Hip Joint - Padda Institute Center for Interventional Pain Management

Sacroiliac joint injection (SIJI)


Low Back Pain (LBP) is often difficult to diagnose because the symptoms overlap considerably with a variety of disorders of the lumbar spine and hip, often causing overlapping symptomology.  Low back pain of sacroiliac (SI) joint origin is a difficult clinical diagnosis and often one of exclusion. Patients usually have pain over the buttock that may extend to the lateral aspect of the hip and thigh. Pain arising from the SI joint may mimic pain originating from the lumbar disk, lumbar facet, or hip joint. Injection of local anesthetic or contrast material is a useful diagnostic test to determine if the SI joint is the pain source; intraarticular injection of corticosteroids may allow long-term pain relief in affected joints.

A sacroiliac joint injection (SIJI) serves several purposes. First, by placing numbing medicine into the joint, the amount of immediate pain relief you experience will help confirm or deny the joint as a source of your pain. Additionally, the temporary relief of the numbing medicine may better allow a chiropractor or physical therapist to treat that joint. Also, time-release cortisone (steroid) will help to reduce any inflammation that you may have within your joint(s).

The SIJI delivers a low volume of concentrated medication directly into the suspected joint space.

 

 

The SIJI is both diagnostic as well as a therapeutic procedure. In other words, if we inject a medication within the suspected joint space and the pain improves, we are fairly confident that this joint is responsible for the pain; conversely, if we inject a medication and the pain is no better, this implies that this joint is likely not responsible for the pain.  In addition the injection contains a potent steroid, which turns off the inflammatory process, which is causing pain from the joint.

 

What are sacroiliac joints?

The sacroiliac joint is a large joint in the region of your low back and buttocks where your pelvis actually joins with the spine. There is a joint on both the right and left side of your spine. If the joints become painful they may cause pain in your low back, buttocks, abdomen, groin or legs.

Other joints in your body are pivot points that allow movement. Unlike any other joint in your body, the sacroiliac joint is actually fused together by ligaments, and doesn’t move.

Cut away view of sacroiliac joints

 

Like any other joint in the body, can become diseased, and thereby become painful.  Arthritis is probably the most common cause of SI joint pain. Arthritis is a degenerative, inflammatory condition that over time results in loss of joint cartilage, bone overgrowth (‘osteophytes’ or ‘spurs’), erosions of the joint, and ultimately instability of the joint itself may occur in this joint.

 

Injecting the joint is done at an angle and requires imaging

 

The sacroiliac joints and their surrounding tissues are lined with nerves. As this degenerative, inflammatory condition progresses, the nerve endings become irritated and inflamed; this produces the sensation of pain. Any and all of this degenerative process may be painful.

The primary role for imaging studies prior to the procedure is that while arthritis is probably the most common cause for sacroiliac joint pain, other rare conditions need to also be considered, and imaging helps to evaluate for this.

 

What is sacroiliac joint pain?

Pain arising from the sacroiliac joints is often difficult to accurately diagnose

SI join pain may be unilateral or bilateral, and may include the following:

  • Groin pain
  • Sitting intolerance (can stay seated for only short periods of time)
  • Referred numbness, burning or tingling in the buttock or lower extremity
  • No associated radiculopathy
Typical pain pattern for sacroiliac joint

 

 

Who benefits from SIJI?

Patients who have chronic low back pain without radicular symptoms are candidates for SIJI.

Routine imaging prior to this procedure includes plain film X-RAYs, but may include CT and/or MRI scanning.  Neurodiagnostic testing such as EMG maybe necessary as well.

 

How is the SIJI done?

The procedure is explained to the patient, questions are answered and informed consent is obtained.

The patient is placed prone (stomach down) on the fluoroscopic table or CT scanner and the lower back is sterilely cleansed with povidone-iodine (Betadine) and alcohol.

The exact level is then located, and the skin overlying this area is anesthetized (numbed) with lidocaine.

A needle is sterilely advanced into the lower ½ of the SI joint.

Typically, as small amount of water-soluble contrast (dye) is injected to confirm proper needle tip position.

Once this is confirmed, a mixture of anesthetic (lidocaine or bupivacaine) and anti-inflammatory medication (steroid) is injected.

The needle is slowly withdrawn

This procedure may be performed with either CT or fluoroscopic guidance, but is most often done with fluoroscopic guidance. The SIJI should NOT be done without guidance imaging, as it is merely a trigger point unless needle tip in the joint can be confirmed.

Joint injection with arthrogram

 

What will happen after the procedure?

Immediately after the procedure, you will get up and walk around and try to imitate something that would normally bring about your usual pain. We ask that you to remain at the Clinic until you feel are ready to leave.  You will then report the percentage of pain relief and record the relief you experience during the next week.

You may not be able to drive the day of your procedure. Your legs may feel weak or numb for a few hours. You may be referred to a physical therapist immediately afterwards while the numbing medicine is still working. If the doctor prescribes physical therapy, it is very important that you continue with the physical therapy program.

Although you may feel much better immediately after the injection (due to the numbing medicine), there is a possibility your pain may return within a few hours. It may take a few days for the steroid medication to start working.

You may experience some weakness and/or numbness in your legs a few hours after the procedure. If so, do not engage in any activities that require lifting, balance and coordination.

Drink plenty of clear liquids after the procedure to help remove the dye from the kidneys.

 

General Pre/Post Instructions:

You should eat a light meal within a few hours before your procedure. If you are an insulin dependent diabetic, do not change your normal eating pattern prior to the procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications).  Do not take pain medications or anti-inflammatory medications the day of your procedure. You need to be hurting prior to this procedure. Please do not take any medications that may give you pain relief. These medications can be restarted after the procedure if they are needed. If you are on Coumadin, Heparin, Plavix or any other blood thinners (including Aspirin), or the diabetic medication Glucophage you must notify this office so the timing of these medications can be explained. You will either be at our clinic facility for approximately 1-3 hours for your procedure. You may need to bring a driver with you. You may return to your normal activities the day after the procedure, including returning to work.

 

Risks of joint injection?

Increased localized back pain and/or leg pain can be expected from several days to several weeks and rarely several months. Destabilization of the sacroiliac joint is a risk and post injection training to strengthen the paraspinous and iliopsoas muscles can reduce this possibility.  There is a rare risk of permanent injury to nerve tissue with weakness or loss of sensation.  There is also a rare risk of complication from anesthesia used to make you feel more comfortable during the procedure.

As with any procedure, there is a risk of significant complications. The most common side effects from the SIJI include (but are not limited to):

  • Allergic reactions to medications
  • Infection (occurs in less than 1 per 15,000 injections)
  • Post-injection flare (joint swelling and pain several hours after treatment, which may last days or weeks)
  • Depigmentation (a whitening of the skin)
  • Local fat atrophy (thinning of the skin)
  • Destruction of a motor or sensory nerve in the path of the needle
  • Bleeding, nerve injury, organ injury and death are rare but possible

 

 

 

 

Hip Joint Injection

The hip joint is a large joint where the leg joins the pelvis, functioning as a ball and socket joint. The top of the thigh bone (the femur) is a round ball, which fits into the socket formed by a cavity in the pelvic bone. The ball is held in the socket by a grouping of ligaments that form a capsule around the joint. This capsule of ligaments contains a lubricating synovial fluid and cartilage, which allows the two bones to move against each other with minimal friction.

 

Bones of the lower extremity

 

 

If this joint experiences arthritis, injury or mechanical stress, one may experience hip, buttock, leg or low back pain. A hip joint injection may be considered for patients with these symptoms, which can help relieve the pain as well as help diagnose the direct cause of pain by injecting medicine directly into the joint. These injections can help diagnose the source of pain, as well as alleviate the discomfort:

Hip Joint Injections

I. Introduction

The Hip Joint injection procedure targets the hip joint thought to be responsible for a patient’s pain. The joint is injected and anesthetized with the intent of relieving this pain. The hip injection procedure delivers a low volume of concentrated medication directly into the affected hip joint. Hip pain usually arises from a degenerated or osteoarthritic hip. However, occasionally it can be “referred” pain, meaning that the patient feels the pain in the hip, but it is actually coming from the lumbar spine, and less commonly from the knee on the same side.

 

The hip joint injection is useful in both the diagnosis and the treatment of hip pain; therefore, it is both a diagnostic as well as a therapeutic procedure. In other words, if we inject a medication within the suspected hip joint space and the pain improves, we are fairly confident that the hip joint is responsible for the pain; conversely, if we inject a medication and the pain is no better, this implies that the pain is likely referred, most often from the lower back or the knee.

 

Frequently a dye is injected in order to evaluate the appearance of the joint and verify positioning of the injected medications.

 

II. The Hip Joints

 

The Hip Joints contain joint fluid and are lined by cartilage.

Like any other joint in the body, hip joints can become diseased, and thereby become painful.

By far the most common disease affecting the hip joints is arthritis. This is a degenerative, inflammatory condition that over time results in loss of joint cartilage, bone overgrowth (‘osteophytes’ or ‘spurs’), erosions of the joint, and ultimately instability of the joint itself.

The hip joints and their surrounding tissues are lined with nerves. As this degenerative, inflammatory condition progresses, the nerve endings become irritated and inflamed; this produces the sensation of pain. Any and all of this degenerative process may be painful.

The primary role for imaging studies prior to the procedure is to evaluate for other arthritis, or other less likely causes of back pain.

III. Patient Selection

 

Unfortunately, while imaging studies (X-rays, MRI and CT scans) are helpful in screening the hips for a potential cause of pain, but are often unreliable in determining whether or not a given hip joint may be the source of pain.

They help in identifying and characterizing the extent of hip degeneration, but like any other joint in the body, the extent of degeneration doesn’t necessarily correlate with the amount of pain. In other words, some patients may show severely degenerated hip joints on imaging studies, but be relatively asymptomatic. Conversely, some patients experiencing severe pain from the hip joints may show relatively mild degenerative findings on imaging studies. For this reason, the patient’s history and physical exam are very important in helping to clarify the source responsible for pain.

 

IV. Procedure: Hip Join Injection

 

The procedure is explained to the patient, questions are answered and informed consent is obtained. The patient is placed on the fluoroscopic table, and the symptomatic hip is sterilely cleansed with povidone-iodine (Betadine) and alcohol.

The exact level is located with the fluoroscope, and the skin overlying this area is anesthetized (numbed) with lidocaine.  A needle is sterilely advanced into the hip joint.  A small amount of water-soluble contrast (dye) is injected to confirm proper needle tip position.  Once this is confirmed, a mixture of anesthetic (lidocaine or bupivacaine) and anti-inflammatory medication (steroid) is injected. The needle is slowly withdrawn.  This procedure is performed with Fluoroscopic (X-RAY) guidance.

 

The injection itself only takes a few minutes, but the overall procedure will usually take between thirty and sixty minutes. After the hip joint injection procedure, the patient typically remains resting on the table for twenty to thirty minutes, and then is asked to move the area of usual discomfort to try to provoke the usual pain. Patients may or may not obtain pain relief in the first few hours after the injection, depending upon whether or not the joint that was injected is the main source of the patient’s pain. On occasion, the patient may feel numb or experience a slightly weak or odd feeling in the leg for a few hours after the injection.

 

Shortly after the procedure, the interventional pain physician will examine the patient to determine if there has been improvement.

 

 

Some individuals may have pain that mimics pain from the hip joint but is actually coming from bursitis adjacent to the hip.

Trochanteric bursitis

 

The trochanteric bursa is located over the prominent bone on the side of the hip. Women and middle-aged to older people are more often affected by this type of bursitis. It may occur spontaneously without specific injury. Also, walking abnormally due to arthritis in the hip, knee, ankle, foot, or back can cause it. Symptoms include pain gradually occurring over the side of the hip (and sometimes traveling down the thigh); pain when sleeping on the side affected by bursitis, rising from a deep chair, sitting in a car, or climbing stairs; and occasionally, pain when walking.

 

Ischial bursitis

 

The ischial bursa is located below the bone in your buttock called the ischium. Inflammation may occur as a result of injury or prolonged sitting on hard surfaces. Symptoms include pain when sitting or lying down on the buttocks and pain that travels to the back of the thigh. Ischial bursitis is also called “weaver’s bottom” or “tailor’s seat.”

 

 

Potential Risks of Hip Joint Injections

As with any procedure, there is a risk of significant complications. The most common side effects from the hip joint or bursa injection include (but are not limited to):

  • Allergic reactions to medication or dye used
  • Infection (occurs in less than 1 per 15,000 injections)
  • Post-injection flare (joint swelling and pain several hours after the corticosteroid injection)
  • Depigmentation (a whitening of the skin)
  • Local fat atrophy (thinning of the skin)
  • Rupture of a tendon located in the path of the injection
  • Bleeding, nerve injury, organ injury and death are rare but possible