Sacroiliac Joint Injection
The SIJs are a pair of joints located between the sacrum bone of the spine and the ilium bone of the pelvis/hip. The sacrum is a triangular shaped bone located just beneath the lumbar spine. The sacroiliac joints serve to connect the spine to the pelvis. There is one SIJ on the right and one SIJ on the left. These joints are held together by strong ligaments, which prevent significant movement of the joint. Most of the movement in this area occurs in the lumbar spine or the hip joint. There are some conditions which can cause unwanted movement and inflammation in these joints, resulting in pain.
A sacroiliac (SIJ) injection is designed to treat the pain and symptoms of SIJ mediated pain. The goal of a SIJ injection is to place anti-inflammatory medications (often steroids) into and around this joint to help reduce pain and inflammation. These injections may be used to treat several conditions associated with SIJ pain, including arthritis.
Your physician will talk with you about your symptoms and perform a thorough physical examination to determine the source of your pain. Imaging, such as x-rays and MRI, can help to assist in this diagnosis, if needed. Usually, SIJ pain produces pain in the lower back, buttocks and possibly the upper portion of the legs. Pain is typically worse with standing and walking, although sitting for long periods of time can make the pain worse as well. Pain is typically better with lying down (taking the weight off the joints). During your appointment in the office, your doctor will discuss the reasons he feels that your pain is coming from your SI Joints.
There are a few recommended criteria to be considered a good candidate for an SIJ injection. Usually, patients should have failed to improve with appropriate conservative measures, such as anti-inflammatory medications, physical therapy, chiropractic care, massage, etc. Prior to being considered a candidate for an injection, most patients will need some form of imaging (x-ray, MRI, etc.) to correlate with history and exam findings. Sacroiliac joint injections tend to have the best results when the majority of pain is coming from the SI joints.
The procedure does involve placing a needle through the skin, so you may feel some mild discomfort. Local anesthetic is used to numb the skin and lessen the pain associated with skin puncture. If you wish, mild IV sedation and pain medication may be given prior to the injection to make you as comfortable as possible (discuss with your doctor). During the injection, it is possible to feel some pain in the back/buttock when the needle tip touches the bones of the SIJ. This is quite common. The physician will be as gentle as possible around these painful areas to make sure the injection is as pain free as possible. Most patients tolerate this procedure without significant discomfort.
This varies with each patient. During the injection, a steroid medication and an anesthetic medication are injected into the sacroiliac joint space. Many patients feel immediate relief due to the anesthetic medication, which partially numbs the joint and surrounding painful structures. Unfortunately, this pain relief is often temporary, as the effects of the anesthetic usually last only a few hours. The steroid medication is a strong anti-inflammatory used to treat any inflammation in the joint. Unlike anesthetics medications, steroids often do not work immediately, as reducing inflammation takes time. It can take 2-3 days until steroids start to provide some pain relief. Steroids reach their maximum effect between 7-14 days.
Sacroiliac Joint injections can provide great pain relief for SIJ mediated pain/inflammation, but provide minimal or no relief for other spine conditions. If most of your pain is coming from the SIJs, there is a good chance that this injection will help a significant portion of your pain. If you have other conditions, such as lumbar degenerative disc disease or facet arthritis contributing to your pain, then this injection may only provide relief for a portion of your pain. Most patients receiving sacroiliac joint injections do not experience 100% pain relief, since they often have more sources of pain than just SIJ pain. The goal of this injection is to reduce pain enough so that you can become more functional. Often, after pain is reduced, starting a therapeutic exercise program or physical therapy can help to prolong the pain reducing response of the injection.
Everyone responds differently to the injection. Prior to your injection, your physician will assess your individual condition and the chances of success of the injection. A good response to the injection will be at least 3 months of good pain relief. It is possible that the injection will provide relief lasting much longer than 3 months. However, it is also possible that the injection will not provide much relief at all. The only way to truly know how effective a sacroiliac joint injection will be is to wait and see.
The number of injections performed depends on your spine condition and your response to the injection. You will be seen back in clinic about 2 weeks after your SIJ injection to assess your response (this is the time it takes for steroids to reach maximum effectiveness). The decision to do more injections will be based off your response to the first injection.
If you have a great response to the first injection (>80% pain reduction), then there is no need to have a second injection immediately. SIJ injections can always be repeated in the future if the same pain should return..
If you have had <80% improvement, but >20% improvement in your pain following your first SIJ injection, a second injection may provide some “additive” benefit. A subset of patients require two injections to see benefits of the injection. You can discuss the possibility of a second injection at your 2 week follow up visit.
If you had minimal improvement with SIJ injection (<20% pain reduction), then your doctor will re-evaluate your condition to determine the next step in the treatment plan.
Due to the side effects of steroids, it is recommended that you get no more than 4 SIJ injections per calendar year. At most, three injections can be performed in a 6 month period.
If the injection does not help your pain, then the doctor will re-evaluate you at your follow up appointment. Some people require more than one injection to get adequate pain relief. However, no pain relief from a sacroiliac joint injection could also mean that your pain is coming from a different source in your back. If this is the case, then a different type of injection may help your pain. It is important to know that these injections do not change your anatomy. If you have a severe arthritis in that joint, the injection may not provide significant long lasting benefit.
Will I eventually need surgery for my spine condition?
The goal of our clinic is to prevent surgical intervention, if possible. There are a few reasons to have surgery on your neck or back. These reasons are:
Sudden numbness in the genital area (saddle anesthesia)
Sudden loss of bowel and/or bladder control.
Severe pain that you cannot tolerate and pain that is not helped with conservative treatments (medications, physical therapy,
chiropractic care, injections, etc.)
If you should ever develop any sudden weakness, saddle anesthesia or loss of bowel/bladder control, you should call your doctor immediately. If you cannot reach your doctor, you need to go to the emergency room immediately to get evaluated.
No, for your safety. You have the option to have mild IV sedation and pain medication through an IV prior to the procedure, however, you cannot be put under general anesthesia for this injection. Your feedback is critical to the safety of this procedure. As the needle approaches the target, it is possible that the needle will come close to the spinal nerves. If this should happen, you may feel some discomfort traveling down your arm or leg. We rely on you to tell us this information, so that we can adjust the needle to another location. If you are put under general anesthesia, there is an increased risk of nerve damage from the needle.
Sacroiliac Joint injections are not performed in our office. They are performed in an ambulatory surgery center with the use of fluoroscopic (live x-ray) guidance. X-ray guidance is critical to ensure that the injection is placed in the correct location. You will usually arrive at the surgery center about 20-30 minutes prior to your appointment to get set up for the procedure. If you are going to get IV sedation or pain medication with your injection, you will be asked to not eat food for 4-6 hours prior to your procedure or drink any liquids for 2 hours prior to your procedure. The decision to get sedation or pain medication is always optional. The total duration of the procedure usually takes about 10-15 minutes. Your doctor will discuss this procedure more in detail during your office visit prior to the injection. If you want IV medication prior to the procedure, you will be required to have a responsible adult driver to get you home. If you do not have a driver, then we unfortunately cannot give you any IV medication. Typically, you will be seen in the office about 2 weeks after the injection to assess the response of the steroid injection.
Generally speaking, this procedure is very safe. However, as with any procedure, there are risks, side effects, and the possibility of complications. Some of these common risks are listed below.
Pain:The injection site may be sore after the injection, due to the needle passing through painful tissue. Usually, any increase in pain is temporary. In most cases, very little discomfort is felt by the patient.
Bruising at the site of injection
Infection:Rare. The skin is cleaned thoroughly prior to the injection to minimize this risk. Everything is done under sterile technique.
Bleeding:Usually any bleeding stops spontaneously. To minimize any bleeding risk, we ask that you stop all blood thinning medications prior to the procedure.
Nerve Damage, Seizures, Paralysis, Death:Exceedingly rare complications.
Steroid medications have several possible side effects. The systemic side effects associated with steroids are typically less with steroid injections than steroid pills. Typical side effects of steroids can include indigestion, upset stomach, nausea, increased appetite, trouble sleeping, increased anxiety/restlessness, heart racing and occasionally headache. If you have a history of diabetes, steroids may cause a temporary increase in your blood sugar readings. If you use insulin to treat your diabetes, you may need to temporarily adjust the dose of the medications. Some of the risks of injected steroids include bone and cartilage damage, skin atrophy, hypopigmentation, and the weakening/rupture of the muscle where injection is given. To ensure safety, the number of steroid injections performed in a particular joint or location is limited to about 4 injections per year.
Stop all aspirin based products and non-steroidal anti-inflammatory (NSAIDs) medications for 5 days prior to your injection. Examples of NSAIDs include Ibuprofen (Advil, Motrin), Naproxyn (Aleve, Naprosyn, Anaprox), Indocin (Indomethacin), Lodine (Etodolac), Relafen (Nabumetone), Daypro (Oxaprozin), Meloxicam (Mobic), Diclofenac (Voltaren, Arthrotec), etc. Celebrex, although a NSAID, does not need to be stopped. If you have any question if a medication you are taking needs to be stopped, please ask your doctor.
Stop fish oil and Vitamin E supplements for 5 days prior to your injection.
Stop all blood thinning medication, including warfarin (Coumadin), pradaxa, debigatran, argatroban, plavix, etc. for 5-7 days prior to the injection. You may need to get permission from your prescribing doctor prior to getting off of these medications prior your injection to ensure that it is safe to stop these medications.
You should take all of your other medications, such as your blood pressure medications, with a small amount of water prior to your injection.
Do not eat for 4-6 hours prior to your injection.
Do not drink for 2 hours prior to your injection.
You may be required to have lab work or an EKG prior to your procedure. Discuss this with your pain physician.
For your safety, it is recommended that you have a responsible adult to drive you home after your injection. If you cannot get a driver to bring you home, you must tell your treating physician. If you do not have a driver, then you will not be able to have IV pain medication or sedation. Failure to have a driver may result in the cancellation of your procedure.
Your activity level after your injection should be at the following levels:
Day of Injection:We recommend no new activities. You should take it easy the day of the procedure. You can still perform regular everyday activities on this day.
Day 2:Up to 50% of your usual activity level.
Day 3:Activity is unrestricted as tolerated.
You may take pain medications, except for aspirin and NSAIDs, immediately after your injection.
You may resume all aspirin, NSAID and blood thinning medications the night of your injection or the following morning.
You may use ice compresses over the injection site – 20 minutes on, then 20 minutes off. Repeat this cycle as required. If using a gel pack, make sure a towel or piece of cloth is placed between the cold pack and the skin. Do not apply the cold packs to the numb areas following injection.
You may eat and drink after your injection is completed.
You may shower immediately, but please avoid swimming or baths/Jacuzzis/hot tubs for the first 2 days after the procedure, to reduce the risk of infection.
Should you develop fever, chills, drainage, excessive swelling or redness at the injection site, bladder or bowel dysfunction, or change in sensation or muscle strength, please contact our office immediately. If you cannot reach your physician, please present to the nearest emergency room.
If you experience a post-procedure headache, please contact our office. For the first 24 hours, lie down as much as possible. You can take Tylenol, up to 3 grams per day in doses of 1 gram every 8 hours. Drink plenty of fluids in the form of caffeinated beverages. The caffeine will often minimize the headache substantially. If you continue with headaches after 24 hours following the procedure, please contact our office.