Sacroiliac joint fusion: incidence, timing, and risk factors for contralateral fusion

Sacroiliac joint (SIJ) dysfunction is implicated in 15% to 25% of cases of chronic lower back pain, a leading cause of disability globally. Sacroiliac joint fusion (SIJF) has become an increasingly utilized treatment for refractory SIJ pain, with its adoption projected to rise significantly. While SIJF can alleviate symptoms, many patients develop contralateral SIJ pathology requiring subsequent surgery. Understanding the incidence, timing, and risk factors for bilateral SIJF is critical for improving patient outcomes, managing expectation, and guiding surgical decision-making.This study aimed to (1) determine the incidence of bilateral SIJF, (2) assess the timing between initial ipsilateral and subsequent contralateral SIJF, (3) identify risk factors associated with progression to contralateral SIJF, and (4) compare the timing to contralateral SIJF between patients presenting with unilateral versus bilateral SIJ dysfunction.

A retrospective review was conducted identifying 323 consecutive SIJFs performed between 2011 and 2024 at an integrated healthcare system. Three clinical cohorts were identified based on progression to SIJF. Cohort 1 included patients who underwent unilateral SIJF only. Cohort 2 patients developed contralateral SIJ pain following initial SIJF, while Cohort 3 patients had bilateral SIJ pain prior to initial SIJF. Demographics and prior spine surgical details were collected and included in multivariate analysis. Kaplan-Meier survival curves were used to evaluate the timing between SIJFs. Comparisons between groups were established with student's t-test and chi-square analysis. Statistical significance was defined as p < .05.

A total of 57 (21%) patients underwent bilateral SIJF. Prior L5-S1 fusion was associated with a higher likelihood of bilateral surgery (OR = 2.55, p = .042), while prior lumbar fusion not involving L5-S1 was protective (OR = 0.20, p = .036). Over 90% of contralateral SIJF cases occurred within 18 months of the initial ipsilateral SIJF procedure. Patients in Cohort 3 progressed more rapidly to contralateral surgery than those in Cohort 2 (6.2 months vs. 12.7 months, p = .004). Average body mass index (BMI) was higher in Cohort 3 patients (31.9 kg/m² vs. 28.2 kg/m², p = .038). Cohort 3 also showed a significantly higher incidence of prior single-level L5-S1 fusion (50% vs. 13%, p = .008). Age, sex, and multilevel lumbar fusions were not significantly associated with bilateral SIJF.

Contralateral SIJF occurs in 21% of patients who have undergone initial unilateral SIJF, with over 90% of cases occurring within 18 months of the initial ipsilateral fusion procedure. Bilateral SIJ pain prior to initial SIJF and prior L5-S1 fusion are key predictors of contralateral surgery. Patients with bilateral SIJ pain had elevated BMI. These findings highlight the importance of early identification of high-risk patients to inform treatment decisions and potentially improve outcomes.