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Chapter 23 Sacroiliac Joint Pain: Pathophysiology and Diagnosis 403
22. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis
of movements of the sacroiliac joints during the standing hip
exion test. Spine. 2000;25(3):364-368.
23. Miller JA, Schultz AB, Andersson GB. Load-displacement
behavior of sacroiliac joints. J Orthop Res O Publ Orthop Res
Soc. 1987;5(1):92-101.
24. Weisl H. e movements of the sacroiliac joint. Acta Anat
(Basel). 1955;23(1):80-91.
25. Sturesson B, Selvik G, Uden A. Movements of the sacroiliac
joints. A roentgenstereophotogrammetric analysis. Acta Orthop
Scand Suppl. 1988;59(suppl 227):89.
26. Vleeming A, van Wingerden JP, Dijkstra PF, et al. Mobility in
the sacroiliac joints in the elderly: a kinematic and radiologic
study. Clin Biomech (Bristol, Avon). 1992;7(1):170-176.
27. Hilton J. e classic: on rest and pain: lecture XIV. Clin Orthop.
2009;467(9):2208-2214.
28. Vilensky JA, O’Connor BL, Fortin JD, et al. Histologic analysis
of neural elements in the human sacroiliac joint. Spine.
2002;27(11):1202-1207.
29. Bernard TN Jr, Cassidy JD. e sacroiliac joint syndrome:
pathophysiology, diagnosis, and management. In: Frymoyer
JW, ed. e Adult Spine: Principles and Practice. 2nd ed.
Philadelphia: Lippincott-Raven; 1997:2343-2366.
30. Murata Y, Takahashi K, Yamagata M, et al. Sensory innervation
of the sacroiliac joint in rats. Spine. 2000;25(16):2015-2019.
31. Yamashita T, Minaki Y, Oota I, Yokogushi K, Ishii S.
Mechanosensitive aerent units in the lumbar intervertebral
disc and adjacent muscle. Spine. 1993;18(15):2252-2256.
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e relationship of lumbosacral plexus to the sacrum
and the sacroiliac joint. Am J Orthop (Belle Mead NJ).
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34. O’Shea FD, Boyle E, Salonen DC, et al. Inammatory and
degenerative sacroiliac joint disease in a primary back pain
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35. Chou LH, Slipman CW, Bhagia SM, et al. Inciting events
initiating injection-proven sacroiliac joint syndrome. Pain Med
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36. Pohlemann T, Tscherne H, Baumgärtel F, et al. [Pelvic
fractures: epidemiology, therapy and long-term outcome.
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Unfallchirurg. 1996;99(3):160-167.
37. Ebraheim NA, Ramineni SK, Alla SR, Ebraheim M.
Sacroiliac joint fusion with bular bone gra in patients
with failed percutaneous iliosacral screw xation. J Traum a .
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38. Fortin JD, Falco FJ. e Fortin nger test: an indicator of
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39. Fortin JD, Washington WJ, Falco FJ. ree pathways between
the sacroiliac joint and neural structures. AJNR Am J
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40. Laslett M, Williams M. e reliability of selected pain
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42. Mens JMA, Huis in ’t Veld YH, Pool-Goudzwaard A. e
active straight leg raise test in lumbopelvic pain during
pregnancy. Man er. 2012;17(4):364-368.
43. Sturesson B, Kools D, Pugmacher R, et al. Six-month
outcomes from a randomized controlled trial of minimally
invasive SI joint fusion with triangular titanium implants vs.
conservative management. Eur Spine J. 2017;26(3):708-719.
44. van der Linden S, Valkenburg HA, Cats A. Evaluation of
diagnostic criteria for ankylosing spondylitis. A proposal
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46. Slipman CW, Sterenfeld EB, Chou LH, Herzog R, Vresilovic E.
e value of radionuclide imaging in the diagnosis of sacroiliac
joint syndrome. Spine. 1996;21(19):2251-2254.
47. Elgafy H, Semaan HB, Ebraheim NA, Coombs RJ. Computed
tomography ndings in patients with sacroiliac pain. Clin
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48. Simopoulos TT, Manchikanti L, Singh V, et al. A systematic
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joint interventions. Pain Physician. 2012;15(3):E305-E344.
49. Mitchell B, MacPhail T, Vivian D, Verrills P, Barnard A.
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50. Dreyfuss P, Henning T, Malladi N, Goldstein B, Bogduk N.
e ability of multi-site, multi-depth sacral lateral branch
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SECTION
III
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Outcomes of Nonsurgical and Surgical
SECTION
24
Treatment of Chronic Sacroiliac Joint Pain
CHAPTER
Nonsurgical and surgical treatments for sacroiliac joint (SIJ)
pain have been the subject of intermittent study since the
early 1900s. Multiple treatments of several modalities are
commonly provided, although published high-quality studies
supporting safety and ecacy are oen lacking. Published
high-quality literature on minimally invasive SIJ fusion is
growing.
Nonsurgical Treatment
Multiple nonsurgical treatment options exist for the management of SIJ pain, with limited evidence to support successful
treatment.
Alexandra Schwartz
Vinko Zlomislic
W. Carlton Reckling*
Daniel Cher*
stabilizing exercises,
impact of physical therapy on SIJ pain related to osteoarthritic
degeneration or SIJ disruption have been published. While
physical therapy remains a reasonable nonsurgical option
and is used as part of the standard management algorithm,
evidence of eectiveness is modest at best and whether it is
cost-eective is not known. Anecdotally, failure of physical
therapy in treatment of SIJ pain is common.
Pelvic Bracing
Bracing with a pelvic belt, used in pregnancy-related pelvic
4,5
pain,
has also been described in the nonsurgical treatment
of SIJ dysfunction,
support its use.
1–3
no high-quality studies determining the
6,7
but no high-quality evidence exists to
III
Medication Management
Medications such as opioids and nonsteroidal antiinammatory drugs may be useful for acute pain control.
Newer agents, including immunomodulators and protease
inhibitors, have shown success in management of inammatory spondyloarthropathy but play no role in the more
common degenerative and disruption-based SIJ syndromes.
Moreover, no medical treatment has been shown to alter the
course of SIJ pain due to degenerative sacroiliitis or SIJ disruption. As with other chronic pain syndromes, opioid abuse
remains a signicant concern.
Physical Therapy
Physical therapy for nonautoimmune SIJ pain is commonly
employed. e goals of therapy are to identify underlying
functional decits and provide improved exibility and
strengthening of stabilizing trunk muscles, oen in combination with direct joint manipulation, while also training the
patient to avoid activities that exacerbate symptoms. In spite of
trials that have shown some benet with manual therapy and
*Dr. Reckling and Dr. Cher are employees of SI-Bone, a medical device company.
Sacroiliac Joint Injection
Intraarticular and periarticular injections have been employed
in the treatment of SIJ pain, with therapeutic eects related to
the (as yet undocumented) anesthetic and steroid phases of
relief. Intraarticular SI injections are increasingly performed
in the United States,8 but there is no high-quality evidence to
support their use. In a blinded randomized trial of periarticular steroid injections, women with pelvic pain aer pregnancy
attributed to SIJ pain had improved pain levels, disability,
6-minute walk test, and isometric trunk extensor test results
at 4 weeks aer inltration of 20 mg of triamcinolone around
(but not into) the SIJ compared to aer saline placebo.9 Two
small blinded randomized trials from a single group in Finland
showed improvement in SIJ symptoms at 1 month aer periarticular steroid inltration compared to lidocaine injec-
10,11
tions.
from periarticular steroids.
Radiofrequency Ablation
Radiofrequency (RF) ablation has also been employed to
provide pain relief through denervation of the SIJ. Two highquality blinded trials have shown short-term (1 or 3 months)
No high-quality study has shown long-term benet
405
406 SURGICAL ANATOMY AND APPROACHES
pain relief aer RF ablation of lateral branches of sacral nerve
12,13
roots.
In these trials, patients were screened using diagnostic periarticular local anesthetic blocks. A 12-month follow-up
in one randomized trial showed moderate pain relief.
14,14a,14b
No high-quality evidence demonstrates long-term pain relief
aer RF ablation of the lateral branches of sacral nerve roots.
e major shortcoming involving percutaneous RF ablation
is that the ventral aspect of the joint cannot be addressed.
Furthermore, due to complex innervation patterns, many of
the nerves ablated during these procedures target other surrounding structures. Finally, much of the innervation of the
SIJ is inaccessible to the RF probe. is may contribute to the
relatively high rates of return of SIJ pain following RF ablation.
Surgical Treatment
In appropriately selected patients who have failed nonsurgical
treatment, surgical management may be considered, with the
treatment of choice being SIJ arthrodesis. Goals of SIJF are
acute stabilization of the SIJ with hardware and long-term
stabilization via biologic fusion. Stabilization and fusion of the
SIJ may allow the spine-pelvis-hip complex to function more
normally, which can contribute to reduction in pain and
improvement of overall function.
Open Surgery
Initially described with a dorsal approach in 1908,15 subsequent detailed descriptions of lateral-based SIJF were described
in the 1920s.
strated variably successful results following open SIJF.
Access to the SIJ may involve either an anterior, posterior,
or lateral approach. e anterior surgical technique utilizes
a standard ilioinguinal approach during which the interval
between the external oblique and gluteal fascia is developed
and the iliacus is elevated from the iliac fossa allowing
exposure of the SIJ. e joint is then curetted and fusion is
achieved with placement of bone gra, with plate and screw
xation (Fig. 24.1A). e anterior approach aords access to
the articular SIJ, especially to the anterior and cranial aspects,
as well as preservation of the primary posterior ligamentous
stabilizers.
Several posterior-based SIJF techniques have been
described, though the posterior approach oers only limited
access to the SIJ articular surfaces. Posterior approaches range
from simple onlay graing of the dorsal sacrum and adjacent
ilium followed by cast immobilization,27 debridement and
graing of the dorsal ligamentous portion of the SIJ,
debridement and graing of the articular SIJ, which requires
removal of a portion of the overlying posterior iliac crest.29
Various types of xation have been described in conjunction
with posterior SIJ fusion, including screws placed laterally
from ilium to sacrum,30 screws in the ilium and sacrum dorsally with a rod spanning the SIJ,23 and hybrid xation with a
plate dorsally and screws laterally.
Smith-Petersen approach may be carried out to access the SIJ
from a lateral approach.16 is involves removing a rectangular
16,17
Since then, scattered case series have demon-
21
20,31
Alternatively, a modied
18–26
26,28
and
A
B
FIG. 24.1 Anteroposterior plain radiographs of the pelvis. (A) Use of T-plate
to achieve arthrodesis of the sacroiliac joint using a modied SmithPetersen approach. (B) Three-hole reconstruction plate spanning the
sacroiliac joint following anterior ilioinguinal approach.
or cylindrical core of ilium (across the joint), allowing exposure, decortication, and graing of the SIJ. e bony core is
then impacted back in so that the thicker iliac component sits
across the joint for a fusion, which may or may not include
supplemental screw xation (Fig. 24.1B).
32,33
Open SIJF is marred by long operative times, high blood
loss, long hospital stays, and signicant patient morbidity—
including infection, prolonged recovery times, and pseudarthrosis.34 In addition, numerous complications have been
reported for open approaches, including injury to the erector
spinae muscle insertions, iatrogenic injury to the dorsal
sensory nerve roots, sacral plexus, and internal iliac vessels.
e most eective method for open SIJF remains unknown,
as no comparative studies have been published. Nonetheless,
given the historical context of limited surgical technology in
use at the time, open SIJF resulted in modest rates of patient
improvement along with radiographic fusion rates near 70%.
Overall, approximately 60% of patients have indicated they
Chapter 24 Outcomes of Nonsurgical and Surgical Treatment of Chronic Sacroiliac Joint Pain 407
would choose to have the surgery again.21 However, with the
advent of minimally invasive approaches, interest in open
fusion has waned and the open technique is now used primarily in the setting of acute trauma or revision surgery.
35
Minimally Invasive Surgery
Recent advances in surgical technology, along with a progression toward minimally invasive surgical (MIS) techniques,
have resulted in the development and commercial availability
of several devices used in MIS SIJF. Minimally invasive SIJF is
predicated on a thorough understanding of the anatomy of the
pelvis, including bony architecture as well as the position of
the neurovascular structures. Appropriate imaging (including
pelvic anteroposterior, inlet, and outlet views, and, if possible,
computed tomography [CT] scan) must be obtained and
studied preoperatively. Images should be reviewed, with particular attention paid to the possibility of a dysmorphic
sacrum, which may signicantly alter, or decrease, the safe
zone for implant placement.
ree approaches similar to those used in open SIJF have
been described for MIS SIJF. First, an anterior approach with
endoscopic placement of a fusion cage has been described.25
Second, two reports describe a dorsal approach with placement of fusion cages into the ligamentous portion of the joint.
In one report, a hollow threaded fusion cage was used, with
modest improvements.36 In a second report, a fusion cage
lled with recombinant human bone morphogenetic protein-2
was used, with somewhat larger improvements.31 As of late
2016, no devices placed via the posterior approach are US
Food and Drug Administration cleared/approved for SIJF.
e most commonly reported technique for MIS SIJF is the
lateral transarticular approach, which was derived in part from
modications of the Smith-Petersen technique.16 In this
approach, devices are placed across the SIJ from lateral to
medial under uoroscopic guidance or navigational control.
Outcomes From Minimally Invasive Sacroiliac Joint Fusion
Although several devices are cleared by the Food and Drug
Administration for lateral transarticular SIJF, the majority of
the published clinical literature for this approach reports use
of porous triangular titanium implants (iFuse Implant System,
SI-Bone). ree prospective multicenter clinical trials, including two randomized clinical trials, report successful outcomes
with use of these implants. A US prospective, multicenter
randomized controlled trial (INSITE; n = 148) compared
minimally invasive SIJF using triangular titanium implants to
nonoperative care.37 Nonsurgical care consisted of medication
management, physical therapy, SIJ steroid injections and RF
ablation of lateral branches of sacral nerve roots, administered
according to patient needs. Success—a composite of pain
reduction, absence of serious adverse events or neurologic
worsening, and absence of repeat surgery—occurred in 82%
in the SIJF group and 26% of in the nonsurgical group (P <
.0001). By month 24, 82% received substantial clinical benet
(Glassman criteria38) in visual analog scale SIJ pain score and
66% had received substantial clinical benet in Oswestry
Disability Index (ODI) score. In the nonsurgical group, these
proportions were less than 10% with nonsurgical treatment
only. Parallel changes were seen for EuroQOL-5D and Short
Form-36 quality-of-life surveys, with larger changes in the
surgery group at 6 months compared to nonsurgical treatment. e rate of adverse events related to SIJF was low. ree
subjects assigned to SIJF underwent revision surgery within
the 24-month follow-up period.
In a second prospective, multicenter randomized controlled
trial conducted in Europe (iMIA; n = 103), patients with SIJ
dysfunction were assigned to either MIS SIJF using titanium
implants or conservative management.39 At 6 months, mean
low back pain improved by 43.3 points in the SIJF group and
5.7 points in the conservative management group (dierence
of 38.1 points; P < .0001). Mean ODI improved by 26 points
in the SIJF group and 6 points in the nonsurgical group (P <
.0001). Other outcomes, such as active straight leg raise test,40
EuroQOL-5D-3L, walking distance and satisfaction, were
statistically superior in the fusion group. e frequency of
adverse events did not dier between groups. One case of
postoperative nerve impingement occurred in the surgical
group. Twelve-month outcomes were sustained.
41
Positive results from both randomized trials are supported
by a large prospective, multicenter, single-arm clinical trial
conducted in the United States (SIFI; n = 172).42 In this study,
patients (mean age, 51 years; 70% women) had SIJ pain for 5
years prior to SIJF, on average. Visual analog scale SIJ pain
levels improved from close to 80 at baseline (0–100 scale) to
31 at 24 months. Large improvements were seen in ODI and
two quality-of-life measures (SF-36 and EuroQOL-5D). Also
observed was a decrease in opioid use for back pain from 76%
at baseline to 55% at 24 months. A total of 4.7% of subjects
underwent a revision surgery during follow-up. e study
showed a high rate of bony apposition to implants on both
sides of the SIJ, with modest 1-year fusion rates.
A pooled analysis of all three prospective porous triangular
titanium implant studies (Fig. 24.2) showed high degrees of
homogeneity across trials and statistically signicant but clinically unimportant predictors of success (smoking and baseline
opioid use).
43
In addition to prospective studies, retrospective case series
show positive outcomes aer SIJF with porous titanium
implants.
44–53
Of these case series, notable studies include
those with 3-year,53 4-year,52 and 5-year44 follow-up. In the
latter study, 5-year joint fusion rates were high.44 ree
34,54,55
studies
comparing open and MIS SIJF substantiated the
potential benets of the MIS approach, including one study55
showing less blood loss, shorter operative times, and shorter
hospital stays as well as improved pain levels at 1 and 2 years
in the MIS approach.
In a comparative long-term case series from Spain, a
minority of patients with diagnosed SIJ dysfunction were able
to undergo MIS SIJF using triangular titanium implants or RF
ablation; the remainder were, due to insurance noncoverage,
forced to undergo continued conservative management.
Patients in the SIJF group showed marked, immediate, and
sustained reductions in SIJ pain and disability scores (ODI),
along with a profound decrease in opioid use (63% at baseline
SECTION
III
408 SURGICAL ANATOMY AND APPROACHES
VAS SIJ Pain
Mean, 95% CI
Months after treatment initiation
Mean, 95% CI
100
102
46
172
75
52
51
50
Mean, 95% CI
25
0
ODI
102
60
46
52
51
172
40
20
101
169
43
49
52
168
100
45
48
51
43
52
52
169
100
01 36
Months after treatment initiation
168
100
45
48
43
52
169
100
169
52
101
44
49
48
158
100
45
147
90
12 18 24
48
159
100
148
147
41
90
41
89
0
01 36
EQ-5D
1.00
0.75
0.50
45
169
102
51
Mean, 95% CI
52
0.25
0.00
01 36
SF-36 PCS
60
40
169
45
102
20
Months after treatment initiation
12 18 24
52
100
52
108
44
48
49
100
157
48
148
89
12 18 24
Months after treatment initiation
100
168
44
100
155
140
89
0
01 36
12 18 24
FIG. 24.2 Improvement in sacroiliac joint (SIJ) pain as measured using a visual analog scale (VAS), Oswestry
Disability Index (ODI), EQ-5D time tradeo index, and Short Form-36 physical component summary (PCS) in
three prospective trials, including two randomized trials, of sacroiliac joint (SIJ) fusion. CI, condence interval.
Chapter 24 Outcomes of Nonsurgical and Surgical Treatment of Chronic Sacroiliac Joint Pain 409
to 7% at last follow-up). In contrast, patients who underwent
either RF ablation or conservative management showed worsening of pain and disability scores, increased opioid use, and
worsened job status at last follow-up.56 CT scans in one study
showed a modest rate of bridging bone at 1 year42 and a high
rate at 5 years.
44
Data supporting other commercially available SIJF systems
include two small retrospective case series using hollow
modular anchor screws,
57,58
one case series in which a minority of patients were treated with the Samba screw,59 one case
series with the Zyga screw,60 and one single-center prospective
study using SI-LOK (Globus).61 ese studies were neither
blinded nor randomized; the degree to which outcomes from
randomized trials of the triangular titanium implant pertain
to screw-based systems is not known and no ongoing comparative studies are in progress. A comparative case series
suggests that screw loosening may be more common than
loosening of triangular titanium implants.
62
Complications From Minimally Invasive Surgical Sacroiliac Joint Fusion
Complications of MIS SIJF fall into four categories: (1) device
breakage, which has been reported with some systems, but not
iFuse implants; (2) standard local operative complications; (3)
implant malposition resulting in neuropathic pain due to
irritation of the L5 or S1 nerve roots by the distal tip of the
misplaced implant; and (4) implants placed insuciently into
the sacrum, resulting in continued or recurrent pain. In prospective trials, local surgical complications did not appear to
occur more commonly than aer other procedures. Implant
malposition causing acute neuropathic pain occurred in about
1% of subjects in prospective clinical trials of triangular titanium implants and at a similar rate in a postmarket surveillance study.63 In most cases with implant malposition causing
new-onset neuropathic pain, pain resolves with repositioning
of the implant(s). Failure to place devices suciently into the
sacrum causes inadequate SIJ stabilization, which may result
in either lack of improvement of SIJ pain or pain recurrence.
Long-term revision rates aer SIJF with triangular titanium
implants appear to be low,64 especially in comparison to some
lumbar spine surgeries.
associated with radiolucencies around the implants due presumably to persistent micromotion. ough not documented,
placement of implants under CT guidance may help to improve
implant placement accuracy.
65,66
In some cases, such failures are
one C-arm is used, it is helpful to mark both positions of the
C-arm base on the oor, as well as the various angles of inlet
and outlet positions on the machine with tape. Adjust the table
height such that no changes need to be made intraoperatively
to obtain a good lateral sacral view. When using a single
C-arm, it is positioned opposite the surgical site.
e ability to obtain proper imaging views must be ensured
before initiation of surgery and should be performed before
prepping and draping the patient. Several factors can interfere
with the ability to visualize appropriate bony landmarks,
including bowel gas, patient habitus, and prior lumbosacral
instrumentation. Consideration of preoperative bowel prep
should be given to improve visualization if needed. e inlet
view is deemed ideal when all sacral bodies are overlapped.
e outlet view is best when the S2 foramina are seen immediately cephalad and adjacent to the superior aspect of the
superior pubic rami. e ideal sacral lateral view is seen when
the greater sciatic notches are perfectly overlapped. e sacral
lateral view is critical to understanding the sacral alar slope.
e alar slope is best estimated by the iliac cortical density
(ICD) and delineates the anterior extent of the “safe zone” if
the implant is posterior and caudal to it.67 Care must be taken
in patients with a dysmorphic sacrum (Fig. 24.3), in which the
sacral alar cortical bone limit is not represented by the ICD.
Due to the more acute slope of the sacral ala, the sacral alar
cortical line is cephalad and anterior to the ICD.
e aected gluteal region is prepped and draped in the
usual sterile fashion. Draping should extend from midline to
the greater trochanter, and from the gluteal crease to proximal
to the iliac crest. A timeout procedure is performed.
Various methods have been described to place percutaneous fusion devices. Depending on the system chosen by
the surgeon, this may involve a cannula through which one
SECTION
III
Minimally Invasive Surgical Fusion Technique
MIS sacroiliac fusion is done with the patient in the prone
position on a radiolucent table. Rolls are placed under the
patient’s chest. Care is taken to pad all bony prominences, and
sequential compression devices are placed on both lower
extremities. e arms are placed in an abducted and externally
rotated position, rather than adducted at the patient’s side, to
allow for lateral uoroscopic imaging. Biplanar uoroscopy
may be used. If two C-arms are used, one is positioned in the
anteroposterior plane and one is placed in the lateral plane. If
FIG. 24.3 The greater sciatic notches are overlapped, indicating an
adequate lateral view. The sacral alar cortical bone limit is not represented
by the iliac cortical density, due to the more acute slope of the sacral ala.
The sacral alar cortical line is cephalad and anterior to the iliac cortical
density.
410 SURGICAL ANATOMY AND APPROACHES
can accomplish a technique to debride the sacroiliac joint
(SImmetry; Zyga Technology), or a percutaneous technique
using cannulated wires, broaches, and triangular titaniumcoated implants without debriding the chondral surfaces
(iFuse Implant System; SI-Bone). e goal of the latter
is to create stability by bony growth onto the implant, not
necessarily bone growth across the SI joint, though anecdotally this has been observed. Various reports describe other
implants used for such minimally invasive, uoroscopically
placed implants.
For the triangular titanium-coated implant system, typically
three implants are inserted. A 2-cm incision is rst made in
line with the midsagittal sacrum. Blunt percutaneous dissection is then carried out to the lateral ilium. e rst cannulated
guide wire placed should be the most cephalad wire. e goal
is to center the guide pin between the S1 foramen and superior
endplate of the sacrum on the outlet view while maintaining
the guide pin parallel to the superior endplate of S1 (Fig.
24.4). On the inlet view, the guide pin should be aimed from
slightly posterior to anterior, care being taken not to violate
the sacral canal or exit the front of the sacrum (Fig. 24.5).
To avoid the L5 nerve root, which drapes across the anterior
sacrum just medial to the sacroiliac joint, the guide pin should
be distal to the ICD. e pin should be parallel to the S1
endplate and aim from posterior to anterior on the lateral
view (Fig. 24.6). Sequential drilling, broaching, measuring,
and ultimately placing the implant are then carried out. Care
should be taken to avoid migration of the guide pin. A parallel
drill guide is then used to facilitate placement of additional
caudal implants, in similar fashion, ensuring that each ends
lateral to the sacral foramina (Figs. 24.7 and 24.8).
Summary
SIJ pathology is a common cause of low back pain and
oen presents in the setting of degenerative lumbar disease.
Accurate diagnosis seems limited by lack of interest in the
FIG. 24.5 On this inlet view, the guide pin is aimed from slightly posterior
to anterior with care being taken not to violate the sacral canal or exit the
front of the sacrum.
FIG. 24.4 In this outlet view, the guide pin is located between the S1
foramen and superior endplate of the sacrum and is parallel to the superior
endplate of S1.
FIG. 24.6 Sacral lateral view demonstrating guide pin caudal to iliac
cortical density (arrowheads).
Chapter 24 Outcomes of Nonsurgical and Surgical Treatment of Chronic Sacroiliac Joint Pain 411
FIG. 24.7 Postoperative inlet view.
FIG. 24.8 Postoperative anteroposterior view.
condition as well as the perceived unreliability of diagnosis.
e fact that high-quality randomized trials have shown that
patients with this condition can be diagnosed and treated with
high levels of ecacy using multiple endpoint types argues
against diagnostic unreliability. Provocative examination of
the SIJ and positive responses to image-guided injections are
necessary to conrm the SIJ as the pain source. Once SIJ etiology is established, multiple modes of treatment exist. While
evidence for nonsurgical treatment is limited, conservative
management with physical therapy and/or injections may be
eective for many patients. For those who remain symptomatic, MIS SIJF is an eective option in reducing pain and
disability and improving quality of life. Currently, strong
literature support is available only for porous triangular titanium implants. e clinical utility of other devices available
for MIS SIJF, which have dierent designs, placement, and
fusion strategies, is less well understood and the applicability
of evidence from published randomized trials of triangular
titanium implants to these other devices is unclear. Procedure
success requires careful attention to technical and anatomic
factors, including sacral bony and neurovascular anatomy.
e likelihood of positive outcomes is increased with careful
patient selection and accurate device placement fully across
the SIJ.
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