NASS and AAOS are deliberately putting their surgeons at Risk! Why?


Becker’s Spine Review for orthopedic spine surgery stated last year that up to 50,000 sacroiliac joint (SIJ) fusions will be performed annually in America by 2020.  That is just over a dozen months away.  Currently thousands of patients with chronic SIJ pain are having these fusion surgeries each year and, by the most recent count, there are now 24 companies (10 years ago there was 1) manufacturing the devices used in these procedures.  The average cost for these devices for one SIJ fusion is $10,000.  Although there exists an average 75% success rate long-term for patients having these surgeries, complications and adverse outcomes can and do occur.  After reviewing recently published follow-up studies (most all paid for by industry) and scrutinizing government data on the complications for SIJ fusions as they are currently performed (those actually reported, which could be <10% of the real number) there is at least a 1-17% chance (very conservative estimate) for having a significant adverse occurrence.  Being very specific for the most commonly performed SIJ fusion surgeries in the U.S., these include, but are not limited to, nerve injuries with transient or permanent paralysis, hemorrhage of major arteries leading to significant morbidities or even death, injuries to the bowel and bladder, fractures of the sacrum and pelvic bones, and others.  Many of these adverse occurrences do require further corrective surgeries and result in failure of the SIJ fusion to accomplish its goals such as relieving chronic pain.

Given the above how are our esteemed and revered national and international spine and orthopedic teaching societies such as the North American Spine Society (NASS) and the Academy of Orthopedic Surgeons (AAOS) involved in creating a significant risk for the surgeons in their membership?  The risks come, not from their involvement or any action they are taking concerning SIJ fusion surgeries, but as a result of their total non-involvement in the issue at all.  It must be that, if they are to be given the benefit of the doubt, they just don’t understand the situation.

They must not understand that these thousands of surgeons under their wings, who are performing these thousands of SIJ fusions in America each year, have not been taught anything about surgery for the chronically painful SIJ in medical school, surgical residency programs or spine fellowships.  They must not understand that these surgeons have not been taught how to diagnose a painful SIJ as part of their patient’s initial low back examination.  They appear not to understand that up to 22%, by conservative measures, of all new low back pain has the SIJ as either the primary pain generator or at least one of them. They must not understand that their surgeons have not been taught how to treat chronic SIJ pain conservatively or how to properly select the right patient for a surgery if that fails. They either don’t understand, or ignore the fact, that industry is and has been the primary educator for all these thousands of surgeons on how to perform these surgeries.  Of course, they must also not understand that each company has a different “play book” that gets used to educate these surgeons with the primary goal of increasing the profit margin for their company.  They don’t seem to appreciate that this represents a tremendous conflict of interest on the part of industry, and that this can have negative effects on patients that do include adverse outcomes and physical harm.

They don’t seem to understand that their silence on the matter only emboldens industry to teach surgeons whatever they want when it comes to selecting  proper surgical patients, determining  SIJ fusion surgeries needed, and teaching surgeons how to perform them.  They also don’t seem to care about following these patients up for the purposes of evaluating overall outcomes for these surgeries, all which have to do with the care and safety of each patient.  They don’t understand that their silence on this matter causes the American Board of Examiners to provide no questions to surgeons on surgeries for the chronically painful SIJs to include the intricate anatomy surrounding these joints, selecting the right patients for the most appropriate SIJ fusion procedures, avoiding and treating the complications which do occur with these surgeries, and the appropriate rehabilitation programs after these surgeries are performed. This results in surgeons not being able to either have or prove proficiency in caring for these tens of thousands of chronic SIJ pain patients.

What both NASS and the AAOS could do to decrease the deliberate risk they are causing for the surgeons under their guidance are the following:


  1. Provide instructional courses for surgeons on how to properly diagnose SIJ pain generators at the time of a patient’s initial examination, order appropriate conservative treatments for these patients, select appropriate patients for surgery, choose the best surgery for the associated SIJ pathology present, handle complications from these surgeries, and rehabilitate the SIJ fusion patient to achieve the best functional result.
  2. Encourage scientific research into the best surgeries and fusion methods to treat these patients based on their unique anatomy and unique pathology.
  3. Remove surgeons from their administrative and educational duties within NASS and the AAOS who have a vested interest in companies manufacturing devices for SIJ fusion surgeries.
  4. Encourage and assist the American Board of Examiners to write questions to test a surgeon’s proficiency in dealing with all aspects of the SIJ and surgery for it.


It is time for NASS and the AAOS to step up to the plate and remove thousands of their surgeons from the unnecessary risk of not being taught to be proficient when treating the chronic SIJ pain patient surgically!  It took the legal system to wake everyone up concerning the pedicle screw crisis in the early 90s (many similarities with what is currently happening with the SIJ). Let’s hope that our esteemed educational organizations will act now to avoid that from happening again.


If you find this article concerning, please share it with those individuals you think can make a difference.  I have learned that starting at the top down is futile when it comes to all these issues and how they affect patients.  It is time for a grassroots effort to protect both patients and surgeons when it comes to caring for chronic SIJ pain. (Dall’s SIJ BLOG)

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