Sacroiliac Joint Injections
Performed by Top Pain Management Doctors in Longview, Lufkin, Sulphur & Tyler, Texas
The sacroiliac joint (SIJ) is a common source of low back pain (Gupta, 2011). There are two SIJs, located in the lower back. The SIJs connect the sacrum to the right and left iliac parts of the pelvic bones. Intra-articular SIJ injections (blocks) are used to determine whether pain is being caused by the SIJ itself or another source. SIJ injections are also administered therapeutically to treat SIJ pain. Often, these two indications are combined in a dual diagnostic and treatment approach.
The SIJ can cause low back pain when its joint capsule and ligamentous tissue are irritated or damaged (Hamauchi et al, 2010). Damage to these components results in sacroiliitis, or inflammation of one or both of the SIJs. Sacroiliitis usually manifests as pain in the low back and buttocks. The pain may be radicular, meaning that it radiates down one or both legs (sciatica) (Buijs et al, 2007).
SIJ dysfunction generally refers to abnormal position or movement of SIJ structures that may result in pain (Laslett, 2008). Such abnormalities often involve excessive or restricted motion at the SIJ, which can alter the mechanics of the spine and pelvis causing pain (Poley & Borchers, 2008). The prevalence of SIJ dysfunction is relatively high, with the condition accounting for approximately 10% of low back pain (Hamauchi et al, 2010).
Typically, it is difficult to determine whether a patient’s low back pain is being caused by the SIJ. The patient history is often nonspecific in the evaluation of low back pain, and initial screening measures during the physical examination are not sensitive or specific enough to diagnose SIJ dysfunction alone (Simopoulos et al, 2012). SIJ injections (diagnostic blocks) are therefore considered the gold standard for diagnosing SIJ dysfunction as the cause of nonspecific low back pain (Poley & Borchers, 2008). If injection of the SIJ with numbing medication causes the patient’s pain to diminish significantly, the SIJ is implicated as the anatomical source of the pain.
A recent systematic evaluation of the diagnostic accuracy of SIJ interventions found evidence is good for the diagnosis of SIJ pain utilizing diagnostic SIJ injections (Simopoulos et al, 2012). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to December 2011, and manual searches of the bibliographies of known primary and review articles. Methodological quality assessment of included studies was performed using Quality Appraisal of Reliability Studies (QAREL), and only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were utilized in the analysis. The level of evidence was classified as good, fair or poor based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF).
Causes of SIJ Pain
- Demographics. According to a recent study, risk factors for SIJ pain appear to be older age, female gender and low body mass index (BMI) (DePalma et al, 2011 & 2012).
- Ankylosing Spondylitis (AS). AS is a chronic, inflammatory disease that can cause SIJ pain. It is an autoimmune spondyloarthropathy (a form of arthritis) that affects the joints in the axial skeleton (the central axis of the skeleton, principally consisting of the skull, spine and ribcage) (Chen et al, 2011). Eventually, AS can result in fusion in affected parts of the spine.
- Osteoarthritis (OA). Another type of arthritis that can lead to SIJ pain is OA, a degenerative, age-related arthritis that can affect the spine, including the SIJs.
- Pregnancy. In pregnancy, additional stress and wear occur in the SIJs due to increased body weight, changes in gait and hypermobility of joints due to secretion of the hormone relaxin, which helps pelvic joints stretch to accommodate childbirth.
- Trauma. Injury to the SIJs, as with athletic injuries, motor vehicle accidents or falls, can result in SIJ dysfunction and pain.
- Infection. The SIJs can become infected, although this is a rare occurrence.
- Surgery. SIJ pain is a potential source of pain in patients who have undergone lumbar or lumbosacral fusion or stabilization surgeries (Liliang et al, 2011). When SI joint pain develops after surgery in spite of physical therapy, SIJ injection is a choice treatment (Hart et al, 2011).
- Tumors. Cancer patients with bone metastases in the SIJ tend to feel pain in this area (Nebreda et al, 2011).
Newer research suggests that painful conditions are best treated with a multi-modal or multi-disciplinary approach (Argoff et al, 2009; Casale et al, 2008; Fine, 2011; McCarberg et al, 2012; Szumita et al, 2010; Van Abbema et al, 2011; Wössmer et al, 2007). In addition to SIJ injections, some concomitant treatment options include pharmacotherapy such as nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, spinal manipulation, relaxation therapy, orthopedic appliances, alternative therapies and cognitive behavioral therapy (CBR). While there are few high-quality studies evaluating and comparing these treatments in individuals with SIJ pain, patients may respond to one, or a combination of these treatments (Poley & Borchers, 2008).
The SIJs are located on either side of the sacral spine in the low back. They form a joint between each side of the sacrum and the left and right aspects of the pelvic bone. The pelvic anatomy is complex, and the SIJ joint spaces are variable and irregular. The SIJ transmits vertical forces from the spine to the lower extremities and has a role in lumbopelvic dynamic motion (Foley & Buschbacher, 2006). Like the knees or the shoulders, the SIJs are diarthrodial, or freely mobile, and synovial, meaning they are constructed with a cartilaginous joint capsule. They are anchored by three flexible, fibrous ligaments which hold the bones in place. Due to its substantial mobility and the vulnerability of the capsule, ligaments and other tissues that comprise the joint, the SIJ is prone to development of painful conditions.
SIJ injections are typically performed using fluoroscopy (live X-ray), ultrasound or Computerized Tomography (CT) guidance (Migliore et al, 2010). This helps the physician ensure accuracy when delivering the injection into the joint. Using imaging guidance, the tip of the needle is advanced into the SIJ. Depending on the type of imaging used, the position of the needle is typically verified with injection of contrast dye. Once the tip of the needle is correctly placed, medications are injected. These may include anesthetic and corticosteroid. Newer research indicates that injection of the neurotoxin botulinum toxin A (Botox®) may also be effective in therapeutic SIJ injections (Lee et al, 2010). If a good response (greater than or equal to 50% pain relief) is obtained while the anesthetic is in effect, then a diagnosis of SIJ dysfunction may be made. Sometimes, a second diagnostic injection is performed with a different anesthetic to verify the results. If pain relief is successful with diagnostic injections, then therapeutic injections of numbing anesthetic and anti-inflammatory corticosteroid may be prescribed for ongoing treatment of the pain. In other cases, the physician may recommend RFA of the lateral branch nerves associated with the SIJ for longer-lasting pain relief (Stone & Bartynski, 2009). In addition to SIJ injections, the patient may be offered a multi-modal pain management regime that includes other therapies to help restore optimal functionality and quality of life.
SIJ injections are recommended by physicians for an array of reasons. SIJ injections:
- Are minimally invasive and reversible since the effects are not permanent;
- Help patients avoid riskier procedures such as surgery (e.g., arthrodesis) which are reserved as a last resort when all other treatments have failed to relieve pain (Wise & Dall, 2008);
- Can be used as an intermediate step before RFA, which has been shown to provide longer-term pain relief (Kapural et al, 2008). For example, a study in 14 patients with chronic SIJ pain who received RFA of relevant nerves (sacral lateral branches and dorsal rami) experienced a clinically relevant degree of pain relief and improved function up to one year following the procedure (Cohen et al, 2008);
- Often permit decreased use of analgesic medications;
- Often boost daily functionality and improve quality of life.
Risks SIJ injections are considered a low-risk procedure as they are minimally invasive and their effects are impermanent. However, like any medical procedure, there are risks and complications associated with SIJ injections. Three senior researchers recorded the presence and types of adverse events in patients who had received SIJ injections (Plastaras et al, 2012). A total of 162 patients (133 women) of varied ages and pain levels underwent SIJ injections. Follow-up data was available for 132 of 191 injections received. There were 32 adverse events reported at a mean follow-up interval of two 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]). A review on complications of joint, tendon and muscle injections found infection was the most common adverse event (Cheng & Abdi, 2007). Any medical procedure that penetrates the skin can result in development of infection, although this outcome is not frequent in SIJ injections. One study reported an outbreak of infection after SIJ injections, but concluded lapses in infection control in that specific clinic likely led to the outbreak. The source of the infections was identified as contaminated single-use vials that were then used for multiple patients (Wong et al, 2010). It should be noted that this incidence is an extreme aberration and highly unlikely to reoccur in modern practice. The same review also found other complications include spinal cord injury and peripheral nerve injuries, pain or swelling at the site of injection, chemical irritation of the meninges (membranes that surround the spinal cord), granulomatous inflammation of the synovial lining of the joint, aseptic acute arthritis, tissue necrosis, skeletal muscle toxicity and tendon and fascial ruptures. The researchers concluded that many of the infectious complications may be preventable by strict adherence to aseptic techniques and that some of the other complications may be minimized when the procedure is performed by a knowledgeable, experienced practitioner. Another risk of SIJ injections is a false positive when obtaining a diagnostic block. The false-positive rate of single, uncontrolled, sacroiliac joint injections is approximately 20% (Hansen et al, 2007). Fortunately, a positive or negative response to an SIJ injection can be verified by repeating the injection.
Imaging-guided SIJ injection of the sacroiliac joints is feasible, accurate and safe, and can reduce SIJ inflammatory activity thereby inhibiting disease progression (Fritz et al, 2011). Reduction of pain can help many individuals regain day-to-day functionality and improve their quality of life. A randomized, controlled trial found SIJ injections appear to be an effective palliative treatment for selected patients with SIJ pain (Hawkins & Schofferman, 2009). Most patients whose pain responded to SIJ steroid injections improved sufficiently and remained well after one to three injections.
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