What's next for SI joint fusion? 8 spine surgeon insights


Sacroiliac joint fusion continues to develop with new technology and recognition from payers. Here is how eight spine surgeons expect the procedure to develop in the near future.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.

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Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CST Wednesday, Feb. 23.

Editor's note: Responses were lightly edited for clarity and length.

Question: What developments do you think will come next for sacroiliac joint fusion in 2023?

Brian Fiani, DO. Mendelson Kornblum Orthopedic & Spine Specialists (Livonia, Mich.): The future is bright for sacroiliac joint fusion in 2023. The market will grow. The competition for the best instrumentation and products will grow. The research for patient outcomes will grow.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: The SI joint fusion groundswell has leveled off quite a bit in the past four to five years. While we cannot replace this joint, I think more interesting companies will come to the fore with simpler techniques and likely integrated with image guidance out of the box. This would be dually good and not so good for patients. While it would help make us better at the operation, it opens the door for unqualified people to do them on likely thin or nonexistent indications. The democratization of spine surgery should not mean everyone should do it, quite simply because they lack the training, insight and ability to manage these patients in the long term.

Vik Mehta, MD. Hoag Hospital (Newport Beach, Calif.): We are better understanding how long thoracolumbar constructs may place additional strain on the SI joint and lead to accelerated degeneration. We are also understanding that back pain is multifactorial and multifidus dysfunction, cluneal neuropathy and SI joint pathology can be a source of "low back pain." I have seen patients do extremely well with SI joint fusion but as with any procedure, proper patient selection is key. A thorough understanding of the provocative testing and symptomatology of SI joint pathology is essential to pick the right patient. A good partnership with a pain management physician can be invaluable to treat this disorder. Minimally invasive posterior approaches may be a good option as opposed to lateral/transgluteal approaches with less muscle disruption and faster recovery and the ability to navigate which may be more familiar to spine surgeons.

Ali H. Mesiwala, MD. DISC Sports & Spine Center (Newport Beach, Calif.): Sacroiliac joint disease is relatively common, but generally overlooked and misunderstood. As a result, many patients do not have the appropriate diagnosis and often go untreated or mistreated for many years. Education remains the single most important tool to improve patient care in the short term.

As clinicians are becoming more aware of sacroiliac joint problems and associated pain, many physicians and surgeons are offering treatment. Treatment has historically involved injections and ultimately fusions if injections provide temporary relief but fail in the long term.

There has been some controversy as to whether surgeons or specialists in pain management should treat these patients surgically, as procedures have been developed for both a lateral percutaneous approach and posterior percutaneous approach. Most lateral procedures involve screws and dowels and are generally reserved for surgical specialties. The reason for this is that complications, although rare, can occur and require substantial surgical revisions in order to salvage a patient's case.

As posterior approaches have become more common, especially for pain management specialists, coding for reimbursement is also changing. The main issue will be whether a posterior approach provides substantial benefits in the long term or is merely a temporary measure, which will ultimately fail and require a more definitive lateral or open fusion in the future.

As of yet, there is no joint replacement for sacroiliac disease. Various devices have been developed but have not had any substantial data in modeling or patient trials. I would not anticipate any sacroiliac joint replacements in 2023, but we may see companies describe their concepts for arthroplasty this year. I suspect that an IDE trial will need to be performed in order to prove that these procedures are superior or equivalent to a fusion. There'll also be the issue of obtaining the proper CPT code for reimbursement.

Edward Perry, MD. Swift Institute (Reno, Nev.): I have recently become interested in the need for SI joint fusion due to my long construct deformity patients exhibiting good axial spinal fusion but experiencing downstream SI joint-specific pain from what I presume is gravitational load transmission to the sacral-pelvic junction. This phenomenon seems to be independent of good postoperative sagittal balance and spinopelvic parameters. The fact that the SI joint is a non-articulating joint but rather a complex, ligamentous, multi-planar shifting skeletal relationship makes the notion of the need for arthrodesis even more perplexing. Work is ongoing to address the biomechanical dilemma of actually fusing this space, and I can say that my experience with seeing innumerable SI joint "fusion" patients as second opinions with current trans-articulation hardware has been less convincing. Currently, I can only say that if is this entity is a true surgically correctable pain generator, then instruments and fixation hardware to complement the articular preparation, perhaps similar to the ideas of rotating curette decortication first presented by Zyga, incorporated in distal posterior constructs to the pelvis, must be developed and may be the answer.

Frank Phillips, MD. Midwest Orthopaedics at Rush (Chicago): Validated sacroiliac joint fusion entails training and expertise in surgical techniques, fusion biomechanics and biologics as well as the ability to manage surgical complications. These all fall into the purvey of well-trained orthopedic or neurosurgeons. Initially SI fusion procedures were driven by excellent data collection and validation of the safety and effectiveness of these specific techniques in high-quality studies. Unfortunately we have seen the expansion of modified procedures in this space billed as "fusion" procedures, performed by practitioners not trained in the field of fusion and more and more frequently performed in the office setting. Unfortunately to those of us trained in fusion surgery, it is painfully obvious that these so-called "fusion" procedures have little or no chance of achieving successful arthrodesis or even stabilization of the SI joint. These procedures have little or no biomechanical or clinical effectiveness data published, and given that these are increasingly performed in office settings, we have no idea as to their safety profile. I would hope these fringe procedures are reined in to protect our patients' interests.

Issada Thongtrangan, MD. Microspine (Scottsdale, Ariz.): I think we will see more of the SI joint fusion system as part of a major adult deformity case, especially with navigation or robotic assistance. The posterior oblique and posterior intra-articular approach will gain more popularity among the interventionists and ASC-based specialists.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): SacroIliac dysfunction, in its accustomed form usage, is a chronic pain syndrome. Radiating pain and neurological components should be excluded and further investigated. The wanton customary treatment is SI fusion with either large transarticular screws, doweling mechanisms or both. With the myriad of post-operative potentiators then applying: failed fusion rates and adjacent level failures, vascular or nerve root injury or commonly, retention of the chronic pain syndrome secondary to misdiagnosis. Awareness and analysis of a condition are essentials in complex spinal practices; however, the regards and effect of an invasive surgical treatment should weigh heavily upon a chronic pain diagnosis. Further economical analysis and overall scrutiny are ongoing relating to efficacy and delegation of these touted procedures since motivating drivers and indications are subjectively imprecise. 

Note: This article was updated to include additional surgeon responses.

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