Chronic sacroiliac joint pain: fusion versus denervation as treatment options

 

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ABSTRACT

Study design: Systematic review.

Objective: To compare the safety and effectiveness of fusion versus denervation for chronic sacroiliac joint pain after failed conservative management.

Summary of background: Methods of confirming the sacroiliac joint as a pain source have been extensively studied and reported in the literature. After confirmation of the origin of the pain by positive local anesthetic blocks, chronic sacroiliac joint pain is usually managed with a combination of medication, physical therapies, and injections. We have chosen to compare two alternative treatments for sacroiliac pain that was refractory to conservative therapies.

Methods: A systematic review of the English-language literature was undertaken for articles published between 1970 and June 2010. Electronic databases and reference lists of key articles were searched to identify studies evaluating fusion or denervation for chronic sacroiliac joint pain after failed conservative management. Studies involving only conservative treatment or traumatic onset of injury were excluded. Two independent reviewers assessed the level of evidence quality using the grading of recommendations assessment, develop­ment and evaluation (GRADE) system, and disagreements were resolved by consensus.

Results: We identified eleven articles (six fusion, five denervation) meeting our inclusion criteria. The majority of patients report satisfaction after both treatments. Both treatments reported mean improvements in pain and functional outcome. Rates of complications were higher among fusion studies (13.7 %) compared to denervation studies (7.3 %). Only fusion studies reported infections (5.3 %). No infections were reported among denervation patients. The evidence for all findings were very low to low; therefore, the relative efficacy or safety of one treatment over another cannot be established.

Conclusions: Sacroiliac joint fusion or denervation can reduce pain for many patients. Whether a true arthrodesis of the joint is achieved by percutaneous techniques is open to question and whether denervation of the joint gives durable pain relief is not clear. Further comparative studies of these two techniques may provide the answers.

STUDY RATIONALE AND CONTEXT The sacroiliac joint as a source of low back pain has been extensively studied and reported in the literature. Pathological conditions which can affect a sacroiliac joint include degenerative and inflammatory arthritis, posttraumatic and postpartum instability, infection and neoplastic disease. Various other conditions which might cause sacroiliac joint pain include leg-length discrepancy, hip arthritis, and lumbosacral fusions for low back pain, as well as iatrogenic violation of the joint following autologous posterior iliac crest bone graft harvest. Numerous physical tests have been described to isolate the sacroiliac joint as the source of low back pain but none have proved reliable. The most accepted test for sacroiliac pain is temporary relief of the pain after injection of local anaesthetic agents into the joint under fluoroscopic* control. Conservative treatment of chronic sacroiliac pain has consisted of analgesic and antiinflammatory medication, physical therapies and several types of injection techniques. More invasive techniques involve fusion of the joint or denervation by ablative therapy. We have chosen to focus our review on these two techniques of long-term pain relief after failure of conservative treatment. * Fluoroscopic image intensification control OBJECTIVES To compare the effectiveness and safety of fusion versus denervation for chronic sacroiliac joint pain after failed conservative management. MATERIALS AND METHODS Study design: Systematic review Sampling: Search: PubMed, Cochrane Collaboration Database, and National Guideline Clearinghouse Databases; bibliographies of key articles Dates searched: 1970–June 2010. Inclusion criteria: (1) chronic sacroiliac joint pain, (2) adults 18 years and older, (3) studies involving initial failed conservative treatment Exclusion criteria: (1) conservative treatment only, (2) unclear whether subjects had first undergone conservative treatment, (3) trauma, (4) less than five subjects per treatment, (5) less than 6-month follow-up Outcomes: patient satisfaction, pain, functional outcomes, wound infection, and complications (health related or surgery specific) Analysis: descriptive statistics pooling rates across studies Details about methods can be found in the web appendix at www.aospine.org / ebsj

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EDITORIAL STAFF PERSPECTIVE

Our reviewers were unanimously in favor of publication of this review, despite the controversial nature of a number of aspects of this condition—starting with uncertainty surrounding physical examination, continuing with diagnostic confirmation and finally treatment. The results of this systematic review point out a commonly encountered conundrum: while there seems to be some evidence suggesting a ‘positive treatment effect’ as reported by patients, closer inspection of the data at hand produces more questions than answers. In summary, the role of the sacro-iliac joint in low back pain and its management remain very much unclear to the present date and is, perhaps, somewhat overemphasized by some. Identification of pathologic entities such as presented by the authors—clear instability, severe degeneration, infection, neoplasia—remains a helpful contribution to patient care by an informed practitioner. Should surgical stabilization be chosen for a sufferer of SI-joint pain, the current state of the literature unfortunately allows little or no real insights due to unclear handling of several confounding variables (ie, previous spine fusion, osteoporosis, obesity, pelvic alignment, physical fitness levels) and inconsistent definition of desired surgical outcomes—are true fusions actually achieved in a large number of the described techniques? That said, are solid fusions actually necessary for a satisfactory outcome? Do the outcomes justify the means? Many questions, few real answers, much to do in the future.