PAIN MANAGEMENT SERVICE LINE

THE ESSENTIALS OF PAIN MANAGEMENT PROCEDURES

Brought to you by:
Procedural Education Committee of the Pain Management Service Line- Resident and
Fellow Section, Society of Interventional Radiology
For comments or suggested edits, please email SIRSurvivalGuide@gmail.com

AUTHORS:

David Maldow, MD, PGY-1

EDITORS:

Hemant Kalia, MD, MPH,

Interventional Pain Management
Specialist, Rochester Regional
Health System
Joseph DeMarco, DO, SIR-RFS
Clinical Education Survival
Guide Liaison

SACROILIAC JOINT INJECTION

INDICATIONS
1. To assess role of SI joint(s) as a source of low back pain
2. Treatment of known inflammatory, degenerative or other painful conditions of SI joint(s)
not adequately controlled by oral NSAIDs
ABSOLUTE CONTRAINDICATIONS
1. Coagulopathy
2. Systemic/local infection
3. Technical inability to target SI joint
4. Pregnancy
5. Maximal corticosteroid dose reached prior to procedure
RELATIVE CONTRAINDICATIONS
1. Severe medication allergy
PREOPERATIVE PREPARATION
1. Generally done on an outpatient basis
2. Sedation rarely required
3. Typically no oral intake restrictions
4. May continue antiplatelet agents (low risk of bleeding)
5. May continue anticoagulants if INR <3
6. Focused ROS with attention to location, nature and severity of back pain
7. Physical examination including lower extremity motor strength
8. Review relevant imaging studies
9. Preliminary CT of SI joints if CT or CT fluoroscopy will be used for procedure
CONSENT
1. Outline treatment benefits, alternatives and complications
2. Risk of bleeding, infection and/or transient lower extremity weakness or paresthesia
PROCEDURE
1. Procedure may be performed using fluoroscopic or CT-guidance
2. May use mild IV sedative and analgesic if necessary
3. Sterile technique
4. Place patient in prone position on fluoroscopy table
5. Localize SI joint
A. Oblique fluoroscope, starting with 5-10 degrees ipsilateral oblique
B. Move C-arm to 10-20 degrees contralateral oblique under live fluoroscopy
C. Look for optimal hyperlucent region at inferior aspect of joint
6. Advance 22-gauge 3.5 or 5-inch spinal needle into postero-inferior aspect of SI joint
A. Target medial aspect of SI joint, which corresponds to the posterior aspect of the
joint (ensures medication delivery throughout joint)
B. Avoid fibrous articulation superiorly by aiming 1-2 cm above most caudal extent
C. As the needle contacts firm tissue on the posterior aspect of the joint, maneuver it
through the ligaments/capsule and into the joint by advancing 5-10mm
D. If periosteum met, rotate needle with gentle pressure to facilitate advancement
7. Confirm appropriate intra-articular needle tip position by injecting nonionic contrast
material (typically 0.2 to 0.5 mL LOCM)
8. Once contrast material outlines joint, inject bupivacaine for diagnostic block or
bupivacaine/corticosteroid for therapeutic block
A. Diagnostic: 1 mL 0.5% bupivacaine hydrochloride
B. Therapeutic: 6 mg (1mL) betamethasone + 1 mL bupivacaine hydrochloride
POST-OPERATIVE CARE
1. Observe for 15-20 minutes before discharge home
2. Instruct patient to avoid operating heavy machinery or soaking in water on day of
procedure (normal activities may be resumed the next day)
2

POSSIBLE COMPLICATIONS
1. Bleeding
2. Infection
3. Transient lower extremity weakness/paresthesias (0.5% complication rate)
4. Transient difficulty with urination
FOLLOW UP
1. Follow-up dependent on patients pain status
2. Serial injections may be necessary
REFERENCES
1. Heran M. Spinal Facet Procedures and Sacroiliac Joint Injections. In: Kandarpa K,
Machan L. Handbook of Interventional Radiologic Procedures. 4th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2011:633-641.
2. Aguirre DA, Bermudez S, Diaz OM. Spinal CT-guided Interventional Procedures for
Management of Chronic Back Pain. JVIR 2005; 16:689-679.
3. Dussault RG, Kaplan PA, Anderson MW. Fluoroscopy-guided Sacroiliac Joint Injections.
Radiology 2000; 214:273-277.
4. Furman, MB. Sacroiliac Intraarticular Joint Injections. In: Atlas of Image-Guided Spinal
Procedures. 1st ed. Philadelphia, PA: Elsevier Saunders; 2013.
5. Narouze S, Benzon H, et. al. Interventional Spine and Pain Procedures in Patients on
Antiplatelet and Anticoagulant Medications: Guidelines From the American Society of
Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia
and Pain Therapy, the American Academy of Pain Medicine, the International
Neuromodulation Society, the North American Neuromodulation Society, and the World
Institute of Pain. Regional Anesthesia and Pain Medicine 2015; 40(3):182-212.