What treatment options are available for sacroilitis with severe joint space narrowing?

Can an Orthopedic Surgeon Help with Sacroilitis and Severe Joint Space Narrowing?

Yes, an orthopedic surgeon can offer surgical intervention for refractory sacroiliitis with severe joint space narrowing, but only after exhausting medical management including NSAIDs, TNF inhibitors, and interventional procedures—surgery should be reserved as a last resort when conservative and medical therapies have failed. 1

Understanding the Treatment Hierarchy

The management of sacroiliitis follows a stepwise escalation approach, with surgical consultation being the final option after medical therapies prove inadequate.

First-Line Medical Management

• NSAIDs are strongly recommended as initial treatment for active sacroiliitis, providing both analgesic and anti-inflammatory benefits. 2, 3, 4
• An adequate trial requires at least 1 month at optimal anti-inflammatory doses before considering treatment failure. 4
• For patients at high gastrointestinal risk, selective COX-2 inhibitors should be prioritized. 4

Second-Line Biologic Therapy

• Adding a TNF inhibitor (etanercept, adalimumab, infliximab, or golimumab) is strongly recommended over continued NSAID monotherapy when NSAIDs fail to control active sacroiliitis. 2, 3, 4
• No particular TNF inhibitor is preferred over another. 2, 4
• For patients with contraindications to TNF inhibitors or who have failed TNF inhibitor therapy, IL-17 inhibitors (secukinumab or ixekizumab) are conditionally recommended. 2, 4

Important caveat: Methotrexate monotherapy is strongly recommended against for sacroiliitis treatment, though sulfasalazine may be considered for patients who have contraindications to or have failed TNF inhibitors. 2, 4

Interventional Pain Management Options

Before considering surgery, several interventional procedures should be attempted:

• Intra-articular corticosteroid injections of the sacroiliac joints are conditionally recommended as adjunctive therapy, ideally performed under imaging guidance (ultrasound or CT). 2, 4, 5
• These injections can provide pain relief lasting up to 6 months in some patients. 5, 6
• Radiofrequency ablation (RFA) of the L5 dorsal ramus and S1-3 lateral branches has demonstrated efficacy in numerous studies, with extensive lesioning strategies showing the strongest evidence. 6
• Prolotherapy may offer potential benefit, though limited data support its use as a primary treatment modality. 1

Physical Therapy as Essential Adjunct

• Physical therapy is strongly recommended for all patients with sacroiliitis to maintain range of motion and strengthen periarticular muscles. 2, 3, 4
• Active supervised exercise interventions are conditionally recommended over passive modalities (massage, ultrasound, heat). 2, 4
• Land-based therapy is conditionally recommended over aquatic therapy. 2, 4

When Orthopedic Surgery Becomes Appropriate

Surgical treatment is indicated only when:

• There is a positive response to diagnostic SI joint injection with >75% pain relief 1
• Failure of all nonsurgical treatments including NSAIDs, biologics, physical therapy, and interventional procedures 1
• Continued or recurrent sacroiliac joint pain despite optimal medical management 1

Surgical Options Available

• Percutaneous (minimally invasive) SI joint arthrodesis is recommended as first-line surgical treatment due to its improved safety profile compared with open arthrodesis. 1
• Open arthrodesis should be reserved for revision surgery, nonunion cases, or aberrant anatomy. 1
• An increasing body of evidence supports minimally invasive procedures as second-line therapies for patients who fail first-line conservative treatment. 7

Critical Pitfalls to Avoid

• Never proceed directly to surgery without exhausting medical management. The treatment algorithm must start with NSAIDs, progress to TNF inhibitors if needed, and include interventional procedures before considering surgical fusion. 3, 4, 1
• Do not use systemic glucocorticoids for axial disease—they are strongly recommended against for sacroiliitis treatment. 2, 4
• Ensure proper diagnosis before surgery. Fluoroscopically guided diagnostic injection with >75% pain relief is considered the gold standard for confirming SI joint as the pain source. 8, 1
• Recognize that severe joint space narrowing may indicate advanced inflammatory disease requiring aggressive biologic therapy rather than immediate surgical intervention. 3, 4

The Bottom Line for Your Patient

An orthopedic surgeon can definitely help, but their role comes after rheumatologic management has been optimized. If your patient with severe joint space narrowing has failed NSAIDs, TNF inhibitors (or IL-17 inhibitors), corticosteroid injections, and radiofrequency ablation, then referral to an orthopedic surgeon for consideration of minimally invasive SI joint fusion is appropriate. 1 However, if biologic therapy has not been attempted or optimized, rheumatology consultation should take priority over surgical evaluation. 3, 4