Sacroiliac pain after PLIF
and/or posterolateral lumbar
fusion;
anesthetic joint blocks with
corticosteroids
R. Hart, R. Bárta, F. Okál, M. Komzák
Dept. of Orthopaedics and Traumatology
General Hospital Znojmo
Czech Republic
Introduction
•
Low back pain persisting or appearing after a technically successful lumbar
fusion challenges spine surgeons. The sacroiliac joint (SIJ) can cause pain
after this surgery. Adjacent segment degeneration following fusion has
attracted considerable attention. However, little attention has been paid to
the SIJ, which is one of the adjacent joints.
•
The fusion at the lumbar spine level increases motion and stresses at the
SIJ (Ivanov et al., 2009). This could be a probable reason for low back pain
in patients after lumbar spine fusion procedures. For 20 % to 30 % of
patients, failed back surgery syndrome is a possible complication.
•
This study is a retrospective review of patients with low back pain after
posterolateral lumbar and lumbosacral allograft fusion with or without PLIF
who had SIJ injections to relieve sacroiliac symptoms.
Material
•
•
•
•
•
•
•
151 patients underwent lumbar („floating“) or lumbosacral („fixed“) fusion in
2006 and 2009 (without posterior iliac bone-graft harvesting).
Meanly 2,2 segments were stabilized (range, 1 – 4 segments).
The SIJ was diagnosed as a contributing factor in failed back surgery
syndrome (by specific diagnostic tests for the SIJ) in 14 of the 34 cases
(41%) (10 women and 2 men).
The mean age in time of the aplication was 56 years (range, 47 to 68
years).
Radiological analysis revealed degenerative changes in the SIJ in 2 men of
14 cases.
There were 4 „floating“ (2 cases L2-4, 1 case L3-5, 1 case L2-3) and 10
„fixed“ fusions (6 cases L5-S1, 2 cases L4-S1, 2 case L3-S1).
A pain-free interval of more than 3 months between surgery and
appearance of the SIJ pain was present in all patients.
Method
•
•
SIJ blocks with corticosteroid/anesthetic were done under fluoroscopic
control
20 mg (0,5 ml) of methylprednisolon (Depo-Medrol®, Pfizer, Puurs,
Belgium) and 4,5 ml of 1 % Mesocain (Zentiva, Praha, Czech Rep.).
•
•
Pain relief was evaluated with use of visual analog scale (VAS).
The pain relief interval after the block was recorded (in weeks).
•
Descriptive statistics was used to characterize the sample.
Results
•
•
•
Pain relief in 24 hours was observed in all cases.
In no case was the relief complete.
Relief of more than 50 % of pain on a VAS was recorded in 10 patients
(71,4%); it means more than 2/3 rate of positive blocks.
•
An average value of the VAS increase was 4,3 (range, 1 to 6); before
application 9,1 points (8 – 10 points) and after application 4,8 points (2 – 7
points).
Modus was 5 points (7 cases), median 50%, and standard deviation 15,1%.
•
•
•
The mean duration of the pain relief was 5,0 weeks (range, 1 to 28 weeks).
Modus was 2 weeks (5 cases), median 2 weeks, and standard deviation 6,8
weeks.
Method
Woman, 51 years, underwent scoliosis correction with unilateral PLIF and PL fusion.
9 months after the surgery she started to complain about the pain in the right buttock.
Method
8 months after unsuccessfull physiotherapy,
the corticosteroid was applied.
The effect lasted only 2 weeks.
Discussion
•
•
•
•
Former studies noted that SIJs are not adversely affected by lumbar spine
fusion and appear to be relatively noncontributory to problems following
such lumbar surgery (Frymoyer et al., 1978).
Recent investigations show that SIJ degeneration develops more often in
patients undergoing lumbar or lumbosacral fusion regardless of the number
of fusion segments (Ha et al., 2008).
SPECT can be of value in the assessment of painful SIJs after fusion
(Onsel et al., 1992) except for clinical tests.
Treatment of the SIJ symptoms is not easy. SIJ fusion for degenerative SIJ
syndrome gives poor, in 82 % not acceptable outcomes (Schütz et Grob,
2006).
Conclusion
•
The corticosteroid/anesthetic block under fluoroscopic control remains the
gold standard for diagnosis of SIJ pain.
•
Unfortunatelly, the duration of its efficacy (the therapeutic effect) is relatively
short.
•
Our results are in accordance with other studies (Liliang et al., 2009,
Maigne et Planchon, 2005, Katz et al., 2003, Maigne et al., 1995).
•
These findings suggest the need for further studies, especially of
physiotherapy in sacroiliac pain after lumbar fusion.
Disclosure
• There is nothing to disclose.
• None of the authors has any potential
conflict of interest.