Sacroiliac Joint Injections
What are Sacroiliac Joint Injections?
Sacroiliac Joint (SIJ) Disease is one of the major causes of low back pain. The sacroiliac joint is located at the junction between the spine and the pelvis. The sacroiliac joint is a weight baring joint as the weight from the upper body is transmitted down the spine, through the sacroiliac joint and into the pelvis, hips, and lower extremities. The sacroiliac joint is supported by many muscle groups and ligaments that are richly innervated by free nerve endings and spinal nerve roots. When there is inflammation to the sacroiliac joint, the abundance of nerves become irritated and patients experience intense low back pain. Patients typically complain that pain associated with sacroiliac joint worsens when sitting for long periods of time or performing twisting motions and will usually resolve with exercise.
The sacroiliac (SI) joint connects the spine with the pelvis, and is a significant source for low back, buttock, groin and lower extremity pain. Dysfunction of the joint has been estimated to affect between 15–38% of the general population1. The most common painful condition of the sacroiliac joint is known as sacroiliac joint dysfunction, which is often caused by direct impact to the buttocks, motor vehicles accidents, or via ballet or ice skating injuries2. It can also be caused by arthritis, infection, or simply as the result of age-associated degeneration. With SI joint dysfunction there is a structural change within the joint with the nearby pelvic and/or sacral bones that induces pain in nearby cartilage or ligaments1.
The sacroiliac joint (SI) is often overlooked as a source of low back pain, especially since there are relatively few techniques to diagnose SI joint pain2. The SI joint can receive referred pain from other locations, further complicating diagnosis1. Thus, diagnosis of SI joint dysfunction tends to occur after excluding other possibilities. The gold standard to definitively confirm a diagnosis of SI joint pain is through provocative injection of the SI joint, in which an injection of fluid into the joint causes distention and reproduces painful symptoms1, 2. If symptoms are reproduced and SI joint pain is confirmed, the diagnostic injection can be followed with a therapeutic injection for pain relief.
The Procedure
Before considering an injection, a doctor will perform a thorough neurological and musculoskeletal examination focusing on the lower back, hips, pelvis and lower extremities1. There are a variety of special maneuvers available to the physician to identify SI joint pathology, and the physical examination can also rule out other potential sources of pain other than the SI joint.
If a SI joint injection is deemed appropriate, a patient will lie face down on a table while the site of injection is cleaned with an antiseptic agent such as alcohol. The injection site is selected a few centimeters below the bottom of the joint over the buttocks2. The skin of the injection site is then anesthetized before a needle is guided through the skin and into the SI joint. Trained physicians use a technology called fluoroscopy, a real-time x-ray, to safely guide the needle through internal tissues without damaging adjacent nerves, blood vessels or other critical structures. Once the needle is properly positioned in the SI joint, an anesthetic/steroid solution is delivered to reduce inflammation and relieve pain.
Although a relatively safe procedure, injections are not without some risk. Steroid injections can be associated with a temporary increase in pain before any relief is experienced1. Further, local and systemic side effects can occur with steroid injections such as high blood pressure, skin color changes at the site of injection and elevated blood pressure.
Treatments
Sacroiliac Joint Steroid Injections: involve injecting a steroid into the joint space of the SIJ, where the irritated nerve roots are located. This injection includes both a long-lasting steroid and a local anesthetic (lidocaine, bupivacaine). The steroid reduces the inflammation and irritation and the anesthetic works to numb nerves in the area. The combination medicine then spreads throughout the joint and surrounding areas, reducing inflammation and irritation. The entire procedure usually takes less than 15 minutes.
SIJ Traumeel Injections: Traumeel is a homeopathic natural anti-inflammatory medication that has very few side-effects and can be injected into the SIJ when steroid medications are not desired.
Medial and Lateral Branch Blocks: The medial and lateral branches innervate the sacroiliac joint and blocking these nerves is diagnostic and therapeutic. If your pain is better after the injections, than you may be a candidate for radiofrequency procedure.
Radiofrequency Ablation: The medial and lateral branches innervate the sacroiliac joint and can be destroyed with radiofrequency. The nerves typically grow back, but people report pain relief from ranging from 3 months to 3 years.
Spinal Cord Stimulation: A small electrode is typically placed in the epidural space and electrical current is directed through the electrode. If pain relief is attained, a permanent system with battery and electrodes can be placed under the skin.
Chiropractic Manipulation: The sacroiliac joint can sometimes be manipulated into place if it is believed to be out of alignment.
TENS unit: Electrical current is directed over the skin to the most painful area. The brain cannot perceive the pain it previously felt, but now feels the “tingling or buzzing” sensation that is commonly used to describe TENS therapy. TENS therapy may also cause the brain to release endorphin (the body’s natural pain fighters).
Physical Therapy: Is extremely important to increase range of motion and continue to maintain strength in a painful shoulder.
Acupuncture: Acupuncture is an alternative treatment that was originally started in China over 2000 years ago and is quickly gaining acceptance and popularity in Western Medicine for the treatment of many conditions (Facco 2007). Research continues to explore the use of acupuncture in the treatment of many chronic pain conditions.
Benefits
Chronic lower back pain is one of the most difficult conditions 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 your daily activities. In patients suffering from chronic sacroiliac joint pain, sacroiliac joint injections are preferred to the more conventional methods of treatment (Pereira 2000).
Risks
SIJ injections are considered an appropriate non-surgical treatment for many patients who suffer from lower back pain. The associated risks, although rare, include nerve damage, bleeding, and infection. Some of the potential side effects of the corticosteroid may include elevated blood sugars, weight gain, arthritis, stomach ulcers, and transient decrease in the immune system.
Outcome
Patients have reported that sacroiliac joint pain began spontaneously or had an insidious onset, while others recognize a specific event that triggered the occurrence of the pain. Frequently the pain can be due to a traumatic injury to the spine resulting in residual sacroiliac joint inflammation. While conservative treatment, such as NSAID’s and physical therapy may be effective, Murakami and Tanaka reported in 2007 that the effect of periarticular injection into the SIJ was 96% effective in pain improvement in patients with sacroiliac joint complaints with minimal complications (2007 Murakami).
References
Williams, K.; Park, A. (2007). Injection Studies. Canale and Beaty: Campbell’s Operative Orthopaedics, 11th Ed. MD Consult Web site, Core Collection.
Isaac, Z.; Devine, J. (2008). Sacroiliac Joint Dysfunction. Frontera: Essentials of Physical Medicine and Rehabilitation, 2nd Ed. MD Consult Web site, Core Collection.
Murakami E, Tanaka Y, Aizawa T, Ishizuka M, Kokubun S. J Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: prospective comparative study. Orthop Sci. 2007 May;12(3):274-80. Epub 2007 May 31
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
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