Continued pain after sacroiliac joint surgery

Marc Darrow, MD, JD.

Failed sacroiliac (SI) joint fusion is generally suspected when a patient continues to experience persistent pain and functional limitation after surgery. Reported causes of failure include pseudarthrosis (nonunion), implant loosening, implant malposition, and continued pain despite partial fusion.

In a 2024 retrospective cohort study (1) of 52 patients undergoing revision SI joint fusion, prior literature cited by the authors reported revision rates of about 2.9% within 2 years, while the study itself found that overall improvement in pain and disability at 1 year did not reach statistical significance and that few patients experienced complete symptom resolution; chronic opioid use was also associated with poorer disability outcomes. The authors suggested that persistent symptoms after surgery may reflect incorrect indications, lack of biologic fusion, or coexisting pain generators They wrote: “(This) study demonstrates patients undergoing revision surgery have moderate improvement in low back pain, however, few have complete resolution of their symptoms. Specific patient factors, such as chronic opiate use and female sex may decrease the expected improvement in patient-reported outcomes following surgery. Failure to obtain relief may be due to incorrect indications, lack of biologic fusion and/or presence of co-pathologies.”

A 2026 study (2) of 48 revision cases similarly found that pseudoarthrosis, implant loosening, continued pain with partial fusion, and implant malposition were the leading indications for revision, with more consistent improvement seen in patients revised for pseudoarthrosis, loosening, or malposition than in those revised for persistent pain despite partial fusion.

A 2025 study (3) on lumbar and lumbosacral fusion suggests that multi-level fusion constructs and fusion to the sacrum may increase the risk of subsequent SI-joint-related pain and later SI joint procedures, although pain outcomes, radiographic degeneration, and revision risk should be interpreted as distinct endpoints rather than interchangeable measures of failure .

Sacroiliac joint pain after lumbar or lumbosacral fusion is now better recognized than it was a decade ago, but the evidence is still mixed. More recent reviews suggest that lumbar fusion can increase stress across the sacroiliac joint and may contribute to new sacroiliac joint dysfunction in some patients, especially when the fusion extends to the sacrum or involves multiple segments. A 2024 systematic review (4)  found that new-onset sacroiliac joint dysfunction after lumbar fusion occurred in about 7% of patients across the included studies, with higher risk reported in patients with fusion of three or more segments. The authors concluded that lumbar fusion appears to predispose some patients to sacroiliac joint dysfunction, likely because of altered biomechanics.

Other reviews have reported even higher rates when the outcome measured is sacroiliac joint pain rather than radiographic degeneration. A 2023 systematic review (5) estimated a pooled incidence of sacroiliac joint pain after lumbosacral fusion of 15.8% overall, and 32.9% when the fusion construct included the sacrum. That review also noted that the literature is limited by inconsistent diagnostic criteria and variable study quality.

A 2024 comparative study (6) of 116 patients helps clarify an important point. In that study, patients who had multi-segment fusion had worse low back pain scores than those who had single-segment fusion at 6 months after surgery, and patients with fusion to the sacrum also had somewhat worse pain scores during follow-up. However, CT evidence of sacroiliac joint degeneration did not significantly differ between the groups. The authors concluded that sacroiliac joint degeneration occurred independently of the number of fused segments or whether the sacrum was included. In other words, larger fusion constructs may be associated with more postoperative pain, but that does not necessarily mean they produce more CT-demonstrated sacroiliac degeneration over 2 years.

Sacroiliac joint fusion remains a debated treatment for chronic sacroiliac joint pain.

Sacroiliac joint fusion remains a debated treatment for chronic sacroiliac joint pain. A 2015 study (7) argued that the procedure was being adopted on the basis of inconsistent diagnostic criteria, weak study design, bias, and limited long-term follow-up, and they warned that its indications had not yet been standardized. That criticism still matters, especially because diagnosing the sacroiliac joint as the true pain generator remains difficult, and outcomes depend heavily on patient selection.

This is the title of a paper published in the journal Neurosurgery clinics of North America : “Sacroiliac Fusion: Another “Magic Bullet” Destined for Disrepute.”(8)

This is what the paper says:

“Pain related to joint dysfunction can be treated with joint fusion; this is a long-standing principle of musculoskeletal surgery. However, pain arising from the sacroiliac joint is difficult to diagnose. . . Evidence establishing (successful) outcomes (of spinal fusion) is misleading because of vague diagnostic criteria, flawed methodology, bias, and limited follow-up. Because of non-standardized indications and historically inferior reconstruction techniques, SI joint fusion should be considered unproven. The indications and procedure in their present form are unlikely to stand up to close scrutiny or weather the test of time.”

There are many people who may disagree that fusion will not help sacroiliac joint pain. Many people do in fact do get pain relief and benefit from surgery. I don’t see this people in my office. I see the people who did not do well after surgery. A December 2019 still asked “What do we know about the biomechanics of the sacroiliac joint and of sacropelvic fixation?” (9)

Here is an explanation of why this surgery may work for some, but may not work for others. “The sacroiliac joint is characterized by a large variability of shape and ranges of motion among individuals. Although the ligament network and the anatomical features strongly limit the joint movements, sacroiliac displacements and rotations are not negligible. 

Currently available treatments for sacroiliac joint dysfunction include physical therapy, steroid injections, Radio-frequency ablation of specific neural structures, and open or minimally invasive SIJ fusion. Several studies reported the clinical outcomes of the different techniques and investigated the biomechanical stability of the relative construct (the construct being the fusion itself), but the effect of sacropelvic fixation techniques on the joint flexibility and on the stress generated into the bone is still unknown. In our opinion, more biomechanical analyses on the behavior of the sacroiliac joint may be performed in order to better predict the risk of failure or instability of the joint.”

“The sacroiliac joint has been estimated to contribute to pain in as much as 38% of cases of lower back pain. There are no clear diagnostic or treatment pathways. . . “

This is a study from December 2020. The doctors in this study use a much stronger language to describe the overreliance of SIJ Fusion. The paper was published in the Journal of pain research. (10)

“The sacroiliac joint has been estimated to contribute to pain in as much as 38% of cases of lower back pain. There are no clear diagnostic or treatment pathways. . . “

Here are some of the points provided by this study:

• “Proposed criteria for diagnosis of sacroiliac joint dysfunction can include pain in the area of the sacroiliac joint, reproducible pain with provocative maneuvers, and pain relief with a local anesthetic injection into the SIJ.
• Conventional non-surgical therapies such as medications, physical therapy, radiofrequency denervation, and direct SI joint injections may have some limited durability in therapeutic benefit. Surgical fixation can be by a lateral or posterior/posterior oblique approach with the literature supporting minimally invasive options for improving pain and function and maintaining a low adverse event profile.
• SIJ pain is felt to be an underdiagnosed and undertreated element of low back pain. There is an emerging disconnect between the growing incidence of diagnosed SI pathology and underwhelming treatment efficacy of medical treatment. This has led to an increase in SI joint fixation (fusions).”

SI Fusion is probably better than traditional conservative care treatments

An August 2022 study (11) found that: “Among patients meeting diagnostic criteria for SI joint pain and who have not responded to conservative care, minimally invasive SI joint fusion is probably more effective than conservative management for reducing pain and opioid use and improving physical function and Quality of Life.” Also noted from these researchers is that side effects and complications “appear to be higher for minimally invasive SI joint fusion than conservative management through 6 months. Based on evidence from uncontrolled studies, serious adverse effects from minimally invasive SI joint fusion may be higher in usual practice compared to what is reported in trials.”

Post-operative opioid use

In December 2023 researchers (12) evaluated the duration and magnitude of post-operative opioid prescriptions after minimally invasive surgical sacroiliac joint fusion as compared to other common spine surgeries. The researchers acknowledge that minimally invasive surgical sacroiliac joint fusion “has been reported to significantly improve quality of life and reduce pain. However, there is a (lack) of reported data on post-operative opioid use in patients undergoing minimally invasive surgical sacroiliac joint fusion for sacroiliac joint dysfunction. In a survey of  4,666 patients who underwent minimally invasive surgical sacroiliac joint fusion, the researchers found patients “continued to fill opioid prescriptions 1-year post-operatively at significantly higher proportions than those undergoing other common spine procedures . . . pre-surgery chronic opioid users filled the highest opiate dosages during the 30-day post-operative period. The conclusion of this research was “minimally invasive surgical sacroiliac joint fusion may result in less effective pain reduction when compared to other common spine surgeries. . . ”

If you have chronic back pain, have had painkillers, physical therapy, and other conservative care options that have not helped, and, now you are being told to have another surgery, we may be able to help reduce pain and increase function non-surgically. Regenerative medicine injections may be an alternative for you. Many people benefit from these treatments, but, they do not work for everyone. Will it work for you? Get a FREE phone consultation.

Call for a free phone consultation with our staff 800-300-9300

Related articles

Postoperative chronic back pain syndrome – Failed Back Surgery Syndrome Conservative care treatments

Misdiagnosis – When it may not be Sacroiliac joint dysfunction

Are MRIs sending people to back surgery who may not need back surgery?

References

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