SI joint injection - a novel approach

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As one of several differential diagnoses for chronic low back or lower extremity pain, sacroiliac (SI) joint dysfunction can involve a biochemical abnormality (e.g., infectious, inflammatory, metabolic) and/or mechanical disturbance (e.g., degenerative joint disease, trauma) of the joint. A common treatment modality is intra-articular sacroiliac joint injection of local anesthetic and/or corticosteroid under fluoroscopic, ultrasound or computed tomographic guidance. The standard fluoroscopic guided method for this injection involves insertion of a single needle into the posteroinferior aspect of the joint space, which localizes the drug into the synovial portion of the joint. However, as several studies have demonstrated, SI joint dysfunction can often involve not only the intra-articular space, but also the SI joint capsule and/or surrounding ligaments. In this paper, we describe a modified technique to the traditional SI joint injection method, which calls for two separate points of needle insertion under fluoroscopic guidance: the commonly performed injection into the posteroinferior intra-articular space and an additional injection into the joint capsule just medial to the posterosuperior margin of the SI joint. Our technique is a combination of the traditional fluoro-guided inferior intra-articular joint injection and the ultrasound-guided technique which targets the superior posterior aspect of the joint, performed simultaneously under fluoroscopy. Specifically, the site of needle insertion superiorly in our two- needle technique is just medial to the superior aspect of the joint at the level of the first posterior sacral foramen (S1). Both needles can be inserted at the same angle of fluoroscopy, not requiring any additional fluoroscopic adjustments compared to the standard technique. We believe this dual injection of the SI joint is easy to perform and can notably additionally decrease the degree of pain by targeting injury pathology in the intra-articular space and the surrounding joint capsule.