International Society for the Advancement of Spine Surgery Policy 2020 Update—Minimally Invasive Surgical Sacroiliac Joint Fusion (for Chronic Sacroiliac Joint Pain): Coverage Indications, Limitations, and Medical Necessity

Abstract

The index 2014 International Society for the Advancement of Spine Surgery Policy Statement-Minimally Invasive Surgical Sacroiliac Joint Fusion-was generated out of necessity to provide an International Classification of Diseases, Ninth Revision (ICD-9)-based background and emphasize tools to ensure correct diagnosis (Appendix Table A1). A timely ICD-10-based 2016 update provided a granular threshold selection with improved level of evidence and a more robust and relevant database. As procedures and treatment options have evolved, this 2020 update reviews and analyzes the expanding evidence base and provides guidance relating to differences between the lateral and dorsal surgical procedures for minimally invasive surgical sacroiliac joint fusion.

Sacroiliac Joint and Pelvic Dysfunction Due to Symphysiolysis in Postpartum Women

“…The largest true synovial joint in the body, the sacroiliac joint (SIJ), is one of the most common sources of chronic lower back pain (LBP), as it is a highly specialized joint that is innervated by spinal nerves and grants stability, limited flexibility, and support of the upper body [1][2][3]. Sacroiliitis is defined as the inflammation of the SIJ that can present in both rheumatic and non-rheumatic disorders and can be caused by both traumatic and atraumatic etiologies [2,4].…”

“…Consequently, the SIJ has been estimated to account for 15%-30% of chronic low back pain in the general population. Risk factors include obesity, low-grade trauma such as jogging, pregnancy, lumbar fusion, scoliosis, leg length discrepancy, and gait abnormalities [ 2 , 3 ]. The pain can be attributed to the posterior extra-articular elements, such as ligamentous or muscular injuries, enthesopathy, or intra-articular elements [ 2 , 3 , 5 ].…”

“…Although there are no specific historic features, provocation tests, or radiological findings that conclude a definite diagnosis of SIJ pain, the diagnostic algorithm is conducted through a proper medical history followed by physical examination, imaging study, and sometimes diagnostic SIJ blocks [ 2 , 3 ]. There is a wide array of non-surgical treatments including pain medication, steroid injections, physical therapy, individualized pelvic stabilizing exercises, and radiofrequency ablation of the sacral nerves [ 3 , 7 ]. Sacroiliac joint fusion, open or minimally invasive, is reserved for those patients with a diagnosis of chronic SIJ pain who experience pain for a minimum of six months and do not respond to conservative treatment [ 3 ].…”

“…There is a wide array of non-surgical treatments including pain medication, steroid injections, physical therapy, individualized pelvic stabilizing exercises, and radiofrequency ablation of the sacral nerves [ 3 , 7 ]. Sacroiliac joint fusion, open or minimally invasive, is reserved for those patients with a diagnosis of chronic SIJ pain who experience pain for a minimum of six months and do not respond to conservative treatment [ 3 ]. Currently, there is a scarcity of published outcomes investigating the occurrence of sacroiliac (SI) joint dysfunction in postpartum women.…”

Novel Interventional Techniques for Chronic Pain with Minimally Invasive Arthrodesis of the Sacroiliac Joint: (INSITE, iFuse, Tricor, Rialto, and others)

“…It affects about 15-25% of patients with axial low back pain [25,26], and up to 40% of patients with ongoing pain following lumbar fusion. [27,28].…”