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.
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.
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
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.
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