When sacroiliac dysfunction does not respond to conservative treatment, including physical therapy, injections and possibly prolotherapy, surgery may be indicated.
The amount of surgery deemed necessary is determined during the preoperative evaluation. All surgeries are done under general anesthesia and patients are placed face down for the procedure.
Before the surgery, the sacroiliac joints and the pelvic girdle are aligned as well as possible. This is again verified once the patient is under anesthesia and positioned. We believe in aligning the joints as well as we can before fixating and/or fusing them although, to date, there is no literature or data proving that this is better than fusing the joint wherever it happens to be.
The surgery can be as simple as a percutaneous screw fixation, where two cannulated titanium bone screws are placed across the joint using X-rays: First, guiding pins are placed through the skin, using tiny incisions (about ¼ inch). The nerves and nerve roots are monitored with electricity during the surgery to minimize the chance of injury or irritation. This usually takes about 30 to 45 minutes on average. Patients can go home the day after surgery. This relatively simple procedure is now used mainly as a test when there is a question whether or not sacroiliac dysfunction is present or if there is a reason not to perform a fusion. The procedure is usually done on one side but can be done on both sides. It is to be noted that the screws are not specifically FDA approved for this use and are therefore used off label.
The standard procedure involves sacroiliac fusion. Currently, this is also done through the skin (percutaneously) with small metal struts. The technique is similar to the screw technique, first placing pins over the struts that are guided into position. We usually place only two struts as this is deemed sufficient to stabilize the joint. More struts could be used but, currently, it has not been proven to be better, even though the company which makes the struts suggests the use of three struts. Contrary to the screws, the struts are FDA approved for this procedure and have now replaced the open fusion with bone graft that was previously used. This percutaneous strut fusion technique requires partial weight bearing on the side of the surgery for about three to four weeks; therefore only one side can be done at a time. Sometimes, screws are placed on the opposite side for further stabilization and can be replaced by struts at a later time.
The wounds are usually closed with deep dissolvable stitches and skin glue to try to obtain a better-looking scar. The advantage is that the wounds can be cleaned with soap and water (actually, this is the only thing that can be used to clean them) and that the patient may take showers. We discourage soaking the wounds in the bathtub (or any other stagnant water) until they are fully healed (this usually takes a couple of weeks) to minimize the chance of infection.
Concomitant piriformis surgery adds another 45 minutes to the procedure in general and occasionally an extra day of hospitalization. Click to learn more about pirformis surgery.
1. Pins guiding screws placement
2. Metal Struts across the sacroiliac joint
3. Metal Struts across sacroiliac joint, CT view
4. 3D CT scan of pelvis to asses symmetry