Chronic sacroiliac joint pain: fusion versus denervation as treatment options

Inhaltsübersicht

ABSTRACT

Study design: Systematic review.

Objective: To compare the safety and effectiveness of fusion versus denervation for chronic sacroiliac joint pain after failed conservative management.

Summary of background: Methods of confirming the sacroiliac joint as a pain source have been extensively studied and reported in the literature. After confirmation of the origin of the pain by positive local anesthetic blocks, chronic sacroiliac joint pain is usually managed with a combination of medication, physical therapies, and injections. We have chosen to compare two alternative treatments for sacroiliac pain that was refractory to conservative therapies.

Methods: A systematic review of the English-language literature was undertaken for articles published between 1970 and June 2010. Electronic databases and reference lists of key articles were searched to identify studies evaluating fusion or denervation for chronic sacroiliac joint pain after failed conservative management. Studies involving only conservative treatment or traumatic onset of injury were excluded. Two independent reviewers assessed the level of evidence quality using the grading of recommendations assessment, develop­ment and evaluation (GRADE) system, and disagreements were resolved by consensus.

Results: We identified eleven articles (six fusion, five denervation) meeting our inclusion criteria. The majority of patients report satisfaction after both treatments. Both treatments reported mean improvements in pain and functional outcome. Rates of complications were higher among fusion studies (13.7 %) compared to denervation studies (7.3 %). Only fusion studies reported infections (5.3 %). No infections were reported among denervation patients. The evidence for all findings were very low to low; therefore, the relative efficacy or safety of one treatment over another cannot be established.

Conclusions: Sacroiliac joint fusion or denervation can reduce pain for many patients. Whether a true arthrodesis of the joint is achieved by percutaneous techniques is open to question and whether denervation of the joint gives durable pain relief is not clear. Further comparative studies of these two techniques may provide the answers.

STUDY RATIONALE AND CONTEXT

The sacroiliac joint as a source of low back pain has been extensively studied and reported in the literature. Pathological conditions which can affect a sacroiliac joint include degenerative and inflammatory arthritis, posttraumatic and postpartum instability, infection and neoplastic disease. Various other conditions which might cause sacroiliac joint pain include leg-length discrepancy, hip arthritis, and lumbosacral fusions for low back pain, as well as iatrogenic violation of the joint following autologous posterior iliac crest bone graft harvest. Numerous physical tests have been described to isolate the sacroiliac joint as the source of low back pain but none have proved reliable. The most accepted test for sacroiliac pain is temporary relief of the pain after injection of local anaesthetic agents into the joint under fluoroscopic* control. Conservative treatment of chronic sacroiliac pain has consisted of analgesic and antiinflammatory medication, physical therapies and several types of injection techniques. More invasive techniques involve fusion of the joint or denervation by ablative therapy. We have chosen to focus our review on these two techniques of long-term pain relief after failure of conservative treatment.

* Fluoroscopic image intensification control

OBJECTIVES

To compare the effectiveness and safety of fusion versus denervation for chronic sacroiliac joint pain after failed conservative management.

MATERIALS AND METHODS

Study design:

Systematic review

Sampling:

• Search: PubMed, Cochrane Collaboration Database, and National Guideline Clearinghouse Databases; bibliographies of key articles

• Dates searched: 1970–June 2010.

• Inclusion criteria: (1) chronic sacroiliac joint pain, (2) adults 18 years and older, (3) studies involving initial failed conservative treatment

• Exclusion criteria: (1) conservative treatment only, (2) unclear whether subjects had first undergone conservative treatment, (3) trauma, (4) less than five subjects per treatment, (5) less than 6-month follow-up

• Outcomes: patient satisfaction, pain, functional outcomes, wound infection, and complications (health related or surgery specific)

• Analysis: descriptive statistics pooling rates across studies

Details about methods can be found in the web appendix at www.aospine.org / ebsj

Fig. 1 Flow chart showing results of literature search

 

Fig. 2 Mean visual analog scale or numeric rating scale improvements after fusion (blue) or denervation (grey) among all studies measuring these outcomes

 

Fig. 3 Oswestry disability index improvements after fusion (blue) or denervation (grey) among all studies measuring these outcomes

 

RESULTS

We identified eleven articles meeting our inclusion criteria (Fig. [1]). Six studies evaluated fusion for sacroiliac joint pain (n = 95 patients). Five studies evaluated denervation for sacroiliac joint pain (n = 68 patients). All studies were case series evaluating a single treatment. No cohort studies comparing one treatment to the other in the same patient population was identified, making statements regarding relative efficacy impossible. Further, follow-up times for denervation studies (6–12 months) were much shorter than fusion studies (17–69 months). All studies involved subjects who had failed other conservative management. A diagnosis of sacroiliac joint pain in all studies was confirmed by injection. Most often an injection with a solution used to reproduce exact pain pattern was followed by a local anesthetic for pain relief. Prior to their denervation treatment all patients in the denervation cohort underwent physical therapy and medical therapy. Some patients also underwent injection therapy or had previous back surgery. Many patients in the fusion cohort had previously undergone lumbar fusion and other types of back surgery.

Outcomes associated with fusion versus denervation for treatment of chronic sacroiliac pain (Table [1], Figs [2] and [3] )

• The majority of fusion studies (n = 4) reported patient satisfaction as an outcome [1], [2], [3], [4]. The mean rate of patient satisfaction was 57.6 % (range, 18 %–100 %) among 59 subjects. Only one denervation study reported patient satisfaction. There was an 89 % patient satisfaction rate out of nine subjects [5] (Table [1]).

• The majority of denervation studies (n = 4) and two fusion studies reported pain improvement as an outcome using a visual analog or numeric rating scale to measure change from pre to posttreatment [1], [3], [5], [6], [7], [8]. All studies reported a mean improvement (range, 3.5–4.9 points) among subjects (Fig [2]).

• Two denervation studies and one fusion study reported a change in Oswestry disability index scores from pre to posttreatment [3], [5], [6]. All studies reported a mean improvement (range, 14–18 points) (Fig [3]).

Complications and infections associated with fusion and denervation for treatment of chronic sacroiliac pain (Table [1] )

• The pooled infection rate among fusion studies (n = 57 patients) was 5.3 % and denervation studies (n = 68 patients) was 0 % [1], [3], [4], [5], [6], [7], [8], [9], [10] (Table [1]).

• All studies reported general health or treatment specific complications [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11] (Table [1]). The pooled complication rate (excluding infections) among fusion studies (n = 95 patients) was 13.7 % and denervation studies (n = 68 patients) was 7.3 %. Fusion studies reported nonunion, pseudarthrosis and painful hardware as complications (excluding infection) while denervation studies reported transient buttock parasthesias, temporary neuritis, and numbness and itchiness of skin overlying treated sacroiliac joint.

Table 1 Common outcomes of studies evaluating fusion versus denervation for treatment for sacroiliac joint pain

 

Table 2 Characteristics of studies of fusion for sacroiliac joint pain

 

Table 3 Characteristics of studies of denervation for sacroiliac joint pain

 

EVIDENCE SUMMARY

Question 1 > To compare the effectiveness of fusion versus denervation for chronic sacroiliac joint pain after failed conservative management

 

Question 2 > To compare the safety of fusion versus denervation for chronic sacroiliac joint pain after failed conservative management

 

DISCUSSION

• The majority of subjects report satisfaction after either treatment. Both treatments appear to demonstrate improvement in outcomes from pre to posttreatment during their follow-up period.

• Complication rates and infection rates are higher among those undergoing fusion compared to those undergoing denervation.

• The existing literature is limited to case series. No studies were identified that compared treatments in the same patient population. Given these limitations, pooled rates from these studies must be taken with caution. The open fusion studies reported poorer results and higher complication rates than the percutaneous studies. However, the concept of ‘fusion’ of the sacroiliac joint after percutaneous fixation with hollow screws or cages filled with bone-graft substitute was based on the absence of loosening on plain x-rays or confirmation of trabecular continuity across the implants on CT scanning. Also, many of the patients in the fusion series had undergone previous spinal surgery, suggesting that a positive response to sacroiliac blocks does not predict successful pain relief after sacroiliac fusion in patients with chronic pain syndromes.

• All of the denervation studies have short follow-up periods, raising the question of duration of effect given that many reported studies of lumbar facet joint denervation show loss of efficacy after about 2 years.

• There is a clear need for more properly constructed comparative studies to establish whether chronic sacroiliac joint pain can be better managed with invasive pain relieving techniques than conventional conservative therapies.

REFERENCES

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EDITORIAL STAFF PERSPECTIVE

Our reviewers were unanimously in favor of publication of this review, despite the controversial nature of a number of aspects of this condition—starting with uncertainty surrounding physical examination, continuing with diagnostic confirmation and finally treatment. The results of this systematic review point out a commonly encountered conundrum: while there seems to be some evidence suggesting a ‘positive treatment effect’ as reported by patients, closer inspection of the data at hand produces more questions than answers. In summary, the role of the sacro-iliac joint in low back pain and its management remain very much unclear to the present date and is, perhaps, somewhat overemphasized by some. Identification of pathologic entities such as presented by the authors—clear instability, severe degeneration, infection, neoplasia—remains a helpful contribution to patient care by an informed practitioner. Should surgical stabilization be chosen for a sufferer of SI-joint pain, the current state of the literature unfortunately allows little or no real insights due to unclear handling of several confounding variables (ie, previous spine fusion, osteoporosis, obesity, pelvic alignment, physical fitness levels) and inconsistent definition of desired surgical outcomes—are true fusions actually achieved in a large number of the described techniques? That said, are solid fusions actually necessary for a satisfactory outcome? Do the outcomes justify the means? Many questions, few real answers, much to do in the future.