation joint between the joint between the ilium and the ilium and the sacrumsacrum

• Least understood Least understood jointjoint

• Sacrum is set obliquely between ilia

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Sacral AnatomySynovial joint

Largest axial joint in the body, with an average surface area of 17.5 cm2

(size and shape of the human ear)

Articular surface: 1. S1-S32. Irregular contour3. Major depression on S2

(receives Bonnaire’s tubercle)

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LIGAMENTS

Interosseoss S/I Ligament-

Most important in the S/I joint

Series of short, strong fibers connecting the sacrum and ilium deep within the joint

Anterior Articular Capsule

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- Not very strong

- sometimes described as just a thickening of the anterior joint capsule

Anterior SI ligament

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Posterior SI ligaments

- stronger than the anterior ligament

- connects the sacrum to the PSIS

categorized into:

– Long- Prevents hyperextension

– Short- prevents hyperflexion

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Innervation

- Controversial and variable

- Murata et al in 2001:

- Dorsal innervation: from the dorsal root ganglions of the lower lumbar and sacral levels (L4 to S2)

- Ventral innervation originates from the dorsal root ganglions of the upper lumbar, lower lumbar, and sacral levels (L1 to S2)

- Free end nerve fibers and mechanoreceptors in the SI ligaments and joint

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BIOMECHANICS

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BiomechanicsBiomechanics

Amphiarthrodial JointMinimal movement

Many interlocking osseous structures limits gross excursion

- No muscles acting directly across it.

- Numerous studies on mobility of the sacroiliac joint have led to a variety of different hypotheses and models of pelvic mechanics over the years

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Biomechanics

The primary motions of the sacroiliac joint are nutation and counter-nutation (flexion and extension about the x-axis)

Rotation and translation about 3 axes of approximately 2-4 degrees

Sturesson et al: flexion and extension was 2.5 ± 0.5° (1.6-3.9°), and a mean translation of 0.7 mm (0.1 -1.6 mm) along the axes of rotation

Walheim and associates reported between 2 – 3 mm translations and up to 3 degrees rotational movement

However, SIJ motion occurs simultaneously in multiple planes, not

linearly. Their direction of movement is irregular

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AGE CHANGES THINGS

ROM is limited increasingly with age

– 0-20 Smooth gliding planes

– 20-50 Interlocking irregularities

– >50 Hypomobility

– >80 Osteophytic, Immobile

Ankylosed in 76% of the population over the age of fifty

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Function

• Stress-relieving joint

• Two Roles:– Longitudinal direction:

Supports L-spine

– Transverse direction: Transmits force to the lower extremities

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SIJ disease

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Prevalence

In the late 1980’s, many physicians "rediscovered" the SI joint as a possible source of back pain

1977, retrospective study by Bernard and Kirkaldy-Willis found a 22.5% prevalence rate of SIJ pain in 1293 adult patients presenting with LBP

studies have shown that the SI joint is the cause of chronic lower back pain in 13% – 30% of patients

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SIJ after Fusion

Clinical studies show a range from 3.2% – 21% of patients undergoing lumbar fusion report an incidence of adjacent segmental disease.28

Ha et al. first reported that, based on results from CT scans and PE, the incidence of SIJ degeneration in the fusion group was significantly higher than in the control group (75 vs. 38.2 %, respectively).

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SIJ after Fusion

Maigne and Planchon prospectively followed 61 pts from 1996 to 2002 after lumbar fusion. 45 developed unilateral persistent pain (or with unilateral prevalence) for more than 6 months with a sacroiliac origin.39

Onsel et al. used SPECT to follow up on 753 patients complaining of lower back pain and found that patients who had increased uptake of the SI joint, 35% (15 of 43) had prior lumbar laminectomy and/or spinal fusion.

In 2005 Katz et al. used fluoroscopically guided SI joint injections to identify the cause of lower back pain in patients following lumbosacral arthrodesis. They followed 34 patients and found SI joint dysfunction to be the cause of pain in 32% of the patients.

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EVALUATION of the S/I JOINT

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EVALUATION of the S/I JOINT

Challenging

Wide range of normal anatomy

Cannot directly palpate the joint

You need:1. Good History2. Physical exam3. Imaging4. X-ray guided injections of lidocaine Azam Basheer

History

– Pain with ascending/descending stairs or standing from a sitting position

– Pain with hopping or standing on the involved leg

– A positive straight leg raise at, or near, the end of range

– Slipman et al. retrospective study to determine the pain referral patterns in 50 patients with injection-confirmed SIJ pain. The most common referral patterns for SIJ pain were found to be radiation into the buttock (94 %), lower lumbar region (72 %), lower extremity (50 %), groin area (14 %), upper lumbar lesion (6 %), and abdomen (2 %).

– The most consistent factor for identifying patients with SIJ pain is unilateral pain (25% of pts)

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Exam

Palpation of bony landmarks: compare both sides

– PSIS– Lumbosacral joint– Iliac Crest – Sacroiliac ligaments – Iliolumbar ligaments

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Patrick's testIf pain is elicited on the ipsilateral +

anteriorly = hip joint disorder on the same side

If pain is elicited on the contralateral + posteriorly = SIJ disorder.

The sensitivity of this test in predicting response from SI injection is 57% and almost 100% specific

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Gaenslen's test

• Patient supine and the hip joint is maximally flexed on one side and the opposite hip joint is extended

• Pressure is applied to the flexed extremity.

• Positive if pain is felt across the SI joint.

• 68% sensitive and 35% specific

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Yeoman's test

• Extending the leg and rotating the ilium

• positive test produces pain over the back of the SIJ

• Sensitivity 46%• Specificity 72%

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Gillet test (aka the march test)

Positive if pain elicited on ipsilateral side of standing leg

sensitivity 12%

specificity 97%

Gillet test

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PPV

Slipman et al. reported a PPV of 60 % in diagnosing SIJ pain in patients using a positive response to three SIJ provocation tests.

Broadhurst and Bond reported a sensitivity of 77–87 % for three positive SIJ provocation tests.

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Imaging

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Not very helpful

No consensus in the literature as to the recommended radiographic view or series to evaluate the SIJ

24.5 % of asymptomatic patients >50 years of age have an abnormal SIJ on plain radiographs

Elgafy et al. found that abnormal CT findings, such

as sclerosis, erosion, and narrowing had a sensitivity of 58 % and a specificity of 69 % for determining which patients would experience pain relief following injection of an anesthetic into the SIJ Azam Basheer

Vacuum Joint

Sherman et al, October 2011 “Sacroiliac joint vacuum phenomenon—underreported finding” Johns Hopkins University

- 17% of 223 patients with Vacuum

SIJ - 85% of the phenomena were

present bilaterally - Higher incidents of SI joint pain

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Treatment

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SIJ Injection

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SIJ Injection Studies

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SIJ Denervation

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SI Denervation studies cont.

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SI Denervation studies cont.

• The majority of subjects report satisfaction after treatment

• All of the denervation studies have short follow-up periods, raising the question of duration of effect given that many reported studies of lumbar facet joint denervation show loss of efficacy after about 2 years.

• There is a clear need for more properly constructed comparative studies to establish whether chronic sacroiliac joint pain can be better managed with invasive pain relieving techniques than conventional conservative therapies.

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SI Fusion

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SI Fusion

First pioneered by Smith-Peterson 1921

Currently transitioning from open to percutaneous techniques

Data is limited to case series

The majority of fusion studies reported patient satisfaction as an outcome

The mean rate of patient satisfaction in fusion studies was 57.6% (range, 18%–100%)

The pooled infection rate among fusion studies was 5.3%

Fusion studies reported nonunion, pseudarthrosis and painful hardware as complicationsAzam Basheer

SI fusion Studies

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Open techniques

The incidence of significant complications after open SIJ fusion has been reported to be between 6 and 25 %

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Posterolateral approach

SMITH-PETERSEN1921 & 1926 ‘‘Uniformly successful’’ ‘‘Complete Recovery’’ 6/13, ‘‘Partial Recovery’’ 3/13, ‘‘Failure’’ 4/13

GAENSLEN 1927‘‘Firm fusion’’ in all, ‘‘Very good’’ 3/9, ‘‘Good’’4/9, RTW 6/9

BUCHOWSKI 200520 patients85% ‘‘Solid fusion’’ in one-year, 20% ‘‘major complications’’( infection in 2 casesleading to nonunion),15% required reoperation

GIANNIKAS 20041/5 ‘‘fusion’’ with CT confirmation4/5: 10/10 on VAS (complete relief)

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Posterior Approachpermanent weakness or pain by injury to the insertions of the long spinal extensors

WISE-DALL 2008100% ‘‘fusion’’ at 6 mo (CT confirmation)‘‘Satisfactory results’’ in 4/4 pts

WAISBROD 1987pain <50%, off narcotics 11/22,11/22 ‘‘unsatisfactory’’

MITCHELL 1938‘‘Complete relief’’ 8/15,‘‘Partial relief’’ 3/15, ‘‘Norelief’’ 2/15

KEATING 199326 pts.VAS: avg. 6 preoperatively,decreased to 3postoperatively

BELANGER-DALL 2001100% ‘‘fusion’’ at 6 months (CT confirmation)‘‘Satisfactory results’’ in 4/4 pts Azam Basheer

Bilateral intra-articular and extra-articular Approach

SCHÜTZ & GROB 2006 -17 pts

- 7 nonunion (9/17 CT proven)- 65% required reoperation- 3/17 improved pain longterm

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Anterior Approach

L5 nerve root & Ext. illiac art.

RAND 1985

GUNER 1998

Endoscopic

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Percutaneous Approach

KHURANA 2009100 ‘‘fusion’’ (CT confirmation) Majeed score: improved from 37to 79

Good or excellent results were reported for 87 % of pts

REILEY 201075 pts92% ‘‘fusion’’ (CT confirmation)VAS: improvement in several areas and in total score (P<0.0001). RTW 28/41 work candidates.43% off all narcotics

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Perc. Approach cont.Rudolf et al 2012 (journal of orthopedics) “Sacroiliac

Joint Arthrodesis-MIS Technique with Titanium Implants: Report of the First 50 Patients and Outcomes”

- retrospective study 40 months

- 82% A clinically significant improvement (>2 point change from baseline) was observed in 7 out of 9 domains of daily living

- >80% of patients would have the same surgery again

- Low complication rate (1 pt deep-soft tissue wound infection. 2 pts experienced a large buttock hematoma)

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MIS technique

1. +/- Adequate bowel cleaning pre-operatively

2. Patients are positioned prone on a radiolucent operating table

3. lateral view is taken to identify the starting point for the guide wire.

4. An incision of approximately 1.5 cm is used and a guide wire is introduced into the center of the triangular portion of the sacroiliac join

5. The gluteal fascia is penetrated bluntly and the muscle is split longitudinally to gain access to the outer table of the ilium

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6. The inlet view is used to guide the wire in the anteroposterior (AP) plane The aim is to place the guide wire between the superior and inferior end-plates of the first sacral vertebra.

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7. outlet view gives a coronal view of the guide wire

The aim is to place the guide wire between the superior and inferior end-plates of the S1 vertebra.

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8. Once the guide wire is in a satisfactory position, a 10 mm hollow modular anchorage screw is inserted over it. Cannulated screw is packed with a bone substitute (BMP, DBX...)

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Post opPlaced in hip-spica for about 4-6

weeks

Fully weight-bearing at 6 weeks

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Mean visual analog scale or numeric rating scale improvements after fusion (blue) or denervation (grey) among all studies measuring these outcomes

SI Fusion vs. Denervation

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Summary

Positive provocative maneuvers combined with 75% pain relief after image guided SI joint injection is a reliable method for diagnosing the SI joint as the pain generator

A positive response to low-volume anesthetic injection into the sacroiliac joint is required before considering surgery.

Patients should have failed at least 6 months of conservative treatment (physical therapy, nonsteroidal anti-inflammatory drugs [NSAIDs], exercise, and therapeutic injections) before considering surgical fusion

The open fusion studies reported poorer results and higher complication rates than the percutaneous studies.

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