Sacroiliac Joint Fusion

An Overview of Sacroiliac Joint Fusion

Anatomy

The pelvis is made up of a ring of three bones, the two iliac bones and the central sacrum, sandwiched in-between. In the front of the pelvis, the pubic symphysis attaches the ilium bones to each other. This pubic symphysis joint is very immovable due to heavy fibrous tissue joining these bones in a configuration called a syndesmosis.

In the back of the pelvis, the area where each ilium bone joins the sacrum is called the sacroiliac joint (SI joint). The sacroiliac joints are mirror images of each other. These joints are unusually complex in that they are made of two different types of joints combined into one.

The rear and inferior portions of the SI joint contains a tough fibrous section similar to the pubic symphysis. This portion of the SI complex binds the pelvis together. These tough fibrous bands prevent most motion.

The front and superior portion of this joint has some aspects of a regular joint like the hip and knee and is called the diarthrodial portion of the joint. Normally diarthrodial joints are designed to slide against each other without friction. The major difference in the diarthrodial sacroiliac joint is that this joint is made of two opposing bony surfaces that are irregular and interdigitate together-preventing motion.

The surfaces of this joint are covered by hyaline cartilage (the same substance that lines hips and knees) and have a thin capsule that encloses this cavity. The capsule is lined with synovial tissue-the tissue that makes the lubrication for this joint.

The SI joint does not act as a typical joint like a hip or knee. There are no “gliding surfaces” like you would expect but a solid interlocking interface between these two bony surfaces. Unlike any other synovial joint in the body, global SI joint function is designed to bond the pelvis together at the rear to make the pelvis a relatively rigid ring. This joint has about 1-2 degrees of total motion (in comparison to the knee joint which has 120 degrees of motion).

The SI joint does change with age. In infants, this joint surface is smooth. As the body ages, peaks and valleys grow until the joint fits like a jigsaw puzzle and has almost no motion. In just about everyone with aging, this joint becomes stiffer. Sometimes the joint actually fuses together by itself.

In women, the sacroiliac joint is somewhat “looser” as women must be able to deliver the baby at the end of pregnancy through this tight pelvic canal. The hormone Relaxin which is secreted during pregnancy, loosens all ligaments in the body accommodating this loosening.

Diagnosis of an SI Joint Pain Syndrome

In-office diagnosis of an SI joint pain syndrome is difficult in that there are no physical examination tests that can insure this diagnosis. These tests include the Patrick’s FABERE test, the Gaenslen’s Test, the pelvic compression test and the pelvic shear test as well as direct palpation of tenderness. These tests will be positive in most patients with SI joint syndrome but will also be positive in a number of other spinal conditions.

X-rays are also generally not helpful for diagnosis. Many individuals have degeneration of the sacroiliac joint based upon X-rays and have absolutely no symptoms. Others with obvious SI joint pain from the joint itself have normal looking joints on X-ray.

MRI scans can be more helpful to look for significant bone changes indicating abnormal loading and wear but even these images may not reveal SI joint pain generation. MRI is the gold standard for diagnosing ankylosing spondylitis and the seronegative spondyloarthopathies.

Diagnostic Blocks

A patient with an SIJ pain disorder should gain relief procuring a sacroiliac injection with an anesthetic (Novocain, Lidocaine, Marcaine), which should numb the joint and temporarily rid the patient of pain. This is called a positive diagnostic block and is the mainstay for diagnosis of this disorder. The injection into the joint is normally accompanied by a corticosteroid, which can be effective for long-term relief and rarely yield a cure. Normally, two positive blocks are considered diagnostic.

There is however, occasionally a problem with this diagnostic test. SI joint injections can inadvertently anesthetize the sciatic nerve if there is a joint capsule tear of the anterior joint. The sciatic nerve sits directly in front of this joint. With a tear of this joint capsule, injected fluid can leak out in front and contact this nerve.

If the sciatic nerve is contributing to SIJ regional pain (from a herniated disc for example), pain will improve from the SIJ injection but the wrong conclusion might be drawn (a false positive test). The doctor might think pain relief indicates an SIJ syndrome when in fact the pain is originating from the anesthetized L5 nerve root. Injection of an X-ray dye agent into the joint can reveal this tear. The dye will leak out the front of the joint and will be visible on fluoroscopy. This leak would allow the injectionist to note the tear and allow more information to be available to the diagnostician.

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Surgery – Sacroiliac Joint Fusion

If the patient has had a prior fusion to the pelvis with screws that cross the sacroiliac joint, removal of these screws can relieve SIJ pain and fusion of this joint may not be necessary. However, it is rare for a patient to have this present in the office.

It is not rare however that a patient with a long fusion could eventually wear down the sacroiliac joint and present with pain. Patients with long scoliosis fusions to the sacrum are at risk for this syndrome. Also, with the older iliac crest bone graft donor site problems (the joint is inadvertently entered when the graft is taken), sacroiliac pain can occur.

Sacroiliac joint fusion is the endpoint treatment for chronic SI pain syndrome. If the patient has failed all other therapies (nerve ablations, physical therapy and activity restriction) and has continued pain, surgery can be chosen. There are generally two types of techniques that have been recently developed.

One technique is implanting three triangular bars or rods (SI Bone) with ingrowth surfaces through the sacroiliac joint. Bone grows into these bars on each side of the joint and the joint is stabilized. The other (Ziga Technologies) has a unique reamer that ablates the joint and allows implantation of bone growth factors (allograft, DBM or even BMP) directly into the joint. Then two large “screws” are driven across the joint to stabilize this articulation.

In either case, the patient needs to avoid full weight bearing on the leg where the joint is located. This means using crutches or a cane on the surgical side for about 6 weeks. Generally, the pain is lessened or eliminated over that 6 weeks.

The long-term success rate for sacroiliac joint fusion appears to be in the range of 70-80%.

For additional resources on sacroiliac joint fusion, please contact the office of Dr. Donald Corenman, back pain doctor and spine surgeon offering diagnostic and surgical second opinions to patients in the USA and around the world.

Related Content

(Click to Enlarge Image) This is a back to front picture of the sacroiliac joint. The left side demonstrates the diarthodial portion (lined with cartilage) and the right side with the tough ligamentous portion.

(Click to Enlarge Image) Top-down image of the sacroiliac joint. To the right is the sacrum and left is the ilium. You can see both portions of the joint (the diarthodial portion that is like the hip or knee joint and the fibrous portion which is stiff and unyielding.

(Click to Enlarge) Left SI arthritis. Arrow points to the thickened bone associated with arthritis.

(Click to Enlarge) SI injection. Small needle is directly in the joint.

(Click to Enlarge) Back to front X-ray of SIJ fusion. You can see this patient had a prior multi level lumbar fusion which is associated with SI joint syndrome.

(Click to Enlarge) Oblique X-ray of SIJ fusion.

(Click to Enlarge) Lateral X-ray of SIJ fusion. Arrow points to the two screws fixing the joint.

Donald Corenman, MD, DC

Average rating:

81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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