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6/1/2011Background• SI Joint primary source of backpain < 1940’s.Mixter & Barr article regardingnucleus pulposus in 1934.Past 15 years, mounting evidence viaCT & MRI of destructive, inflammatory& degenerative pathology suggestreconsideration SI joint as source oflow back pain.4Low Back Pain22.5% presenting with LBP‣ One of largest studies by Bernardand Kirkland-Willis found a 22.5%prevalence rate in 1293 adultpatients presenting with LBP.30% presenting with LBP‣ Schwarzer et al. 43 consecutivepatients with chronic LBP below 5-1(SI injections) 30% prevalence.Ha reported 75% incidence ofSI joint degeneration at 5years post-lumbar fusionsurgery.S-I20%Other10%Facet30%Disc40%HighPrevalence(20% of LBP)MIS solutionsare becomingavailablePatientscontrolled byPainManagementSacroiliac Joint DysfunctionIncreasingsurgeonawareness &interestInjections aregold standardfor treatmentInjections areineffectivelong-termtreatment62

6/1/2011Non-operative Measures• Should patient present positive symptoms, surgeonsmay refer patient to pain management specialists.• Treatment by following methods effective buttemporary.Treatment options may include:‣ Anti-inflammatory meds‣ Sacral belt‣ 6-12 weeks of PT‣ SI Joint InjectionsAlternative Treatments Options:‣ Prolotherapy‣ Neuroaugmentation‣ Viscosupplementation‣ Radiofrequency Ablation‣ Accupuncture..Surgical CandidatesPatients maybe candidates for SI fusion if they met the following criteria:Failed combination of previoustreatmentsExhibit chronic pain > 6mosDisabled from ADLMentally capable of goal directionand reasonable expectations postsurgery11Anatomic Corridor4

6/1/2011Lateral View• Use the Lateral View to locate theaccess starting pointOverlapping projection of right andleft joints in the sagittal planeShows critical boundaries of the safezone such as the anterior sacralcortex, the alar slope, the sacralforamina, and the spinal canal.• Move to the Inlet View for anteriorposteriortrajectory confirmation13• Use the Inlet View to confirmtrajectoryAxial projection of the sacrumConfirms safe zone trajectoryrelative to the spinal canal andanterior sacral cortex• Move to the Outlet View forcaudal-cephalad trajectoryconfirmation and jointpreparationInlet View14• Use the Outlet View toconfirm trajectory andprepare jointOutlet ViewProjection of the whole sacrumConfirms safe zone trajectoryrelative to the neuroforaminaand S1 endplate.155

6/1/2011iFuse Implant System• Porous plasma spraycoated titaniumimplants• Lengths: 35-55mm• Diameter: 4-7mm• Minimally invasivelateral approach• No bone graft is used• Implants are fixatedacross the SI jointDIANA Cage• Cage is indicated for lumbarinterbody fusion• Posterior approach• Self-tapping, hollow & fenestratedcage• Implants distracts the joint• Length: 30mm• Diameter: 13-19mm• Joint preparation & bone graftingare part of the procedure• Implants are inserted between theSI joint surfacesSImmetry Procedure OverviewThree phases of SImmetryprocedure:AccessJoint PreparationImplant Delivery186

6/1/2011Joint PreparationBone GraftingImplant Delivery7

6/1/2011Final ImplantJoint Preparation InstrumentsSpecially designed curettes allow for:- Minimally Invasive Perpendicular Access to the SI joint- Removal of cartilage and preparation of the joint surfaceIlium Curette Function: Create room in joint Tip Height: 2.5 mm Cutting Diameter: up to 25mmSacrum Curette Function: Prepare Ilium Tip Height: 3mm Cutting Diameter: up to 25mmDual Currette Function: Prepare Sacrum Tip Height: 4.5mm Cutting Diameter: up to 25mm23Joint Preparation – DissectedJoint248

6/1/2011Clinical Experience• Cases• Images• Follow-up• How I found patients• Etc25Adding SIJ Fusion to yourPractice• Screening for patients• Reimbursement = spinal fusion• DRG 460• CPT 27280, 22899(27216), 20930, 2093626The Future of SIJ Fusion• SIJ Fusion is Hot Topic!• Minimally Invasive solutions are popping up• Will become significant part of surgeon practice• Outpatient surgery279

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