Elsevier

The Spine Journal

Volume 5, Issue 5, September–October 2005, Pages 520-528
The Spine Journal

Clinical Studies
Functional and radiographic outcome of sacroiliac arthrodesis for the disorders of the sacroiliac joint

https://doi.org/10.1016/j.spinee.2005.02.022Get rights and content

Abstract

Background context

The sacroiliac joint is known to be a possible cause of chronic low back pain, but the diagnosis and treatment of disorders of the sacroiliac joint have been difficult and controversial.

Purpose

To describe the outcome of sacroiliac joint arthrodesis for sacroiliac joint disorders, with the hypothesis that sacroiliac arthrodesis leads to improved postoperative function.

Study design/setting

Consecutive case series performed in an academic medical institution.

Patient sample

The patient population consisted of 20 patients undergoing sacroiliac joint arthrodesis between December 1994 and December 2001. Patients undergoing concomitant procedures at the time of sacroiliac joint arthrodesis were excluded. The 3 men and 17 women in the study group had an average age of 45.1 years (range 21.8–66.4 years), a mean duration of symptoms of 2.6 years (range 0.5–8.0 years), and a mean follow-up period of 5.8 years (range 2.0–9.0 years).

Outcome measures

Outcome measures included general health and function, clinical evaluation, and radiographic assessment.

Methods

For all 20 patients, nonoperative treatment had failed, and for all, the diagnosis was confirmed by pain relief with intraarticular sacroiliac joint injections under fluoroscopic guidance. Sacroiliac joint arthrodesis (via a modified Smith-Petersen technique) was recommended only when a positive response to the injection was noted, and patients had recurrence of symptoms after the initial positive response. Preoperative and postoperative general health and function were assessed via the 36-item Short-Form (SF-36) Health Survey and American Academy of Orthopaedic Surgeons (AAOS) Modems Instrument, which were collected prospectively. Medical records and plain radiographs were reviewed retrospectively to determine the clinical and radiographic outcome.

Results

Multiple etiologies of sacroiliac symptoms were observed: sacroiliac joint dysfunction (13 patients), osteoarthritis (5 patients), and spondyloarthropathy and sacroiliac joint instability (1 each). Seventeen patients (85%) had solid fusion. Fifteen patients (75%) completed preoperative and postoperative SF-36 forms. Significant (p≤.05) improvement occurred in the following categories: physical functioning, role physical, bodily pain, vitality, social functioning, role emotional, and neurogenic and pain indices. Improvement (not statistically significant) was also noted in general and mental health.

Conclusions

For carefully selected patients, sacroiliac arthrodesis appears to be a safe, well-tolerated, and successful procedure, leading to significant improvement in functional outcome and a high fusion rate. To the authors' knowledge, the current report is the largest series to document the functional and radiographic outcome of sacroiliac joint arthrodesis.

Introduction

For quite some time, the sacroiliac joint has been known to be a source of pain. According to Lynch [1], interest in the sacroiliac joint began with the observation by Hippocrates that a woman's pelvis separated during labor and remained so after birth. In 1905, Goldthwait and Osgood [2] reported that the sacroiliac joint can be a source of unexplained low back and leg pain; more recently, other authors [3], [4], [5], [6], [7] have reported similar findings. In fact, the sacroiliac joint has been implicated as a cause of chronic low back pain in at least 13% to 30% of patients seen in a specialty spine care center [8], [9], [10].

Many causes of sacroiliac joint pain have been described. Perhaps the most common, but also the most controversial, is sacroiliac joint dysfunction [11], [12], which is thought to be the primary source of low back pain in 22.5% of patients with low back pain [3]. In patients with previous spine surgery, sacroiliac joint dysfunction can be an even more important source of pain and is one of the potential causes of failed back surgery syndrome [8], [13], [14]. Inflammatory arthritides can also affect the sacroiliac joint, leading to sacroiliitis and in many cases ankylosis of the sacroiliac joint [4], [15], [16], [17]. Sacroiliac joint osteoarthritis and posttraumatic arthritis can also lead to sacroiliac pain [4], [18], [19], [20], [21], [22], [23]. Pain in the sacroiliac joint can also result from infection [18], [19], [24], [25], [26] and other less common disorders of the sacroiliac joint [1], [2], [4], [27], [28], [29]. Because pain originating from the sacroiliac joint may be difficult to diagnose and may mimic pain referred from other sources [4], [8], [9], [30], [31], [32], [33], physical examination is not particularly useful [8], [9], [11], [34], [35]. Plain radiographs and other noninvasive radiology tests can be used as adjunctive diagnostics for sacroiliac joint disorders, but none have proved both sensitive and specific enough to be reliable for diagnosis when used alone [4], [8], [12], [33]. With the advent of fluoroscopy, intraarticular sacroiliac joint injections have become keys in diagnosing disorders of the sacroiliac joint [8], [10], [12], [31], [32], [34], [36], [37], [38].

The mainstay of therapy for disorders of the sacroiliac joint has been nonoperative treatment, including rest, nonsteroidal anti-inflammatory agents, and physical therapy [4]. When these modalities fail, some have recommended sacroiliac joint arthrodesis [4], [7], [16], [18], [19], [20], [22], [23], [24], [25], [33], [39], [40]. Although sacroiliac joint arthrodesis has been described as a treatment for sacroiliac joint osteoarthritis and posttraumatic arthritis [18], [19], [20], [22], [23], sacroiliitis secondary to spondyloarthropathy [16], and infection of the sacroiliac joint recalcitrant to antibiotic treatment [18], [19], [24], [26], the reports have suffered from small numbers of patients and lack of information on functional outcome. For this reason, the current authors elected to conduct a study to examine the surgical, radiographic, and functional outcome of patients undergoing sacroiliac joint arthrodesis for disorders of the sacroiliac joint, with the hypothesis that in carefully selected patients, the procedure is safe, is well-tolerated, has a high fusion rate, and leads to significant improvement in functional outcome.

Section snippets

Patient selection

The current authors reviewed the records of one multidisciplinary tertiary care university hospital to identify consecutive patients from December 1994 to December 2001 with disorders of the sacroiliac joint who were treated surgically and who had a minimum of 24 months of follow-up. Patients who had concomitant other procedures at the time of sacroiliac arthrodesis were excluded from the study. Twenty patients who satisfied the criteria were found and recruited for the study.

The medical

Clinical evaluation

On presentation, chief complaints were low back pain (10/20 patients, 50%), buttock pain (5/20 patients, 25%), pain localized to the sacroiliac joint (4/20 patients, 20%), hip pain (2/20 patients, 10%), and leg pain (1/20 patients, 5%). Some patients had more than one complaint. Clinical evalution revealed that no single physical examination finding was able to diagnose predictably a disorder of the sacroiliac joint. Although some patients had more than one positive physical examination

Discussion

Interest in the sacroiliac joint began many centuries ago when Hippocrates observed that a woman's pelvis separated during labor and remained so after birth [1]. Early studies since that time have focused mainly on the potential motion of the joint, changes during and after pregnancy, and changes during development and aging. Starting in the early twentieth century, however, investigators began to notice that the sacroiliac joint could also be a source of pain. Goldthwait and Osgood [2] first

Conclusions

Disorders of the sacroiliac joint are challenging to diagnose and treat. Patients who do not respond to nonoperative measures can be successfully treated with sacroiliac joint arthrodesis, which can be expected to yield a high fusion rate with few complications and lead to improvement in functional outcome. Success of surgery, however, depends on careful patient selection.

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