The document discusses the sacroiliac joint (SIJ), including its anatomy, biomechanics, evaluation, and treatment options for SIJ pain. Key points include: - The SIJ is a synovial joint between the sacrum and ilium bones that allows limited motion. It is innervated by lumbar and sacral nerve roots and plays a role in stress relief and force transmission. - Evaluation of SIJ pain is challenging due to its anatomy. History, physical exam maneuvers like Patrick's test, and image-guided injections are used to diagnose SIJ pain. - Treatment options for SIJ pain include conservative care, injections, denervation, and fusion surgery. Per

1. THE SACROILIAC JOINT:
To fuse or not to fuse
Azam Basheer MD
Henry Ford Neurosurgery
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2. Disclosures
None
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3. 60 y/o F with LBP and neurogenic claudications
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4. L3-5 lumbar lami and fusion. Pain
alleviated
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5. 1 year later, she presents with left lower back pain radiating
to her groin with point tendernesss over the SI joint
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6. - Diagnosed with left SI joint pain
- Sent to the pain clinic for SI joint injection
which relieves the pain for 3 months and
then returns again with the same
symptoms.
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7. Anatomy
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8. AnatomyAnatomy
• Bony articulationBony articulation
joint between thejoint between the
ilium and theilium and the
sacrumsacrum
• Least understoodLeast understood
jointjoint
• Sacrum is set
obliquely between
ilia
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9. Sacral Anatomy
Synovial joint
Largest axial joint in the body, with
an average surface area of
17.5 cm2
(size and shape of the human ear)
Articular surface:
1. S1-S3
2. Irregular contour
3. Major depression on S2
(receives Bonnaire’s
tubercle)
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10. LIGAMENTS
Interosseoss S/I
Ligament-
Most important in the S/I joint
Series of short, strong fibers
connecting the sacrum and ilium
deep within the joint
Anterior Articular
Capsule
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11. - Not very strong
- sometimes described as just a
thickening of the anterior joint
capsule
Anterior SI ligament
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12. Posterior SI ligaments
- stronger than the anterior
ligament
- connects the sacrum to
the PSIS
categorized into:
– Long- Prevents
hyperextension
– Short- prevents
hyperflexion
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13. Innervation
- Controversial and variable
- Murata et al in 2001:
- Dorsal innervation: from the
dorsal root ganglions of the
lower lumbar and sacral levels
(L4 to S2)
- Ventral innervation originates
from the dorsal root ganglions of
the upper lumbar, lower lumbar,
and sacral levels (L1 to S2)
- Free end nerve fibers and
mechanoreceptors in the SI
ligaments and joint
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14. BIOMECHANICS
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15. BiomechanicsBiomechanics
Amphiarthrodial Joint
Minimal movement
Many interlocking osseous structures limits gross excursion
- No muscles acting directly across it.
- Numerous studies on mobility of the sacroiliac joint
have led to a variety of different hypotheses and models
of pelvic mechanics over the years
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16. Biomechanics
The primary motions of the sacroiliac joint are nutation and counter-
nutation (flexion and extension about the x-axis)
Rotation and translation about 3 axes of approximately 2-4 degrees
Sturesson et al: flexion and extension was 2.5 ± 0.5° (1.6-3.9°), and a
mean translation of 0.7 mm (0.1 -1.6 mm) along the axes of rotation
Walheim and associates reported between 2 – 3 mm translations and
up to 3 degrees rotational movement
However, SIJ motion occurs simultaneously in multiple planes, not
linearly. Their direction of movement is irregular
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17. AGE CHANGES THINGS
ROM is limited increasingly with age
– 0-20 Smooth gliding planes
– 20-50 Interlocking irregularities
– >50 Hypomobility
– >80 Osteophytic, Immobile
Ankylosed in 76% of the population over the age of fifty
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18. Function
• Stress-relieving joint
• Two Roles:
– Longitudinal direction:
Supports L-spine
– Transverse direction:
Transmits force to the lower
extremities
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19. SIJ disease
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20. Prevalence
In the late 1980’s, many physicians "rediscovered" the SI joint as
a possible source of back pain
1977, retrospective study by Bernard and Kirkaldy-Willis found a
22.5% prevalence rate of SIJ pain in 1293 adult patients
presenting with LBP
studies have shown that the SI joint is the cause of chronic lower
back pain in 13% – 30% of patients
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21. SIJ after Fusion
Clinical studies show a range from 3.2% – 21% of
patients undergoing lumbar fusion report an
incidence of adjacent segmental disease.28
Ha et al. first reported that, based on results from
CT scans and PE, the incidence of SIJ
degeneration in the fusion group was
significantly higher than in the control group (75
vs. 38.2 %, respectively).
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22. SIJ after Fusion
Maigne and Planchon prospectively followed 61 pts from 1996 to
2002 after lumbar fusion. 45 developed unilateral persistent
pain (or with unilateral prevalence) for more than 6 months
with a sacroiliac origin.39
Onsel et al. used SPECT to follow up on 753 patients
complaining of lower back pain and found that patients who
had increased uptake of the SI joint, 35% (15 of 43) had prior
lumbar laminectomy and/or spinal fusion.
In 2005 Katz et al. used fluoroscopically guided SI joint injections
to identify the cause of lower back pain in patients following
lumbosacral arthrodesis. They followed 34 patients and found
SI joint dysfunction to be the cause of pain in 32% of the
patients.
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23. EVALUATION of the S/I JOINT
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24. EVALUATION of the S/I JOINT
Challenging
Wide range of normal anatomy
Cannot directly palpate the joint
You need:
1. Good History
2. Physical exam
3. Imaging
4. X-ray guided injections of lidocaineAzam Basheer

25. History
– Pain with ascending/descending stairs or standing from a sitting
position
– Pain with hopping or standing on the involved leg
– A positive straight leg raise at, or near, the end of range
– Slipman et al. retrospective study to determine the pain referral
patterns in 50 patients with injection-confirmed SIJ pain. The
most common referral patterns for SIJ pain were found to be
radiation into the buttock (94 %), lower lumbar region (72 %),
lower extremity (50 %), groin area (14 %), upper lumbar lesion
(6 %), and abdomen (2 %).
– The most consistent factor for identifying patients with SIJ pain
is unilateral pain (25% of pts)
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26. Exam
Palpation of bony
landmarks:
compare both sides
– PSIS
– Lumbosacral joint
– Iliac Crest
– Sacroiliac ligaments
– Iliolumbar ligaments
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27. Patrick's test
If pain is elicited on the ipsilateral +
anteriorly = hip joint disorder on
the same side
If pain is elicited on the contralateral
+ posteriorly = SIJ disorder.
The sensitivity of this test in
predicting response from SI
injection is 57% and almost
100% specific
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28. Gaenslen's test
• Patient supine and the hip
joint is maximally flexed on
one side and the opposite
hip joint is extended
• Pressure is applied to the
flexed extremity.
• Positive if pain is felt across
the SI joint.
• 68% sensitive and 35%
specific
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29. Yeoman's test
• Extending the leg and
rotating the ilium
• positive test produces pain
over the back of the SIJ
• Sensitivity 46%
• Specificity 72%
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30. Gillet test (aka the
march test)
Positive if pain elicited
on ipsilateral side of
standing leg
sensitivity 12%
specificity 97%
Gillet test
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31. PPV
Slipman et al. reported a PPV of 60 % in
diagnosing SIJ pain in patients using a
positive response to three SIJ provocation
tests.
Broadhurst and Bond reported a sensitivity
of 77–87 % for three positive SIJ
provocation tests.
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32. Imaging
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33. Not very helpful
No consensus in the literature as to the
recommended radiographic view or series to
evaluate the SIJ
24.5 % of asymptomatic patients >50 years of age
have an abnormal SIJ on plain radiographs
Elgafy et al. found that abnormal CT findings, such
as sclerosis, erosion, and narrowing had a
sensitivity of 58 % and a specificity of 69 % for
determining which patients would experience
pain relief following injection of an anesthetic
into the SIJ Azam Basheer

34. Vacuum Joint
Sherman et al, October 2011 “Sacroiliac
joint vacuum phenomenon—
underreported finding” Johns Hopkins
University
- 17% of 223 patients with Vacuum
SIJ
- 85% of the phenomena were
present bilaterally
- Higher incidents of SI joint pain
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35. Treatment
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36. SIJ Injection
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37. SIJ Injection Studies
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38. SIJ Denervation
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39. Azam Basheer

40. SI Denervation studies cont.
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41. SI Denervation studies cont.
• The majority of subjects report satisfaction after treatment
• All of the denervation studies have short follow-up periods,
raising the question of duration of effect given that many
reported studies of lumbar facet joint denervation show loss of
efficacy after about 2 years.
• There is a clear need for more properly constructed
comparative studies to establish whether chronic sacroiliac
joint pain can be better managed with invasive pain relieving
techniques than conventional conservative therapies.
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42. SI Fusion
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43. SI Fusion
First pioneered by Smith-Peterson 1921
Currently transitioning from open to percutaneous
techniques
Data is limited to case series
The majority of fusion studies reported patient satisfaction
as an outcome
The mean rate of patient satisfaction in fusion studies was
57.6% (range, 18%–100%)
The pooled infection rate among fusion studies was 5.3%
Fusion studies reported nonunion, pseudarthrosis and
painful hardware as complicationsAzam Basheer

44. SI fusion Studies
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45. Azam Basheer

46. Azam Basheer

47. Open techniques
The incidence of significant complications
after open SIJ fusion has been reported to
be between 6 and 25 %
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48. Posterolateral approach
SMITH-PETERSEN
1921 & 1926
‘‘Uniformly successful’’ ‘‘Complete Recovery’’ 6/13,
‘‘Partial Recovery’’ 3/13, ‘‘Failure’’ 4/13
GAENSLEN 1927
‘‘Firm fusion’’ in all, ‘‘Very good’’ 3/9, ‘‘Good’’
4/9, RTW 6/9
BUCHOWSKI 2005
20 patients
85% ‘‘Solid fusion’’ in one-year,
20% ‘‘major complications’’( infection in 2 cases
leading to nonunion),
15% required reoperation
GIANNIKAS 2004
1/5 ‘‘fusion’’ with CT confirmation
4/5: 10/10 on VAS (complete relief)
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49. Posterior Approach
permanent weakness or pain by injury to the
insertions of the long spinal extensors
WISE-DALL 2008
100% ‘‘fusion’’ at 6 mo (CT confirmation)
‘‘Satisfactory results’’ in 4/4 pts
WAISBROD 1987
pain <50%, off narcotics 11/22,
11/22 ‘‘unsatisfactory’’
MITCHELL 1938
‘‘Complete relief’’ 8/15,
‘‘Partial relief’’ 3/15, ‘‘No
relief’’ 2/15
KEATING 1993
26 pts.
VAS: avg. 6 preoperatively,
decreased to 3
postoperatively
BELANGER-DALL 2001
100% ‘‘fusion’’ at 6 months (CT confirmation)
‘‘Satisfactory results’’ in 4/4 pts Azam Basheer

50. Bilateral intra-articular and extra-
articular Approach
SCHÜTZ & GROB 2006
-17 pts
- 7 nonunion (9/17 CT proven)
- 65% required reoperation
- 3/17 improved pain longterm
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51. Anterior Approach
L5 nerve root & Ext.
illiac art.
RAND 1985
GUNER 1998
Endoscopic
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52. Percutaneous Approach
KHURANA 2009
100 ‘‘fusion’’ (CT confirmation)
Majeed score: improved from 37
to 79
Good or excellent results were reported for 87 % of pts
REILEY 2010
75 pts
92% ‘‘fusion’’ (CT confirmation)
VAS: improvement in several areas and in total score
(P<0.0001).
RTW 28/41 work candidates.
43% off all narcotics
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53. Perc. Approach cont.
Rudolf et al 2012 (journal of orthopedics) “Sacroiliac
Joint Arthrodesis-MIS Technique with Titanium Implants:
Report of the First 50 Patients and Outcomes”
- retrospective study 40 months
- 82% A clinically significant improvement (>2 point
change from baseline) was observed in 7 out of 9
domains of daily living
- >80% of patients would have the same surgery again
- Low complication rate (1 pt deep-soft tissue wound
infection. 2 pts experienced a large buttock
hematoma)
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54. MIS technique
1. +/- Adequate bowel cleaning
pre-operatively
2. Patients are positioned prone
on a radiolucent operating
table
3. lateral view is taken to identify
the starting point for the guide
wire.
4. An incision of approximately
1.5 cm is used and a guide
wire is introduced into the
center of the triangular portion
of the sacroiliac join
5. The gluteal fascia is penetrated
bluntly and the muscle is split
longitudinally to gain access to
the outer table of the ilium
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55. 6. The inlet view is used to guide the wire in the anteroposterior (AP)
plane
The aim is to place the guide wire between the superior and inferior end-
plates of the first sacral vertebra.
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56. 7. outlet view gives a coronal view of the guide wire
The aim is to place the guide wire between the superior and inferior
end-plates of the S1 vertebra.
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57. 8. Once the guide wire is in a satisfactory position, a 10 mm hollow modular
anchorage screw is inserted over it.
Cannulated screw is packed with a bone substitute (BMP, DBX...)
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58. Azam Basheer

59. Post op
Placed in hip-spica for about 4-6
weeks
Fully weight-bearing at 6 weeks
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60. Mean visual analog scale or numeric rating scale improvements after fusion
(blue) or denervation (grey) among all studies measuring these outcomes
SI Fusion vs. Denervation
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61. Summary
Positive provocative maneuvers combined with 75% pain
relief after image guided SI joint injection is a reliable
method for diagnosing the SI joint as the pain generator
A positive response to low-volume anesthetic injection into
the sacroiliac joint is required before considering
surgery.
Patients should have failed at least 6 months of
conservative treatment (physical therapy, nonsteroidal
anti-inflammatory drugs [NSAIDs], exercise, and
therapeutic injections) before considering surgical fusion
The open fusion studies reported poorer results and higher
complication rates than the percutaneous studies.
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