Sacroiliac Joint Fusion Indications

and Techniques
Vito Masagus

Spine Division Neurosurgery Departement

Faculty of Medicine – Universitas Padjajaran
Bandung - 2022
Introduction
Sacroiliac Joint (SIJ)
an often-overlooked source of low back pain that can radiate to the buttock, groin, or lower extremity

SIJ Pain impact :

Burden of SIJ pain is higher than many commonly disabling medical conditions such as chronic obstructive
pulmonary disease and angina

Level There is superiority of minimally invasive SIJ fusion compared with nonsurgical
1 management for patients with SIJ dysfunction at 6 months and 12 months of follow –
up and have shown benefit as long as 5 years after SIJ fusion
evidence

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Patient Selection
Clinical Examination
1. Standing position :
a. Fortin Finger test : point to the greatest site of pain
b. The posterior superior iliac spine (PSIS) is then evaluated for point tenderness to palpation
2. Supine position : picture

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Patient Selection
Radiographic
Evaluation
Anteroposterior (AP), lateral, and ferguson plain radiographs of the pelvis

Diagnostic Injection

Patients with three or more

If a patient does not report at
positive physical examination
The patient is instructed to least 50% pain relief, SIJ
findings next receive a
record pain response to dysfunction is unlikely to be
diagnostic injection of local
typically provocative painful the cause of the symptom s
anesthetic (lidocaine only) in
movements in the 1 to 2 or is unlikely to be
the SIJ by a qualified
hours after the injection responsive to surgical
radiologist or interventional
intervention.
specialist

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Patient Selection
Nonsurgical Management

Physical therapy SIJ injection with

(PT) by a therapist Lifestyle local anesthetic
Sacroiliac belts NSAID
specifically skilled modifications and steroid
in SIJ PT medication

if the patient has repeated return of significant pain despite technically adequate SIJ injection,
then the patient may be considered for radiofrequency ablation (RFA) or for SIJ fusion

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Patient Selection
Surgical Management Minimally
invasive (MIS)
Open anterior Open posterior
lateral
Fusion of the SIJ can be performed via : approaches

MIS SIJ fusion leads to clinically and

statistically significant improvements in
back pain, function, and health-related
Open approach for SIJ
quality of life with high patient satisfaction fusion has been typically
and low complication rates associated with :

Prolonged recovery periods

resulting from extensive soft
Substantial pain Blood loss tissue dissection as well as
nonunion rates varying from
9 to 41%

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Preoperative Preparation
obtained to evaluate sacroiliac anatomy for
Noncontrast CT scan of the pelvis feasibility of implant placement

Preoperative PT teaching session for crutches modality training for toe-touch

weight-bearing

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Operative Procedure
Minimally Invasive SIJ Fusion
Positioning : prone with hips and
knees extended on a radiolucent
table using either fluoroscopic
General anesthesia guidance with AP and lateral
images, or three-dimensional
computer navigation based on
intraoperative CT scan

Once imaging has been used to

determine a starting point on the
lateral gluteal region, the skin is
infiltrated with local anesthetic and
a 3- to 5-cm incision is made in the
skin and fascia with dissection
carried down to the ilium

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Operative Procedure
Minimally Invasive SIJ Fusion

Using image guidance, a After drilling a pilot hole

Kirschner (K-wire) is with a cannulated drill bit,
Fluoroscopy is used to Cannulated serial dilators
placed across the SIJ into a cannulated broach is The implant is then
check location. Implant are used for the soft tissue
the sacrum , exercising malleted across the SIJ, manually inserted.
length is determined. envelope.
vigilance to remain lateral taking care not to advance
to the neuroforamina. the K-wire

Other techniques using

Intraoperative CT scan is This process is repeated
screw-in type devices with The wound is irrigated and Fluoroscopy is used to
used to check final implant for a typical total of three
or without fenestrations closed. check location.
location implants.
are available as well

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Operative Procedure
Open Anterior SIJ Fusion

An ilioinguinal incision The external oblique and The iliacus is elevated

Patient under general approximately 20 cm long gluteal fascia are from the iliac fossa with
anesthesia with the is made through skin and exposed with sharp subperiosteal dissection
patient supine. subcutaneous tissue over dissection, and an interval with monopolar
the symptomatic joint. is developed. electrocautery.

A retractor is placed
A pointed Homan
The capsule is then inside the iliopectineal
retractor is inserted on
removed off the iliac and line of the pelvis until the
the sacral ala after careful
sacral portion of the SIJ superior capsule of the
exposure to avoid injuring
using a 15-blade scalpel. sacroiliac joint is
the L5 nerve root.
visualized.

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Operative Procedure
Open Anterior SIJ Fusion
The SIJ cartilage is resected
using a series of curettes and
rongeurs, removing all
cartilage back to the posterior
ligamentous structures.
The external oblique and
transversalis fascia are
repaired to the gluteal fascia
with multiple figure-of-eight
sutures and the wound closed
in layers.
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Bone graft is harvested from
the inner table of the ilium
then morselized and packed
into the SIJ after predrilling
both the sacral and the iliac
side with multiple 2.5-mm drill
holes.
Gelfoam is placed into the
bone graft harvest site.
A three-hole 4.5- mm
reconstruction plate is
contoured and fixed with a
fully threaded 6.5-m m
cancellous screw on the sacral
side and with two cortical
screws on the iliac side.
The plate is inspected to
ensure that no soft tissue is
trapped or placed under
tension. A 1/8-inch Hemovac
drain is placed into the iliac
fossa.
Operative Procedure
Revision SIJ Fusion

When surgery fails to heal or fails to relieve the patient’s pain and SIJ physical
examination maneuvers remain positive, re-evaluation is appropriate.
Typically, we use CT-guided SIJ injection with local anesthetic.

If this relieves the patient’s pain then he or she may be a candidate for SIJ
revision surgery

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Postoperative Management
Minimally Invasive SIJ Fusion
The procedure is performed
on a same-day or overnight-
stay basis.
Before the patient is
discharged home, PT
AP/lateral/Ferguson plain evaluation is performed to
radiographs are obtained ensure safety with toetouch
prior to discharge weight-bearing on the
operative side using crutches
or a front-wheeled walker.
Toe-touch weight-bearing is
Beginning 2 weeks
continued for 3 weeks
postoperatively, patients
postoperatively and then
undergo individualized PT
twice a week for 6 weeks
progressively increased to full
ambulation.
Postoperative radiographs of the pelvis with
three fusion rods across the SIJ
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Postoperative Management
Open Anterior SIJ Fusion
The patient is admitted for
inpatient stay until pain
control is adequate and
flatus returns.
At postoperative week 6 :
patients begin pool therapy
and continue for 4 weeks with
progressive weight-bearing,
followed by 8 weeks of land-
based PT focusing on core
body strengthening
Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
Imaging : AP/lateral/Ferguson
plain radiographs are obtained
before discharge
Physical Therapy : Patients
are evaluated by PT for safety
with toe-touch weight-bearing Open anterior sacroiliac joint fusion. (a) Preoperative
on the operative side using
crutches or a front-w heeled radiograph of the pelvis. (b) Postoperative radiograph of the
walker, which is continued for pelvis with a threehole reconstruction plate spanning the
6 weeks postoperatively
sacroiliac joint.
Conclusion
Dysfunction of the SIJ is easily overlooked unless specifically evaluated with
a targeted algorithm of specific physical examination maneuvers and
diagnostic injections, as well as radiographs to exclude spine and hip
pathology.

Level 1 evidence suggests that patients with SIJ dysfunction benefit from
MIS-SIJ fusion compared with continued nonoperative management

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
THANK
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