Chapter 6

Diagnosing SI Joint Disorders: SI Joint Injection Demonstration

The current standard is that an SI joint injection should be performed under fluoroscopic guidance, utilizing contrast to confirm needle placement, injecting no more than 2 ccs. of solution whether it's a diagnostic and/or a therapeutic injection.

The percent pain reduction sought after a diagnostic sacroiliac joint pain injection under fluoroscopy is performed is greater than or equal to a 75% pain reduction when comparing pre-procedure and post-procedure visual analog pain scores within 15 to 30 minutes. 

The provocative maneuvers or simple functional activities like sitting, standing and walking are typical measures used to ascertain pain reduction. Furthermore, patients take home a pain diary log where they record their pain intensity scores every two hours for up to 24 hours.

After a therapeutic sacroiliac joint injection is performed a pelvic strengthening and stabilization program is typically the next step in the treatment plan.  This program typically lasts for as long as six to eight weeks.

When patients are unresponsive to therapeutic sacroiliac joint injections in conjunction with physical rehabilitation treatment then the next step in the treatment plan would be to consider a minimally invasive SI joint fusion.


Dr. Patel is a paid consultant of SI-BONE Inc.

The iFuse Implant System is intended for sacroiliac fusion for conditions including sacroiliac joint dysfunction that is a direct result of sacroiliac joint disruption and degenerative sacroiliitis. This includes conditions whose symptoms began during pregnancy or in the peripartum period and have persisted postpartum for more than 6 months. There are potential risks associated with the iFuse Implant System. It may not be appropriate for all patients and all patients may not benefit. For information about the risks, visit: www.si-bone.com/risks

"Dr. Amish Patel will discuss and demonstrate the recommended technique for SI Joint injection.

Typically the current gold standard is that SI joint injection should be performed under fluoroscopic guidance, utilizing contrast to confirm needle placement, injecting no more than 2 ccs. of solution whether it’s a diagnostic and/or a therapeutic injection.

The percent pain reduction that we’re looking for after a diagnostic sacroiliac joint pain injection under fluoroscopy is performed is greater than or equal to a 75% pain reduction when comparing pre-procedure and post-procedure visual analog pain scores within 15 to 30 minutes.  

We use the provocative maneuvers or simple functional activities like sitting, standing and walking as typical measures of the pain reduction.

Furthermore, patients will take home a pain diary log where they’ll record their pain intensity scores every two hours for up to 24 hours.

During the intra-articular SI Joint injection procedure, a C-arm is used to identify the inferior portion of the SI Joint with the patient in the prone position. 

Some physicians place a pillow under the abdomen at the level of the iliac crests.  

 “So when we do the SI Joint injection, we typically want to start off by getting a true lateral image, which looks like this. This is where the anterior and posterior SI joints are superimposed, okay, which is what we see in this particular picture. Then what I’m going to do is I’m going to rotate it towards me,  and what you’re going to notice here is that the SI Joint is going to start to separate. And that’s what we’re seeing right now, to the point that we basically see our posterior joint, which is right here, and our anterior joint, which is right here, separating completely. Okay. And what we think is that the posterior joint, which is the medial one, is located right here: this is our opening. So this is basically where we’re going to want to make our mark, and anesthetize the skin.” 

The sterilized area is anesthetized with 1% Lidocaine.

 “At this point we don’t want to put any numbing medicine in the muscle, because we don’t want to create any sort of a false positive anesthetization of the muscle. So we want to do just superficial anesthesia.”

A 22-gauge 3.5” styletted spinal needle will then be used to advance toward the target using intermittent fluoroscopic guidance.  

 “So the next step now is we’re just going to put the needle over the numbing area, and it should view overlying the SI Joint. So let’s get that to look like that. So the needle typically should start at the media aspect of the joint line, which is what we see in this picture here.”

 “And we poke through the skin, and the needle is still along the needle part of the joint line, which is perfect.”

Dr. Patel advances the 22-gauge, 3.5 inch styletted spinal needle, and the tip encounters an “articular slide” after piercing the joint capsule. A distinct “pop” can be felt when the joint is penetrated.

 “So at this point when we take a look at the needle here, I’m just piercing the capsule only, I don’t want to drive it through and through. So what happened was I put the needle to hit bone, and then I walked it into the joint, and now what we want to do is inject a little bit of contrast.” 

Once the needle is properly positioned within the inferior portion of the joint, 0.25 milliliters of one’s contrast medium of choice is injected.

 “So now we can start seeing the contast flowing up into the joint here. And you can see it flowing up into the capsule there. Now what I want to do is see if I can get a little bit deeper…right there.”

 “So in this particular photo you can see all the contrast basically filling up the posterior part of the joint, which is right here. Okay. And this is the anterior part of the joint.”

 “And in the lateral view here you can actually see the contrast flowing up into the joint space right here. Okay. So at this point I don’t want to inject any more contrast; I want to go ahead and basically put the numbing medicine into the joint. And we’re going to inject about 1.7 cc’s of anesthetic.”

For diagnostic injections such as this, up to 2 ml of local anesthetic may be injected. For therapeutic injections, 0.75 milliliters of the steroid of one’s choice and 1.25 milliliters of 0.5% Marcaine would be used. 

 “And we’re all done, okay. Needle out on three: one, two, three. All finished, okay.”

 “I just wanted to point a few distinctive differences between the diagnostic injection you just saw compared to this patient.  What you noticed on the first patient was that the contrast was only going into the posterior part of the SI joint and in this particular diagnostic injection that we performed just recently you’re going to see it going through the posterior and anterior SI joint.  

So here’s a picture of the actual needle in the distal third of the SI joint in the posterior aspect of the joint, like we talked about before, which is mostly located along the medial aspect; while this line here, this joint space, is the ventral aspect.  

Going to the next photo here you can see as the contrast extravasates it actually goes up both, along the posterior contour, and the anterior contour of the SI joint there.  

Moving to the next image, this is our lateral view, OK.  You can actually see the medication basically extravasating into both the posterior and the anterior SI joint.  And you can also notice on this view that the medication is not leaking out of the joint.  Which tells me that when I inject this numbing medicine I don’t run the risk of developing a false positive diagnosis, and running the risk of anesthetizing the L-5 nerve root, the S-1 nerve root or the lumbosacral plexus.

And this is just in our oblique view where once again you can see the medication nicely going along the anterior SI joint and along the posterior SI joint and you can see it’s staying within the confines of the capsule and none of it is leaking out.”  

 “It’s really important to understand that when performing a diagnostic SI joint injection that you’re not always going to get contrast that flows through the posterior and anterior SI joint spaces.  But it’s very important that you at least see medication or contrast flowing into the posterior SI joint space.”

A therapeutic sacroiliac joint injection can definitely yield a long-term result in reduction of pain.  Typically what we expect after the first therapeutic sacroiliac joint injection is within a two-week period a 40-50% pain reduction. 

As noted in the Zelle paper, the injection of corticosteroids has shown to improve the pain for several months.

However, the anti-inflammatory effect is not permanent, and the injections do not offer an opportunity to stabilize an incompetent joint.

After a therapeutic sacroiliac joint injection is performed a pelvic strengthening and stabilization program is typically the next step in the treatment plan.  This program typically lasts for as long as six to eight weeks.

When patients are unresponsive to therapeutic sacroiliac joint injections in conjunction with physical rehabilitation treatment then the next step in the treatment plan would be to consider a minimally invasive SI joint fusion."