Incidence and Risk Factors of Sacroiliac Joint Pain Following Lumbar Surgery with and without Fusion in Patients with Spinal Stenosis and Low-Grade Degenerative Spondylolisthesis: A Nonrandomized Clinical Trial

Abstract

Background

Failed back surgery syndrome affects 10 to 46% of lumbar spine surgery patients, often resulting in persistent pain and functional impairment. Sacroiliac joint pain (SIJP) is a significant contributor, particularly following spinal fusion. This study aimed to assess SIJP incidence following lumbar surgery with and without fusion, and identify risk factors for sacroiliac joint syndrome (SIJS).

Materials and Methods

This prospective, nonrandomized clinical trial included 102 patients undergoing lumbar decompression alone (Dec group, n = 50) or decompression with fusion (DecPlus group, n = 52) at two university hospitals. Patients with persistent postoperative pain were assessed for SIJS using clinical provocative tests and fluoroscopy-guided sacroiliac joint blocks. Primary outcomes included SIJP incidence, visual analog scale (VAS) for pain, Oswestry Disability Index (ODI) for disability, and Short-Form (SF)-36 Health Survey for quality of life. Patients were followed for 3 months postoperatively.

Results

SIJP was diagnosed in 36.3% of patients, with significantly higher incidence in the DecPlus group (50%) compared with the Dec group (22%) (p < 0.01). Pain scores (VAS) improved significantly in both groups, but ODI and SF-36 scores showed greater improvement in the Dec group (p < 0.01). SIJP has a significant relation with the upper instrumented vertebra (UIV) and length of fusion; however, extension of fusion to S1 does not significantly increase the SIJP. There was no significant association between SIJP and smoking, body mass index, or other comorbidities.

Conclusion

Based on our study, lumbar instrumented posterolateral fusion, compared with decompression without fusion, should be considered a risk factor for SIJP. In patients with instrumented fusion, the UIV and the length of fusion are related to SIJP; however, extending fusion to S1 does not significantly affect SIJP incidence.

Keywords

decompression - fusion - sacroiliac joint pain - failed back surgery syndrome

Introduction

Global data indicate that the failure rate of lumbar spine surgery ranges from 10 to 46%.[1] This condition, commonly referred to as failed back surgery syndrome (FBSS), describes persistent pain or unsatisfactory outcomes following lumbar spine surgery, failing to meet patient's or surgeon's expectations.[2] The management of FBSS remains a significant challenge for both spine surgeons and pain specialists. Treatment strategies encompass pharmacological interventions, physical therapy, and behavioral modifications, alongside interventional techniques such as injections, radiofrequency ablation, adhesiolysis, spinal cord stimulation, and, in select cases, revision surgery. Effective management of FBSS necessitates a thorough understanding of its contributing factors. As highlighted by Chan and Peng in 2011,[3] the most effective approach to mitigating FBSS incidence and complications lies in emphasizing preventive measures.

FBSS is driven by multiple factors, and successful pain management primarily hinges on their accurate identification.[4] Although its exact etiology remains unclear, consensus suggests that FBSS has a multifactorial origin, with contributing factors classified into preoperative, intraoperative, and postoperative categories.[2] Among the primary causes, sacroiliac joint pain (SIJP) is particularly significant, accounting for ∼25% of cases. Despite its prevalence, the optimal diagnostic approach for SIJP remains a topic of debate. Notably, when spinal fusion extends to the sacrum, the sacroiliac joint (SIJ) is prone to degenerative changes.[5] [6] [7] The biomechanical consequences of fusion at or near the SIJ may lead to sacroiliitis and sacroiliac joint syndrome (SIJS).

The diagnosis and treatment of SIJP following spinal fusion remain controversial, with clinical studies yielding inconsistent and sometimes conflicting findings. Accurate diagnosis is critical due to the substantial morbidity associated with SIJS following lumbar surgery. Notably, sacroiliitis frequently presents without radiological abnormalities, necessitating reliance on clinical findings.[8] [9] [10] [11] [12] In this study, we utilized provocative tests and SIJ blocks with anesthetic agents to determine the prevalence of SIJS.[8] [13] [14] [15] Given that this method provided an objective means to evaluate the prevalence of SIJS in patients with persistent low back pain following lumbar fusion.

The primary objective of this nonrandomized clinical trial was to assess the incidence of SIJP in two patient cohorts with persistent low back pain: those who underwent lumbar surgery with fusion and those without fusion. Secondary objectives included identifying risk factors for SIJS development following technically successful lumbar surgery and determining predictors of a positive response to joint block intervention. Outcome measures included the visual analog scale (VAS), Oswestry Disability Index (ODI), and Short-Form (SF)-36 Health Survey to evaluate the impact of surgical techniques and the efficacy of SIJ block in these two patient groups.

Materials and Methods

Study Design

This multicenter clinical trial was conducted using a prospective, nonrandomized, and nonblinded design between December 2020 and November 2022. The study enrolled 102 patients at two university hospitals. All patients were followed up for 3 months postoperatively. The trial was registered with the Iranian Registry of Clinical Trials (ID: IRCT20231127060204N1). Ethical approval was granted by the ethics committee of our institution (IR.TUMS.SHARIATI.REC.1402.067). Written informed consent was obtained from all participants, following clear and comprehensible verbal explanations.

Participants

Eligibility of the patients to participate in the study was confirmed following a comprehensive neurosurgical evaluation and imaging studies. A systematic framework for inclusion and exclusion criteria was applied for patient selection ([Table 1]). Baseline demographic, clinical, imaging, and laboratory data were documented, along with VAS, ODI, and SF-36 Health Survey scores to assess pain, disability, and quality of life, respectively. Data collection occurred at three key time points: preoperative (baseline assessment), 1-month postoperative follow-up, and 3-month postoperative follow-up. If, at any point, a patient no longer met the inclusion criteria or met exclusion criteria, they were withdrawn from the study, with documentation of the reason.

Table 1 Inclusion and exclusion criteria of the study

Inclusion criteria

Exclusion criteria

• Aged 18–75 y  • Symptomatic lumbar spinal stenosis associated with low-grade degenerative spondylolisthesis (3–18 mm)  • Diagnosis and need to the surgery confirmed by a neurosurgeon and a radiologist  • Failed conservative treatments for more than 8 wk  • Able to participate in follow-ups  • No history of previous spine surgery

• Vertebral fractures, tumors, or metastatic vertebral lesions  • Postoperative infections  • History of inflammatory disease or psychological conditions  • Indication for anterior fusion (such as interbody cage placement)  • Suspicion of osteoporosis based on plain lumbosacral radiography (bone densitometry was performed to confirm suspicion in questionable cases)  • Any spinal deformity with a Cobb angle exceeding 20 deg or sagittal imbalance with SVA greater than 9 cm  • Patients with clinical signs of SIJP prior to surgery

Abbreviations: SIJP, sacroiliac joint pain; SVA, sagittal vertical axis.

Interventions

Patients were assigned to one of the two following groups: the decompression without fusion group who underwent laminectomy alone for spinal canal decompression (Dec) and the decompression with fusion group who received posterolateral fusion with pedicular screws and autologous bone grafting from the lamina and spinous processes (DecPlus). Group assignment was determined based on lumbar vertebral instability observed in flexion-extension radiographs. If instability was detected as movement exceeding 3 mm at the spondylolisthesis level, the patient was assigned to the fusion group; otherwise, they were placed in the decompression-alone group. A total of 52 patients were included in the DecPlus group and 50 in the Dec group, yielding a total study cohort of 102 patients.

At each postoperative follow-up, 1 month and 3 months after surgery, patients experiencing persistent low back pain and new-onset localized tenderness were evaluated for SIJS. The diagnostic criteria for SIJS included tenderness in the sacroiliac groove upon palpation, at least three positive provocative tests[16] for SIJ dysfunction (Thigh Thrust, FABER, Compression, Gaenslen's, Distraction), and the exclusion of lumbar pathology, particularly the absence of adjacent disc degeneration on magnetic resonance imaging and the absence of pseudarthrosis. Patients meeting these criteria underwent SIJ block intervention.

For the SIJ block procedure, the SIJ region was anesthetized using 1% lidocaine. A 20-gauge, 50-mm needle was advanced into the inferior portion of the SIJ under fluoroscopic guidance. One milliliter of nonionic contrast was injected to confirm intra-articular placement. The joint was then anesthetized with a total of 5 mm of solution, comprising 2.5 mL of 2% lidocaine, 1 mL of triamcinolone, and 1.5 mL of distilled water. Pain levels were assessed before and after the block using the VAS. Preblock pain was measured by asking, “How intense has your pain been this morning?” Pain was reassessed 15 minutes postinjection and after 5 minutes of walking and sitting. A positive SIJ block was defined as at least 75% pain relief, confirming SIJS. While other diagnostic methods such as bone scintigraphy and single-photon emission computed tomography have been utilized in prior studies for diagnosing SIJS,[17] [18] [19] [20] fluoroscopically guided SIJ block was employed as the gold standard for determining the prevalence of SIJS in this study.

Outcome Measurements

The primary outcome of SIJP incidence was determined by a positive SIJ block, confirming the diagnosis of SIJS. Other outcome measurements included pain intensity, functional disability, and quality of life. To assess the pain intensity, the VAS was used. Functional status of subjects at baseline and follow-ups was measured using ODI, a higher score indicated greater disability. To assess the quality of life of the patients, the SF-36 questionnaire was used, which captures patients' perceptions of their health status and satisfaction. The SF-36 comprised 36 questions across eight subscales, each containing 2 to 10 items covering multiple dimensions of health-related quality of life.

Data Analysis

Baseline characteristics of patients in both groups were compared using the t-test for continuous variables (reported as mean ± standard deviation), and chi-square test or Fisher's exact test for categorical variables (presented as numbers and percentages) with statistical significance set at p < 0.05. Normality of distribution of measurements was assessed using the Kolmogorov–Smirnov's test.

Results

Baseline and Surgical Characteristics

A total of 102 patients (mean age: 63.5 years) were included, with 69 women (68%) and 33 men (32%), divided into DecPlus (n = 52) and Dec (n = 50) groups. Baseline characteristics were similar between the groups ([Table 2]). Regarding surgical levels, fusion procedures were more frequent at three or more levels, while decompression was more commonly done at two levels ([Table 3]).

Table 2 Baseline characteristics of the patients who included in the study

Variable	Fusion and decompression (n = 52)	Decompression (n = 50)	p-Value
Age (y)	64.1 ± 8.1	62.8 ± 7.1	0.38
Sex (male/female)	(14/38)	(19/31)	0.23
Height (cm)	158.9 ± 8.4	160.6 ± 9.6	0.34
Weight (kg)	70.4 ± 11.1	70.5 ± 10.4	0.94
BMI (kg/m2)	27.9 ± 4.8	27.4 ± 4.3	0.56
Smoking
N (%)	15 (28%)	11 (22%)	0.42
Pack year	38 ± 13	33 ± 12	0.40
DM, n (%)	9 (17%)	8 (19%)	0.85
Opioid addiction, n (%)	4 (7%)	2 (4%)	0.42
Anxiety or depression, n (%)	13 (25%)	11 (22%)	0.72
Physical inactivity	26 (50%)	27 (54%)	0.68

Abbreviations: BMI, body mass index; DM, diabetes mellitus.

Table 3 Data of operation and postoperation complications in patients in both groups

Variable	Fusion and decompression (n = 52)	Decompression (n = 50)	p-Value
Level count
One level, n (%)	0 (0%)	11 (22%)	<0.01
Two levels, n (%)	0 (0%)	33 (66%)
Three levels, n (%)	31 (59%)	6 (12%)
Four levels, n (%)	12 (23%)	0 (0%)
Five levels, n (%)	9 (17%)	0 (0%)
Upper vertebrae
L2 and upper, n (%)	14 (26%)	0 (0%)	<0.01
L3, n (%)	25 (48%)	13 (26%)
L4, n (%)	13 (25%)	35 (70%)
L5, n (%)	0 (0%)	2 (4%)
Lower vertebrae
L4, n (%)	4 (7%)	16 (32%)	<0.01
L5, n (%)	14 (26%)	34 (78%)
S1, n (%)	34 (65%)	0 (0%)
PJK, n (%)	2 (3%)	1 (2%)	0.96
Site infection, n (%)	3 (5%)	2 (4%)	0.67
Rod fracture or loose screw, n (%)	2 (3%)	N/A	N/A

Abbreviations: N/A, not available; PJK, proximal junctional kyphosis.

Note: Bold values indicate statistical significance at p<0.05.

Surgical and Functional Outcome

Postoperative complications such as proximal junctional kyphosis (PJK), surgical site infections, and hardware failures were rare and showed no significant difference between the groups ([Table 3]). Both groups exhibited significant pain reduction (VAS scores) over 3 months. In the DecPlus group, pain scores decreased by 49.45%, and in the Dec group, by 53.36%, with no significant difference between the groups (p = 0.77, [Table 4]). ODI scores improved in both groups, but at 3 months, the Dec group had significantly lower disability scores (p < 0.01, [Table 4]). SF-36 scores improved significantly in both groups, but the Dec group showed a greater improvement in both physical component summary and mental component summary (p < 0.01, [Table 4]).

Table 4 Comparison of outcome measurements between the groups

Variable	Fusion and decompression n = 52)	Decompression (n = 50)	p-Value
Pain intensity (VAS), mean ± SD
At baseline	63.9 ± 13.0	60.9 ± 16.8	0.31
First mo post op	43.0 ± 12.8	37.6 ± 11.0	0.02
Third mo post op	31.6 ± 12.7	32.5 ± 15.8	0.77
Oswestry Disability Index, mean ± SD
At baseline	68.6 ± 11.3	69.7 ± 12.4	0.62
First mo post op	45.4 ± 12.3	41.4 ± 10.0	0.07
Third mo post op	35.8 ± 9.1	30.0 ± 9.9	<0.01
Quality of life (SF-36), mean ± SD
PCS at baseline  MCS at baseline	25.0 ± 7.0 19.9 ± 5.9	19.6 ± 8.5 22.2 ± 6.8	0.01 0.06
PCS at first mo post op  MCS at first mo post op	45.6 ± 11.0 47.9 ± 10.0	50.3 ± 12.1 44.3 ± 8.6	0.04 0.05
PCS at third mo post op  MCS at third mo post op	52.4 ± 12.5 59.9 ± 10.4	61.6 ± 15.5 70.1 ± 7.7	0.01 <0.01
Incidence of sacroiliac joint pain, number (%)
First mo post op	24 (46%)	11 (22%)	0.01
Third mo post op	12 (23%)	6 (12%)	0.14
Total in first or third mo	26 (50%)	11 (22%)	<0.01

Abbreviations: MCS, mental component summary; PCS, physical component summary; Post op, postoperative; SD, standard deviation; VAS, visual analog scale.

Note: Bold values indicate statistical significance at p<0.05.

At 3 months postsurgery, 37 patients (36.3%) developed SIJS, with a higher incidence in the DecPlus group (50%) compared with the Dec group (22%) (p < 0.01, [Table 4]). The majority of SIJS cases in the DecPlus group were observed within the first month (46%), while in the Dec group, incidence was lower (22% at 1 month and 12% at 3 months).

Identifying Risk Factors for SIJP

Instrumented fusion is significantly higher in patients with SIJP (p = 0.004). A statistically significant difference was observed in decompression levels between patients with and without SIJP (p = 0.0004) using a chi-square test. The SIJP group had a higher proportion of one-level (27 vs. 12.3%) and two-level (73 vs. 47.7%) decompressions than the other group. On the other hand, patients without SIJP had higher proportions of three-level (33.8 vs. 0%) and four-level (6 vs. 0%) decompressions ([Table 5]).

Table 5 Characteristics of the patients who have and have not been confirmed with SIJP

Variable	With SIJP (n = 37)	Without SIJP (n = 65)	p-Value
Age (y)	64.8 ± 7.3	62.7 ± 7.7	0.16
Sex (male/female)	(11/26)	(22/43)	0.66
BMI (kg/m 2 )	27.0 ± 4.2	28.1 ± 4.7	0.27
Smoking
N (%)	9 (24%)	17 (26%)	0.83
Pack year	41 ± 12	33 ± 12	0.15
DM, n (%)	5 (13%)	12 (18%)	0.51
Opioid addiction, n (%)	2 (5%)	4 (6%)	0.87
Anxiety or depression, n (%)	9 (24%)	15 (23%)	0.88
Physical inactivity	23 (62%)	30 (46%)	0.12
Fusion	26 (70%)	26 (40%)	0.004
Decompression level count
One level, n (%)	10 (27%)	8 (12.3%)	0.0004
Two levels, n (%)	21 (73%)	31 (47.7%)
Third levels, n (%)	0 (0%)	22 (33.8%)
Four levels, n (%)	0 (0%)	4 (6%)
PJK, n (%)	1 (2%)	2 (2.5%)	0.63
Site infection, n (%)	2 (5%)	3 (4%)	0.85
Rod fracture or loose screw, n (%)	1 (2%)	1 (1%)	N/A

Abbreviations: BMI, body mass index; DM, diabetes mellitus; N/A, not available; PJK, proximal junctional kyphosis; SIJP, sacroiliac joint pain.

Note: Bold values indicate statistical significance at p<0.05.

Subgroup Analysis

[Table 6] compares patients with and without SIJP in patients with fusion (DecPlus group). There is a significant difference between the number of fused levels and SIJP (p < 0.0001). Lower instrumented vertebra had no significant effect on SIJP (p = 0.114), but there was a significant difference between upper instrumented vertebra (UIV) distribution in patients with and without SIJP (p < 0.0001).

Table 6 Comparison of surgical characteristics in DecPlus group

Variable	With SIJP (n = 26)	Without SIJP (n = 26)	p-Value
Fusion level count
Two levels, n (%)	22 (84.6%)	0 (0%)	<0.0001
Third levels, n (%)	0 (0%)	19 (73%)
Four levels, n (%)	4 (15.4%)	3 (11.6%)
Five levels, n (%)	0 (0%)	4 (15.4%)
Upper instrumented vertebrae
L2 and upper, n (%)	0 (0%)	8 (30.8%)	<0.0001
L3, n (%)	4 (15.4%)	14 (53.8%)
L4, n (%)	13 (50%)	4 (15.4%)
L5, n (%)	9 (34.6%)	0 (0%)
Lower instrumented vertebrae
L4, n (%)	0 (0%)	4 (15.4%)	0.114
L5, n (%)	13 (50%)	11 (42.3%)
S1, n (%)	13 (50%)	11 (42.3%)

Abbreviation: SIJP, sacroiliac joint pain.

Note: Bold values indicate statistical significance at p<0.05.

[Table 7] compares patients with and without SIJP in patients without fusion (Dec group). There was no significant difference between patients with and without SIJP in terms of decompression levels count (p = 0.757), upper decompressed vertebra (p = 0.241), and lower decompressed vertebra (p > 0.999).

Table 7 Comparison of surgical characteristics in Dec group

Variable	With SIJP (n = 11)	Without SIJP (n = 45)	p-Value
Decompression level count
One level, n (%)	2 (18.2%)	9 (20%)	0.757
Two levels, n (%)	7 (63.6%)	26 (57.8%)
Three levels, n (%)	2 (18.2%)	4 (8.9%)
Upper decompressed vertebrae
L3, n (%)	4 (36.4%)	9 (20%)	0.241
L4, n (%)	6 (54.5%)	35 (77.8%)
L5, n (%)	1 (9.1%)	1 (2.2%)
Lower decompressed vertebrae
L4, n (%)	3 (27.3%)	13 (28.9%)	>0.999
L5, n (%)	8 (72.7%)	34 (75.6%)

Abbreviation: SIJP, sacroiliac joint pain.

Post hoc analysis using standardized residuals revealed significant contributions to the overall chi-square result from specific fusion levels. The key differences driving the significant chi-square test are the higher-than-expected number of two-level fusions in the SIJP group and the higher-than-expected number of three-level fusions in patients without SIJP. Based on standardized residuals, the four-level and five-level fusions did not show significant deviations.

Post hoc analysis using standardized residuals revealed significant contributions to the overall chi-square result from specific UIV levels. The key differences driving the significant chi-square test are the lower-than-expected number of L2 and upper vertebrae instrumentations in the SIJP group and the higher-than-expected number of L5 instrumentations in the SIJP group.

Discussion

The rate of lumbar spinal fusion has significantly increased over the past 30 years.[21] [22] However, FBSS remains a major concern, with failure rates ranging from 20 to 40%, particularly in more invasive procedures.[23] [24] Reducing the rate of FBSS requires accurate identification of pain sources, recognition of high-risk patients, and exhaustion of conservative treatments before reoperation.[23] Despite this, evidence-based guidelines remain limited due to the complexity of FBSS, its multifactorial etiology, and the lack of high-quality clinical trials.[25] [26] SIJP is a well-recognized contributor to FBSS, occurring in 41 to 42% of patients with SIJ involvement,[27] [28] particularly when fusion extends to the sacrum.[24] Its incidence correlates with the number of fused segments.[29] However, controversy persists regarding optimal diagnostic and treatment strategies, making this topic an ongoing subject of debate.

This nonrandomized prospective clinical trial evaluated 102 patients with lumbar spinal stenosis and low-grade degenerative spondylolisthesis, comparing laminectomy with fusion versus laminectomy alone concerning SIJP incidence. Our findings suggest that decompression alone provides superior pain relief and functional improvement compared with fusion and leads to lower postsurgical SIJP rates during 3 months postoperative follow-up. The overall SIJP incidence was 36.3%, with a significantly higher rate in the DecPlus group (50%) compared with the Dec (22%) group. Considering our short follow-up period (3 months), the true incidence may be even higher. This figure exceeds that reported in some studies (12–43%), emphasizing fusion's potential role in SIJP development.[24] [30] Similar results were reported by Koheil and Dorgham in 2021,[31] who found SIJP to be a recurrent complication in 47% of fusion patients. Additionally, a systematic review by Longo et al in 2014[24] revealed SIJ degeneration in 75% of imaging studies following lumbar fusion, further highlighting the necessity of provocative tests and SIJ blocks for early detection.

Moreover, 10 patients (19.2%) in the DecPlus group required repeat SIJ blocks due to recurrent pain, compared with 6 patients (54.5%) in the Dec group. This suggests that SIJP following fusion often necessitates multiple interventions, reinforcing the therapeutic utility of SIJ blocks beyond diagnosis. A study by Sandén et al in 2011[32] identified smoking as a predictor of poorer lumbar surgery outcomes, but in our study, SIJP incidence was not significantly associated with smoking, body mass index, age, or psychiatric conditions. This suggests that mechanical factors related to fusion may play a larger role in SIJP development than lifestyle factors.

We also found that PJK, infections, and hardware failure did not significantly impact SIJP rates (p > 0.05). Our results showed that SIJP risk is higher in two-level fusions than three-level or more fusions. There was a significant difference in UIV distribution between patients with and without SIJP. However, instrumentation extending caudally to the sacrum did not increase the SIJP incidence. This suggests that the UIV and fusion length play a critical role in SIJP development. In the study by Lee et al,[30] no significant increase in the frequency of SIJP was observed in patients whose fusion included the sacrum or in those with a greater number of fusion levels. Conversely, a systematic review by Longo et al[24] identified extended fusion to the sacrum as a risk factor for increased degenerative changes in the SIJ. The results of the current study do not support the association between higher levels of intervention and increased rate of SIJP. Conversely, higher levels of fusion may decrease the risk of SIJP.

Regarding the clinical outcome of the patients, a meta-analysis by Ahmed et al[33] suggested that fusion provides greater pain relief and disability reduction than decompression alone, but our study contradicts this finding. While ODI and SF-36 scores improved significantly in both groups, decompression alone yielded greater functional gains, aligning with the results of Försth et al in 2016,[34] who found no long-term benefits of fusion over decompression. Similarly, Austevoll et al in 2017[35] suggested that many patients can be managed effectively with decompression alone, further reinforcing our findings. The challenge moving forward is to identify which patients benefit from fusion versus decompression alone, ensuring individualized treatment approaches. However, this finding of our study may have limited value, as it must be considered that patients were not randomly assigned to the Dec or DecPlus groups. Those selected for fusion had instability on flexion/extension X-rays, which should be considered when interpreting our results.

Limitations

This study's primary limitations include a short follow-up period, which may not fully capture the long-term incidence of SIJP postfusion. In addition, nonrandomized design and small sample size are other study limitations. We did not utilize preoperative imaging to assess the condition of SIJ degeneration. This factor may influence postoperative SIJP, and future studies employing the proper imaging techniques will clarify its impact. Due to ethical considerations, noninterventional treatments were routinely provided postoperatively for those experiencing SIJP. However, to decrease the risk of bias, only SIJ blocks were used for SIJP diagnosis and treatment, ensuring objective confirmation of SIJP cases. After a positive block, patients with recurrent SIJP symptoms underwent repeat confirmatory blocks to strengthen diagnostic accuracy.

Future Direction

Further large-volume, randomized, multicenter studies are needed to confirm our results. Future research should explore the relative role of lower lumbar fusion in SIJP and other risk factors for SIJP development, long-term SIJP incidence after lumbar fusion beyond 3 months, and optimal fusion techniques to minimize SIJP risk.

Conclusion

Based on our study, lumbar instrumented posterolateral fusion, compared with decompression without fusion, should be considered a risk factor for SIJP. In patients with instrumented fusion, the UIV and the length of fusion are related to SIJP; however, extending fusion to S1 does not significantly affect SIJP incidence.

Conflict of Interest

None declared.

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Publication History

Article published online:
10 June 2025