Minimally Invasive Sacroiliac Joint Fusion: A Lateral Approach Using Triangular Titanium Implants and Navigation

• Published in: JBJS essential surgical techniques 2020-10, Vol.10 (4), p.e19.00067-e19.00067
• Main Authors: Polly, Jr, David W, Holton, Kenneth J
• Format: Article
• Language: English
• Subjects: Subspecialty Procedures
• ISSN: 2160-2204; 2160-2204
• DOI: 10.2106/JBJS.ST.19.00067

Minimally invasive sacroiliac (SI) joint fusion is indicated for low back pain from the SI joint that is due to degenerative sacroiliitis and/or sacroiliac joint disruption. This technique is safe and effective in relieving pain uncontrolled by nonoperative management . There is some controversy, but there continues to be increasing evidence of effectiveness. This procedure is performed, with the patient under general anesthesia and in the prone position, using fluoroscopy or 3-dimensional (3D) navigation such as cone-beam computed tomographic (CT) imaging. After navigation setup, a navigated probe is used to approximate the desired location of each implant and trajectory. These positions are marked on the skin, and the skin is incised. A 3 to 5-cm lateral incision is made. The gluteal fascia is bluntly dissected to the outer table of the ilium. A guide pin is passed across the SI joint and into the center of the sacrum lateral to the neural foramina, which is confirmed with imaging. This is then drilled and broached. Triangular titanium rods are placed. Typically, 3 implants are placed, 2 in S1 and 1 in S2. Multiplanar postplacement imaging of the pelvis is obtained. The wound is irrigated and closed in layers. Nonsurgical alternatives have been reported to include pharmacological therapies, such as nonsteroidal anti-inflammatory drugs, therapeutic SI joint blocks , and physical therapy, such as core stabilization, orthotics (SI belts), and radiofrequency ablation . The surgical alternative is an open anterior or posterior approach with SI joint arthrodesis. The anterior approach differs by the resection of the SI joint cartilage, the use of a plate or screws across the joint for stabilization, and the packing of bone graft to facilitate fusion . These are more morbid and have a much longer recovery. Conservative management for SI joint pain is inadequate for all patients. Having 3 of 5 positive physical examination maneuvers , having confirmatory diagnostic block(s) , and ruling out the hip or spine as the pain generator provide a success rate of >80%. These patients have early and sustained clinically important and significantly improved outcomes across varying measures compared with conservative treatment . Patients can expect to experience decreased pain, reduced disability, increased daily function, and improved quality of life soon after the procedure is performed. These patients typically have an improvement of ≥50% in the Oswestry Disability Index