Fusion treatment of sacroiliac joint related low-back pain
Low-back pain is a highly prevalent condition affecting a large portion of the adult population in industrialised countries [1]; however, while low-back pain is extremely common, the diagnosis of the underlying cause of the pain is challenging. Scientific research has identified sacroiliac joint disease as the reason for low-back pain accounting for 10–30 per cent of cases [2,3]. Among the so-called failed back surgery patients the sacroiliac joint can even be considered as the most likely source of pain [4].
When conservative treatment of the sacroiliac joint disease has not been successful, interventional strategies, such as distraction interference arthrodesis with the DIANA procedure (distraction interference arthrodesis, neurovascular anticipating), represent a valid treatment option [5]. With this surgical method, an implant is anchored at the hardest point of the pelvic bone in order to ensure that the distance between the painful joint surfaces that is being restored by surgery is maintained during the healing phase. When the new bone graft material is transformed into solid bone, the joint stabilises.
Unlike with other surgical strategies, the joint is not screwed in place but the joint space is retained or is corrected by distraction. The posterior approach, away from nerves and large blood vessels, is safe and preserves the ligamentous, muscular and neurovascular structures.
The efficacy and safety of the DIANA procedure has been reported since 2008 [6]. Recently, new long-term results from a prospective multi-centre study with 163 patients were presented at the annual meeting of the German Spine Society in 2014 [7]. These results show a significant improvement of patients’ condition based on all assessed scores (VAS, ODI, MPQ, SF12v2). Also, no intraoperative complications in the form of injuries to the vascular, muscular or nerve structures were observed, confirming the safety of the procedure.
The advantages of the DIANA method can be summarised as follows:
safe posterior approach away from the nerves and large blood vessels
stabilising ligamentous apparatus remains intact
bony and muscular structures are not impaired
controlled bony fusion
implant position can be controlled radiographically on three different planes during surgery
improvement in back and leg pain has been demonstrated.
Uwe Siedler, managing director of SIGNUS Medizintechnik GmbH, the company that manufactures and distributes the DIANA implant, outlines the benefits of the DIANA procedure.
In your opinion, what are the main advantages of the DIANA method compared with other sacroiliac surgical interventions?
DIANA is a posterior approach for fusion of the sacroiliac joint that aims at restoring the natural joint space rather than screwing two bone regions, the sacrum and ilium, together. This biomechanical alignment differentiates the DIANA method from other methods. Also, the procedure is safe and gentle to the surrounding neurovascular and osseous structures. The DIANA instrumentation is sequential and supports the anatomically correct positioning of the implant.
What should be considered when performing sacroiliac joint surgery?
The challenges of a successful fusion of the sacroiliac joint are significant. Proper diagnosis, pre-operative planning, insertion technique and postoperative care are key for treatment success. This requires experience and thorough preparation on the side of the surgeon performing the treatment. The DIANA approach is designed to define margins of physiologic and anatomic safety, but it remains incumbent on the surgeon to confirm that the DIANA method can be safely applied.
How do you support surgeons?
SIGNUS offers anatomy and practical surgical courses on a regular basis. Also, we support the continuous exchange of experience among the DIANA users so as to broaden the awareness of the range of indications and to expand the evidence-based data.
References
- Anderson, G.B. (1999) Lancet 345, 581–585
- Schwarzer, A.C., et al. (1995) Spine 20(17), 1878–1883
- Sembrano, J.N., et al. (2008) Spine 34(1) E27–E32
- DePalma, M., et al. (2011) Pain Medicine 12(5), 732–739
- Lorio, M.P., et al. (2014) ISASS Policy Statement. Int. J. Spine Surg. 8, 25
- Stark, J.G., et al. (2008) AAOS, San Francisco, USA
- Fuchs, V., et al. (2014) Eur. Spine J. – DWG Abstract Supplement 23, 2473–2569
SIGNUS Medizintechnik GmbH
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