Sacroiliac joint fusion (SIJ fusion) represents the surgical treatment for all patients with low back and/or buttock pain who do not respond to medical or physiotherapeutic treatment 1,2. The treatment shows excellent outcomes in these patients. Alongside the standard surgical treatment is minimally invasive surgery (MIS), which seems to be better tolerated by patients than the typical open surgery treatment.
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Epidemiology
Sacroiliac pain is responsible for 15-30% of back pain, the diagnosis of which is mainly medical using a series of physical manoeuvres 3.
Indications
In many cases, the treatment involves the intra-articular injection of an anaesthetic. In patients who do not or do not respond well, surgery has been proposed.
Procedures
Open surgery
The open technique is preferably carried out using a trans-iliac approach 1,2.
Once the lateral surface of the ileum is exposed, a deep incision is made to expose the cartilaginous surface of the sacrum. A curettage is then made to expose the spongy bone. Once the "cleaning" is done, the removed portion of bone is repositioned and secured with a plate and screws.
Alternatively, an anterior approach can be used. In this case, after making an incision at the level of the iliac crest to expose the fascia of the external oblique muscle, the gluteus medius muscle and the external oblique muscles are separated. The iliac muscle is then dissected to expose the sacroiliac joint. The cartilage is then removed and fused by inserting a bone graft. The joint is fixed with a plate and screws.
Minimally invasive surgery
Minimally invasive surgery systems have started to be proposed in the last decade. It has shown a better risk-benefit ratio and is the preferred treatment in those patients who do not improve with complete non-operative treatment 1,2.
The minimally invasive technique owes its popularity to introducing advanced imaging techniques that allow access to the sacroiliac joint in a less invasive manner.
The approaches can be transiliac or posterior. The transiliac technique involves decortication or not of the joint and bone grafting. The joint is stabilised with transiliac implants. The posterior approach is intra-articular, characterised by decortication of the joint and bone grafting.
In most minimally invasive surgery systems, the fusion of the sacroiliac joint is done through cannulation with Kirschner wire.
In both approaches, intraoperative imaging is used, whether 2D fluoroscopy or 3D image-guided navigation.
Complications
The introduction and advancement of the Kirschner wire may injure the pelvic vessels, rectum, or sacral nerve roots.
Outcomes
There are still not many studies in the literature comparing the open approach with the minimally invasive technique.
However, the published studies seem to show a preference for minimally invasive techniques concerning risks and benefits, considering the outcome of these patients to be significantly better in the group treated with the minimally invasive surgery technique.
In particular, it has been shown that surgical time, blood loss, and even hospital stay are significantly reduced with a minimally invasive surgical approach. In addition, the benefits reported by patients were more significant in the minimally invasive group.
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