What are the considerations for sacroiliac (SI) joint surgery clearance in an elderly patient?

Preoperative Clearance for Sacroiliac Joint Surgery in an Elderly Man

Elderly patients over 65 years undergoing sacroiliac joint surgery require mandatory frailty screening using a validated tool, comprehensive geriatric assessment, and co-management by a geriatrician or physician specialized in older adult care, starting preoperatively and continuing through the postoperative period. 1

Preoperative Risk Stratification

Age and Frailty Assessment

• All patients over 65 years must be screened for frailty using a validated tool before proceeding with SI joint surgery 1
• Frailty is the strongest predictor of mortality at 12 months post-surgery, along with increased ASA status 1
• Frailty demonstrates a dose-dependent effect on failure-to-rescue (FTR), postoperative complications, reoperation, and all-cause mortality in older surgical patients 1
• The risk-adjusted FTR rate is significantly higher in patients ≥75 years after pulmonary or infectious complications 1

Cardiovascular Evaluation

• Men 45 years or older starting any surgical program should undergo cardiovascular risk assessment using screening tools from the American College of Cardiology and American Heart Association 1
• Evaluate for valvular heart disease, particularly aortic stenosis, which requires special consideration in elderly patients 1
• Screen for cardiac disease, as it represents a modifiable variable that must be optimized preoperatively 1

Medical Optimization

The systematic multidisciplinary preoperative assessment must include:

• Nutritional status evaluation - malnutrition is a critical modifiable risk factor 1
• Electrolyte and volume status - disturbances must be corrected 1
• Anemia screening - full blood count and correction if needed 1
• Renal function assessment - impacts medication dosing and perioperative management 1
• Cognitive baseline function - dementia and delirium risk assessment 1
• Pulmonary disease evaluation - chest X-ray required 1
• ECG and cardiac assessment 1

Diagnostic Confirmation Before Surgery

Confirming SI Joint as Pain Generator

• Fluoroscopically guided diagnostic SI joint injection with ≥75-80% pain relief is required to confirm the SI joint as the source of pain before considering surgery 2, 3, 4
• At least 3 of 5 positive provocative physical examination tests are needed, providing 94% sensitivity and 78% specificity 2
• Image-guided injection is mandatory, as palpation-guided injections have poor accuracy 1

Imaging Requirements

• Conventional radiography of the sacroiliac joints should be obtained first 5
• MRI of the sacroiliac joints without contrast (sensitivity 79%, specificity 89%) if radiographs are negative or equivocal but clinical suspicion remains high 5, 2
• Complementary spine radiographs (cervical and lumbar) should be performed 5

Surgical Candidacy Criteria

Indications for Surgery

Surgery should only be considered when:

• Positive response to SI injection with >75% relief 3
• Failure of nonsurgical treatment including physical therapy, NSAIDs, activity modification, and SI belt 3
• Continued or recurrent SI joint pain despite conservative measures 3
• Failure of radiofrequency ablation if attempted 2, 4

Surgical Approach Selection

• Minimally invasive SI joint fusion is recommended as first-line surgical treatment due to improved safety profile compared with open arthrodesis 2, 3
• Open arthrodesis should be reserved for revision surgery, nonunion, or aberrant anatomy 3
• Be aware that minimally invasive SI fusion carries a 13.2% complication rate at 90 days and 16.4% at 6 months 6
• Novel lumbar pathology develops in 3.6% at 90 days and 5.3% at 6 months post-surgery, with men experiencing higher rates (6.7% and 9.1% respectively) 6

Perioperative Management Protocols

Geriatric Co-Management

• Involvement of a physician specialized in care of older adults must occur as soon as possible preoperatively 1
• Comprehensive geriatric assessment (CGA) significantly reduces mortality, length of stay, and discharge to higher levels of care 1
• Integration of a geriatric assessment team with promotion of patient-oriented rehabilitation and early discharge planning is essential 1

Monitoring and Complication Prevention

• Local protocols with physiological track and trigger systems must be implemented to alert to deterioration and prevent failure-to-rescue 1
• Rapid response teams including an intensivist experienced in postoperative surgical management should be available 1
• Early intervention protocols are critical, as prevention of cascade from initial complication to FTR is a specific area for improvement 1

Common Pitfalls

• Proceeding without documented ≥75% pain relief from diagnostic injection - this is the most critical error, as it fails to confirm the SI joint as the pain generator 3, 4
• Failing to screen for frailty in patients over 65 - frailty is the strongest predictor of poor outcomes and must be assessed 1
• Inadequate preoperative medical optimization - elderly patients require correction of malnutrition, anemia, electrolyte disturbances, and cardiac/pulmonary issues 1
• Not involving geriatric co-management preoperatively - waiting until postoperatively misses critical optimization opportunities 1
• Underestimating complication rates - minimally invasive SI fusion has higher complication rates than previously reported, particularly in men for development of novel lumbar pathology 6