Is medication or surgery medically indicated for a patient with sacroiliitis and debilitating bilateral lumbosacral back pain, status post (after) arthrodesis sacroiliac joint?

Post-Surgical Sacroiliac Joint Arthrodesis Management

For a patient who has already undergone sacroiliac joint arthrodesis for sacroiliitis with debilitating bilateral lumbosacral back pain, additional surgery is not indicated unless there is documented nonunion or surgical failure; medical management should focus on optimizing pain control, physical therapy, and addressing any persistent inflammation if the fusion is solid.

Clinical Context and Evaluation

The key question here is whether the patient has achieved successful fusion and what is driving any persistent pain:

• Assess fusion status radiographically - Solid fusion occurs in approximately 85% of cases following SI joint arthrodesis, with significant functional improvement expected in 75% of patients 1
• Evaluate for surgical complications including nonunion, hardware failure, or adjacent segment disease 2, 1
• Distinguish between mechanical pain from the surgical site versus ongoing inflammatory sacroiliitis - This requires clinical examination and potentially imaging 3

Medical Management Post-Arthrodesis

If Fusion is Solid but Pain Persists

NSAIDs remain first-line for residual inflammatory symptoms:

• On-demand NSAID treatment is conditionally recommended over continuous treatment for stable disease 3, 4
• NSAIDs should be trialed for at least 1 month before considering treatment failure 3

Biologic therapy for persistent inflammation:

• If active sacroiliitis persists despite NSAIDs (confirmed by clinical examination and/or MRI findings), TNF inhibitor therapy is strongly recommended 4, 3
• No particular TNF inhibitor is preferred as first choice 4, 3
• For patients with contraindications to TNF inhibitors or TNF inhibitor failure, IL-17 inhibitors (secukinumab or ixekizumab) are conditionally recommended 4, 3

Local interventions:

• Intra-articular corticosteroid injections into the SI joint are conditionally recommended for isolated active sacroiliitis despite NSAID treatment 4, 3
• These injections should ideally be performed with imaging guidance (ultrasound or CT) in experienced centers 4, 3
• Following lumbar spine fusion, SI joint injections with anesthetic-corticosteroid combinations provide average pain relief of approximately 47% lasting an average of 5 weeks, though duration varies considerably 5

Physical therapy is essential:

• Physical therapy is strongly recommended for all patients with sacroiliitis, including post-surgical cases 4, 3
• Active supervised exercise interventions are conditionally recommended over passive modalities 4, 3

Treatments NOT Recommended

Systemic glucocorticoids are strongly contraindicated:

• Systemic glucocorticoids are strongly recommended against for axial disease treatment 4, 3
• Short-term oral glucocorticoids (<3 months) may only be conditionally considered as bridging therapy during initiation of biologic therapy in cases of high disease activity 4, 3

Conventional DMARDs have no role:

• Methotrexate monotherapy is strongly recommended against for sacroiliitis 4, 3
• Conventional DMARDs (sulfasalazine, methotrexate, leflunomide) are not recommended for purely axial disease 4, 3

Surgical Considerations

Revision surgery is indicated only in specific circumstances:

• Documented nonunion - If radiographic assessment demonstrates failure to achieve solid fusion 2, 1
• Hardware failure or aberrant anatomy requiring open arthrodesis 2
• Adjacent segment disease - SI joint dysfunction can occur as an "adjacent segment" problem after lumbar spine stabilization, with overloading of the SI joints 5

Surgery is NOT indicated if:

• Solid fusion is present on imaging 1
• Pain is primarily inflammatory in nature and responsive to medical management 3
• Conservative and interventional non-surgical options have not been exhausted 6, 2, 7

Common Pitfalls

• Assuming all post-surgical pain requires revision surgery - Most patients with solid fusion and persistent pain benefit from medical management rather than additional surgery 1
• Using systemic steroids for axial symptoms - This is strongly contraindicated and ineffective 4, 3
• Failing to distinguish inflammatory versus mechanical pain - This distinction guides whether biologic therapy versus surgical revision is appropriate 3, 7
• Premature surgical intervention - Conservative management including physical therapy, NSAIDs, and interventional procedures should be attempted before considering revision surgery 6, 2, 7