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Licensed Unlicensed Requires Authentication Published by De Gruyter October 1, 2017

Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain

Bo Nyström, Birgitta Gregebo, Adam Taube, Stig-Olof Almgren, Birgitta Schillberg and Yingyan Zhu

Graphical Abstract



It has been reported that in 13-32% of patients with chronic low back pain, the pain may originate in the sacroiliac (SI) joints. When treatment of these patients with analgesics and physiotherapy has failed, a surgical solution may be discussed. Results of such surgery are often based on small series, retrospective analyses or studies using a minimal invasive technique, frequently sponsored by manufacturers.


To report the clinical outcome concerning pain, function and quality of life following anterior arthrodesis in patients presumed to have SI joint pain using validated questionnaires pre- and post-operatively. An additional aim was to describe the symptoms of the patients included and the preoperative investigations performed.

Material and methods

Over a 6 year period we treated 55 patients, all women, with a mean age of 45 years (range 28-65) and a mean pelvic pain duration of 9.1 years (range 2-30). The pain started in connection with minor trauma in seven patients, pregnancy in 20 and unspecified in 28. All patients had undergone long periods of treatment including physiotherapy, manipulation, needling, pelvic belt, massage and chiropractic without success, and 15 had been operated for various spinal diagnoses without improvement. The patients underwent thorough neurological investigation, plain X-ray and MRI of the spine and plain X-ray of the pelvis. They were investigated by seven clinical tests aimed at indicating pain from the SI joints. In addition, all patients underwent a percutaneous mechanical provocation test and extra-articular local anaesthetic blocks against the posterior part of the SI joints. Before surgery all patients answered the generic Short-Form-36 (SF-36) questionnaire, the disease specific Balanced Inventory for Spinal Disorders (BIS) questionnaire and rated their level of pelvic and leg pain (VAS, 0-100). At follow-up at a mean of 2 years 49 patients completed the same questionnaires (89%).


At follow-up 26 patients reported a lower level of pelvic pain than before surgery, 16 the same level and six a higher level. Applying Svensson’s method RPpelvic pain = 0.3976, with 95% CI (0.2211, 0.5740) revealed a statistically significant systematic improvement in pelvic pain. At follow-up 28 patients reported a higher quality of life and 26 reported sleeping better than pre-operatively. In most patients the character of the pelvic pain was dull and aching, often accompanied by a stabbing component in connection with sudden movements. Referred pain down the leg/s even to the feet and toes was noted by half of the patients and 29 experienced frequency of micturition.


It is apparent that in some patients the SI joints may cause long-term pain that can be treated by arthrodesis. We speculate that continued pain despite a healed arthrodesis may be due to persistent pain from adjacent ligaments. The next step should be a prospective randomized study comparing posterior fusion and ligament resection with non-surgical treatment.


Anterior arthrodesis can apparently relieve pain in some patients with presumed SI joint pain. The problem is how to identify these patients within the low back pain group.

Present address: Department of Neuroscience, Section of Neurosurgery, University Hospital, SE-75185 Uppsala, Sweden

1 Present address: Department of Neuroscience, Section of Neurosurgery, University Hospital, SE-75185 Uppsala, Sweden.

2 Present address: Länskirurgikliniken, Region Örebro Län, Karlskoga sjukhus, SE-69181 Karlskoga, Sweden.

  1. Ethical issues: All patients were thoroughly informed about the study and gave their informed consent. The study was approved by the Institutional Review Board.

  2. Conflicts of interest: The authors have no conflict of interest.


[1] Schwarzer AC, Aprill CN, Bogduk N. The sacroiliacjoint in chronic low back pain. Spine 1995;20:31–7.10.1097/00007632-199501000-00007Search in Google Scholar PubMed

[2] Maigne J-Y, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996;21:1889–92.10.1097/00007632-199608150-00012Search in Google Scholar PubMed

[3] Katz V, Schofferman J, Reynolds J. The sacroiliac joint: a potential cause of Pain after lumbar fusion to the sacrum. J Spinal Disord Tech 2003;16:96–9.10.1097/00024720-200302000-00015Search in Google Scholar PubMed

[4] Dreyfuss P, Dreyer SJ, Cole A, Mayo K. Sacroiliac join pain. J Am Acad Orthop Surg 2004;12:255–65.10.5435/00124635-200407000-00006Search in Google Scholar PubMed

[5] Nachemson AL. Newest knowledge of low back pain. Clin Orthop Rel Res 1992;279:8–20.10.1097/00003086-199206000-00003Search in Google Scholar

[6] Buchowski JM, Kebaish KM, Sinkov V, Cohen DB, Sieber AN, Kostuik JP. Functional and radiographic outcome of sacroiliac arthrodesis for the disorders of the sacroiliac joint. Spine J 2005;5:520–8.10.1016/j.spinee.2005.02.022Search in Google Scholar PubMed

[7] Maigne JY, Planchon CA. Sacroiliacjoint pain after lumbar fusion. A study with anesthetic blocks. Eur Spine J 2005;14:654–8.10.1007/s00586-004-0692-6Search in Google Scholar PubMed PubMed Central

[8] Vleeming A, Albert HB, Östgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J 2008;17:794–819.10.1016/B978-044310178-6.50033-5Search in Google Scholar

[9] Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine 1996;21:2594–602.10.1097/00007632-199611150-00009Search in Google Scholar PubMed

[10] Sturesson B, Udén G, Udén A. Pain pattern in pregnancy and “catching” of the leg in pregnant women with posterior pelvic pain. Spine 1997;22:1880–4.10.1097/00007632-199708150-00013Search in Google Scholar PubMed

[11] Cohen SP. Sacroiliacjoint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesth Analg 2005;101:1440–53.10.1213/01.ANE.0000180831.60169.EASearch in Google Scholar PubMed

[12] Broadhurst NA, Bond MJ. Pain provocation tests forthe assessment of sacroiliac joint dysfunction. J Spinal Disord 1998;11:341–5.Search in Google Scholar

[13] Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliacjoint pain: validity of individual provocation tests and composites of tests. Man Ther 2005;10:207–18.10.1016/j.math.2005.01.003Search in Google Scholar PubMed

[14] van derWurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliacjoint procedures. Arch Phys Med Rehab 2006;87:10–4.10.1016/j.apmr.2005.09.023Search in Google Scholar PubMed

[15] Ronchetti I, Vleeming A, van Wingerden JP. Physical characteristics of women with severe pelvic girdle pain after pregnancy. Spine 2008;33:E145-51.10.1097/BRS.0b013e3181657f03Search in Google Scholar PubMed

[16] Berthelot J-M, Labat J-J, Le Goff B, Gouin F, Maugars Y. Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain. Joint Bone Spine 2006;73:17–23.10.1016/j.jbspin.2004.08.003Search in Google Scholar PubMed

[17] Stuge B, Laerum E, Kirkesola G, Vollestad N. The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy. Spine 2004;29:351–9.10.1097/01.BRS.0000090827.16926.1DSearch in Google Scholar

[18] Loving S, Nordling J, Jaszczak P, Thomsen T. Does evidence support physiotherapy management of adult female chronic pelvic pain? A systematic review. Scand J Pain 2012;3:70–81.10.1016/j.sjpain.2011.12.002Search in Google Scholar PubMed

[19] van Zwienen CMA, van den Bosch EW, Snijders CJ, van Vugt AB. Triple pelvic ring fixation in patients with severe pregnancy-related low back and pelvic pain. Spine 2004;29:478–84.10.1097/01.BRS.0000092367.25951.4ASearch in Google Scholar

[20] Kibsgård TJ, Röise O, Sudmann E, Stuge B. Pelvic joint fusions in patients with chronic pelvicgirdle pain: a23-yearfollow-up. Eur Spine J 2013;22:871–7.10.1007/s00586-012-2512-8Search in Google Scholar PubMed PubMed Central

[21] Graham Smith A, Capobianco R, Cher D, Rudolf L, Sachs D, Gundanna M, Kleiner J, Mody MG, Shamie AN. Open versus minimally invasive sacroiliac joint fusion: a multi-center comparison of perioperative measures and clinical outcomes. Ann Surg Innov Res 2013;7:14 in Google Scholar PubMed PubMed Central

[22] Sachs D, Capobianco R. One year successful outcomes for novel sacroiliacjoint arthrodesis system. Ann Surg Innov Res 2012;6:13 in Google Scholar PubMed PubMed Central

[23] CummingsJr J, Capobianco RA. Minimally invasive sacroiliacjoint fusion: one-yearoutcomes in18 patients. AnnSurg Innov Res 2013;7:12 in Google Scholar PubMed PubMed Central

[24] Rudolf L. Sacroiliac joint arthrodesis-MIS technique with titanium implants: report of the first 50 patients and outcomes. Open Orthop J 2012;6:495–502.10.2174/1874325001206010495Search in Google Scholar PubMed PubMed Central

[25] Rudolf L, Capobianco R. Five-yearclinical and radiographic outcomes after minimally invasive sacroiliacjoint fusion using triangular implants. Open OrthopJ 2014;8:375–83.10.2174/1874325001408010375Search in Google Scholar PubMed PubMed Central

[26] Sachs D, Capobianco R. Minimally invasive sacroiliac joint fusion: one-year outcomes in 40 patients. Adv Orthop 2013,,536128.10.1155/2013/536128Search in Google Scholar PubMed PubMed Central

[27] Duhon BS, Cher DJ, Wine KD, Lockstadt H, Kovalsky D, Soo C-L. Safety and 6-month effectiveness of minimally invasive sacroiliacjoint fusion: a prospective study. Med Devices 2013;6:219–29.10.2147/MDER.S55197Search in Google Scholar PubMed PubMed Central

[28] Polly DW, Cher DJ, Wine KD, Whang PG, Frank CJ, Harvey CF, Lockstadt H, Glaser JA, Limoni RP, Sembrano JN. Randomized controlled trial of minimally invasive sacroiliac joint fusion using triangular titanium implants vs nonsurgical management for sacroiliac joint dysfunction: 12-month outcomes. Neurosurgery 2015;77:674–91.10.1055/s-0036-1583136Search in Google Scholar

[29] Russo GS, Whang PG, Woods BI, Radcliff K. Is the SIJ a cause of pain that can be accurately identified and treated with an SI fusion? Clin Spine Surg 2017;30:187–90.10.1097/BSD.0000000000000548Search in Google Scholar PubMed

[30] Nyström B, Taube A, Leja E, Schillberg B. Deep spatial discrimination in the lumbarspine. J Neurol Neurosci 2016;7:6.10.21767/2171-6625.1000160Search in Google Scholar

[31] Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36), I. Conceptual framework and item selection.Med Care 1992;30:473–83.10.1097/00005650-199206000-00002Search in Google Scholar

[32] Svensson E, Schillberg B, Kling A-M, Nyström B. The balanced inventory for spinal disorders. The validity of a disease specific questionnaire for evaluation of outcomes in patients with various spinal disorders. Spine 2009;34:1976–83.10.1097/BRS.0b013e3181b07d6aSearch in Google Scholar

[33] Svensson E, Schillberg B, Kling A-M, Nyström B. Reliability of the balanced inventory for spinal disorders, a questionnaire for evaluation of outcomes in patients with various spinal disorders. J Spinal Disord Tech 2012;25:196–204.10.1097/BSD.0b013e31821534daSearch in Google Scholar

[34] Svensson E, Schillberg B, Zhao X, Nyström B. Responsiveness of the balanced inventory for spinal disorders, a questionnaire for evaluation of outcomes in patients with various spinal disorders. J Spine Neurosurg 2015;4:40:2, in Google Scholar

[35] Svensson E. Ordinal invariant measures for individual and group changes in ordered categorical data. Stat Med 1998;17:2923–36.10.1002/(SICI)1097-0258(19981230)17:24<2923::AID-SIM104>3.0.CO;2-#Search in Google Scholar

[36] Avdic A, Svensson E. Svensson method.1.Interactive software supporting Svensson’s method. 1st ed; 2010, Orebro. Accessed from: in Google Scholar

[37] Giannikas KA, Khan AM, Karski MT, Maxwell HA. Sacroiliac joint fusion for chronic pain: a simple technique avoiding the use of metalwork. Eur Spine J 2004;13:253–6.10.1007/s00586-003-0620-1Search in Google Scholar

[38] Al-khayer A, Hegarty J, Hahn D, Grevitt MP. Percutaneous sacroiliac joint arthrodesis. A novel technique. J Spinal Disord Tech 2008;21:359–63.10.1097/BSD.0b013e318145ab96Search in Google Scholar

[39] Wise CL, Dall BE. Minimally invasive sactroiliac arthrodesis. Outcomes of a new technique. J Spinal Disord Tech 2008;21:579–84.10.1097/BSD.0b013e31815ecc4bSearch in Google Scholar

[40] Smith-Petersen MN, Rogers WA. End-result study of arthrodesis of the sacroiliac joint for arthritis - traumatic and non-traumatic. J Bone Joint Surg (Am) 1926;8:118–36.Search in Google Scholar

[41] Solonen KA. The sacroiliacjoint in the light of anatomical, roentgenological and clinical studies. Acta Orthop Scand 1957;(Suppl.27):1–127.10.3109/ort.1957.28.suppl-27.01Search in Google Scholar

[42] Belanger TA, Dall BE. Sacroiliac arthrodesis using a posterior midline fascial splitting approach and pedicle screw instrumentation: a new technique. J Spinal Disord 2001;14:118–24.10.1097/00002517-200104000-00005Search in Google Scholar

[43] Keating JG, Avillar MD, Price M. Sacroiliacjoint arthrodesis in selected patients with low back pain. In: Vleeming A, Mooney V, Snijders CJ, Dorman TA, Stoeckart R, editors. Movement, stability & low back pain.The essential role of the pelvis. London: Churchill Livingstone; 1997. p. 573-86.Search in Google Scholar

[44] Schutz U, Grob D. Poor outcome following bilateral sacroiliac joint fusion for degenerative sacroiliac joint syndrome. Acta Orthop Belg 2006;72: 296-308.Search in Google Scholar

[45] Zaidi HA, Montoure AJ, Dickman CA. Surgical and clinical efficacy of sacroiliac joint fusion: a systematic review of the literature. J Neurosurg Spine 2015, in Google Scholar

[46] Heiney J, Capobianco R, Cher D. A systematic review of minimally invasive sacroiliac joint fusion utilizing a lateral transarticular technique. Int J Spine Surg 2015;9, in Google Scholar PubMed PubMed Central

[47] Whang P, Cher D, Polly D, Frank C, Lockstadt H, Glaser J, Limoni R, Sembrano J. Sacroiliac joint fusion using triangular titanium implants vs. non-surgical management: six-month outcomes from a prospective randomized controlled trial. Int J Spine Surg 2015;9:6, in Google Scholar PubMed PubMed Central

[48] Kibsgård TJ, Röise O, Stuge B. Pelvic joint fusion in patients with severe pelvic girdle pain - a prospective single-subject research design study. BMC Musculoskel Disord 2014;15:85 in Google Scholar PubMed PubMed Central

[49] Walheim GG, Olerud S. Arthrodesis of the pelvic joints in “pelvic instability”.An analysis of fifteen patients. In: Walheim G, editor. Pelvic instability. Aspects on diagnosis and treatment. Stockholm; 1983 [Thesis].Search in Google Scholar

[50] Fortin JD, Dwyer AP, West S, Pier J. Sacroiliacjoint: pain referral maps upon applying a new injection/arthrography technique. Part I: Asymptomatic volunteers. Spine 1994;19:1475–82.10.1097/00007632-199407000-00010Search in Google Scholar

[51] Slipman CW, Whyte II WS, Chow DW, Chou L, Lenrow D, Ellen M. Sacroiliac joint syndrome. Pain Physician 2001;4:143–52.10.36076/ppj.2001/4/143Search in Google Scholar

[52] Sturesson B, Selvik G, Udén A. Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine 1989;14:162–5.10.1097/00007632-198902000-00004Search in Google Scholar PubMed

[53] Sturesson B, Udén A, Vleeming A. A radiostereometric analysis of the movements of the sacroiliac joints in the reciprocal straddle position. Spine 2000;25:214–7.10.1097/00007632-200001150-00012Search in Google Scholar PubMed

[54] Sturesson B, Udén A, Vleeming A. A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine 2000;25:364–8.10.1097/00007632-200002010-00018Search in Google Scholar PubMed

[55] Haufe SMW, Mork AR. Sacroiliacjoint debridement: a novel technique for the treatment of sacroiliac joint pain. Photomed Laser Surg 2005;23:596–8.10.1089/pho.2005.23.596Search in Google Scholar PubMed

Received: 2017-02-22
Revised: 2017-06-13
Accepted: 2017-06-20
Published Online: 2017-10-01
Published in Print: 2017-10-01

© 2017 Scandinavian Association for the Study of Pain

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