Simplifying Sacroiliac Joint Arthrodesis Using MIS Fusion Implants
Mark A, Reiley, M.D., Fred H. Geisler, M.D., Leonard M. Rudolf, M.D., Arnold Graham-Smith, M.D., J. Jay Halki, M.D., David W. Polly, M.D., A. Nick Shamie, M.D., Michael Amaral, M.D. Abstract Presented at the World Congress of Low Back and Pelvic Pain in Los Angeles, CA (WCLBPP), Nov 2010
SIMPLIFYING SACROILIAC JOINT ARTHRODESIS USING MIS FUSION IMPLANTS
Authors: Mark A. Reiley, MD1, Fred H. Geisler, MD2, Leonard M. Rudolf3, MD, Arnold Graham-Smith, MD4, J. Jay Halki, MD5, David W. Polly, MD6, A. Nick Shamie, MD7, Michael A. Amaral, MD8
Purpose: According to Sembrano and Polly (2009), up to twenty five percent (25%) of individuals who presented with low back complaints had their sacroiliac joint (SIJ) as one of the pain generators. Despite the large number of patients with SI joint symptoms, most of the recent treatment focus in the spine has centered on the disc. In addition few if any lumbar MRI’s routinely extend below S1 to examine this joint. A minimally invasive surgical (MIS) procedure may help to address this significant unmet clinical need.
Figure 1. AP and Lateral X-rays of the Fusion Rod treatment of the SI Joint.
Relevance: In response to the increasing awareness of symptomatic SIJ pathology, an innovative, patented, intramedullary MIS implant to treat the SIJ (Figure 1) was developed. This surgical procedure requires only a minimal incision and uses a titanium implant. In this system, the implants are coated with a porous plasma spray that acts as an
interference surface to help decrease implant motion. These implants, because of their size and metallurgy, are able to produce exceedingly strong constructs. A system similar to
this has been used successfully in over 1,000 cases of dysfunctional foot joints.
Diagnostic methods: SIJ diagnoses require appropriate interpretation of a patient’s history, clinical exam, and imaging studies (Often hip and lumbar pathology coexists with SIJ pathology). Physical examination for SIJ pathology includes pain, palpable tenderness of the posterior pelvic SIJ region, minimum of 3 provocative tests, and the absence of neurologic deficits. Image-guided injection provides confirmation of SIJ pathology. If Lidocaine is injected into the SIJ and symptoms temporarily resolve, this is excellent confirmation of the diagnosis. Some physicians repeat the injection to reduce the chance
of a false positive. Concomitant abnormalities on a lumbar MRI can cloud the correct diagnosis. When findings point to SIJ, chronic, degenerative changes in the lumbar spine
or bulging discs should not override a diagnosis of SIJ pathology.
Methods: The MIS surgical procedure is performed under general in the prone position.
4.0mm or 7.0 mm triangular implants are inserted through a 2 to 3cm incision. The drills,
broaches, and implants are cannulated to allow precise placement over a guide pin. As a rule, patients are implanted with three MIS implants across the SIJ. However, implant numbers may vary based on the size of the patient. Post-operatively patients are kept non-weight bearing for 6 weeks, depending on the patient’s pain level and physician recommendation. Routine activities are allowed at 12 weeks after surgery. Radiologic studies include post-op films, and 3, 12, and 24 month X-rays. CT is recommended at 3, 12, and 24 months to document implant position and to observe bone growth across the joint.
Clinical Results: The investigators treated 52 patients included in this report. Patients were tested quantitatively for SIJ symptoms, pre-operatively, at 3, 6, 12 and 24 months (when available). Patients have been able to return to full and unrestricted activity at 3 months. Some patients exhibited evidence of SIJ fusion as early as 2 months post-op, as seen on sagittal CT view (Figure 2). Symptoms were evaluated pre-op, 3, 6, and 12 months, and showed consistent improvement from pre-op to follow-up. In response to questioning, 90% of patients indicated they would have the procedure again.
Figure 2. Sagittal CT of the pelvis shows bone crossing the SI joint 2 months after surgery.
Conclusions: SIJ dysfunction syndromes are common. Several treatments available have shown limited efficacy or moderate collateral damage. This study reinforces the need for awareness that the SIJ can produce symptoms and that referring pain physicians need to have an outlet for previously, unsatisfied SIJ patients. In some patients with residual symptoms after hip arthroplasty or lumbar spine procedures, the SIJ may be the symptom generator. With the advent of this new MIS procedure, the surgeon may now be able to successfully treat patients refractory to conservative medical therapy and offer SIJ patients new solutions.
1 Berkeley Orthopaedic Medical Group, Inc., Berkeley, California, USA
2 Department of Neurosurgery, Illinois Neuro-Spine Center, Aurora, Illinois, USA
3 Department of Orthopaedic Surgery, Alice Peck Day Health Systems, Lebanon, NH, USA
4 Department of Orthopaedic Surgery, Baptist Health of Northeast Florida – South, Jacksonville, FL, USA
5 Department of Orthopaedic Surgery, Northern Nevada Medical Center, Reno, NV, USA
6 Center for Minimally Invasive Surgery, Orthopaedic Clinic, University of Minnesota, Minneapolis, Minnesota, USA
7 Department of Orthopaedic Surgery, UCLA, Santa Monica, California, USA
8 Brain and Spine Institute, Gwinnett Medical Center, Lawrenceville, Georgia, USA
Key Words: SI joint, sacroiliac dysfunction, minimally invasive surgical, implant, symptom scales, low back pain, lumbar.
