SACROILIAC JOINT DYSFUNCTIONADJACENT SEGMENT DISORDERS

LEONARD RUDOLF,MDLEBANON, NEW HAMPSHIRE

DISCLOSURES

• CONSULTANT: SI-BONE CO.• STOCKHOLDER: SI-BONE CO.

Sacroiliac Joint Syndromes• SI Joint Dysfunction

– “a state of relative hypomobility within a portion of the joint’s ROM with subsequent altered structural (positional) relationships between the sacrum and ilium.”

– Dreyfuss P. Spine 1994.

• SI Joint Pain– Pain arising from the SI joint

– Laslett M. Aust J Physiother 2006.

• Sacroiliac Syndrome– Pain arising from the SI joint and/or its surrounding

ligaments.– Berthelot JM. Joint Bone Spine 2006.

INCIDENCE

• SIJD in LB Pathology patients– 2% (Manchikanti L et al. Pain Physician 2001)

– 18.5% (Maigne JY et al. Spine 1996)

– 27% (Irwin RW et al. Am J Phys Med Rehabil 2007)

– 13-30% (Schwarzer AC. Spine 1995)

Polly/Sembrano Study 200 Pts

• 82% have spine pathology• Only 65% have spine only

pathology• 15% have SI jt pathology• 25% have SI and/or hip

pathology• 12% have hip joint

pathology• 10% undefined pain

source

82%

15%

12%

25% XX

65%

10% ?

SIJ DYSFUNCTION

MULTIPLE CAUSES

• INFLAMMATORY• OVERUSE• TRAUMA• PREGNANCY• SURGICAL DISRUPTION• MECHANICAL:ADJACENT SEGMENT DISORDER

SIJ DYSFUNCTION CLASSIFICATION

TYPE I: PRIMARY DEGENERATIVEOVERUSEGESTATIONALIDIOPATHIC

TYPE II: INFLAMMATORY

TYPE III:TRAUMATIC

TYPE IV:ADJACENT SEGMENT DISORDER

Adjacent Segment Disorder

• Evolving Concepts• Hip-Spine Codependence Established• Lumbar Segments Traditionally Associated

with Spinal Fusion• Studies Show SIJ as Legitimate Site of ASD

Literature Review

Longterm Effects of Spinal Fusion on SIJ Accelerated Degeneration› Frymoyer Clin Ortho 1978

Violation of SIJ from ICG› Ebraheim Spine 2000

Adjacent Segment Degeneration Following Spine Fusion Review of Literature› Levin Bulletin NYU HJD 2007

Fusion at Lumbar Spine Increased Motion and Stress at SIJ› Ianov Spine 2009

Literature Review

34 PTS with Gluteal Pain after Lumbar Fusion› 34 % Very Likely SIJ Pain Generator› 29 % Probably SIJ Pain Generator

Katz Journal Spine Disorders 2003 CT Evalutation of SIJ After Instrumented Lumbar

Fusion› 75 % SIJ Degeneration at 5 YRS in Fusion Group› 38 % Control Group

HA Spine 2008 LBP After Technically Successful Lumbar Fusion

› SIJ Block 35 % + Maigne Eur Spine J 2005

LS FUSION AND THR PRIOR TO SIJF

LS FUSION WITH IILIAC CREST GRAFT

L4-S1 FUSION WITH SIJ CONFIRMED PG

DIAGNOSTIC CHALLENGE

• CHRONIC LOW BACK PAIN ASSESSMENT

PROCESS OF INCLUSION/EXCLUSION OF ALL POTENTIAL PAIN GENERATORS IN THE LUMBAR-SIJ-HIP AXIS

Paradigm Shift

• Lumbar-SIJ-Hip Axis• Adjacent Segment Disorder• Primary and Secondary Pain Generators

DIAGNOSIS

• SIJ DYSFUNCTION IS DIAGNOSIS OF EXCLUSION AND INCLUSION

• LUMBAR SPINE-SIJ-HIP AXIS • ASSESSMENT OF IMAGING STUDIES• SINGLE VS MULTIPLE PAIN GENERATORS• INDEX OF SUSPICION FOR SIJ DYSFUNCTION

SIJ Evaluation Overview

• Acknowledge SIJ as Potential Pain Generator• Recognize Elements of History Reflective of SIJ

Dysfunction• Perform Physical Examination:

– Palpation– Provocative Tests

• Review Imaging Studies• Index of Suspicion

– Low – Assess Alternative Pain Generators in Spine-Hip-SIJ Axis– High– H+P Suggestive

• Multiple + Provocation Tests• Other Pain Generators Secondary or AbsentIMAGE GUIDED CONFIRMATORY INJECTION

SIJ EVALUATION

• PAIN: KEY ELEMENT IN PRESENTATION

• PATIENT FUNCTIONAL CHANGES VARIABLE

• PHYSICAL EXAM FINDINGS NON-SPECIFIC

SI JOINT INJECTION

• GOLD STANDARD to confirm SacroIliac joint as Pain Generator

• IMAGE GUIDED: Fluoroscopic or CT

• Blind injection not reliable

GOLD STANDARD

• IMAGE GUIDED SIJ INJECTION BEST METHOD TO ASSESS SIJ AS PAIN GENERATOR

• MAIGNE• SLIPMAN

• RESPONSE TO INJECTION CRITICAL FOR SURGICAL INDICATION

• BUCHOWSKI

INJECTION RESPONSE• > 75% PAIN IMPROVEMENT: positive test/SIJ

considered Pain Generator

• NO RESPONSE: negative test/SIJ not a PG

• 50-75% PAIN IMPROVEMENT: EQUIVICAL TEST -repeat to confirm SIJ as PG -consider SIJ as SECONDARY pain generator

• Residual Pain: investigate additional pain generators: LS Spine-hip

Treatment Paradigm Shift

• Lumbar-SIJ-Hip Axis

• Adjacent Segment Disorder

• Primary and Secondary Pain Generators

SIJ Evaluation in Context of Lumbar Surgery with Residual Pain

1. Index Procedure Related• Is it “Failed?”

– Surgery Well Performed / No Complications / Well Healed on Examination and Imaging

• Review Pre-Operative Diagnosis: Correct vs Incorrect• Assess Procedure Indication / Choice: Correct vs Incorrect• Assess Procedure Outcome: Healed vs Complication• (50 % of LS Fusions for DDD Do Not Provide Pain Relief)

2. Assess Axis For Multiple Pain Generators• Lumbar: Additional vs Residual Pathology• Hip• SIJ: ?primary PG vs ADJACENT SEGMENT DISORDER• Diagnostic testing results

3. Treatment of Confirmed Pain Generators

5-S1 FUSION/4-5 FUSION RESIDUAL PAIN

SIJ CONFIRMED PG

R SIJF WITH PAIN RELIEF

SIJ Evaluation- New Onset LBP after Lumbar/Hip Surgery

1. Assess Index Procedure: Well Healed vs Complication

2. Assess Adjacent Segment DegenerationLumbar Spine-SIJ-Hip Axis

3. Treatment of Confirmed Pain Generators

2 Yrs s/p L4-S1 FUSION

SIJ CONFIRMED AS POST FUSION PG

RIGHT SIJ FUSION WITH PAIN RESOLVED

SACROILIAC JOINT FUSION

Fusion Candidate

• Longstanding SIJ Pain• De Novo Pain Secondary to ASD• SIJ Considered Primary Pain Generator, or

Primary PG Treated, with Ongoing SIJ Pain• > 75 % Unequivocal Response to Diagnostic

Injection• Complaint with Partial-Weightbearing for 3-4

Weeks

SACROILIAC JOINT FUSION

• Purpose– Pain Relief Through Fixation of Joint

• Short –Term Goal– Initial SIJ Stabilization from Fixation

• Long-Term Goal– Implant-bone Ingrowth for Permanent Stabilization– Facilitate Boney Arthrodesis

SACROILIAC JOINT FUSION

• Long-Term Goal– Implant-bone Ingrowth for Permanent

Stabilization– Facilitate Boney Arthrodesis

SECOND GENERATION ARTHRODESIS Reiley

TECHNIQUE

iFuse™ Implants: › 7mm Triangular / Titanium Sintered for Ingrowth› 3 Implants Transversely Across SIJ

Prone Position General Anesthesia Double C-Arm Fluoroscopy AP/Lateral

Percutaneous Placement / Lateral 3 cm Incision

RIGHT SIJ FUSION

LEFT SIJ FUSION

HOSPITAL STAY

• SAME DAY SURGERY

• SDS WITH OVERNIGHT OBSERVATION

• CT SCAN POST-OP PRIOR TO DISCHARGE

POST OPERATIVE COURSE• 3-4 WEEKS PARTIAL WB: CRUTCHES VS WALKER• 2 WEEKS ADVANCE TO FULL WB• AT 8 WEEKS ROUTINE ACTIVITIES

• XRAYS AT 3-6-12 MONTHS

• CT: 6 & 12 MONTHS TO ASSESS SECOND GENERATION FUSION

IMAGING OUTCOMESRADIOGRAPHS

• X-RAYS DONE AT 3-6-12 MONTHS

• IMPLANT POSTION UNCHANGED

• EDGE-RADIOLUCENCY NON PROGRESSIVE

• BONE INGOWTH DIFFICULT TO ASSESS ON XRAY

3 MONTH POST OP AP

1 YEAR POST OP AP

3 MONTH POST OP AP

12 MONTH POST OP AP

IMAGING OUTCOMES CT

• CT AT 6 AND 12 MONTHS POST OP• AXIAL-SAGITAL-CORONAL IMAGES

• BONE IN-GROWTH SEEN BEST ON SAGITALS

• TRIANGULAR IMPLANT-EDGE HALOS EXPLAIN RADIOGRAPH LUCENCY AS ARTIFACT

• WALL-BONE DENSITY REFLECT INGOWTH

1 YEAR CT SAGITAL IMAGE

1 YEAR SAGITAL CT

SIJ DYSFUNCTION ADJACENT SEGMENT DISORDERS

PERSONAL EXPERIENCE

54 Consecutive SIJ Fusion Candidates

*23 with prior Lumbar Fusion- 43%

*10 with coexistent Spondylosis (no prior surgery) *1 with prior THR- 20% with multiple PG

44% with prior surgery- SIJ as PG in the context of Adjacent Segment Disorder

DEMOGRAPHICS

• 54 PTS 36 F 18 M

• RIGHT-38 LEFT-15 BILATERAL-8 (61 JOINTS) THREE PTS WITH SECOND SIDE

• AGE RANGE 24 TO 85 AVERAGE 53.5

FOLLOW UP

• 3 YR---2 PTS• 2 YR---16 PTS• 1 YR---14 PTS• 6 MO--10 PTS

• NO PT WITH OPPOSITE SIDE DEGENERATION• NO REGRESSION IN PAIN SCORE

IMPROVEMENT

SIJ FUSION OUTCOMES

• >80% GOOD TO EXCELLENT OUTCOMES

• STRONG CORRELLATION BETWEEN DIAGNOSTIC INJECTION AND SURGICAL IMPROVEMENT

S/P LS FUSION WITH SIJ PAIN

INTRA-OP AP

INTRA-OP LATERAL

POST OP CORONAL CT

POST OP SAGGITAL CT

INTRA OP AP

INTRA OP LATERAL

POST OP AXIAL CT

POST OP CORONAL CT

PRIOR ILIAC CREST GRAFT

PRIOR ILIAC CREST GRAFT

CONTROVERSIES

• Is Implant/Bone Ingrowth sufficient for longterm Arthrodesis

• Is a single Diagnostic Injection routinely sufficient to indicate for surgery

• Is Fusion a reasonable treatment without prior non-operative management– Exceptions:• Post-traumatic Instability• SIJ pain 2nd to Adjacent Segment Disorder

CONCLUSIONS

• SIJ DYSFUNCTION IS A FREQUENT FINDING WITH PREVIOUS LUMBAR SURGERY

• SIJ FUSION CAN SUCCESSFULLY TREAT SIJ DYSFUNCTION FROM ADJACENT SEGMENT DISORDER OR DE- NOVO ONSET

• FUSION IMPLANTS CAN BE INDICATED TO TREAT SIJ DYSFUNCTION