A New Paradigm for Sacroiliac Joint Surgery
The sacroiliac joint is no longer an island, it is part of the spine! This has definite ramifications for those having and treating low back pain. Despite the fact that the first published paper in a peer reviewed journal on surgery for the sacroiliac joint occurred in the 1920s, this joint has been and continues to be considered in isolation existing between the lowest joint in the lumbar spine and the hip joint in the pelvis. In a letter to the editor entitled “Someone Needs to Claim It” ( Spine J 2009 Feb; 9 (2): 190-1), I made a plea to surgical societies that one of them should claim this joint. By doing so it would open up dialogue and research avenues desperately needed for both research and treatment for those patients suffering with a painful dysfunctional sacroiliac joint. It has been estimated for decades that perhaps one out of every four patients presenting with low back pain have some or all of that pain coming from the sacroiliac joint. Despite the knowledge base available in 2009 no societies, to include the North American Spine Society (NASS) and the American Association of Orthopedic Surgeons (AAOS), have pulled this “island joint” into its organization. Further research and publications by interested and devoted surgeons have continued, despite a lack of interest by the now very political surgical organizations, and as a result the status of the sacroiliac joint as an isolated island of its own is undergoing an upgrade.
Three major events have occurred in the past two years that have placed the sacroiliac joint on a new level of understanding that affect caregivers for patients with a painful dysfunctional sacroiliac joint, providers in industry who make the products necessary to adequately treat the sacroiliac joint, and all patients, present and future, who have a serious problem with chronic low back pain. The first event was the publishing of the first textbook on surgical treatment for the sacroiliac joint.
In this book there is a chapter devoted to an algorithm designed to assist the clinician in properly making a diagnosis for the painful sacroiliac joint, while also considering the possible pathology that might be present in the spine as well. There are instances in the book where both the sacroiliac joint and the spine were operated on at the same setting with satisfactory long-term outcomes.
The second major event was the publication of a paper in the an orthopedic journal in Belgium, “Outcomes of bilateral sacroiliac joint fusions and the importance of understanding potential co-existing lumbosacral pathology that might also require surgical treatment” (Acta Orthop Belg. 2015 Jun; 81 (2): 233-239). The main message of this peer reviewed paper is that surgical pathology can and does exist in both the Sacroiliac Joints and the Spine in the same patient at the same time, and that, when properly diagnosed, both require treatment in order to have a successful outcome.
The third event was a presentation by my colleague Dr. Sonia Eden concerning the intimate relationship between the sacroiliac joint(s) and the lumbosacral spine in terms of co-existing surgical pathology at the first-ever conference dealing only with the sacroiliac joint. This conference took place in Hamburg, Germany under the guidance of Michael Dierks, CEO of SIMEG, an organization devoted totally to the sacroiliac joint, in collaboration with Dr. Volker Fuchs, orthopedic spine surgeon, also from Germany. The talk given by Dr. Eden has quickly spurred interest in concurrent sacroiliac joint and lumbosacral spine surgeries that she was subsequently invited to Austria for a conference addressing that subject. It seems that the Europeans have a much better understanding of this concept than the U.S.
All the literature concerning sacroiliac joint fusions, up to the recent publication mentioned above, dealt only with the sacroiliac joint in isolation and ignored the potential concurrently lurking pathology of the lumbosacral spine. Due to the successful long-term results published when pathologies in both the sacroiliac joints and the lumbosacral spine were addressed together it is creating a new paradigm for both diagnosing and treating chronic low back pain.
For the spine surgeon this new information means that when a patient presents with chronic low back pain, both the lumbosacral spine and the sacroiliac joints must be thought to be possible pain generators until, through an appropriate workup (see Algorithm in textbook mentioned above), one or the other, or both are proven to be the origin of the pain. Once the pain generators are identified they all need to be dealt with in order for a successful outcome. To take this one step further a more comprehensive need is to get surgical societies (e.g. NASS) to understand these principles and start addressing the sacroiliac joint as the “lowest joint in the spine”, which is its rightful place.
For industry this information means that companies working with spine surgeons must start considering that it might take a combination surgery to address all of the patients disabling pathology. As it has been proven at our institution many times, It might take fusion surgery for both the spine and the sacroiliac joint(s) to obtain the best patient outcomes. This will take working with surgeons having the latest knowledge, and who are doing independent research and publishing data that reflects the sacroiliac joint as part of the spine and not just an uncharted not well understood island.
For anyone having chronic low back pain, especially if they have had one or more failed back surgeries, it is important to gain more information from knowledgeable sources (see textbook mentioned above) and seeking out the help you need. If your surgeon understands and performs only one type of sacroiliac joint fusion or they seem somewhat confused by this joint, they may not have the latest understanding of this joints intimate association with the spine. In the publication mentioned above, it is interesting that a large number of patients having successful long-term results after a concurrent lumbosacral and sacroiliac joint fusion had previous failed back surgeries, were being chronically followed and treated in pain clinics, had been in conservative treatment for several years, and had no firm diagnoses on initial presentation in our office.
The sacroiliac joint and its relationship to the lumbosacral spine is now published, and as a result poses new challenges for surgeons, clinicians, industry, and patients. Much more science based and evidence-based research and education are needed for all of us to better understand the sacroiliac joint.