26 July 2010
Sacroiliac Joint (SIJ) disease is a leading cause of lower back pain and lower extremity radiculopathy (Dreyfuss). The SIJ is the junction between the lumbosacral spine and the iliac bones of the pelvis. The SI joint experiences degenerative changes frequently because it is a weight bearing joint. As the weight from the upper body is transmitted down the spine through the pelvis, the SI joint absorbs and distributes the impact (Smith).
The placement of the sacroiliac joint is predisposed to pain. As there is a support system of many ligaments and muscle groups that are all dense with nerve ending and spinal nerves, should there be inflammation to the joint, it is a large network of nerves, muscles and ligaments that is affected. This causes excruciating low back pain.
Procedural Description
Using a steroid that is long lasting as well as a local anesthetic, the injection will reduce any inflammation to the area, which will have a positive effect on the nerves and nerve endings. In addition, the anesthetic will numb the nerves, eliminating the pain due to inflammation and irritation. This is a minimally invasive procedure that usually takes less than 15 minutes.
Computed tomography (CT) or fluoroscopy can be used to assist in proper needle placement (Rosenberg). The patient is placed in the prone position on the CT gantry/ fluoroscopy table. Serial axial CT slices or real time fluoroscopy images are taken through the region of interest. After administering local anesthetic to numb the area, under CT/ fluoroscopic guidance, a 22-gauge spinal needle is advanced into the sacroiliac joint into the middle third of the joint. Two to three cc of contrast is injected into the joint to ensure appropriate position.
Approximately 5 mL of Kenalog 10 and 1–2 mL of an anesthetic (lidocaine, bupivacaine) are then injected (Silbergleit). Occasionally intravenous sedation can be used for patient comfort.
Indications
When there is persistent acute or chronic sacroiliac joint pain refractory to physical therapy and oral medications (nonsteroidal anti-inflammatories, opiates), sacroiliac joint injections are generally the next step and are an alternative to surgery. Silbergleit). Common causes of sacroiliac pain are (O'Shea, Peh):
- Trauma
- Degenerative disease
- Sacrolilitis from seronegative spondyloarthropaties
- Osteitis Condensans Ilii (post partum)
- Obesity
Risks
Patients taking anticoagulation medications have an increased bleeding time and therefore should be discontinued for up to 7 days prior to and for 24 hours following the injection.
The associated risks of the joint injection, although rare, include:
- Nerve damage
- Bleeding
- Infection
- Post procedural weakness
Numbness from the anesthetic may last about an hour. A dull aching pain may occur at the injection site. Should you have an iodine allergy, alert your treating physician, as the dye used for location contains iodine. However, because the contrast is injected into a joint rather than intravenously, allergic reactions are rare.
Like with any procedure, there are possible side effects, which include weight gain, arthritis of the join, ulcers of the stomach, elevation of blood sugar and possible decrease in the immune system. However, since the corticosteroid is given intra-articularly and not systemically, reactions from the steroids are not likely to occur (Mayo).
Following approximately 25% of the injections, contrast material migrated into the epidural canal which likely causes a temporary lower extremity weakness immediately following the procedure (Rosenberg).
Benefits
As lower back pain is sometimes subjective and only present under certain circumstances, it is often difficult for physicians to treat. Commonly seen, the pain may go into remission with periods of decreased or absent symptoms, however, more frequently than not, the pain returns and causes a chronic pain syndrome in most people. Sacroiliac joint injections are a minimally invasive, low risk procedure that can cause a significant decrease in symptoms without disrupting daily activities. For those patients with sacroiliac joint pain, an injection is often the go-to method to eradicate pain. (Pereira 2000).
References
Paul Dreyfuss, MD, Susan J. Dreyer, MD, Andrew Cole, MD and Keith Mayo, MD Sacroiliac Joint Pain J Am Acad Orthop Surg, Vol 12, No 4, July/August 2004, 255-265.
2004
Arnold Graham Smith, M.D., F.R.C.S The Diagnosis And Treatment Of The Sacro-Iliac Joint As A Cause Of Low Back Pain — The Management Of Pain In The Butt Jacksonville Medicine / April, 1999
Richard Silbergleit, MD2, Bharat A. Mehta, MD, William P. Sanders, MD and Sanjay J. Talati, MD3 Imaging-guided Injection Techniques with Fluoroscopy and CT for Spinal Pain Management. Radiographics. July 2001.
O’Shea FD, Bole E, Salonen DC, Ammendolia C, Peterson C, Hsu W, Inman RD. Inflammatory and degenerative sacroiliac joint disease in a primary back pain cohort. Arthritis Care Res (Hoboken). 2010 Apr;62(4):447-54.
Wilfred C. G. Peh, MD, FRCP, FRCR Osteitis Condensans Ilii. American Journal of Orthopedics. April.
Rosenberg JM, Quint TJ, de Rosayro AM. Computerized tomographic localization of clinically-guided sacroiliac joint injections. Clin J Pain. 2000 Mar;16(1):18-21.
http://www.mayoclinic.com/health/steroids/HQ01431
Pereira PL, Günaydin I, Duda SH, Trübenbach J, Rémy CT, Kötter I, Kastler B, Claussen CD. Corticosteroid injections of the sacroiliac joint during magnetic resonance: preliminary results J Radiol. 2000 Mar;81(3):223-6
