Intra-articular Sacroiliac Joint Injections Research Articles

The therapeutic effectiveness of fluoroscopically guided intra-articular sacroiliac joint injections in patients with sacroiliac joint dysfunction, an observational study

ObjectiveThe goal of this project is to evaluate the therapeutic effectiveness of fluoroscopically guided intra-articular sacroiliac (SI) joint injections in patients with diagnosed SI joint dysfunction. Patient reported outcomes related to pain and quality of life measures were evaluated. DesignThis is a retrospective observational study of patients receiving intra-articular SI joint injections under a single provider at the Cleveland Clinic from September 2013 to April 2019. Three hundred fifty-one patients received injections and were administered patient reported outcomes (PROs) including the Numeric Rating Scale, Patient Health Questionnaire, Pain Disability Questionnaire, EuroQol-5 Dimensions Questionnaire, and PROMIS-GH Physical and Mental Health at baseline and approximately 1-, 3-, 6-, 12-, and 24-month time points during follow-up appointments. The primary outcome measure was the percentage of patients receiving their first injection who achieved minimal clinically important difference (MCID) in these PROs at each follow-up time point. Secondary outcomes were the percentage of patients achieving MCID in each PRO for each injection analyzed (including patients who received repeat injections) and average change in these PROs at each time point for first and all injections. ResultsA total of 351 patients were included in the analysis, with varying time points of follow-up. The average patient age was 52.3 (±14.9) years with 74.9% female and 59.0% white. For first time injections, the MCID was achieved for Numeric Rating Scale in 60.6%, 42.1%, 47.5%, and 32.5% of patients at 1-, 3-, 6-, and 12-month follow-up, respectively. There was significant improvement in PROMIS-GH Physical Health at 3-month, 6-month, and 1-year follow-up. There was no significant improvement in PROMIS-GH Mental Health at any follow-up time points. ConclusionsFluoroscopically guided intra-articular SI joint injection for SI joint dysfunction is effective in providing therapeutic pain relief exceeding MCID values in greater than 60% of patients at 1 month and greater than 40% at 3- and 6- months after injection. However, while this intervention may provide significant pain relief and improvement in function, it may not address the psychosocial aspect of chronic pain to the same extent.

ID: 222376 Far-Contralateral Oblique (FCO) Sacroiliac Joint Injection: Description of a Novel Technique

Axial low back pain (LBP) has been one of the primary causes of years lived with a disability, and it continues to be an expanding burden on health systems as the global population continues to grow. Though some patients experience LBP originating from facet mediated and vertebrogenic pain, about 15-25% of patients with LBP have pain originating primarily from the sacroiliac joint (SIJ). As the treatments offered for SIJ mediated pain continue to evolve, appropriately diagnosing this diarthrodial joint as the primary pain mediator becomes even more critical. Traditionally, the intra-articular SIJ injections are targeted towards the inferior 1/3 of the SIJ. Due to patients’ variable anatomy and pathological changes that occur with time, accessing the joint from this area may become challenging. For the objective of our study, we propose entering the superior ⅓ of the SIJ, by way of an alternative far-contralateral oblique approach. Furthermore, to promote future studies on the efficacy of this approach and possibly comparing it with the traditional approach.

Review of Current Evidence for Minimally Invasive Posterior Sacroiliac Joint Fusion.

The sacroiliac joint (SIJ) is a large, irregularly shaped, serpentine joint structure bordered anteriorly and posteriorly by the sacroiliac ligaments. With increased recognition of the SIJ as a pain source, treatments have been historically nonsurgical in nature. Common treatments include bracing, medications, activity modification, manual therapy, chiropractic manipulation, physical therapy, and intra-articular SIJ injections. Surgical stabilization and/or fusion of the SIJ may be considered when a patient has persistent moderate to severe pain, functional impairment, and failed conservative management. Surgical stabilization and fusion has traditionally been by way of the transiliac approach. More recent SIJ fusion systems have proposed not only a posterior approach but one that stabilizes the joint space by placing an allograft within the SIJ. Anatomically, a posterior approach is able to avoid neurovascular structures that otherwise are encountered with the transiliac approach and may be performed percutaneously. Preliminary evidence reports consistent pain reduction with minimal complications. This paper is purposed to detail the present evidence of minimally invasive posterior SIJ fusion, as well as highlight the need for further research moving forward.

The Success Rate of Ultrasound-Guided Sacroiliac Joint Steroid Injections in Sacroiliitis: Are We Getting Better?

The sacroiliac joint is one of the most common sources of low back pain; however, it is difficult to place the needle accurately inside the joint space without image guidance. Improvement of ultrasound technology may lead to a high success rate for intra-articular drug deposition. Assessment of the success rate of ultrasound-guided intra-articular sacroiliac joint injection. Prospective observational study. Ultrasound-guided injections were performed on 34 patients suffering from sacroiliitis. After injection of the drug solution and withdrawal of the needle, an anteroposterior fluoroscopy image was obtained and recorded for the injected joint to detect whether it was predominantly intra-articular or peri-articular. Clinical outcome using a numeric pain rating scale as well as limitation of physical functioning measured by the Oswestry Disability Index (ODI) were determined. Thirty-three injections (84.6%) were intra-articular, while 6 injections (15.4%) were peri-articular, as confirmed by fluoroscopy, with no statistical difference regarding clinical outcome between them. The baseline mean pain score decreased from 7.21 to 1.92 1month after injection, and the mean ODI scores improved from 61.41% to 17.13%. Intervention was well tolerated, and 91.2% of patients were satisfied or mostly satisfied. Ultrasonography provides a high success rate of intra-articular sacroiliac joint injection as confirmed by fluoroscopy. No significant difference in clinical outcome between intra-articular and peri-articular injection was found.

Intra-Articular Sacroiliac Joint Injection: Technical Guide.

Sacroiliac (SI) joint pathology has been an increasingly discussed pathology as a potential etiology for significant low back and lower extremity pain. While patient history and examination maneuvers can assist with identifying the SI joint as a potential cause of pain, an intra-articular SI joint injection is critical to properly diagnose the SI joint as a clinically relevant pain generator. In addition to the diagnostic information from the injection, SI joint intra-articular injections can be performed for therapeutic benefit as part of a multi-modal, conservative treatment approach for SI joint pathology. We discuss our technique for safe and effective SI joint intra-articular injections as a both diagnostic and therapeutic aid for SI joint pathology.

The Sacroiliac Joint Injection

Background: the sacroiliac joint (SIJ) is the largest axial joint in the body, with an average surface area of 17.5 cm2, it is an accepted source of low back and/or buttock pain with or without lower extremity pain. Based upon history and physical examination findings, the prevalence of sacroiliac joint pain in chronic low back pain population has been shown to range from 22.5% to 62.8%. Aim of this work: to evaluate the therapeutic benefit of intra articular corticoid injections into the sacroiliac joints in a standardized fashion. Patients and Methods: This study included 20 adults with SIJ pain due to different reasons and who were scheduled to undergo SIJ injection of corticosteroids and local anesthetic. Demographic data to consider include sex, age, weight, occupation, affected side, co morbidity and suggested pathology of the examined SIJ. Results: there is a significant decrease of the inflammatory back pain in 85% of patients; on mean post 2.00±1.86 compared to pre 7.50±1.24 according to VAS of patients after 6 months follow up (p-value <0.001 HS). Its minimally invasive procedure & good result by single injection to all patients during 6 months follow up. Conclusion: CT guided sacroiliac joint minimally invasive, short time, very accurate and good results obtained. Intra articular SIJ injection is an effective method for alleviating pain in patients suffers from SIJ pain at least in short term.

Intraarticular Sacroiliac Joint Injection Under Computed Tomography Fluoroscopic Guidance: A Technical Note to Reduce Procedural Time and Radiation Dose

A technique for computed tomography fluoroscopy (CTF)-guided intraarticular (IA) sacroiliac joint (SIJ) injection was devised to limit procedural time and radiation dose. Our Institutional Review Board approved this retrospective analysis and waived the requirement for informed consent. Overall, 36 consecutive diagnostic or therapeutic IA SIJ injections (unilateral, 20; bilateral, 16) performed in 34 patients (female, 18; male, 16) with a mean age of 45.5 years (range 20-76 years) under CTF guidance were analyzed, assessing technical success (i.e., IA contrast spread), procedural time, and radiation dose. All injections were successful from a technical perspective and were free of serious complications. Respective median procedural times and effective doses of SIJ injection were as follows: unilateral, 5.28 min (range 3.58-8.00 min) and 0.11 millisievert (mSv; range 0.07-0.24 mSv); and bilateral, 6.72 min (range 4.17-21.17 min) and 0.11 mSv (range 0.09-0.51 mSv). Given the high rate of technical success achieved in limited time duration and with little radiation exposure, CTF-guided IA SIJ injection is a practical and low-risk procedure.

Adverse Events Associated With Fluoroscopically Guided Sacroiliac Joint Injections

To describe the type, incidence, and factors that contribute to adverse events associated with fluoroscopically guided intra-articular sacroiliac joint injections (IASIJ). A retrospective cohort study. Tertiary, academic, outpatient physical medicine and rehabilitation interventional spine clinic. English-speaking adults aged 18-90 years who underwent fluoroscopically guided IASIJ injections between March 8, 2004, and April 19, 2007. After IASIJ injections, 3 senior researchers recorded the presence and types of adverse events. The relationship of adverse events with age, gender, fluoroscopy time, vital signs, and trainee presence was analyzed with the Fisher exact or the Wilcoxon rank sum 2-sided tests. The frequency of immediate (during or immediately after the procedure) or delayed (within 24-72 hours after the procedure) adverse events. A total of 162 patients (133 women) underwent 191 procedures. The range of subject age was from 20 to 90 years (15.8 years, standard deviation [SD]). The range (SD) of the preprocedure 11-point Likert Pain Scale was from 1.0 to 10.0 (2.0) and for the postprocedure 11-point Likert Pain Scale was from 0.0 to 9.0 (2.5). Trainees were involved in 57% of the procedures. Reported immediate adverse events were vasovagal reaction (2.1% [n = 4]) and steroid-clogged needle (0.5% [n = 1]). Follow-up data were available for 132 of 191 procedures (69%). There were 32 adverse events reported at a mean follow-up interval of 2 days, of which, the most frequent adverse events were injection-site soreness (12.9% [n = 17]), pain exacerbation (5.3% [n = 7]), and facial flushing and/or sweating (2.3% [n = 3]). Delayed adverse events decreased with older age (P = .0029). The patients who underwent bilateral procedures experienced more delayed adverse events than the patients who underwent unilateral procedures (P = .024). Fluoroscopically guided IASIJ injection is associated with minimal adverse effects. The most common immediate adverse event was vasovagal reaction, and the most common delayed adverse event was injection-site soreness. Younger age is significantly related to reported delayed adverse events.

SI joint injection - a novel approach

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.

Structural Etiology of Chronic Low Back Pain Due to Motor Vehicle Collision

To estimate prevalence rates of discogenic, facet, and sacroiliac joint pain, and describe clinical features of chronic low back pain patients whose symptoms were initiated by motor vehicle collisions. Retrospective chart review. Academic spine center. Twenty-seven motor vehicle collision-induced chronic low back pain patients were included after undergoing diagnostic procedures. Lumbar provocation discography, dual diagnostic facet joint blocks, and intra-articular sacroiliac joint injections. Enrolled patients underwent diagnostic procedures based on clinical presentation until the pain source was identified. The prevalence of each source of low back pain was estimated. Clinical, categorical, and continuous characteristics within the source groups were calculated with SAS v.9.2 (SAS Institute Inc., Cary, NC). Etiology and prevalence were analyzed for each diagnosis group. Of the 27 patients, 15/27 (56%) were diagnosed with discogenic pain, 7/27 (26%) with sacroiliac joint pain, and 5/27 (19%) with facet joint pain. Seventy-eight percent were female. Mean age was 42.5 years (standard deviation = 10.4) with median duration of symptoms of 24 months (interquartile range = 6-48). Our study is the first to demonstrate that diagnostic spinal injections can identify particular spinal structures, namely the intervertebral disc, facet joint, and sacroiliac joint, as the specific source of chronic low back pain due to inciting motor vehicle collisions. The most common source of motor vehicle collision-induced chronic low back pain appears to be the disc followed by the sacroiliac and facet joints.

Poster 115: Final Needle Position on Lateral Fluoroscopic Image During Confirmed Intra-articular Sacroiliac Joint Injections: A Retrospective Review

Poster 115: Final Needle Position on Lateral Fluoroscopic Image During Confirmed Intra-articular Sacroiliac Joint Injections: A Retrospective Review

Sacroiliac Joint Interventions: A Systematic Review

The sacroiliac joint is a diarthrodial synovial joint with abundant innervation and capability of being a source of low back pain and referred pain in the lower extremity. There are no definite historical, physical, or radiological features to provide definite diagnosis of sacroiliac joint pain, although many authors have advocated provocational maneuvers to suggest sacroiliac joint as a pain generator. An accurate diagnosis is made by controlled sacroiliac joint diagnostic blocks. The sacroiliac joint has been shown to be a source of pain in 10% to 27% of suspected cases with chronic low back pain utilizing controlled comparative local anesthetic blocks. Intraarticular injections, and radiofrequency neurotomy have been described as therapeutic measures. This systematic review was performed to assess diagnostic testing (non-invasive versus interventional diagnostic techniques) and to evaluate the clinical usefulness of interventional techniques in the management of chronic sacroiliac joint pain. To evaluate and update the available evidence regarding diagnostic and therapeutic sacroiliac joint interventions in the management of sacroiliac joint pain. A systematic review using the criteria as outlined by the Agency for Healthcare Research and Quality (AHRQ), Cochrane Review Group Criteria for therapeutic interventions and AHRQ, and Quality Assessment for Diagnostic Accuracy Studies (QUADAS) for diagnostic studies. The databases of EMBASE and MEDLINE (1966 to December 2006), and Cochrane Reviews were searched. The searches included systematic reviews, narrative reviews, prospective and retrospective studies, and cross-references from articles reviewed. The search strategy included sacroiliac joint pain and dysfunction, sacroiliac joint injections, interventions, and radiofrequency. The results of this systematic evaluation revealed that for diagnostic purposes, there is moderate evidence showing the accuracy of comparative, controlled local anesthetic blocks. Prevalence of sacroiliac joint pain is estimated to range between 10% and 27% using a double block paradigm. The false-positive rate of single, uncontrolled, sacroiliac joint injections is around 20%. The evidence for provocative testing to diagnose sacroiliac joint pain is limited. For therapeutic purposes, intraarticular sacroiliac joint injections with steroid and radiofrequency neurotomy were evaluated. Based on this review, there is limited evidence for short-term and long-term relief with intraarticular sacroiliac joint injections and radiofrequency thermoneurolysis. The evidence for the specificity and validity of diagnostic sacroiliac joint injections is moderate. The evidence for accuracy of provocative maneuvers in diagnosis of sacroiliac joint pain is limited. The evidence for therapeutic intraarticular sacroiliac joint injections is limited. The evidence for radiofrequency neurotomy in managing chronic sacroiliac joint pain is limited.

A Systematic Review of Sacroiliac Joint Interventions

The sacroiliac joint is an accepted source of low back pain with or without associated lower extremity symptoms. The diagnosis and management of sacroiliac joint pain and the role of interventional techniques have been controversial. To evaluate the clinical usefulness of sacroiliac joint interventions in the diagnosis and management of sacroiliac joint pain. A systematic review using the criteria as outlined by the Agency for Healthcare Research and Quality (AHRQ), Cochrane Review Group Criteria, and QUADAS criteria for diagnostic studies. The databases of EMBASE and MEDLINE (1966 to November 2004), and Cochrane Review were searched. The searches included systematic reviews, narrative reviews, prospective and retrospective studies, and cross-references from articles reviewed. The search strategy included sacroiliac joint pain and dysfunction, sacroiliac joint injections, interventions, and radiofrequency. The results of this systematic evaluation showed that for diagnostic purposes, there is moderate evidence showing the accuracy of comparative, controlled local anesthetic blocks. Prevalence of sacroiliac joint pain was demonstrated to be 10% to 19% by a double block paradigm. The false-positive rate of single, uncontrolled, sacroiliac joint injections was reported as 20%.For therapeutic purposes intraarticular sacroiliac joint injections with steroid and radiofrequency neurotomy were evaluated. Based on this review, there was moderate evidence for short-term and limited evidence for long-term relief with intraarticular sacroiliac joint injections. Evidence for radiofrequency neurotomy in managing sacroiliac joint pain was limited or inconclusive. The evidence for the specificity and validity of diagnostic sacroiliac joint injections was moderate.The evidence for therapeutic intraarticular sacroiliac joint injections was limited to moderate. The evidence for radiofrequency neurotomy in managing chronic sacroiliac joint pain was limited.

Functional and radiographic outcome of sacroiliac arthrodesis for the disorders of the sacroiliac joint

Background context The sacroiliac joint is known to be a possible cause of chronic low back pain, but the diagnosis and treatment of disorders of the sacroiliac joint have been difficult and controversial. Purpose To describe the outcome of sacroiliac joint arthrodesis for sacroiliac joint disorders, with the hypothesis that sacroiliac arthrodesis leads to improved postoperative function. Study design/setting Consecutive case series performed in an academic medical institution. Patient sample The patient population consisted of 20 patients undergoing sacroiliac joint arthrodesis between December 1994 and December 2001. Patients undergoing concomitant procedures at the time of sacroiliac joint arthrodesis were excluded. The 3 men and 17 women in the study group had an average age of 45.1 years (range 21.8–66.4 years), a mean duration of symptoms of 2.6 years (range 0.5–8.0 years), and a mean follow-up period of 5.8 years (range 2.0–9.0 years). Outcome measures Outcome measures included general health and function, clinical evaluation, and radiographic assessment. Methods For all 20 patients, nonoperative treatment had failed, and for all, the diagnosis was confirmed by pain relief with intraarticular sacroiliac joint injections under fluoroscopic guidance. Sacroiliac joint arthrodesis (via a modified Smith-Petersen technique) was recommended only when a positive response to the injection was noted, and patients had recurrence of symptoms after the initial positive response. Preoperative and postoperative general health and function were assessed via the 36-item Short-Form (SF-36) Health Survey and American Academy of Orthopaedic Surgeons (AAOS) Modems Instrument, which were collected prospectively. Medical records and plain radiographs were reviewed retrospectively to determine the clinical and radiographic outcome. Results Multiple etiologies of sacroiliac symptoms were observed: sacroiliac joint dysfunction (13 patients), osteoarthritis (5 patients), and spondyloarthropathy and sacroiliac joint instability (1 each). Seventeen patients (85%) had solid fusion. Fifteen patients (75%) completed preoperative and postoperative SF-36 forms. Significant (p≤.05) improvement occurred in the following categories: physical functioning, role physical, bodily pain, vitality, social functioning, role emotional, and neurogenic and pain indices. Improvement (not statistically significant) was also noted in general and mental health. Conclusions For carefully selected patients, sacroiliac arthrodesis appears to be a safe, well-tolerated, and successful procedure, leading to significant improvement in functional outcome and a high fusion rate. To the authors' knowledge, the current report is the largest series to document the functional and radiographic outcome of sacroiliac joint arthrodesis.

Abstract 50 sacroiliac joint dysfunction: diagnosis by clinical evaluation compared with intra-articular sacroiliac joint injection. Maryane Marim-Dinkins, MS, PT; Peter T. Dorsher, MS, MD (Mayo Clin, Jacksonville, FL), e-mail: dorsher.peter@mayo.edu

Abstract 50 sacroiliac joint dysfunction: diagnosis by clinical evaluation compared with intra-articular sacroiliac joint injection. Maryane Marim-Dinkins, MS, PT; Peter T. Dorsher, MS, MD (Mayo Clin, Jacksonville, FL), e-mail: dorsher.peter@mayo.edu

Sacroiliac joint injections performed with sonographic guidance.

To investigate the feasibility and effectiveness of sonographic guidance for therapeutic intra-articular sacroiliac joint injections in patients with sacroiliitis. Thirty-four consecutive patients with sacroiliitis were enrolled in this study. The synovial portions of 60 sacroiliac joints received injections under sonographic guidance. For treatment, a mixture of a corticosteroid and a local anesthetic was injected intra-articularly. Fluoroscopic spot images were obtained to assess the accuracy of the sonographically guided technique. Of the 60 sonographically guided injections, 46 (76.7%) were successful (i.e., intra-articular), and 14 (23.3%) were missed. The successful intra-articular injection rate was 60% in the first 30 injections, and it gradually improved, reaching 93.5% in the last 30 injections. The mean procedure time was 9 minutes. Our initial experience suggests that sonographically guided therapeutic injections to sacroiliac joints could be valuable alternatives to other guidance modalities in patients with sacroiliitis. In the hands of experienced radiologists, this technique is safe, rapid, and reproducible.

Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests

Research suggests that clinical examination of the lumbar spine and pelvis is unable to predict the results of diagnostic injections used as reference standards. The purpose of this study was to assess the diagnostic accuracy of a clinical examination in identifying symptomatic and asymptomatic sacroiliac joints using double diagnostic injections as the reference standard. In a blinded concurrent criterion-related validity design study, 48 patients with chronic lumbopelvic pain referred for diagnostic spinal injection procedures were examined using a specific clinical examination and received diagnostic intraarticular sacroiliac joint injections. The centralisation and peripheralisation phenomena were used to identify possible discogenic pain and the results from provocation sacroiliac joint tests were used as part of the clinical reasoning process. Eleven patients had sacroiliac joint pain confirmed by double diagnostic injection. Ten of the 11 sacroiliac joint patients met clinical examination criteria for having sacroiliac joint pain. In the primary subset analysis of 34 patients, sensitivity, specificity and positive likelihood ratio (95% confidence intervals) of the clinical evaluation were 91% (62 to 98), 83% (68 to 96) and 6.97(2.70 to 20.27) respectively. The diagnostic accuracy of the clinical examination and clinical reasoning process was superior to the sacroiliac joint pain provocation tests alone. A specific clinical examination and reasoning process can differentiate between symptomatic and asymptomatic sacroiliac joints