Recognising and managing sacroiliac joint pain

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By Steven R Garfin

The sacroiliac joint has approximately 4 degrees of motion, synovial lining along the anterior inferior portion, cartilaginous surfaces, strong ligaments, rich innervation (L2-S4), and arthritic/aging changes like other arthrodial joints. Also, chronic sacroiliac joint pain is perceived by patients as roughly equivalent to chronic depression, severe chronic obstructive pulmonary disease (COPD), and cardiac disease in terms of diminution in quality of life.

The diagnosis of sacroiliac joint pain depends on obtaining a consistent history with pain over a sacroiliac joint with activity or prolonged sitting. The clinical exam should rule out other causes (eg. hip, lumbar spine) and should have three positive tests out of six sacroiliac joint tests and confirmatory sacroiliac joint injections. These injections should include multiple duration length anaesthetics (eg. lidocaine, Marcaine) injected in to the joint with fluoroscopic control creating pain relief for an appropriate amount of time, with activities that normally would reproduce the pain.

 

Management

Standard non-operative treatments should always be tried and some physicians also use radiofrequency ablation. If these fail, surgery can be considered. There are a number of articles reviewing varying open sacroiliac joint fusions and techniques, and those published after 1985 have shown mixed results—some showing reasonably good relief and others only 30-60% patient satisfaction.1–4

More recent studies assess sacroiliac joint fusion using minimally invasive techniques. The most published technique is with the iFuse device (SI Bone). All show marked improvement in Oswestry Disability Index (ODI), SF-36, Visual Analogue Scale (VAS) scores, and patient satisfaction.5–27

In the majority of the recent studies for sacroiliac joint fusion, pain relief has been rapid and sustained (one article had follow-up to 40 months11). Duhan et al demonstrated postoperative improvement in VAS scores of almost 50 points, ODI scores of 16 points, EQ5D scores of 21 points, and SF36 for physical component scores and mental component scores of approximately six points, with 85% patient satisfaction. There are also many articles that have shown the sacroiliac joint can become painful following long posterior lumbar-sacral fusions, and have recommended sacroiliac fusion in these cases.13,19 For example, Schroeder et al looked at six patients at least 15 years after they had long thoracolumbosacral fusions for scoliosis. The patients, who had painful sacroiliac joints, reported marked improvement on VAS, ODI and Scoliosis Research Society 22 scores following sacroiliac joint fusion. Furthermore, Graham-Smith and others looked at open vs. minimally invasive surgery procedures for fusing the sacroiliac joint.17–22 All parameters, including intraoperative measures, VAS, and patient satisfaction improved significantly with minimally invasive surgery compared with open surgery.

The economic data for sacroiliac joint fusion is also compelling.25–2 Though the costs of a fusion is higher over the time of surgery than non-operative care, the cumulative costs following a fusion compared with persistent non-operative care are significantly lower. More than US$600 million is being spent yearly by Medicare for non-operative care.


Conclusion

Looking at all the recent literature, minimally invasive sacroiliac joint fusion is safe, with low rates for complications, complaints, and revisions. It is efficacious with marked improvement in pain. In light of this, Medicare has provided a new code for payment effective on 1 January 2015, removing the “T” (experimental procedure) code that had been in place.

In summary, the sacroiliac joint is a pain generator with a relatively high prevalence. The correct diagnosis is key (thorough sacroiliac joint exam, provocative tests, and injections). Treatment options include non-operative care with little published evidence of efficacy and minimally invasive sacroiliac joint fusion with growing peer reviewed literature support when non-operative care fails. Sacroiliac joint pain is an economic burden; surgery can be a cost-effective option. Very positive clinical reports are increasing (level II-IV) in peer-review journals, along with academic society presentations. Despite the fact we have ignored the sacroiliac joint in the past, the literature strongly supports the concept that the sacroiliac joint is a pain generator and can be treated effectively with surgery if indicated.


References

1. Keating et al. The integrated function of the lumbar spine and sacroiliac joint (Rotterdam, Churchill Livingstone) 1995: 361–65

2. Buchowski et al. Spine J 2005; 5: 520–528; discussion 529

3. Schütz et al; Acta Orthop Belg 2006; 72: 296–308

4. Kibsgård et al. Eur Spine J 2013; 22: 871–77

5. Al-Khayer et al. J Spinal Disord Tech 2008; 21: 359–63

6. Wise et al. J Spinal Disord Tech 2008; 21: 579–84

7. Khurana et al. J Bone Joint Surg Br 2009; 91: 627–31

8. Mason et al. Eur Spine J 2013; 22: 2325–31

9. Endres et al. Indian J Orthop 2013; 47: 437–42

10. Miller et al. Med Devices Evid Res 2014; 2014: 125–30

11. Rudolf et al. Open Orthop J 2012; 6: 495–502

12. Sachs et al. Ann Surg Innov Res 2012; 6: 13

13. Rudolf et al. Open Orthop J 2013; 7: 163–68

14. Miller et al. Med Devices Evid Res 2013; 6: 77–84

15. Sachs et al. Adv Orthop 2013; 2013: 536128.

16. Cummings et al. Ann Surg Innov Res 2013; 7: 12

17. Graham-Smith et al. Ann Surg Innov Res 2013; 7: 14

18. Gaetani et al. J Neurosurg Sci 2013; 57: 297–301

19. Schroeder et al. Hosp Spec Surg J 2013; 10: 30–35

20. Duhon et al. Med Devices Evid Res 2013; 6: 219–29

21. Lindsey et al. Med Devices Evid Res 2014; 2014: 131–37

22. Ledonio et al. Med De22vices Evid Res 2014; 2014: 187–93

23. Cher et al. Med Devices Evid Res 2014; 7: 1–9

24. Ackerman et al. Clin Outcomes Res 2013; 2013: 575–87

25. Ackerman et al. Clin Outcomes Res 2014; 2014: 63–74

26. Ackerman et al. J Neurosurg Spine 2014; 20: 354–63

27. Shaffrey et al. J Neurosurg Spine 2014; Epub

Steven R Garfin, distinguished professor and chair, UC San Diego, Department of Orthopaedic Surgery, San Diego, USA; Conflict of interest: consultant for SI Bone

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