This is a landmark study comparing the results of SIJ fusion surgery and sham surgery, and compliments to the authors for actually conducting such a study. I believed before the publication of the results that whatever the outcome, it was a very significant study for those of us who specialize in the sacroiliac joint, it provides many new avenues for discussion.

As a result, there was no significant difference in outcomes between the two groups.

However, despite these results, I still do not agree that surgical treatment should be abandoned. There are certainly cases of patients with difficult-to-treat sacroiliac joint dysfunction who chose to operate when there was nothing they could do about it, and they returned to society.

I would now like to ask the authors, will the results of this study lead to a policy of not performing sacroiliac joint fusion surgery in Norway and Sweden? If they decide to perform sacroiliac joint fusion, how do they plan to define the indications for such a procedure?

I am going to ask them to give a talk on this subject in Graz in September this year. I am convinced that there will be a wide variety of opinions.

The inclusion criteria in this study are generally perfect for diagnosing sacroiliac joint dysfunction/pain. However, the conventional physical findings that lead to a diagnosis may not be sufficient to detect severe cases that are truly indications for surgery.

The concept of SIJ inability by Dr. Bengt Sturesson is important, and the true indication for fusion surgery is the long-term failure of the sacroiliac joint function as a load-bearing joint. This is his final conclusion about the indications for surgery in severe cases of sacroiliac joint dysfunction based on the changes in load bearing after pelvic external fixation, and I agree with him.

Therefore, I suspect that if the inclusion criteria do not include this loading abnormality, the selection of patients who would truly benefit from sacroiliac joint fusion surgery will not be successful.

The surprising result of this paper is that the surgical cases showed such a small benefit in their outcomes.

Of course, I had experienced some own cases that did not get better, but 75% of the cases I operated on were good. The reason why this cannot be considered a placebo is that we have seen many patients who had already undergone lumbar herniectomy or lumbar fusion prior to, and when they did not improve, they were diagnosed by using sacroiliac joint injections and returned to their work after sacroiliac joint fusion.

The results of this paper are valuable because the RCT was done with the best protocol available today. However, there is a possibility that the patients who would truly benefit from sacroiliac joint fusion were not properly selected. SIMEG will need to clarify this and develop a new algorithm to address it.

Second, several experts may argue that it is a matter of surgical instrumentation. After learning and discussing with Dr. Bengt Sturesson, I believe that the iFUSE implant used in this case will produce good postoperative results if a highly skilled sacroiliac joint expert decides on the indications for surgery and provides good postoperative management. Of course, there are other opinions, and I appreciate the passionate beliefs of each sacroiliac joint expert.

Let's discuss together at Graz, challenging and inspiring each other to reach higher!

Daisuke Kurosawa