Si joint injection
Started by PinchandBurn
Not my pics, but nice article with pics.
I would tell him who gives f about needle depth as long as the contrast is clearly in the joint.
Maybe I'm unusual here, but I don't do AP or laterals for SI joint injections. I oblique and slide in the needle.
Length doesn’t matter. It’s more the motion in the joint. Tell the wife that all the time
I don't ever take laterals unless things really aren't adding up or I've got a medical student and I'm trying to be academic. Here are a few below.
Typically start 5-10 degrees feet tilt, 10-15 degrees contra-oblique and then adjust the oblique until I find what seems right for the joint.
Typically start 5-10 degrees feet tilt, 10-15 degrees contra-oblique and then adjust the oblique until I find what seems right for the joint.
You may not be getting anterior/posterior spread with this, if it even matters. Is SIJ pain still really “a thing”? Over diagnosed in my opinion
This is a great picture form the article.
I get a lateral since I stopped using contrast.
I think of it as the great masquerader in the sense there’s some variability in distribution of the typical pain pattern. If they fail RFA 4-5 and 5-1 I consider it. I could be over treating it though.
What else would you call pain in the SI region the responds to SIJ injections? Possibly some facet involvement too but SI pain is real and treatable.
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Yes. If I'm at that anterior sacrum border, my AP contrast spread is almost always textbook flow straight up the joint. If less than halfway between anterior and posterior borders, AP is usually an ugly blob, not confident in in.
Probably overdiagnosed. SIJ is probably 10% of what I do. Typically younger people with no spine pathology on imaging or people with low lumber fusions.
The joint only holds 2-3 cc so if needles feels in the joint, 0.5-1.0 cc of contrast looks good I don’t belabor getting a textbook flow and inject the Depo.
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Brutal thread.
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LinkedIn - Where pain doctors go to lose credibility.
I stopped doing contrast after I did a bunch of SI-Joint injections under CT. Even with the needle CLEARLY in the middle of the joint, the contrast often would not spread as expected. The point is, a great linear tract is great - but the absence of this proves nothing. Take a look at that picture above from the pain physician article - The contrast often pools at the bottom of the joint, giving that scooped look - really cool pattern. But if it doesn't track up - that pooled contrast (that is clearly intra-articular) in an AP view looks like a blob-o-gram.
Here are some images of an SI-J I did today.
This is on the right side - not a true AP. The fluorscope is tilted caudad (with reference to the detector, not the source) and contra-lateral. The caudad tilt brings the Posterior Superior Iliac Spine (PSIS) to (about) mid joint. Then, rotate contralateral (towards midline) until the two joint lines cross just under the PSIS. This will usually give a flashlight sign - meaning, you get a small square that lights up. This is your spot. It is extremely rare that if you line it up as such, that the needle doesn't slide in the joint.
The red line highlights the PSIS. The blue lines highlight the two joint lines as they cross right below the PSIS.
The lateral in this injection is not as far anterior as I would have liked to go. However, as mentioned above, doing these under CT has given me a much great appreciated for how these joint edges are - and sometimes, there is no way you can go further because of the jagged edges.
What type of magic is this?
Every SI joint is a little different but epiduralman technique is the best I've found and use regularly. Needle depth on lateral highly variable but if you feel the "gummy bear" feeling of the needle entering joint and high pressure you know you are in. I use a reverse LOR technique as well. Start very high pressure (surmise that needle is in the cartilage of joint) and retract as slowly as possible and as soon as LOR take a picture and typically get good flow pattern ~90% of time.
A few more from today. Picture on right good example of anterior, posterior, and inferior joint capsule contrast flow. Ignore the superior needle on the picture on right (or not) ... had a Bertolotti joint injection attempt.
Deets? Am considering one for a patient
wow…. Ummm… cold you please offer average caudal and contra numbers for me to ballpark on my first attempt with this Monday? Is it like 15 and 15?
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Ple
His interacept talk at SIS a few years ago was embarrassing.
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His interacept talk at SIS a few years ago was embarrassing.
I can't really. It is very different for each patient. Tilt caudad until the PSIS is 1/3 to 1/2 up the joint. Tilt contra-lateral until those two joint lines cross right under the PSIS.
Just touch down on the pseudo-articulation. You don't need to enter the false joint. It is a peri-articular injection.
A little head tilt, a little contra oblique to try to square off some of the pseudo joint. Aimed for the joint and felt inferior os. Injected some contrast and was a blob - got some facet type flow after adjusting needle superior and a mm deeper. Will see if it works.
SI injection recreated typical pain for patient.
Another family practice pain surgeon
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Just a link.
You find a clever pattern of contrast and you try to make up something that isn't real...There are a lot of smart ppl in the world who are better than you at your job. They may take exception to your BS and publically embarrass you.
For all the hate on Centeno...He is an experienced and intelligent guy who knows a lot about MSK, Spine, Pain...Etc.
Often times I find if I do a lateral to medial approach(as many of the pictures posted are) I end up struggling to get into the joint and to advance if and when I do enter.
A slight medial-to-lateral approach more mimics the natural orientation of the joint (in most patients -- some have a more "block" shaped sacrum than the typical "wedge" shape). The iliac portion of the joint often overhangs the sacral portion of the joint which can make entry and advancement difficult, if not occasionally impossible, when taking a lateral-to-medial approach.
A slight medial-to-lateral approach more mimics the natural orientation of the joint (in most patients -- some have a more "block" shaped sacrum than the typical "wedge" shape). The iliac portion of the joint often overhangs the sacral portion of the joint which can make entry and advancement difficult, if not occasionally impossible, when taking a lateral-to-medial approach.
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Here is another example that I did today.
Caudad tilt (reference to detector) to get the PSIS about mid joint. Then rotate contralateral (so needle will go medial to lateral) until the two lines cross EXACTLY underneath the PSIS. You will see the "box" highlight where the two lines coalecse. In this case the joint lines below this point are overlapping so that appears highlited (bright) as well, but often times, the bright spot is just below the PSIS.
(RED line highlights PSIS. Blue lines highlight the two lines you intersect right below the PSIS).
There is some button or something that moved in the way (because the patient was wiggling all over the place - stupid marines) just as I entered the joint. It started out away from the line of site.
A lateral shows the needle well within the joint. Joint is highlighted.
are you trying to go coaxial to the beam, or are you purposely going in a lateral to medial direction?
The needle and approach aren’t a lateral to medial direction. The camera is directed in a good amount of contra lateral,
Here are two of my patients that got 100% relief of their back pain after SI injections, despite having had 10+ years of low back pain and multiple unsatisfactory injections by others (LESI, MBB). Despite some people poopooing SI pain, the results don't lie.
Folie a deux based on history and response to injections.
I will ignore you taking a shot at me by saying I am part of the "deux" in the "folie."
Regardless, I will say, hey, whatever works. Placebo or not, they are happy with the sustained pain relief, I have done no harm, and the images look good.
Glad you got them better by a therapeutic interaction. SIJ for 10+ years as LBP and failing multiple other interventions now 100% better. That's not how injections work. Also, no contrast in those images. Could be 1/2" under the skin.
I was wondering why you asked this because I did mention that the needle approach was medial to lateral.
This pic may help.
D
deleted131481
What is the reason for the cephalad til? To lengthen/go more in line with the joint?
Okay we need to talk about terms.
Lets first define terms for the fluoroscopy machine. Since my background was in Chemistry playing with lasers (Raman spectroscopy), I have always thought as a source and a detector. You guys use words like "image intensifier" or other weird jargon.
So to me, the SOURCE of the x-ray beam is called the Source (the small part usually below the bed), and the large part above the bed I call the detector. I don't think it uses a PMT (photomultiplier tube) and I have no idea how it detects. It may use solid state semiconductors, but regardless, it is still a detector.
The other thing is people referece caudal or cephelad to different parts of the camera. I think the CORRECT way is to talk with reference to the SOURCE, however, I always refer to movement of the DETECTOR with relationship to the patient because that is the part of the camera I can see.
Okay, SO - with that in mind, I move the fluorscope caudad. The reason is to move the PSIS cephalad (in the image) until it is about mid joint. Thus, my angle of injection is usually Caudal to cephalad.
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D
deleted131481
Hmm I've always just gone below PSIS but going to start with the tilt and see if it may look more open. This forum is great for this reason - picking up pointers on seemingly very simple injections.
And I know what you meant by the tilt. I talk in terms of the detector and my tech is used to it!
if you ask a rad tech, moving the top part downwards is cephalad.
most rad techs i know have given up on trying to tell pain docs the "correct" terminology.
i use the term "top downwards" or "top towards me". technically also not true radiologic terms, but easier for various rad techs to understand.
most rad techs i know have given up on trying to tell pain docs the "correct" terminology.
i use the term "top downwards" or "top towards me". technically also not true radiologic terms, but easier for various rad techs to understand.
Don't care what anyone calls it. Just use your hands and make the motion of the direction you want it to go in.
Cranial tilt the ii (bring the top of the machine towards the head)
Caudal tilt the ii (bring the tube at the bottom of the machine toward the head)
Rotate the C towards me (ii towards me)
Rotate away (ii away from me)
Piston towards or away from me.
Wigwag: move the entire base of the machine to be parallel towards what we are looking at so we can eliminate parallax.
Cranial tilt the ii (bring the top of the machine towards the head)
Caudal tilt the ii (bring the tube at the bottom of the machine toward the head)
Rotate the C towards me (ii towards me)
Rotate away (ii away from me)
Piston towards or away from me.
Wigwag: move the entire base of the machine to be parallel towards what we are looking at so we can eliminate parallax.
How often do you use the wigwag?
What was said? lol
Says the guy using random French terms?
Not the OP but fairly frequently when a true lateral is important like cervical RFA.
I primarily use wigwag for cervical RFA and for kyphos
Sounds like a basic question but sometimes when I use the wigwag I notice I have to go quite a bit in terms of the angulation which leads to the target being at the edge of the image so when I slide the base of the machine to get the target back in range of the source it seems all the work I put in with the wigwag went to waste as the image needs to be lined up again. Does anyone else have this issue or tips for this?
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