SI Joint Surgery: Options and Recovery Times - Health Central

Pain in your lower back, groin, hip, or leg? If your physician or surgeon has suggested "SI joint surgery" to help, you may be wondering what the SI joint is—and whether alternatives to surgery are possible.

You have two sacroiliac joints, or SI joints. They connect the iliac bones (the large "wings" that make up the sides of your pelvis) and the sacrum, the triangle-shaped fusion of vertebrae located between the iliac bones at the base of the spine.

Pain in this area may come from sacroiliitis, or inflammation of an SI joint. Your doctors will probably consider causes such as trauma, arthritis, pregnancy, or (rarely) infection. Referred pain may be involved, as can wear and tear from the stress of weight bearing.

"There are many potential causes," says Steven Garfin, M.D., interim vice chancellor, health sciences; interim dean, School of Medicine; and Distinguished Professor of Orthopaedic Surgery, University of California San Diego.

"Perhaps 20-plus percent of back pain can be related to the SI joint," Dr. Garfin says. Let's look at options for treating that pain.

SI Joint Fusion Surgery

First, note that surgery is rarely—if ever—the first line of treatment for SI joint pain. You almost always will have tried some of the nonoperative treatment methods below before you go under the knife. But, if you tell your physician that the pain has become intolerable, and he or she has gone through the steps to determine that an SI joint is causing your pain, surgery to stop its movement would appear the next best option.

Surgery "was never done very much," says Dr. Garfin. It caused three major complications: inflection (because of the location near the rectum), poor healing (the joint is difficult to immobilize), and continued pain. Open SI joint surgery involved slicing through skin, muscles, and ligaments to reach the joint, scrape out cartilage, and put in a plug of bone, all of which contributed to a lot of tissue trauma and a long recovery time.

In the 1990s, a private company pioneered a minimally invasive SI joint fusion technique; Dr. Garfin was involved early on and helped design its studies. Using X-ray guidance, surgeons now send a thin wire over which screws or bolts are placed to stop motion in the affected joint. Holes in the hardware allow for bone addition, or for bone to grow naturally across or onto the area to maintain stability.

The minimally invasive versions of this surgery can be either outpatient procedures or overnight, depending on surgeon preference and what kind of support you have available.

SI Joint Surgery Recovery Time

For most patients, recovery time includes about three weeks on crutches. The amount of pain to manage depends on whether screws or bolt are involved; the pounding of bolts tends to be more uncomfortable. Nonetheless, post-op pain dissipates in days or a couple of weeks.

Fusion itself takes six or more months to complete. But because the joint's motion—only about four degrees, far less than the hip or the knee—is stopped, "clinically the success is pretty quick," Dr. Garfin says.

Given that the SI joints transmit all weight of the body above the pelvis down through the sacrum to the hips and legs, "they're the center of a lot of forces," Dr. Garfin points out. Surgery stops the joints' movement "but doesn't appear to have any obvious side effects," says Dr. Garfin.

Indeed, minimally invasive SI joint surgery from the side has "become a recognized safe, predictable, and preferred surgical method for the management of intractable, debilitating primary or secondary [SI joint] pain disorders," write the authors of an International Journal of Spine Surgery article.

If initial efforts to stop pain in ways short of surgery help, that's great, Dr. Garfin says. If not, and you and your physician choose to go with a procedure, as the journal article puts it: "Studies demonstrate consistent improvements in pain, function, and [quality of life]."

When Do You Need SI Joint Surgery?

Barring major trauma or disease, pain will lead the decision on surgery, Dr. Garfin says. "You don't just rush in and operate…. We can try injections, medications, physical therapy, time and other things to try to calm down the inflammation. If all that fails, and the patient just can't tolerate the pain, then you consider surgery."

Surgery is not for patients with less than six months of confirmed localized pain or impairment, though, and other causes need to be ruled out, write the authors of a 2020 article in the International Journal of Spine Surgery. This period is useful for trying alternatives first.

Conservative Treatments for SI Joint Pain

Rest and Medication

Decreasing pressure on the SI joint for a while may help. Staying off your feet for a few days, using ice bags or a heating pad on your lower back or buttocks, and massaging nearby muscles may all help if the apparent cause is an injury. Your doctor may suggest using a cane, walker, or crutches to buy some time and see—under medical supervision—whether the problem is the SI joint after all.

Medications to try early include anti-inflammatories such as ibuprofen, naproxen, or their prescription alternatives. Acetaminophen helps with pain but not inflammation. "If you decrease inflammation, theoretically the pain goes down, too," says Dr. Garfin.

Corticosteroids

A common nonsurgical treatment is the steroid cortisol, injected under X-ray guidance. Steroids are the most powerful anti-inflammatory we have, Dr. Garfin says, and with injection rather than oral form, they go directly to where they're needed rather than spreading throughout the body (which can cause undesirable side effects). Regardless, there is a limit to the number a specialist will want to try, both because of the difficulty of getting it into the right joint and because "repeat injections tend not to work as well," says Dr. Garfin.

Physical Therapy

Some physical therapists believe that if there's displacement of the SI joint, they may be able to strengthen the muscles around it and realign the joint, even minimally. Just as the joint should not become too loose, it shouldn't become stiff, either, Dr. Garfin notes—not taking a position on the effort.

Complementary, Alternative, and Emerging Treatments

Treatment possibilities that have been tried, though Dr. Garfin is "not necessarily a fan," include platelet-rich plasma ("I don't think the science is there to confirm its utility," he says) and radiofrequency ablation to stop the pain signal ("the nerve regenerates" in perhaps six months). Corsets tend not to work, he adds.

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