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Minimally Invasive SI Joint Fusion May Lessen Pain, Improve Quality of Life

May 10, 2017
Experts weigh in on the findings of a study comparing patients with sacroiliac (SI) joint pain who received either conservative measures or denervation procedure with a group of patients who received a minimally invasive SI joint fusion.

Interviews with Vicente Vanaclocha, MD, PhD, David A. Spinner, DO, Edward Michna, MD, and David W. Polly, Jr., MD

Minimally invasive sacroiliac (SI) joint fusion was associated with significant improvements in pain relief and disability, as well as a decreased reliance on opioids, according to findings of a retrospective study published in Neurosurgery.1

This study compared outcomes against conservative management (CM) or SI joint denervation, demonstrating that pain and disability levels returned to baseline levels with traditional approaches.

In selected patients, minimally invasive SI joint fusion can offer “a more normal life with less opioid dependence and less side effects from [opioid use],” lead author Vicente Vanaclocha, MD, PhD, Hospital General Universitario de Valencia, University of Valencia, Spain, told Practical Pain Management.

Dr. Vanaclocha hopes that in the future “SI joint fusion in the percutaneous lateral approach will be an accepted treatment method for patients who do not improve with other more conservative measures.”

Minimally invasive SI joint fusion may improve pain, lessen opioid use

SI Joint Fusion Reduced Pain, Disability, and Opioid Use

In the study, all groups showed reduced pain at their 1-month follow-up. However, patients in the SI joint fusion group showed a reduction in pain that was maintained throughout their follow up, where as pain returned to baseline levels for patients in the CM and SI denervation groups, reported the authors.

The patients in the SI joint group experienced a 6- and 4.5-point greater improvement in mean pain score compared with the CM and SI denervation groups, respectively (P < 0.001 for both comparisons).1Similarly, the SI joint group showed a 24- and 17-point greater improvement in mean Oswetry Disability Index (ODI) after 6 months compared with patients receiving CM and SI denervation (P 0.001 for both comparisons.

The percentage of patients taking opioids decreased from 63% at baseline to 7% at last follow-up in the SI joint fusion group, but increased from 49% to 84% in the CM group (P < 0.001) and from 55% to 85% in the SI denervation group (P = 0.0012).1

Retrospective Study Design

The researchers examined outcomes data from 137 patients with chronic SI joint pain who received minimally invasive SI joint fusion using triangular-shapted titanium implants (iFuse Implant; n=27), SI denervation (n=47), or CM because they were denied insurance coverage for SI denervation and SI joint fusion (n=63).1 All patients were treated at a single outpatient neurosurgery clinic. Patients with causes of SI joint pain other than osteoarthritic degeneration or joint disruption were excluded from the study.

At baseline, the SI joint fusion group had a shorter mean duration of SI joint pain compared with the CM and SI denervation groups (1.6 vs 4.6 and 2.9 years, respectively; P < 0.0011. In addition, the proportion of patients who had undergone prior lumbar fusion was significantly lower in the SI joint fusion group compared with the CM and SI denervation groups (7% vs 43% and 34%, respectively; P < 0.0045).

Follow-up data was available for all patients at 1 year, a majority of patients at 2 and 3 years, and a small subset of the overall group at 6 years (n=19).

Tempered Reaction From Pain Experts

“Sacroiliac joint pathology is difficult to diagnosis and difficult to treat,” said David A. Spinner, DO, director of pain management at the Icahn School of Medicine at Mount Sinai in New York City. “The ever-increasing risk of misuse, hyperalgesia, and death from long-term and escalating opioid management drives providers to find other treatment options,” Dr. Spinner told Practical Pain Management.

“SI joint fusion has not been popular for a few reasons, mainly procedural risk and long-term outcome data. This article provides reasonable data with positive outcomes and low risk. The study should be confirmed by another center able to provide treatment irrespective of healthcare coverage,” Dr. Spinner said.

Edward Michna, MD, an assistant professor of anesthesiology at Harvard Medical School in Boston, Massachusetts, said that SI joint fusion may be a treatment option for patient who are resistant to conservative therapies and whose pain has a major impact on their quality of life.2,3 He noted difficulty in drawing definitive conclusions regarding the impact of the treatment arms on opioid use given that the study was not randomized and the study groups were not matched.

“The CM and SI denervation groups had a significantly longer duration of pain at baseline and a significantly higher incidence of previous lumbar fusion compared with the SI joint fusion group,” Dr. Michna told Practical Pain Management. “These compounding variables will affect whether or not patients were on opioids.”

“Also, given that SI joint pain is challenging to diagnose, did patients in the CM group really have true SI joint pain?” said Dr. Michna, who is on the American Pain Society Board of Directors. “Patients who have a multifactorial pain disorder and are taking opioids often complain of pain everywhere, and may not necessarily have SI joint pain pathology. If you treat SI joint pain, these patients may have temporary relief because of a placebo effect or another mechanism, but they may not really have SI joint dysfunction.”

“This study shows us that when insurance denies coverage for minimally invasive SI joint fusion, patients do not get better and their opioid use increases, while patients who do receive surgery are able to get off of narcotics and do profoundly better,” said David W. Polly, Jr., MD, professor and chief of spine surgery at the University of Minnesota in Minneapolis.

“The treatment groups were not matched in all categories, but were incredibly commensurate in terms of baseline visual analog scale and ODI scores,” Dr. Polly said. “The effect size and the change in pain and disability scores between the groups is so profound as to cast any doubt aside, and parallel findings from 2 multicenter randomized cohort studies, a prospective cohort study, and a meta-analysis of 18 prospective or retrospective studies. Decrease in opioid use with SI fusion also was reported in 1 of the randomized controlled trials [INSITE],4 but a greater reduction was found in the study by Vanaclocha.”

“All evidence is pointing to a consistent effect size and pain response pattern, and the number of studies supporting these findings is such that insurance companies can no longer justify that minimally invasive SI joint fusion is not a standard of care for chronic SI joint pain,” Dr. Polly told Practical Pain Management. “In contrast, the level of evidence supporting nonsurgical interventions is of extremely low quality.”

“SI joint fusion isn’t perfect and typically does not make patients completely pain free, but it does reduce pain and impairment by half,” Dr. Polly concluded.

Last updated on: May 10, 2017
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