SIJ injection

[Pain Applicant1]

What's the best way to get into the SIJ. I often line the camera up with a nice open shot of the SIJ, place the needle, feels like its in, and then I'll move the camera into more of an oblique position to check and the needle looks way off, like its not even following the joint. How oblique do you make the camera? I'm not even convinced that injecting into the joint will give you more relief than injecting periarticular.

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[Aether2000]

Guess it depends on whether your target is the synovial portion of the joint, the syndesmosis portion, or the extra-articular area.

 

[emd123]

What's the best way to get into the SIJ. I often line the camera up with a nice open shot of the SIJ, place the needle, feels like its in, and then I'll move the camera into more of an oblique position to check and the needle looks way off, like its not even following the joint. How oblique do you make the camera? I'm not even convinced that injecting into the joint will give you more relief than injecting periarticular.

SIs will do that. Sometimes you think you're looking at the poster portion of the joint but you're actually looking at the anterior portion. The parallel stripes can look very similar, so when you think you're between the "two stripes" you're not. Or it may look like you're not in, but you are, because on that angle the portion of the "joint" you're looking at at that moment is the anterior portion. Oblique back so the posterior stripes align and "you're in" all of a sudden. SI is by feel to some extent. You should feel it pop through the membrane, ideally, and confirm with a little contrast. The best view seems to be a slight oblique across the mid-line, not lateral to the mid-line like the typical oblique view.

 

[drf]

If you aren't able to overlap the anterior and posterior joint or don't want to take the time, just go medial to both. With a little bend in the needle, then walk laterally until you feel the needle advance into the joint space. Another indicator is when you are still on the sacrum, the needle with the bend will rotate freely. Once you slip into the joint, and the bend is cephalad, turning the needle will only turn the shaft. The tip will often remain pointing up and the shaft springs back when you let go.

 

[Aether2000]

Ya gotta love those spring loaded shafts...

 

[myrandom2003]

I was taught line up the "stripes"

enter the skin at the tip of the opening of the joint and get a good purchase so the needle isnt flopping around

then tilt toward the head to open up the space betwen the needle tip and joint on the screen

drive the needle point into the joint (curve the tip of the needle for better maneuvering)

once you feel it enter, inject some contrast to confirm, then medicine

 

[SIIMS]

I don't bother lining up the A and P joint lines, I just try and slightly contralateral oblique until the inferior portion of the joint looks crisp and then caudal tilt 20 degrees or so and aim for the very inferior portion of the joint and then hope and pray

Looks like it should be so easy.......

With that being said if anybody else can share there foolproof method

 

[lobelsteve]

There is no such thing as foolproof in Pain.


For left Sij, start with c in AP. Then contralateral oblique to align the anterior and posterior inferior limbs of the joint. The medial one on AP is posterior. Raise the wheal 1cm medial to the joint 1 cm from the inferior aspect of the joint. Insert spinal needle, prep an drape first. As you gain depth head lateral. The joint is 3D and not flat. The lateral side of the joint sits up to 1cm posterior than the medial. If you came too far lateral to start you will not get in. Also, I've seen notes where folks claim to inject the top of the joint. Must be craniosacral specialists injecting fused sutures.

 

[Tenesma]

SI joint injection under fluoro is easily the hardest joint to inject properly - thankfully with the least amount of risk.

What helps me is if I have any previous CTs or MRIs of the pelvis (most patients that I see have had a Abd/Pel CT in the last 5-10 years), so that I can calculate the angle of entry and that makes it easier for the procedure.

What also helps (in slim patients - few and far between) - is to actually feel the medial edge of the iliac bone and place your needle just medial to that, and then line up your fluoro...

otherwise i agree w/ lobel

 

[PMR 4 MSK]

I was going to star the exact same thread yesterday after my second difficult SI joint injection for the week.

My standard technique is to start AP and visualize the medial border of the posterior ileal spine and the SI joint. Normally the PIS will be medial to the SIJ. I then turn it oblique until the medial and lateral portions of the SIJ line up, and preferably, so the PIS is now lateral to the SIJ. I can get it that way in 75%+ of people. Sometimes I need a little cephalad or caudal tilt as well. Usually, the needle enters the joint easily. I then go back AP to ensure the needle is lateral enough, as my trajectory is oblique from medial to lateral. I aim for the lower 1/3 of the joint.

I get problems, like this week, where when the joint lines up, the medial edge of the PIS is still medial to the joint, making the trajectory difficult. I then have to start more medial and use multiple angles. For one of them this week, it was obvious the only way I was going to get intra-articular was with the needle bent 90 degrees- i.e. I wasn't getting truly in the joint. In AP, the medial and lateral margins of the joint were in line, in the oblique with the PIS lined up, there was no joint. Argh.

 

[caedmon]

I like to begin with the contralateral oblique view with the "stripes" lined up, then begin to oblique out ipsilaterally (occasionally under live fluoro if it's difficult) until I get a "Y" view with a crisp view of the inferior portion of the joint. If you get this view you will generally be caudad enough to avoid the ilium.

Needle entry is slightly medial to the joint line, advanced to the lucent inferior joint line. Usually entry into the joint will feel like advancing from a muscle or fatty density into a "cheesy" density- a bit more firm. Look for linear superior flow of contrast. Unless the contrast flow looks perfect (sometimes contrast will pool in the inferior aspect of the joint and may look like a blobogram), I'll swing lateral and ensure that it is anterior enough. Often it will have a "U" appearance inthe bottom of the joint.

do most people inject into joint only or infiltrate ligament as well?

 

[specepic]

Probably the thing that has helped me with these more than anything else is adding tilt with the image intens. going towards the head. I have not see consistent results one way or the other with either lining up to 2 joint lines or keeping them separate. By adding detail you can then came for the more inferiorly projected joint space. I often find that the more you oblique with this joint more off target you will eventually be. I try to stay fairly straight AP or just slightly off AP.

I also inject these quite a bit with ultrasound and I am also able to inject underneath the PSIS across the superior aspects of the joint with ultrasound. This likely gives a much higher quality PSIS area trigger point/ligamentous/soft tissue injection, but I have no data back to back that statement up.

 

[epidural man]

What's the best way to get into the SIJ. I often line the camera up with a nice open shot of the SIJ

CT Scanner. It's as simple as eating blueberry pie. Although I can't always inject, but I know the needle is inside the joint.

I'm not even convinced that injecting into the joint will give you more relief than injecting periarticular.

I think there is data on this. I agree - probably peri-articular is just as effective. When doing them under fluoro, after my "intra-articular" injection at the inferior portion of the joint, I march the needle up the joint line and do a peri-articular injection mid joint, and again at the upper 1/3.

Someone just showed me (taught me) to get a lateral after you have the needle in the joint - I had never done that but it gave me a good indication that I was for sure in the joint. Also, the contrast pattern in the lateral was clearly in the joint as it outlined the inferior portion - however, the AP view looked a lot like a blobogram.

My problem is being able to inject while in the joint - sometimes - despite all the tricks (like rotating the needle, etc) - I still can't inject at all.

 

[lobelsteve]

If you are in the joint and cannot inject, you are subperiosteal. Pull back 1mm and it will flow.

 

[drf]

I also inject these quite a bit with ultrasound and I am also able to inject underneath the PSIS across the superior aspects of the joint with ultrasound. This likely gives a much higher quality PSIS area trigger point/ligamentous/soft tissue injection, but I have no data back to back that statement up.

Couple questions. Have you been confirming with fluoro, at least for some of them?

Do you start at PSIS short axis, move caudal until entry into the greater sciatic notch, then move back cephalad for the inferior joint? Or do you simply follow the joint line until you see the S1 or S2 foramen to decide where to inject?

 

[Jcm800]

If you aren't able to overlap the anterior and posterior joint or don't want to take the time, just go medial to both. With a little bend in the needle, then walk laterally until you feel the needle advance into the joint space. Another indicator is when you are still on the sacrum, the needle with the bend will rotate freely. Once you slip into the joint, and the bend is cephalad, turning the needle will only turn the shaft. The tip will often remain pointing up and the shaft springs back when you let go.

i used to superimpose the joint lines, oblique like 15-25 degrees, whatever it took...

now i go straight ap, and go at the medial "line" and the success on a single pass is amazing. contrast up as far as the day is long. did one a yesterday in like 30 seconds. it was beautiful. obviously not all of them go that easy, but more and more do since i quite trying to superimpose/oblique approach. seems cooler to line them up, but it sucks...

 

[knoxdoc]

i used to superimpose the joint lines, oblique like 15-25 degrees, whatever it took...

now i go straight ap, and go at the medial "line" and the success on a single pass is amazing. contrast up as far as the day is long. did one a yesterday in like 30 seconds. it was beautiful. obviously not all of them go that easy, but more and more do since i quite trying to superimpose/oblique approach. seems cooler to line them up, but it sucks...

I do the same. Straight AP, aim for the joint line that is medial (the posterior joint line) just a bit above the inferior aspect of the joint. Push and pray.

Then you get a patient like I had today who tells me that when I injected the contrast she felt pain go all the way down the back of her leg to her heel. I reiterated that this was an SIJ injection, not the S1 TFESI she got last time. Suddenly the pain was gone. ????

 

[Ligament]

My problem is being able to inject while in the joint - sometimes - despite all the tricks (like rotating the needle, etc) - I still can't inject at all.

In this situation, agree with lobel's advice. If that still does not work, get a 1cc LUER LOCK syringe, and use that. The pressures you can generate with a 1cc syringe are amazing. You will get contrast in.

 

[Tenesma]

knoxdox --- most of us go to the inferior portion of the joint - but it is not a deep joint at that point and going through the joint with the needle tip could cause some issues, maybe you got close to her descending nerve? also remember that the joint is not a completely closed joint - sometimes there is an anterior opening where local/steroid can spread out (check your contrast views and you will sometimes see it)...

 

[clubdeac]

I too just line up AP and go for the medial line. Often times they fuse at the most inferior pole in AP anyway. Just aim for that an voila. Of course when I have students is when I get blobograms! And I looked at an MRI once with a radiologist and he noted that the L5 nerve root descends just anterior to the joint so if you get some anterior spillage, you could definitely be doing an L5 TFESI as well. Just some food for thought.

 

[Aether2000]

So all one has to do to charge for 2 procedure codes is to drill just a little further....

 

[knoxdoc]

knoxdox --- most of us go to the inferior portion of the joint - but it is not a deep joint at that point and going through the joint with the needle tip could cause some issues, maybe you got close to her descending nerve? also remember that the joint is not a completely closed joint - sometimes there is an anterior opening where local/steroid can spread out (check your contrast views and you will sometimes see it)...

Point well taken. But this chick also had the radiating pains when I anesthetized her skin with a 1.5 inch needle (and she ain't petite). She is certifiably crazy.

 

[lobelsteve]

Point well taken. But this chick also had the radiating pains when I anesthetized her skin with a 1.5 inch needle (and she ain't petite). She is certifiably crazy.

You shouldn't inject crazy people.
Though I suppose you would call all those who get left arm and jaw pain nut jobs. All because a little chest muscle isn't fully oxygenated. ?

 

[PMR 4 MSK]

You shouldn't inject crazy people.
Though I suppose you would call all those who get left arm and jaw pain nut jobs. All because a little chest muscle isn't fully oxygenated. ?

Every time I have a bat-sheet crazy pt, who is not doing well with meds and PT, I feel like I need to try something and then have a battle with myself over whether to bring out the needle.

Then if I do go for the needle, my nurse looks and me and says "No! WTF is wrong with you?!?"

 

[onewithpain]

I like this approach. About 30 degrees contralateral oblique, and I inject about 3/4 of the med into the articular aspect (where the needle is in the pic) and about 1/4 into the ligamentous aspect as I withdraw the needle.

 

[lobelsteve]

http://practicalhorsemanmag.com/article/identify-and-treat-equine-sacroiliac-problems-11803

SIJ pain, not just for people.

 

[Doctodd]

Hey Steve, how do you think they treat horse injuries?

http://practicalhorsemanmag.com/article/cutting-edge-cell-based-therapies-for-horses

 

[lobelsteve]

Hey Todd, why so long in the face.

 

[Doctodd]

Cuz im smiling and laughing?.....at you

 

[giddyup]

Don't even get me started on this

 

[geauxg8rs]

Don't even get me started on this

Why the long face?

 

[Phyzicz]

I usually do L5-S1 dorsal ala block, then S1, S2, S3 lateral branch blocks and SI joint intra-articular injection. I doubt I am getting reimbursed for all this. What are you guys coding for both ICD-10 and CPT codes for your SIs?
ICD-10 I use sacroilitis, sacral sprain, and sacrococcygeal spondylosis.
CPT I use 64450 x 3 and 64493
You guys?