Name: Endoscopic Approach to Sacroiliac Lateral Branch Nerve Transection
Uploaded: 2026-05-07T00:00:00Z
Channel: Arthrex
Description: Saqib Hasan, MD (San Francisco, CA), demonstrates the endoscopic approach for transecting the L5 medial branch nerve and S1-S3 lateral branch nerves.

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Saqib Hasan, MD (San Francisco, CA), demonstrates the endoscopic approach for transecting the L5 medial branch nerve and S1-S3 lateral branch nerves.

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video

VID1-008420-en-US | A | Endoscopic Approach to Sacroiliac Lateral Branch Nerve Transection

Saqib Hasan, MD

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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Endoscopic Approach to Sacroiliac Lateral Branch Nerve Transection

Speaker  So today we're going to talk about how we perform the lateral branch transection for denervation of the SI joint. And the first thing we want to start off with is making sure we have the X-ray at the right angle. Typically, the sacrum can have varied morphology. You can have one that's a little bit sloped like this. You can have one that's more flat like this. I generally tend to have the angle of the beam almost just perpendicular to the sacrum. Sometimes it may be easier to just come up with a straight AP, as long as you have good visualization on the X-ray, first thing I'm going to do is draw a line that is marking the top of the sacrum, and you can see that my line is going to be the most proximal extent of any working I'm going to be doing. And let's draw another line at the bottom of the SI joint. You can see that's the bottom of the SI joint there. So now you know you have your box, which you have to work within to even make it a little bit easier. You can just have another line that's the middle. Okay. So the next thing you want to do is you want to actually draw the lateral extent of the SI joint. And in this situation, let's see where the SI joint goes into. You can see the bone. I'm going to kind of I want to kind of illustrate on the imaging where the SI joint is. Speaker  If you see my marker here, you see, if I was to go lateral to this point, I would not be able to get into the see, I wouldn't be able to get into the sacrum. I'd be more on the ilium. And as I go a little bit more medial. Now, I know I can actually get past the ilium. And everyone's sacral morphology is different. Some people might have a more narrow SI joint. Some people might have more of a wide SI joint. Obviously this procedure is easier when you have a wider SI joint. So the first thing we're going to do now is the way we do this procedure is we mark two incisions. And each incision is supposed to target two nerves. So from our understanding of anatomy of the SI joint and the innervation. The medial branch of the L5 nerve root comes off from about here. So the medial branch comes off and then lands right there in the sacral Ala right there. Right here. Yes. So we know we have to be able to get this nerve here. And as we go down, probably the largest contributor of the SI joint innervation is going to be the S1 foramen which is right there. So you can see if I made a marked line here and I marked a line here, I'm going to if I go in between those two lines going a little bit louder right there. Speaker  This will allow me to get both the medial branch of L5 and the lateral branch of S1. So that's my first incision here. Now the same concept goes for the distal part of the SI joint again. This is a little bit more challenging because the ileum, which is right here, I'm going to mark the ileum coming out like that. So the best way to get the branches more distally is again we're going to see the bottom of the SI joint which is here. And then we want to go to the ileum which is right here. So and I'm going to make one in the middle of those two right there. If I come in, if this is the distal extent of my incision, and it allows me to wand up to here, back and forth, getting all the branches that come off from the foramen the same concepts here. If I'm starting here and I can wand back and forth, allowing me essentially to meet in the middle. And the concept of this procedure is you want to be able to transect all neural tissue, which comes from lateral to the sacral foramen entering to the medial part of the SI joint. So that's the principle of the procedure, is to be able to get all the neural tissue to fully denervate the SI joint. Speaker  And again, like we mentioned, the innervation of the SI joint is the medial branch of L5, but more dominantly the lateral branch of S1, S2 and S3 and occasionally S4. First thing I'm going to do is put our needle in there, and if I'm going to put the needle in, remember my angle of the X-ray is angled almost perpendicular to the sacrum. So I'm going to I'm going to be the beam here. So you can see I'm actually between the the nerve at the medial branch of L5 and the lateral branch of S1. And sometimes if you're not quite sure where your position is and you want to make sure you're on the sacrum and not caught on the ilium, it's always helpful to get a lateral to confirm your position. So let's get a lateral so you can see that right now I am on the top of the sacrum. I'm not too deep. Now, if I was not in the correct position, you'd notice that my needle would not be at the correct depth of the sacrum right now. And what we're going to do next is we like our position on the AP and the lateral. We can actually start by then putting our wire in. I will then make. I like to make a vertical incision, and the reason why I make the vertical incision is it allows me to wand both proximally and distally. Speaker  Now, the reason why I like to be in the lateral in this position, it lets me know how much I can wand back and forth. So if I was in there, I know I can get up to there, right? And then I can wand back up this way. X-ray right there. X-ray. So now I know I can get that the, the probably the most dangerous part of the procedure in this procedure, which is a very benign procedure with a very low complication profile, is you can actually travel ventral here. And if you do that and you have the setting really high on your RF probe, you can actually cause thermal injury to the L5 exiting nerve root. So it's very I think it's very important when you're in this area to always get a lateral to make sure you're not in the wrong spot. X-ray again, see, this is where you want to be. You don't want to veer up off the sacral ala here. X-ray. Okay. You never want to be there. So you always want to be here X-ray again. And then you can obviously wand yourself down like that X-ray there. Now, notice that I use this wanding technique to also release some of the soft tissue, because you're going to have a lot of ligamentous tissue here. And I can have a tactile feedback and really feel myself denuding some of the bone here. Speaker  So you see, we have many different types of bevels. I generally tend to, for sergeant procedures gravitate towards these bevels. You can have even bevels that are a little bit less angle. These bevels which are typically used for interlaminar endoscopic surgery. They actually will have too much soft tissue coming into the into the field of view. So that's why I like to have the one that's a little bit more angled. You can actually kind of angle it into the way that the SI joint is angled as well. So we're going to then put our dilator down here. Okay. And then again, the most dangerous part of the surgery is veering to ventral on the lateral. Okay. So I like that position. And then what we're going to do is if you want to take one more shot, we can go AP. Just to confirm our position. And then I like to stay on the lateral. So let's go the AP confirm where we are. And you can see again, I am in between the spots that I first picked out, which is between the medial branch, L5, lateral branch of S1. So then now we're going to take our endoscope and place it through the working cannula. And then what we should see, Typically we'll see some fat and soft tissue. So let's get a pituitary and grab some of that out. Speaker  First thing you want to do is you want to kind of make sure you dissect some of the soft tissue. Now the sometimes you'll be lucky and see the lateral branches traversing through the area. And sometimes you won't because there's a lot of soft tissue here. So for me, the endpoint that I look for is to have periosteum. When you can see periosteum and you know that you're in between. If you look at the screen this way is going to be the sacral foramen. And then towards me is going to be the si joint. So obviously if I just see periosteum in between the two, then I know I've gotten any neural tissue. And sometimes these branches are very tiny and you won't be able to see them. And a lot of them will maybe even removed when I denude the bone with the blunt dissection. So now as I do this, you can actually wand up and down. So let's get a lateral, you can see that I can actually work my way a little bit more north. Take an X-ray there. Okay. Right here. X-ray there. Okay. Now, this this procedure really relies on the lateral X-ray, as you can see, as I'm going down here. As I mentioned before, if you take your probe and slide too much this way, take an X-ray. You see how easily you can slide towards the exiting nerve root. Speaker  So you have to be very conscious of where you are when you're at the top of the sacrum. So again, I'm going to go back and now again I'm getting all of the soft tissue. And you can and you can see all of the soft tissue that is lateral to the sacral foramen is being débrided. As you see, as I go down, I'm traveling distally. You see how much progress I've made just by moving my hand, just like half a centimeter. So I'll keep going. Distally you can start to see some branches here. You see these branches right there? Give me a scissor. Take an X-ray there. You can see I'm working my way down. And again there's a lot of soft tissue attachments here. And as long as I'm lateral to the sacral foramen, which I keep repeating, because that's the key part of the procedure, we're going to be in a good area. And you can see if you look at the angle of my scope, I keep angling. And you can see that as I angle, I'm angling kind of that way because we know the sacral foramen are here, the SI joints here. So I'm working that way. You can even turn your scope till you can see better that way. So we get this here. You can see it right there. We've lucked out. And I found a branch. Okay. Okay. Speaker  And as I keep going, you're going to notice that at some point you may be able to not go any more distal. Let's take an X-ray and see where we are and keep working our way south. But I'm reaching kind of the extent and and you know that I'm I'm at a good spot because you can look at the, the S1 S2 disc space right there. So you can see on the X-ray, the S1 S2 disc space, you're pretty much where the sacral foramen are there. So we can go a little bit more distal, but I'm reaching the end of my, my incision. Okay. It's about as far as I can go distally. Now you can even see my angle. I'm pretty distal. Now let's get an AP and we'll do the other two nerves. So you can see we took our X-ray and we are at the level of the sacral S1 foramen. We actually are where we said we were going to be. Now, the challenging thing about this particular cadaver is that you can see that even though I want to be kind of here to keep working myself down right there, all of this is still ilium because the ilium is jutting out towards the midline. So this is the more challenging case. So we're going to have to kind of make our second incision again like we said before, cheat it somewhere here. Speaker  So you can see again the ilium flares out. That's why it's a little more challenging. So what we're going to do now is because we know where our position is. We're going to actually use our scope holder. So now I can actually take my scope out. I know that I want to kind of meet in the middle to make sure I get all of the sacral branches. So what I can do now again, just to remind you, X-ray again right there. Okay, you want to go a little bit more medial to that to avoid the ilium. Okay. And I'm going to be right around the bottom, not too close halfway between last two. So you can see that in this particular situation, because of the the slope or the the in the medial approach of the ileum, I have to start a little bit more medial and. And you can see that I'm kind of meeting my previous dilator. So I'm going to be able to get all the sacral branches that are lateral to the foramen. Let's get an X-ray to see where we are on the, on the lateral. Now we're going to do the same steps that we did before. Now you can see my one step dilator here. Let's take an X-ray there. And now I'm going I'm going to do is I'm going to take my wand and kind of work my way south, dissecting some of the soft tissue here. Speaker  And you can see my hand is actually because that side joint again is that way. I'm angling this way. So when again, some scraping here, you see how much I was able to move all from here, all the way down this way. And that's what you want to be able to do, is you want to be able to make sure that your scope can eventually be all the way distal down there. Okay. So I like that. And then we're just going to change our scope. Okay. Again, same concept. Getting soft tissues. Sometimes you can see some ligamentous tissue like this. It's okay to cut that ligamentous tissue. In fact, I think that when you look at the radiofrequency ablation effectiveness rates, I think the effectiveness rates for, you know, the pain management version of this procedure aren't as high. I think it's partially because there's a lot of ligamentous tissue that our colleagues are not able to get to. So it's nice you can visualize it, cut some of this tissue and that's her old cannula there. So now we're going to work our way down. So I know I'm getting the bone here. I'm going to pull back here. So now as I work my way down. I can actually take my hand, watch it come all the way down this way. And I can even turn my camera this way and kind of work it down this way. Speaker  Now that we know that we were able to essentially get the L5 and S1, we don't really need this one anymore. So we can take this out. We can get the holder off. So one little comment here. You can actually see some of the ilium here. And we talked about how high the ilium was. So sometimes you have to kind of go a little bit more medial to avoid the ilium. So we're going to go a little bit more medial here like there. You can see we're working our way down there. And now I have a little bit more freedom to go down because I was kind of stopped by the ilium. So again, we're we're starting to see that sacrum again that we talked about and we're working our way down. I want you to start to focus on where my, where my scope is. It's angled. We angled like this when we came in, and now we're angled that way. We've made quite a bit of progress distally, so we're going to keep going. We are pretty far distal as you can see. I think that we're pretty much done here. We'll just do we'll do a final AP. We'll do a final AP to confirm. But we'll clean up some more soft tissue here. And you can see as I take my camera out, you can see all the all we can just see periosteum from here. Speaker  Okay. From here, let me just get this tissue so we can see periosteum here and we can follow it here. Take an X-ray again and I can keep following it here. Let's see some more periosteum. Here, X-ray. Keep working up. X-ray. You see. Keep working up. X-ray. And we're up to here. X-ray. You can see I've denuded all of the bone all the way down here. And let's get our final AP X-ray there. And you can see that we are now at the about the distal extent of the SI joint right there. And we were able to essentially wand from the top of the sacral Ala down to the SI joint, allowing us to fully transect and debride all the neural tissue that comes lateral to the sacral foramen, including the medial branch of L5 and the sacral branches S1, S2, S3, and occasionally S4. Surgery takes roughly anywhere from 25 to 45 minutes. The complication profile is very low, and the durability of the procedure. We've had up to 70 to 80% improvement for up to two years. And we have some patients who it's been over five years and they still have some pain relief. So I think it's an excellent procedure. And I think it's an important tool that every spine surgeon who treats SI joint dysfunction should add to their armamentarium.

Sacroiliac Joint Denervation