Sacropelvic Fixation With S2 Alar Iliac Screws May Prevent Sacroiliac Joint Pain After Multisegment Spinal Fusion.

STUDY DESIGN: A retrospective study. OBJECTIVE: To examine the postoperative incidence of sacroiliac joint pain (SIJP) at the lower fusion level following multisegment fusion. SUMMARY OF BACKGROUND DATA: Recently, multisegment fusion is being increasingly performed. While proximal junctional kyphosis (PJK) commonly develops following multisegment fusion, SIJP also commonly occurs following this surgery. In surgery for adult spinal deformity, fixation is often extended to the pelvis to include the sacroiliac joint. Therefore, the question of whether SIJP occurs in such cases is interesting. Here, we examined postoperative incidence of SIJP at the lower fusion level, including the incidence of PJK, and postoperative lumbopelvic alignment. METHODS: Participants included 77 patients who underwent corrective fusion (≥3 segments). Patients were divided into three groups based on the lower fixation end: L5 (L5), S (sacrum), and P (pelvis). In the P group, an S2 alar iliac screw was used. Postoperative incidence of SIJP and PJK in each group was examined along with lumbopelvic parameters. RESULTS: SIJP incidence was 16.7%, 26.1%, and 4.2% in the L5, S, and P groups, respectively, indicating the highest value in the S group and a significantly lower value in the P group. PJK incidence was 23.3%, 30.4%, and 29.2% in the L5, P, and S groups, respectively, with no significant differences. Regarding postoperative lumbopelvic parameters, there was no significant difference between the groups; however, lumbar lordosis tended to be better in the P group. CONCLUSION: SIJP incidence was extremely high with fixation to the sacrum, and in the group with fixation to the pelvis, there was hardly any SIJP. Sacropelvic fixation using S2 alar iliac screws could prevent SIJP onset following multisegment fusion. LEVEL OF EVIDENCE: 3.

Repeated Low Back Pain Caused by Regional Migratory Osteoporosis of the Sacroiliac Joint.

INTRODUCTION: Regional migratory osteoporosis (RMO) is a rare, self-limiting disorder characterized by migratory arthralgia that mainly occurs in the weight-bearing joints of the lower extremities. RMO is most commonly observed in middle-aged men, and its etiology is unknown. We report the case of a middle-aged man who experienced repeated low back pain that was caused by RMO of the sacroiliac joint (SIJ). CASE REPORT: In this case, the patient initially complained of left low back pain; however, there were no specific findings in plain radiography of the lumbar spine and pelvis. In addition, blood chemistry test findings were normal. Magnetic resonance imaging (MRI)revealed a diffuse bone marrow edema in the left SIJ. Conservative treatment was effective, and the pain was relieved within 3 months. However, 2 months later, a similar pain developed on the right side. MRI showed bone marrow edema in the right SIJ and the left-sided lesion had disappeared. The symptom was relieved by conservative treatment. After 5 months, the pain disappeared and the MRI findings became normal. During the next 2 years of follow-up, there is no recurrence of the illness. CONCLUSIONS: To the best of our knowledge, this is the first report of RMO with a lesion that moved to the SIJ of both sides. We believe that knowledge of this disorder can prevent invasive procedures, particularly, in treating a patient with low back pain.

A Diagnostic Scoring System for Sacroiliac Joint Pain Originating from the Posterior Ligament.

Objective: Sacroiliac joint (SIJ) pain originating from the posterior ligament manifests in not only the buttocks but also the groin and lower extremities and thus may be difficult to discern from pain secondary to other lumbar disorders. We aimed to develop a simple clinical diagnostic tool to help physicians distinguish between patients with SIJ pain originating from the posterior ligament and those with lumbar disc herniation (LDH) or lumbar spinal canal stenosis (LSS). Design: Prospective case-control study. Patients and Methods: We evaluated 62 patients with SIJ pain originating from the posterior ligament and 59 patients with LDH and LSS. Pain areas, pain increasing positions, provocation test, and tenderness points were investigated. A scoring system based on multivariate logistic regression equations using the investigated items was developed. Results: Two pain areas (the posterosuperior iliac spine (PSIS) detected by the one-finger test and groin), pain while sitting on a chair, provocation test, and two tenderness points (PSIS and the sacrotuberous ligament) had high odds ratios (range, 25.87­1.40) and were used as factors in the scoring system. An integer score derived from the regression coefficient and clinical experience was assigned to each identified risk factor. The sum of the risk score for each patient ranged from 0­9. This scoring system had a sensitivity of 90.3% and a specificity of 86.4% for a positivity cutoff point of 4. Conclusion: The scoring system can help distinguish between patients with SIJ pain originating from the posterior ligament and those with LDH and LSS.

Sacroiliac joint pain after multiple-segment lumbar fusion: a long-term observational study-Non-fused sacrum vs. fused sacrum.

INTRODUCTION: Sacroiliac joint pain (SIJP) after lumbar fusion surgery has recently gained attention as a source of low back pain after lumbar fusion. There are two risk factors for postoperative SIJP, i.e., fusion involving the sacrum and multiple-segment fusion. In this study, we examined whether SIJP could occur more frequently in patients with two risk factors (multiple-segment fusion to sacrum). Further, we examined SIJP after multiple-segment (≥3) lumbar fusion, focusing on the difference between floating fusion (non-fused sacrum) and fixed fusion (fused sacrum). METHODS: Ninety-one patients who underwent multiple-segment lumbar fusion were included. Patients without preoperative clinical SIJP were considered. Of these, 17 developed new-onset SIJP. We investigated postoperative SIJP development, duration from surgery to SIJP onset, and postoperative treatment outcomes of SIJP patients using Japanese Orthopaedic Association (JOA) scores. We compared the findings between floating fusion group and fixed fusion group. RESULTS: The incidence of SIJP was significantly higher with fixed fusion (32.1%) than with floating fusion (12.7%). The mean time of onset of sacroiliac joint pain was at 8.63 (2-13) months after surgery in the floating fusion group and 3.78 (1-10) months after surgery in the fixed fusion group, indicating that incidence occurred significantly earlier in the fixed fusion group. Our treatment outcome indicated that the mean JOA score significantly improved in the floating fusion group from 5.13 at the time of onset to 9.50 at the time of final follow-up; however, in the fixed fusion group, it improved from 5.78 at the time of onset to 7.33 at the time of final follow-up, indicating no significant improvement. CONCLUSIONS: In multiple-segment lumbar fusion, fixed fusion (fused sacrum) has a very high risk of SIJP. In addition, the onset of SIJP in such cases may occur earlier. This aspect deserves consideration, given the difficulty of pain treatment.

Fusion of Multiple Segments Can Increase the Incidence of Sacroiliac Joint Pain After Lumbar or Lumbosacral Fusion.

STUDY DESIGN: A retrospective study. OBJECTIVE: To determine the risk factors for sacroiliac joint pain (SIJP) after lumbar or lumbosacral fusion. SUMMARY OF BACKGROUND DATA: Recently, the sacroiliac joint has gained increased attention as a source of pain after lumbar or lumbosacral fusion. We examined the factors related to the development of SIJP after lumbar or lumbosacral fusion. METHODS: In total, 262 patients who underwent lumbar or lumbosacral fusion from June 2006 to June 2009 were included in this study. All patients who did not show SIJP clinically in the preoperative screening period were considered. Of these patients, 28 newly developed SIJP. We investigated whether development of SIJP after lumbar or lumbosacral fusion is related to the presence of fusion involving the sacrum (floating fusion vs. fixed fusion) and the number of fused segments. RESULTS: The incidence of SIJP was higher with fixed fusion (13.1%) than with floating fusion (10.0%). With regard to the number of fused segments, the incidence of SIJP was 5.8% for one fused segment, 10.0% for two segments, 20.0% for three segments, 22.5% for at least four segments. Thus, the incidence was significantly higher when at least three segments were fused. Logistic regression analysis was performed to determine if the development of SIJP was related to the presence of fusion involving the sacrum or the number of fused segments. The analysis revealed that the number of fused segments was significantly associated with the development of SIJP. CONCLUSION: SIJP is a potential cause of low back pain after lumbar or lumbosacral fusion surgeries. Our study indicated that fusion of multiple segments (at least three) can increase the incidence of SIJP after lumbar or lumbosacral fusion. LEVEL OF EVIDENCE: Level 3.

PLIF with a titanium cage and excised facet joint bone for degenerative spondylolisthesis--in augmentation with a pedicle screw.

OBJECTIVES: To determine the validity of posterior lumbar interbody fusion (PLIF) using a titanium cage filled with excised facet joint bone and a pedicle screw for degenerative spondylolisthesis. METHODS: PLIF using a titanium cage filled with excised facet joint bone and a pedicle screw was performed in 28 consecutive patients (men 10, women 18). The mean age of the patients was 60 years (range, 52 to 75 y) at the time of surgery. The mean follow-up period was 2.3 years (range, 2.0 to 4.5 y). The operation was done at L3/4 in 5, L4/5 in 20, and L3/4/5 in 3 patients. The mean operative bleeding was 318+/-151 g (mean+/-standard deviation), and the mean operative time was 3.34+/-0.57 hours per fixed segment. Clinical outcome was assessed by Denis' Pain and Work scale. Radiologic assessment was done using Boxell's method. Fusion outcome was assessed using an established criteria. RESULTS: On Pain scale, 20 and 8 patients were rated P4 and P5 before surgery, and 11, 12, 2, 2, and 1 patients were rated P1, P2, P3, P4, and P5 at final follow-up, respectively. On Work scale (for only physical labors), 12 and 9 patients were rated W4 and W5, before surgery, and 12, 5, 1, and 3 patients were rated W1, W2, W3 and W5 at final follow-up, respectively. There was significant difference in clinical outcome (P<0.01, Wilcoxon singled-rank test) The mean %Slip and Slip Angle was 17.9+/-8.1% and 3.9+/-5.8 degrees before surgery. The mean % Slip and Slip Angle was 5.4+/-4.4% and -2.0+/-4.8 degrees at final follow-up. There was a significant difference between the values (P<0.01, paired t test). "Union" and "probable union" was determined in 29 (93.5%) and 2 (6.5%) of 31 operated segments at 2.3 years (range, 2.0 to 4.5 y), postoperatively. CONCLUSIONS: PLIF using a titanium cage filled with excised facet joint bone and a pedicle screw provided a satisfactory clinical outcome and an excellent union rate without harvesting and grafting the autologous iliac bone.