Minimally Invasive SI Joint Fusion May Lessen Pain

Minimally Invasive SI Joint Fusion May Lessen Pain, Improve Quality of Life – Practical Pain Management – May 2017

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.

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.”

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

Similarly, 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).

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).

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.

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

Edward Michna, MD, an assistant professor of anesthesiology at Harvard Medical School 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.

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

“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.

“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.”

Of course, this study assumes that all surgeries had perfect outcomes, which is unrealistic.

We know that such studies are prone to “throwing out” negative results, and I find it hard to believe that 100% of over 130 fusion operations were ALL successful, unless there were a few more initial study participants whose failed surgeries would not be included.

Any surgery is a great risk for people who already have some kind of chronic pain, so this seems more a treatment of “last resort” for people for whom nothing else, including opioids, has worked.

Other thoughts?

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