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Lumbar spine curvature varies with modic changes and disc degeneration in asymptomatic individuals
The Spine Journal 16 (2016) S72–S93
Posters Back Pain (Lumbar Degenerative) Persistent cerebrospinal fluid (CSF) leak post spinal surgery and cerebrospinal fluid dynamic disturbances: cause or consequence? Akbar Khan, Claudia Craven, Ahmed Toma, Laurence Watkins; National Hospital for Neurology & Neurosurgery, Queen Square, London WC1N 3BG BACKGROUND CONTEXT: Cerebrospinal fluid (CSF) leak following spinal surgery is a relatively common surgical complication. A small group of CSF leak patients require multiple surgical repairs and prolonged hospital admission. Spinal CSF leaks are usually classically associated with symptoms of low intracranial pressure (ICP). However, there is a paucity of literature investigating the associated CSF dynamics. PURPOSE: Scientific investigation of persistent spinal CSF leak post-surgery. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Patients with persistent CSF leak referred to the hydrocephalus service in our unit for intracranial pressure monitoring. OUTCOME MEASURES: Physiological and clinical outcome. METHODS: Retrospective case series study of patients with persistent CSF leak referred to the hydrocephalus service in our unit for intracranial pressure monitoring. Medical notes were reviewed for clinical presentation, management and outcome. Images were reviewed and ICP data were analysed. All patients underwent continuous ICP monitoring using Spiegelberg ICP bolts. RESULTS: Three patients had spinal fixation surgery, complicated by prolonged CSF leaks (mean of 56 days). Each patient required two reexploration spinal surgeries and multiple lumbar drains insertions prior to 24 hours of ICP monitoring. All patients were shown to have raised ICP (>15.2 mmHg). One patient underwent a right transverse venous sinus stent insertion. Two patients underwent insertion of ventriculoperitoneal shunts (VPS). All three had resolution of their CSF leaks immediately post intervention. CONCLUSIONS: Our results suggest that abnormal cerebrospinal fluid dynamics should be explored in patients with persistent CSF leak post spinal surgery. Whether abnormal pressure and dynamics represent a pre-existing abnormality or is induced by spinal surgery should be subject for further studies. CONFLICTS OF INTEREST: Nil. FUNDING SOURCES: Nil.
PURPOSE: We aim to determine whether LDR is an effective operation and how single level (SL) compares to multi-level (ML) replacement. STUDY DESIGN/SETTING: We present our prospectively collected outcome data for single and multiple level arthroplasty using the Activ-L disc replacement. PATIENT SAMPLE: All patients who underwent lumbar disc replacement at our hospital were included. OUTCOME MEASURES: Clinical outcome measures include the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS), Low Back Outcome Score (LBOS) and the Centre for Epidemiologic Studies Depression Scale (CES-D). METHODS: All patients suffering from degenerative disc disease and who were suitable for LDR were assessed preoperatively, at 6, 12 and 24 months by members of the spinal team who collected the outcome data scores. RESULTS: Results for 177 patients comprising 97 SL and 80 MLs are reported. Significant improvement occurred in all four outcome measures in the first 6 months, followed by a more gradual improvement over the following 18 months. CES-D outcome scores improved to a greater degree in the ML cohort. CONCLUSIONS: This is the largest study to date comparing SL against ML lumbar disc arthroplasty. Our results suggest both SL and ML lumbar disc replacements are an effective operation for the treatment of Degenerate Disc Disease (DDD) with continued benefit over the course of 24 months. CONFLICTS OF INTEREST: No conflicts of interest. FUNDING SOURCES: No funding obtained. http://dx.doi.org/10.1016/j.spinee.2016.01.082
Lumbar spine curvature varies with modic changes and disc degeneration in asymptomatic individuals Anastasia Pavlovaa, Janet Deaneb, Richard Aspdenc, Alison McGregord; a University of Aberdeen, Institute of Medical Sciences, Foresterhill, Aberdeen AB25 2ZD; bImperial College London, Musculoskeletal Lab, Charing Cross Campus, London W6 8RP; cUniversity of Aberdeen, Institute of Medical Sciences, Foresterhill, Aberdeen AB25 2ZD; dImperial College London, Musculoskeletal Lab, Charing Cross Campus, London W6 8RP
http://dx.doi.org/10.1016/j.spinee.2016.01.081
Single-level versus multiple-level lumbar disc arthroplasty: a prospective study with 24-months follow-up Nader Rehmatullah, Clare Morgan, Poornanand Goru, Ian Shackleford; Warrington and Halton Hospitals NHS Trust, Lovely Lane, Warrington, Cheshire WA5 1QG BACKGROUND CONTEXT: Low back pain is one of the most prevalent spinal problems in the Western world and is only set to increase as the population ages. Degenerative disc disease is a significant contributor. Lumbar disc replacement (LDR) aims to preserve motion and avoid fusion-related complications.
BACKGROUND CONTEXT: Degenerative lumbar disc disease (DLDD) is significantly associated with signs of lumbar disc (LDD) and vertebral degeneration (modic change or MC) and symptoms of recurrent low back pain. An association between spinal curvature and DLDD in asymptomatic individuals has not been previously considered. PURPOSE: To compare lumbar spine morphology between asymptomatic individuals. STUDY DESIGN/SETTING: Cross-sectional 3Tesla Magnetic Resonance Imaging (3T MRI) study. PATIENT SAMPLE: Thirteen asymptomatic adults aged 45–70. OUTCOME MEASURES: Lumbar MC, modified Pfirrmann grades (LDD) and mode scores characterising lumbar spine shape from statistical shape modelling (SSM). METHODS: T2-weighted sagittal lumbar spine images were acquired and graded for MC and LDD at each vertebral level by an experienced
Posters / The Spine Journal 16 (2016) S72–S93 radiologist. An SSM was built describing the spine from T12 to S1 and identified patterns (modes) in lumbar morphology variation. Individuals’ mode scores were compared between those with (N=8 and 10) and without (N=5 and 3) MC or LDD (modified Pfirrmann ≥6) at one or more levels, respectively. RESULTS: Mode 1, describing total curvature, accounted for 66% variation. People with MC were more lordotic (larger M1 score) (p=.02, t-test), whereas individuals with LDD had no significant differences in M1 but scored lower in M7 (p=.02), describing reduced disc space specifically at L5/S1. Seven people (54%) had both MC and LDD and scored lower in M7 (p=.02). CONCLUSIONS: Asymptomatic MC individuals were more lordotic than those without. This is in contrast to previous studies of symptomatic patients who have flattened lordosis. These early results suggest spinal shape is associated with standard markers of DLDD and could play a biomechanical role in future pain development. CONFLICTS OF INTEREST: No conflicts of interest. FUNDING SOURCES: Arthritis Research UK £232,344 Nurse and Allied Health Professional Training Fellowship #20172 (JD) and Society for Back Pain Research £1000 Travel Fellowship (Anastasia Pavlova). http://dx.doi.org/10.1016/j.spinee.2016.01.083
A cross-sectional survey of the understanding of cauda equina syndrome Rowa Taha, Andrea Thompson, Shuaib Karmani, Sherief Elsayed; South East Spinal Surgery, Brighton University Hospitals NHS Trust, Brighton BACKGROUND CONTEXT: Cauda equine syndrome, CES, is a rare disorder with a disproportionately high litigation rate. Recognition of CES by all groups of clinicians is often delayed. The most junior member of the team routinely performs initial assessment; we rely on their clinical judgement in identifying these patients correctly and promptly instigating appropriate investigation and management. PURPOSE: To assess junior doctor understanding of CES and to assess variability in knowledge amongst clinicians from different specialities. STUDY DESIGN/SETTING: Prospective survey of junior doctors in various specialities. PATIENT SAMPLE: Not applicable. OUTCOME MEASURES: Knowledge and competence in recognising and managing CES. METHODS: Questionnaires distributed at departmental and deanery teaching. Data anonymously collected and analysed using SPSS (v20). RESULTS: N=39; Foundation Year 1 to Specialist Registrar. 74% of assessing clinicians were foundation doctors, with only undergraduate teaching in CES. Only 5% had received specific CES teaching within the prior 6 months. 10 (26%) would perform rectal examination. 13 (33%) perform a bladder scan pre- and post-voiding. 87% reported knowledge of CES was not satisfactory, and all doctors (100%) stated they needed additional teaching. 12 (31%) recognised post-void residual of >100 mL as abnormal. There was wide variation in what was perceived to be the most clinically significant finding. CONCLUSIONS: Many doctors assessing CES have not received any formal postgraduate teaching on CES. There is poor understanding of the clinical significance of certain symptoms and use of bedside investigations. A universal teaching course is required for all doctors assessing CES. Improved education may lead to prompt recognition, timely investigation and treatment, thus reducing the risk of residual neurological compromise and consequent litigation. CONFLICTS OF INTEREST: No conflicts of interest. FUNDING SOURCES: No funding obtained. http://dx.doi.org/10.1016/j.spinee.2016.01.085
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Midterm results for coflex interspinous dynamic stabilisation device in degenerative lumbar stenosis. The good, the bad and the ugly Tamer Kamala, Sherif El Niketyb, James Cashab, Nitin Shahb; aRoyal Hampshire County Hospital, Winchester; bEast Kent Hospital, Margate BACKGROUND CONTEXT: The concept of ‘dynamic stabilisation’ or ‘soft stabilisation’ was introduced with the aim to provide a solution to problems related with spinal fusion. In theory, dynamic stabilisation system should provide sufficient support at the inserted level, allowing for load transmission of a spinal motion segment, without major restriction to motion at the affected segment, allowing to relieve pain and avoiding adjacent level disease encountered with spinal fusion. PURPOSE: Assessment of outcomes of coflex dynamic stabilisers. STUDY DESIGN/SETTING: Prospective study between February 2008 and December 2011 at the Queen Elizabeth The Queen Mother Hospital, East Kent NHS Trust, Margate, Kent. PATIENT SAMPLE: Mild to moderate degree lumbar degenerative foraminal stenosis. OUTCOME MEASURES: Self-report measures: validated pain rating scale and Oswestry disability questionnaire. METHODS: 121 patients with mild to moderate degree degenerative lumbar spinal foraminal stenosis (LSS) were included in a prospective study at the Queen Elizabeth The Queen Mother Hospital, East Kent NHS Trust, Margate, Kent. RESULTS: The majority of patients were satisfied with the results in the immediate postoperative period, with 82% of patients happy with surgical outcome. Visual analogue score (VAS) results improved in both groups, with a mean preoperative VAS score of 8.4, 4 at 1 year, 3.2 for the decompression and coflex group (p<.05), and a mean preoperative score VAS score of 7.8, 4.5 at 1 year and 5.1 at 2 years (p=.4). The mean preoperative ODI score was 76.8% and 36.25% at 1 year and 42.8% at 2 years. Around the 2- to 3-year period, there was a higher rate of recurrence of symptoms with pain not responding to non-operative management, with 36% rate of revision surgery. CONCLUSIONS: The coflex interspinous implant is a simple surgical treatment strategy with a low risk. Early results show a good improvement of both clinical and radiological parameters combined with patient satisfaction, especially if combined with spinal decompression. Despite early satisfactory results, it seems that the device efficacy gradually decreases, with patients complaining of recurrence of symptoms at 18- to 36-month period. Between 24 months and 48 months postoperative follow-up demonstrated a high rate of recurrence and even worsening of symptoms with 36% rate of revision surgery. CONFLICTS OF INTEREST: No conflicts of interest. FUNDING SOURCES: No external funding obtained. http://dx.doi.org/10.1016/j.spinee.2016.01.086
Sacroiliac minimal invasive fusion compared to physical therapy: sixmonth outcome from a multicentre randomised controlled trial Bengt Sturesson, Julius Dengler, Djaja Kools, Robert Pflugmacher, Domenico Prestamburgo; Aleris Ortopedi, Sjukhuset, Södra vägen, 26252 Ängelholm BACKGROUND CONTEXT: Sacroiliac (SI) joint dysfunction is a common cause of chronic, unremitting lower back or buttocks pain. PURPOSE: To compare outcomes after surgical and non-surgical conservative treatment for SI joint dysfunction. STUDY DESIGN/SETTING: Multicentre prospective randomised controlled trial. PATIENT SAMPLE: 103 patients. OUTCOME MEASURES: Visual Analogue Score (VAS), Oswestry Disability Index (ODI), EuroQOL-5D, Zung depression questionnaire, provocative physical examination tests and active straight leg test (ASLR). METHODS: 103 subjects with Sacro Iliac Joint (SIJ) dysfunction were randomly assigned to minimally invasive SI joint fusion with triangular titanium
Posters Back Pain (Lumbar Degenerative) Persistent cerebrospinal fluid (CSF) leak post spinal surgery and cerebrospinal fluid dynamic disturbances: cause or consequence? Akbar Khan, Claudia Craven, Ahmed Toma, Laurence Watkins; National Hospital for Neurology & Neurosurgery, Queen Square, London WC1N 3BG BACKGROUND CONTEXT: Cerebrospinal fluid (CSF) leak following spinal surgery is a relatively common surgical complication. A small group of CSF leak patients require multiple surgical repairs and prolonged hospital admission. Spinal CSF leaks are usually classically associated with symptoms of low intracranial pressure (ICP). However, there is a paucity of literature investigating the associated CSF dynamics. PURPOSE: Scientific investigation of persistent spinal CSF leak post-surgery. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Patients with persistent CSF leak referred to the hydrocephalus service in our unit for intracranial pressure monitoring. OUTCOME MEASURES: Physiological and clinical outcome. METHODS: Retrospective case series study of patients with persistent CSF leak referred to the hydrocephalus service in our unit for intracranial pressure monitoring. Medical notes were reviewed for clinical presentation, management and outcome. Images were reviewed and ICP data were analysed. All patients underwent continuous ICP monitoring using Spiegelberg ICP bolts. RESULTS: Three patients had spinal fixation surgery, complicated by prolonged CSF leaks (mean of 56 days). Each patient required two reexploration spinal surgeries and multiple lumbar drains insertions prior to 24 hours of ICP monitoring. All patients were shown to have raised ICP (>15.2 mmHg). One patient underwent a right transverse venous sinus stent insertion. Two patients underwent insertion of ventriculoperitoneal shunts (VPS). All three had resolution of their CSF leaks immediately post intervention. CONCLUSIONS: Our results suggest that abnormal cerebrospinal fluid dynamics should be explored in patients with persistent CSF leak post spinal surgery. Whether abnormal pressure and dynamics represent a pre-existing abnormality or is induced by spinal surgery should be subject for further studies. CONFLICTS OF INTEREST: Nil. FUNDING SOURCES: Nil.
PURPOSE: We aim to determine whether LDR is an effective operation and how single level (SL) compares to multi-level (ML) replacement. STUDY DESIGN/SETTING: We present our prospectively collected outcome data for single and multiple level arthroplasty using the Activ-L disc replacement. PATIENT SAMPLE: All patients who underwent lumbar disc replacement at our hospital were included. OUTCOME MEASURES: Clinical outcome measures include the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS), Low Back Outcome Score (LBOS) and the Centre for Epidemiologic Studies Depression Scale (CES-D). METHODS: All patients suffering from degenerative disc disease and who were suitable for LDR were assessed preoperatively, at 6, 12 and 24 months by members of the spinal team who collected the outcome data scores. RESULTS: Results for 177 patients comprising 97 SL and 80 MLs are reported. Significant improvement occurred in all four outcome measures in the first 6 months, followed by a more gradual improvement over the following 18 months. CES-D outcome scores improved to a greater degree in the ML cohort. CONCLUSIONS: This is the largest study to date comparing SL against ML lumbar disc arthroplasty. Our results suggest both SL and ML lumbar disc replacements are an effective operation for the treatment of Degenerate Disc Disease (DDD) with continued benefit over the course of 24 months. CONFLICTS OF INTEREST: No conflicts of interest. FUNDING SOURCES: No funding obtained. http://dx.doi.org/10.1016/j.spinee.2016.01.082
Lumbar spine curvature varies with modic changes and disc degeneration in asymptomatic individuals Anastasia Pavlovaa, Janet Deaneb, Richard Aspdenc, Alison McGregord; a University of Aberdeen, Institute of Medical Sciences, Foresterhill, Aberdeen AB25 2ZD; bImperial College London, Musculoskeletal Lab, Charing Cross Campus, London W6 8RP; cUniversity of Aberdeen, Institute of Medical Sciences, Foresterhill, Aberdeen AB25 2ZD; dImperial College London, Musculoskeletal Lab, Charing Cross Campus, London W6 8RP
http://dx.doi.org/10.1016/j.spinee.2016.01.081
Single-level versus multiple-level lumbar disc arthroplasty: a prospective study with 24-months follow-up Nader Rehmatullah, Clare Morgan, Poornanand Goru, Ian Shackleford; Warrington and Halton Hospitals NHS Trust, Lovely Lane, Warrington, Cheshire WA5 1QG BACKGROUND CONTEXT: Low back pain is one of the most prevalent spinal problems in the Western world and is only set to increase as the population ages. Degenerative disc disease is a significant contributor. Lumbar disc replacement (LDR) aims to preserve motion and avoid fusion-related complications.
BACKGROUND CONTEXT: Degenerative lumbar disc disease (DLDD) is significantly associated with signs of lumbar disc (LDD) and vertebral degeneration (modic change or MC) and symptoms of recurrent low back pain. An association between spinal curvature and DLDD in asymptomatic individuals has not been previously considered. PURPOSE: To compare lumbar spine morphology between asymptomatic individuals. STUDY DESIGN/SETTING: Cross-sectional 3Tesla Magnetic Resonance Imaging (3T MRI) study. PATIENT SAMPLE: Thirteen asymptomatic adults aged 45–70. OUTCOME MEASURES: Lumbar MC, modified Pfirrmann grades (LDD) and mode scores characterising lumbar spine shape from statistical shape modelling (SSM). METHODS: T2-weighted sagittal lumbar spine images were acquired and graded for MC and LDD at each vertebral level by an experienced
Posters / The Spine Journal 16 (2016) S72–S93 radiologist. An SSM was built describing the spine from T12 to S1 and identified patterns (modes) in lumbar morphology variation. Individuals’ mode scores were compared between those with (N=8 and 10) and without (N=5 and 3) MC or LDD (modified Pfirrmann ≥6) at one or more levels, respectively. RESULTS: Mode 1, describing total curvature, accounted for 66% variation. People with MC were more lordotic (larger M1 score) (p=.02, t-test), whereas individuals with LDD had no significant differences in M1 but scored lower in M7 (p=.02), describing reduced disc space specifically at L5/S1. Seven people (54%) had both MC and LDD and scored lower in M7 (p=.02). CONCLUSIONS: Asymptomatic MC individuals were more lordotic than those without. This is in contrast to previous studies of symptomatic patients who have flattened lordosis. These early results suggest spinal shape is associated with standard markers of DLDD and could play a biomechanical role in future pain development. CONFLICTS OF INTEREST: No conflicts of interest. FUNDING SOURCES: Arthritis Research UK £232,344 Nurse and Allied Health Professional Training Fellowship #20172 (JD) and Society for Back Pain Research £1000 Travel Fellowship (Anastasia Pavlova). http://dx.doi.org/10.1016/j.spinee.2016.01.083
A cross-sectional survey of the understanding of cauda equina syndrome Rowa Taha, Andrea Thompson, Shuaib Karmani, Sherief Elsayed; South East Spinal Surgery, Brighton University Hospitals NHS Trust, Brighton BACKGROUND CONTEXT: Cauda equine syndrome, CES, is a rare disorder with a disproportionately high litigation rate. Recognition of CES by all groups of clinicians is often delayed. The most junior member of the team routinely performs initial assessment; we rely on their clinical judgement in identifying these patients correctly and promptly instigating appropriate investigation and management. PURPOSE: To assess junior doctor understanding of CES and to assess variability in knowledge amongst clinicians from different specialities. STUDY DESIGN/SETTING: Prospective survey of junior doctors in various specialities. PATIENT SAMPLE: Not applicable. OUTCOME MEASURES: Knowledge and competence in recognising and managing CES. METHODS: Questionnaires distributed at departmental and deanery teaching. Data anonymously collected and analysed using SPSS (v20). RESULTS: N=39; Foundation Year 1 to Specialist Registrar. 74% of assessing clinicians were foundation doctors, with only undergraduate teaching in CES. Only 5% had received specific CES teaching within the prior 6 months. 10 (26%) would perform rectal examination. 13 (33%) perform a bladder scan pre- and post-voiding. 87% reported knowledge of CES was not satisfactory, and all doctors (100%) stated they needed additional teaching. 12 (31%) recognised post-void residual of >100 mL as abnormal. There was wide variation in what was perceived to be the most clinically significant finding. CONCLUSIONS: Many doctors assessing CES have not received any formal postgraduate teaching on CES. There is poor understanding of the clinical significance of certain symptoms and use of bedside investigations. A universal teaching course is required for all doctors assessing CES. Improved education may lead to prompt recognition, timely investigation and treatment, thus reducing the risk of residual neurological compromise and consequent litigation. CONFLICTS OF INTEREST: No conflicts of interest. FUNDING SOURCES: No funding obtained. http://dx.doi.org/10.1016/j.spinee.2016.01.085
S73
Midterm results for coflex interspinous dynamic stabilisation device in degenerative lumbar stenosis. The good, the bad and the ugly Tamer Kamala, Sherif El Niketyb, James Cashab, Nitin Shahb; aRoyal Hampshire County Hospital, Winchester; bEast Kent Hospital, Margate BACKGROUND CONTEXT: The concept of ‘dynamic stabilisation’ or ‘soft stabilisation’ was introduced with the aim to provide a solution to problems related with spinal fusion. In theory, dynamic stabilisation system should provide sufficient support at the inserted level, allowing for load transmission of a spinal motion segment, without major restriction to motion at the affected segment, allowing to relieve pain and avoiding adjacent level disease encountered with spinal fusion. PURPOSE: Assessment of outcomes of coflex dynamic stabilisers. STUDY DESIGN/SETTING: Prospective study between February 2008 and December 2011 at the Queen Elizabeth The Queen Mother Hospital, East Kent NHS Trust, Margate, Kent. PATIENT SAMPLE: Mild to moderate degree lumbar degenerative foraminal stenosis. OUTCOME MEASURES: Self-report measures: validated pain rating scale and Oswestry disability questionnaire. METHODS: 121 patients with mild to moderate degree degenerative lumbar spinal foraminal stenosis (LSS) were included in a prospective study at the Queen Elizabeth The Queen Mother Hospital, East Kent NHS Trust, Margate, Kent. RESULTS: The majority of patients were satisfied with the results in the immediate postoperative period, with 82% of patients happy with surgical outcome. Visual analogue score (VAS) results improved in both groups, with a mean preoperative VAS score of 8.4, 4 at 1 year, 3.2 for the decompression and coflex group (p<.05), and a mean preoperative score VAS score of 7.8, 4.5 at 1 year and 5.1 at 2 years (p=.4). The mean preoperative ODI score was 76.8% and 36.25% at 1 year and 42.8% at 2 years. Around the 2- to 3-year period, there was a higher rate of recurrence of symptoms with pain not responding to non-operative management, with 36% rate of revision surgery. CONCLUSIONS: The coflex interspinous implant is a simple surgical treatment strategy with a low risk. Early results show a good improvement of both clinical and radiological parameters combined with patient satisfaction, especially if combined with spinal decompression. Despite early satisfactory results, it seems that the device efficacy gradually decreases, with patients complaining of recurrence of symptoms at 18- to 36-month period. Between 24 months and 48 months postoperative follow-up demonstrated a high rate of recurrence and even worsening of symptoms with 36% rate of revision surgery. CONFLICTS OF INTEREST: No conflicts of interest. FUNDING SOURCES: No external funding obtained. http://dx.doi.org/10.1016/j.spinee.2016.01.086
Sacroiliac minimal invasive fusion compared to physical therapy: sixmonth outcome from a multicentre randomised controlled trial Bengt Sturesson, Julius Dengler, Djaja Kools, Robert Pflugmacher, Domenico Prestamburgo; Aleris Ortopedi, Sjukhuset, Södra vägen, 26252 Ängelholm BACKGROUND CONTEXT: Sacroiliac (SI) joint dysfunction is a common cause of chronic, unremitting lower back or buttocks pain. PURPOSE: To compare outcomes after surgical and non-surgical conservative treatment for SI joint dysfunction. STUDY DESIGN/SETTING: Multicentre prospective randomised controlled trial. PATIENT SAMPLE: 103 patients. OUTCOME MEASURES: Visual Analogue Score (VAS), Oswestry Disability Index (ODI), EuroQOL-5D, Zung depression questionnaire, provocative physical examination tests and active straight leg test (ASLR). METHODS: 103 subjects with Sacro Iliac Joint (SIJ) dysfunction were randomly assigned to minimally invasive SI joint fusion with triangular titanium