The

sacroiliac joint The sacroiliac joint or SI joint (SIJ) is the joint between the sacrum and the ilium bones of the pelvis, which are connected by strong ligaments. In humans, the sacrum supports the spine and is supported in turn by an ilium on each side. The ...

is a paired joint in the

pelvis The pelvis (plural pelves or pelvises) is the lower part of the trunk, between the abdomen and the thighs (sometimes also called pelvic region), together with its embedded skeleton (sometimes also called bony pelvis, or pelvic skeleton). The ...

that lies between the

sacrum The sacrum (plural: ''sacra'' or ''sacrums''), in human anatomy, is a large, triangular bone at the base of the spine that forms by the fusing of the sacral vertebrae (S1S5) between ages 18 and 30. The sacrum situates at the upper, back part ...

and an ilium. Due to its location in the lower back, a dysfunctional sacroiliac joint may cause lower back and/or leg pain. The resulting leg pain can be severe, resembling

sciatica Sciatica is pain going down the leg from the lower back. This pain may go down the back, outside, or front of the leg. Onset is often sudden following activities like heavy lifting, though gradual onset may also occur. The pain is often described ...

or a

slipped disc Spinal disc herniation is an injury to the cushioning and connective tissue between vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physic ...

. While nonsurgical treatments are effective for some, others have found that surgery for the dysfunctional sacroiliac joint is the only method to relieve pain. Sacroiliac joint dysfunction is diagnosed by a physician. Associated surgery should only occur when certain criteria are satisfied.Dall BE Eden SV Brumblay HG. Sacroiliac joint dysfunction: an algorithm for diagnosis and treatment. (2010) http://www.borgess.com/files/bbsi/pdf/si_joint_white.pdf Surgical options, such as the degree of invasiveness, can then be evaluated when deciding on a treatment plan. If complications occur, they are often detected early (during surgery or shortly after) and correlate with the surgical approach.Shutz U Grob D. Poor outcome following bilateral sacroiliac joint fusion for degenerative sacroiliac joint syndrome. Act Orthop Belg. (2006) 72 (3) 296-308Wise CL Dall BE. Minimally invasive sacroiliac arthrodesis: outcomes of a new technique. J Spinal Disord Tech. (2008) 21 (8) 579-584Rudolf L. Sacroiliac joint arthrodesis-MIS technique with titanium implants: report of the first 50 patients and outcomes. Open Orthop J. (2012) 6 495-502Dall BE Editor. Surgical Treatment for the painful dysfunctional sacroiliac joint: a clinical guide. Springer Publishing. (2014) Results and outcomes vary according to the patient, pathology, surgeon, procedure, and methods.

History

Sacroiliac joint The sacroiliac joint or SI joint (SIJ) is the joint between the sacrum and the ilium bones of the pelvis, which are connected by strong ligaments. In humans, the sacrum supports the spine and is supported in turn by an ilium on each side. The ...

surgery was first described in 1926 by the

Journal of Bone and Joint Surgery ''The Journal of Bone and Joint Surgery'' is a biweekly peer reviewed medical journal in the field of orthopedic surgery. It is published by the non-profit corporation The Journal of Bone and Joint Surgery, Inc. It was established as the ''Transact ...

.Smith-Petersen MN Rogers WA. End-result study of arthrodesis of the sacroiliac joint for arthritis-traumatic and non-traumatic. J Bone Joint Surg Am; 1926 (8) 118-136 Following its appearance, the original procedure was documented in several publications and practices for nearly a century.Waisbrod H Krainick JU Gerbershagen HU. Sacroiliac joint arthrodesis for chronic lower back pain. Archives of Orthopedic and Traumatic Surgery: 1987 (4) 106; 238-240Belanger TA Dall BE. Sacroiliac arthrodesis using a posterior midline fascial splitting approach and pedicle screw instrumentation: A new technique. J Spinal Discord: (2001) 14 (2) 118-124Buchowski JM et al. Functional and radiographic outcome of sacroiliac arthrodesis for disorders of the sacroiliac joint. Spine J: (2005) 5 (5) 520-528 Discussion 529Keating JG. Sacroiliac joint fusion in a chronic low back pain population. In Vleeming A, editor. The integrated function of the lumbar spine and sacroiliac joints: second interdisciplinary world congress on low back pain. Rotterdam:ECO; (1995) 361-365Kibsgard TJ et al. Pelvic joint fusions in patients with chronic pelvic girdle pain: a 23-year follow up. Eur Spine J; (2013) 22 (4) 871-877Giannikas KA et al. Sacroiliac joint fusion for chronic pain: a simple technique avoiding he use of metalwork. Euro Spine J. (2004) 13 (3) 253-256Haufe SM Mork AR. Sacroiliac joint debridement: a novel technique for the treatment of sacroiliac joint pain. Photoed Laser Surg. (2005) 23 (6) 596-598Kurana A et al. Percutaneous fusion of the sacroiliac joint with hollow modular anchorage screws: clinical and radiological outcome. J Bone Joint Surg Br. (2009) 91 (5) 627-631Al-hayer A et al. Percutaneous sacroiliac joint arthrodesis: a novel technique. J Spinal Disord Tech; (2008) 21 (5) 359-363Mason LW Chopra I Mohanty K. The percutaneous stabilization of the sacroiliac joint with hollow modular anchorage screws: a prospective outcome study. Euro Spine J. (2013) 22 (10) 2325-2331Sachs D Capobianco R. One year successful outcomes for novel sacroiliac joint arthrodesis system. Ann Surg Innov Res. (2012) 6(1)13

surgeries have improved significantly beyond their nascency, which lacked the advent of hardware or instrumentation. The first use of sacroiliac joint surgical materials appeared in 1987 with the use of ceramic blocks to aid in joint fusing. The year 2001 marked the advent of spinal rods and screws to facilitate

internal fixation Internal fixation is an operation in orthopedics that involves the surgical implementation of implants for the purpose of repairing a bone, a concept that dates to the mid-nineteenth century and was made applicable for routine treatment in the m ...

. Continued improvements have been documented as surgeons reduce their incision size while avoiding tissues such as muscle, blood vessels, and nerves. Modern sacroiliac joint surgery utilizes instrumentation systems attempts to be as minimally invasive as possible. The first surgical textbook on sacroiliac joint surgery was published in 2014.

Diagnosis

The diagnosis for a dysfunctional sacroiliac joint results from a combination of patient history, clinical evaluation,Maigne JY Aivaliklis A Pfefer F. Results of the sacroiliac joint double block and value of sacroiliac provocation tests in 54 patients with low back pain. Spine: (1996) 21 1889-1892 and one or more injections. The gold standard diagnostic injection utilizes a long-acting

anesthetic agent Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), am ...

with radiographic dye. A diagnosis can be made following injections into the posterior sacroiliac transverse ligament.

Conservative treatment

Currently, there is no standard treatment regimen that must precede sacroiliac joint surgery. However, an algorithm has been designed (2010) to guide the treatment process before committing a patient to surgery. This algorithm allows for the use of alternative treatments (prolotherapy, radio frequency neural ablation, cryotherapy, acupuncture, and others) if desired by a clinician or patient.

Surgical options

Fusion

When preparing to fuse the

, a surgeon must consider the desired degree of invasiveness, surgical approach (fascial splitting that is posterior midline, posterior lateral, posterior lateral inferior, lateral, anterior), instrumentation, type of bone grafting material (

autograft Autotransplantation is the transplantation of organs, tissues, or even particular proteins from one part of the body to another in the same person ('' auto-'' meaning "self" in Greek). The autologous tissue (also called autogenous, autogene ...

allograft Allotransplant (''allo-'' meaning "other" in Greek) is the transplantation of cells, tissues, or organs to a recipient from a genetically non-identical donor of the same species. The transplant is called an allograft, allogeneic transplant, o ...

, and

xenograft Xenotransplantation (''xenos-'' from the Greek meaning "foreign" or strange), or heterologous transplant, is the transplantation of living cells, tissues or organs from one species to another. Such cells, tissues or organs are called xenograft ...

), and type of

bone graft Bone grafting is a surgical procedure that replaces missing bone in order to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly. Some small or acute fractures can be cured wit ...

enhancing material (

bone morphogenetic proteins Bone morphogenetic proteins (BMPs) are a group of growth factors also known as cytokines and as metabologens. Originally discovered by their ability to induce the formation of bone and cartilage, BMPs are now considered to constitute a group of piv ...

). Another consideration is a patient's desired postoperative weight bearing status, as some procedures result in full weight bearing while others only partial. Current diagnostic criteria (not standard but generally accepted) include at least 6 months of chronic pain, failure of previous treatments, disability from daily activities, and a diagnostic injection. There is no current standard operating procedure, though some surgeons may prefer an approach based on his or her training and exposure (there are exceptions). The most frequently practiced fusion procedure is the lateral minimally invasive approach. One leading explanation for this involves the

FDA The United States Food and Drug Administration (FDA or US FDA) is a federal agency of the Department of Health and Human Services. The FDA is responsible for protecting and promoting public health through the control and supervision of food ...

having made possible a Premarket notification (510(k)) for instrumentation that has a predicate preceding 1976. Several lateral minimally invasive instrumentation systems have acquired this designation. Some procedures are unique in that they do not rely on a fusion of the joint.

Neuromodulation

Recent research by Guentchev et al. 2017 shows that peripheral nerve stimulation is a successful long-term therapy for degenerative sacroiliitis in older patients.

Complications of fusion

Operating on a dysfunctional sacroiliac joint is an elective procedure and should never be an emergency. Preoperative planning and preparation should prevent or lessen the likelihood of most complications. However, aside from the general complications that encompass any

reconstructive surgery Reconstructive surgery is surgery performed to restore normal appearance and function to body parts malformed by a disease or medical condition. Description Reconstructive surgery is a term with training, clinical, and reimbursement implica ...

, specific complications are associated with the sacroiliac joint. The sacroiliac joint is essentially halfway between the ventral and dorsal sides of the body deep within the

, a location in close proximity to several vital structures. Those structures within a few centimeters of the sacroiliac joint include the

, ilium,

sciatic nerve The sciatic nerve, also called the ischiadic nerve, is a large nerve in humans and other vertebrate animals which is the largest branch of the sacral plexus and runs alongside the hip joint and down the lower limb. It is the longest and widest si ...

, dorsal and ventral

sacral nerves A spinal nerve is a mixed nerve, which carries motor, sensory, and autonomic signals between the spinal cord and the body. In the human body there are 31 pairs of spinal nerves, one on each side of the vertebral column. These are grouped into the ...

lumbar plexus The lumbar plexus is a web of nerves (a nervous plexus) in the lumbar region of the body which forms part of the larger lumbosacral plexus. It is formed by the Ventral ramus of spinal nerve, divisions of the first four lumbar nerves (L1-L4) and ...

superior gluteal artery The superior gluteal artery is the largest and final branch of the internal iliac artery. It is the continuation of the posterior division of that vessel. It is a short artery which runs backward between the lumbosacral trunk and the first sacral ...

, iliac vessels, and

large intestine The large intestine, also known as the large bowel, is the last part of the gastrointestinal tract and of the digestive system in tetrapods. Water is absorbed here and the remaining waste material is stored in the rectum as feces before being r ...

. While these structures could be injured during any type of sacroiliac joint procedure, the lateral minimally invasive approach is associated with the greatest number of complications.

Outcomes

Surgical outcome following dysfunctional sacroiliac joint correction has yet to be evaluated by multi-center studies. Multiple peer-reviewed articles have conducted followups, describing an overall success or satisfaction rate in the 70-80% range. However, one article was suggestive of poor outcomes with only 18% of patients being satisfied. Surgery has been demonstrated to also be effective for some pathologies that involve sacroiliac joint dysfunction. The one exception is

inflammatory arthritis Inflammatory arthritis is a group of diseases which includes: rheumatoid arthritis, psoriatic arthropathy, inflammatory bowel disease, adult-onset Still's disease, scleroderma, juvenile idiopathic arthritis, and systemic lupus erythematosus (SLE). ...

, for which surgery achieves mixed results.

Future

Surgeries for the dysfunctional sacroiliac joint are currently in their infancy, despite their many advances. Prospective and multi-center studies are needed to move this surgery into the knowledge base of surgical education and surgical societies.Dall BE. Someone needs to claim it. Spine J (2009) 2 190-191 Advancements in surgery are expected to continue as science is applied further to the diagnosis and treatment of sacroiliac joint dysfunction.

References

{{reflist Surgical procedures and techniques