The gentleman placed his hands on my shoulder and said “One word: Plastics.” There was a dramatic pause for effect and then, with a big smile, he continued: “Do you remember The Graduate? I have two words for you: SI joint. I think you should consider an academic career studying the SI joint.” Those were the words that my Residency Program Director, an orthopedic traumatologist, told me over a decade ago on a cold winter night in Hartford, Connecticut. We just had just heard Dr John Fulkerson share his path to understand and treat patellofemoral pain and my program director saw potential parallels to SI pain. He had seen, first-hand, many patients with posttraumatic sacroiliac (SI) pain but at that time, he had no reliable solution to offer them. My program director was Dr Bruce Browner, lead Editor of Skeletal Trauma and of course, the current Editor-in-Chief of Techniques in Orthopaedics.
At the time, neither of us could predict the future. Years later, I would find myself, as spine surgery fellow, under the mentorship of Dr Steven Garfin at University of California, San Diego, one of the pioneers of a new generation of minimally invasive SI surgery, and fast forward to the present and now the field has matured enough to produce a complete symposium issue for Techniques in Orthopaedics.
Even today, SI joint pain remains one of the frontiers for orthopedic surgery. While something like an anterior lumbar interbody fusion has roots drawing back to 1932 or 1933 with Burns and Capener, and can be considered a still evolving but refined, mature procedure (still requiring thoughtful patient selection), SI surgery actually has roots drawing back even earlier to 1908 with Painter’s paper on “Excision of the os innominatumn.” Yet despite starting earlier than the anterior lumbar interbody fusion, it is only recently within the last decade that there has been a resurgence of interest in surgical treatment for the SI joint.
Why has this resurgence happened? If you’re one of the patients suffering from SI pain, you may claim that modern medicine has finally stepped out into the light and is no longer satisfied with assigning a label of idiopathic back pain or myofascial pain to anyone without stenosis, scoliosis, or spondylolisthesis. If you’re one of the surgeons who have performed SI stabilization surgeries, you may claim to have seen incredible appreciativeness of patients who have finally gotten relief for a chronic pain they thought was permanent. If you’re one of the manufacturers with a device used in the treatment of SI pain, you may claim that there is now a critical mass of scientific knowledge and clinical expertise related to the SI joint, as well as the benefit of modern advanced manufacturing and engineering know-how.
The reality is that it is a little bit of all of the above. The science has led to better recognition of diagnostic criteria for patients that are good surgical candidates and newer functional imaging studies such as SPECT Connecticut may in fact be able to provide objective predictive imaging for the SI joint, albeit not yet practical for routine clinical use. Level I evidence is even now available for a direct lateral approach to SI stabilization surgery which has opened the doors for gaining private insurer coverage in the United States as well as approvals for SI joint surgery in national health care systems in the United Kingdom and France.
In this symposium, we have attempted to consolidate the relevant international knowledge known by the end of 2018, and create the new reference for back pain attributable to the SI joint and its management. This ambitious goal has only been made possible by the generous time investment our authors have put into these detailed and thoughtful articles. I thank them for their contributions and invite and welcome you, the reader, to this symposium issue on the SI joint.
Last, a detailed and direct statement related to my conflicts of interest is warranted. This symposium has taken over a year of planning and preparation and effort. Throughout the time of my role as Guest Editor for this issue, I had no relevant conflicts of interest, and all manuscripts underwent formal independent peer review. That said, I am the Chief Medical Officer of PrinterPrezz Inc. PrinterPrezz blends a workforce of active clinicians, design engineers, and manufacturing experts to provide advanced 3D design and medical device contract manufacturing services, leveraging the latest metal 3D printing technologies. Because of the rarity and complexity of metal 3D printing, we serve a broad range of customers including academia and industry. One of the companies that began utilizing our services in December of 2018 is SI-Bone, a company that designs and distributes implants for SI surgery. They were also selected for the “Industry Perspective” in this symposium issue based upon their implant having the broadest approval from insurers including implant-specific approval in the United Kingdom and France.