Sacroiliac Joint Injection Periprocedural Care

Updated: Feb 10, 2017
  • Author: Stephen Kishner, MD, MHA; Chief Editor: Erik D Schraga, MD  more...
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Periprocedural Care

Preprocedural Planning

In assessing the etiology of low back pain, a complete history, physical examination, psychosocial evaluation, and appropriate imaging may be helpful. Various clinical tests specific to the sacroiliac (SI) joint during the physical examination have been documented in aiding the diagnosis of SI pain.

Physical examination

The Gillette test is done with the patient in the standing position. The patient stands on one leg while flexing the opposite hip and knee into the chest. Motion of the SI joint is assessed by placing one thumb under the posterior superior iliac spine (PSIS) on the side of hip flexion, with the other thumb in the midline at the S2 level. Normally, the thumb under the PSIS drops inferiorly and laterally with hip flexion. Restriction is indicated by decreased motion compared to the normal side.

In the Fortin finger test, the patient points to the area of pain with one finger. The result is positive if the site of pain is within 1 cm of the PSIS, generally inferomedially.

The Patrick test or Faber maneuver involves flexion, abduction, and external rotation of the hip. The patient lies supine, with the heel of the tested side placed on the opposite knee. Pressure is put on the flexed knee and the opposite anterior superior iliac spine (ASIS) area. The  test result is positive for SI dysfunction if pain is elicited in the SI joint area. The sensitivity of this test in predicting response from SI joint injection is reportedly low (57%), [18, 19, 20]  whereas others have reported 77% sensitivity and 100% specificity [21] ; however, the accuracy of these studies has been questioned. [22]

In the Gaenslen test, the patient is supine. The hip and knee are maximally flexed toward the trunk, and the opposite leg is extended. Pressure is applied to the flexed extremity. The finding is positive if pain is felt across the SI joint. This test was found to be 68% sensitive and 35% specific. [23, 24]  However, the validity of this test has also been questioned. [25]

In the compression test, the patient lies on one side. The examiner applies pressure on one pelvic brim in the direction of the other. A positive result is pain across the SI joint.

In the Van Durson standing flexion test, the patient is standing with the examiner behind him. The examiner’s thumbs are placed just below each PSIS. The patient flexes the trunk forward without bending the knees. A positive sign is asymmetric motion.

In the Piedallu seated flexion test, the patient is seated with the examiner behind him. The examiner’s thumbs are placed just below the PSIS. The patient flexes the trunk forward. A positive result is asymmetry of motion.

An individual positive clinical test result may not prove to be indicative of SI joint pain. However, if three clinical tests reveal positive results, the likelihood that the pain originates from the SI joint is greatly increased. [26]

Imaging

If the SI joint is strongly suspected as the origin of the pain, imaging may be indicated. Plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI) of the SI joint can be performed, but results can be misleading. In fact, one study showed that CT findings were negative in 42% of symptomatic SI joints. [27]  MRI has not been proved to be positively correlated with the diagnosis of SI joint pain.

The International Association for the Study of Pain (IASP) proposed the following criteria for making the diagnosis of SI joint pain [28] :

  • Pain is present in the region of the SI joint
  • Stressing the SI joint by performing clinical tests that are selective for the joint reproduces the patient’s pain
  • Selectively infiltrating the putatively symptomatic joint with local anesthetic completely relieves the patient of pain
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Equipment

Equipment used for SI joint injection includes the following:

  • Standard C-arm fluoroscopy unit with monitor
  • Spinal needle, 22 gauge, 3.5 in.
  • Contrast agent (eg, iohexol)
  • Steroids - Steroids typically used include betamethasone sodium phosphate or acetate and methylprednisolone; there is no consensus on the type of steroids that should be used in this injection
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Patient Preparation

Anesthesia

Procedural sedation (eg, with midazolam or fentanyl) is seldom (but occasionally) used, because it is important for the patient’s perception of pain to remain intact during the injection. For this reason, anxiolytics are preferred to analgesics in this setting.

Positioning

The patient should be in the modified Sims position, with the pelvis rotated until the joint appears clearly under fluoroscopy. [29]  Placing a pillow under the patient's hip can further enhance visualization of the SI joint. A 30º cephalad tilt view and Ferguson view provide good visualization of the anterior and posterior articular margins of the SI joint. [30]

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