Dr. Amish Patel will discuss and demonstrate
the recommended technique for SI Joint injection.
Typically the current gold standard is that
SI joint injection should be performed under
fluoroscopic guidance, utilizing contrast
to confirm needle placement, injecting no
more than 2 ccs. of solution whether it’s
a diagnostic and/or a therapeutic injection.
The percent pain reduction that we’re looking
for after a diagnostic sacroiliac joint pain
injection under fluoroscopy is performed
is greater than or equal to a 75% pain reduction
when comparing pre-procedure and post-procedure
visual analog pain scores within 15 to 30
minutes.
We use the provocative maneuvers or simple
functional activities like sitting, standing
and walking as typical measures of the pain
reduction.
Furthermore, patients will take home a pain
diary log where they’ll record their pain
intensity scores every two hours for up to
24 hours.
During the intra-articular SI Joint injection
procedure, a C-arm is used to identify the
inferior portion of the SI Joint with the
patient in the prone position.
Some physicians place a pillow under the abdomen
at the level of the iliac crests.
“So when we do the SI Joint injection, we
typically want to start off by getting a true
lateral image, which looks like this.
This is where the anterior and posterior SI
joints are superimposed, okay, which is what
we see in this particular picture.
Then what I’m going to do is I’m going
to rotate it towards me, and what you’re
going to notice here is that the SI Joint
is going to start to separate.
And that’s what we’re seeing right now,
to the point that we basically see our posterior
joint, which is right here, and our anterior
joint, which is right here, separating completely.
Okay.
And what we think is that the posterior joint,
which is the medial one, is located right
here: this is our opening.
So this is basically where we’re going to
want to make our mark, and anesthetize the
skin.”
The sterilized area is anesthetized with 1%
Lidocaine.
“At this point we don’t want to put any
numbing medicine in the muscle, because we
don’t want to create any sort of a false
positive anesthetization of the muscle.
So we want to do just superficial anesthesia.”
A 22-gauge 3.5” styletted spinal needle
will then be used to advance toward the target
using intermittent fluoroscopic guidance.
“So the next step now is we’re just going
to put the needle over the numbing area, and
it should view overlying the SI Joint.
So let’s get that to look like that.
So the needle typically should start at the
media aspect of the joint line, which is what
we see in this picture here.”
“And we poke through the skin, and the needle
is still along the needle part of the joint
line, which is perfect.”
Dr. Patel advances the 22-gauge, 3.5 inch
styletted spinal needle, and the tip encounters
an “articular slide” after piercing the
joint capsule.
A distinct “pop” can be felt when the
joint is penetrated.
“So at this point when we take a look at
the needle here, I’m just piercing the capsule
only, I don’t want to drive it through and
through.
So what happened was I put the needle to hit
bone, and then I walked it into the joint,
and now what we want to do is inject a little
bit of contrast.”
Once the needle is properly positioned within
the inferior portion of the joint, 0.25 milliliters
of one’s contrast medium of choice is injected.
“So now we can start seeing the contast
flowing up into the joint here.
And you can see it flowing up into the capsule
there.
Now what I want to do is see if I can get
a little bit deeper…right there.”
“So in this particular photo you can see
all the contrast basically filling up the
posterior part of the joint, which is right
here.
Okay.
And this is the anterior part of the joint.”
“And in the lateral view here you can actually
see the contrast flowing up into the joint
space right here.
Okay.
So at this point I don’t want to inject
any more contrast; I want to go ahead and
basically put the numbing medicine into the
joint.
And we’re going to inject about 1.7 cc’s
of anesthetic.”
For diagnostic injections such as this, up
to 2 ml of local anesthetic may be injected.
For therapeutic injections, 0.75 milliliters
of the steroid of one’s choice and 1.25
milliliters of 0.5% Marcaine would be used.
“And we’re all done, okay.
Needle out on three: one, two, three.
All finished, okay.”
“I just wanted to point a few distinctive
differences between the diagnostic injection
you just saw compared to this patient.
What you noticed on the first patient was
that the contrast was only going into the
posterior part of the SI joint and in this
particular diagnostic injection that we performed
just recently you’re going to see it going
through the posterior and anterior SI joint.
So here’s a picture of the actual needle
in the distal third of the SI joint in the
posterior aspect of the joint, like we talked
about before, which is mostly located along
the medial aspect; while this line here, this
joint space, is the ventral aspect.
Going to the next photo here you can see as
the contrast extravasates it actually goes
up both, along the posterior contour, and
the anterior contour of the SI joint there.
Moving to the next image, this is our lateral
view, OK.
You can actually see the medication basically
extravasating into both the posterior and
the anterior SI joint.
And you can also notice on this view that
the medication is not leaking out of the joint.
Which tells me that when I inject this numbing
medicine I don’t run the risk of developing
a false positive diagnosis, and running the
risk of anesthetizing the L-5 nerve root,
the S-1 nerve root or the lumbosacral plexus.
And this is just in our oblique view where
once again you can see the medication nicely
going along the anterior SI joint and along
the posterior SI joint and you can see it’s
staying within the confines of the capsule
and none of it is leaking out.”
“It’s really important to understand that
when performing a diagnostic SI joint injection
that you’re not always going to get contrast
that flows through the posterior and anterior
SI joint spaces.
But it’s very important that you at least
see medication or contrast flowing into the
posterior SI joint space.”
A therapeutic sacroiliac joint injection can
definitely yield a long-term result in reduction
of pain.
Typically what we expect after the first therapeutic
sacroiliac joint injection is within a two-week
period a 40-50% pain reduction.
As noted in the Zelle paper, the injection
of corticosteroids has shown to improve the
pain for several months.
However, the anti-inflammatory effect is not
permanent, and the injections do not offer
an opportunity to stabilize an incompetent
joint.
After a therapeutic sacroiliac joint injection
is performed a pelvic strengthening and stabilization
program is typically the next step in the
treatment plan.
This program typically lasts for as long as
six to eight weeks.
When patients are unresponsive to therapeutic
sacroiliac joint injections in conjunction
with physical rehabilitation treatment then
the next step in the treatment plan would
be to consider …(deletion)
…a minimally invasive SI joint fusion.
