It is now recognized that adjacent segment degenerative disease does affect the SIJ when a long lumbosacral fusion is performed. If the SIJ is fixated when performing a long lumbosacral fusion, certain pitfalls such as over abundant iliac bone graft harvesting, with its associated potential effects on the SIJ and the ramifications of positive sagittal balance, especially in the elderly, must be considered by the spine surgeon proactively to avoid potential long-term complications. When both positive sagittal balance and the SIJs are symptomatic and require surgery, the spine surgeon must be cognizant of the best methods to use and in what sequence to use them in order to achieve the best overall result for the patient.