by mechanical torquing of the joint either acute or chronic, stretch of the ligaments across the
joint, excessive laxity of the ligaments permitting micromovements of the joint, or nerve ingrowth
into the joint as a result of injury. There are also rheumatological diseases such as
spondyloarthropathies and rheumatoid arthritis which affect the interior of the joint surface rather
than the ligaments. The diagnosis is difficult to make, but is outlined in sacroiliac pain syndrome.
ANESTHESIA: Local, local with sedation, heavy sedation are all three used.
BLOCK PERFORMANCE: Fluoroscopy x-ray is mandatory since it has been demonstrated to be
nearly impossible to place the needle into the joint blindly.
With the patient lying face down, an antimicrobial skin preparation is used. With the fluoroscopy
beam tilted to show good alignment of the sacroiliac (SI) joint, a small needle is passed into the
lower and middle parts of the joint where contrast is injected to demonstrate the outline of the
joint. Next, steroid and local anesthetics are injected. On rare occasions, other substances may
be injected into the joint. Usually relief occurs within a few hours and sustained relief is possible
due to the steroid
effect.
POST INJECTION THERAPY: In cases of SI instability, it is important to continue working with
physical therapy to learn techniques to stabilize the muscle structure around the SI joint and to
learn techniques which will permit self-mobilization of the joint back to a neutral position. For
some patients, SI belts must be worn whereas in others, intermittent mobilization/stabilization
may be useful. Typically side effects from the block are very minimal with some mild muscle
soreness from the injection itself. Rarely, a patient will have a significant flare up of pain which is
thought to be due to psychological factors, central hypersensitization, secondary gain issues, or
lying face down for the procedure.
POTENTIAL COMPLICATIONS: Rare bleeding, infection, nerve injury.
OTHER THERAPIES FOR SI DYSFUNCTION:
Prolotherapy is controversial and has little support in the scientific literature, but is frequently
used in the SI joint in lieu of other viable alternatives. Prolotherapy consists of injection of an
agent which is designed to inflame the ligaments, thereby increasing blood flow, bringing in white
blood cells and fibroblasts which may thicken the ligaments. These injections are usually
performed in an office setting since the target is the ligament overlying the joint rather than the
joint itself.
Hyaluronic acid injections incorporate Hyalgan or Synvisc into the joint for pain relief. There are
small studies to support such use.
Radiofrequency denervation uses needles which are insulated except for the tips, placed into the
joint or placed onto the nerves which go into the joint. With heat activation, the nerves are
interrupted. This therapy is modestly effective.
Laser intra-articular denervation is placement of a side firing laser tip into the joint and
subsequently destroying the pain producing nerves. Considered experimental, I have had
moderate success with this technique.
SI Fusion: When all else fails, it is possible to surgically fuse the SI joint, however the success
rate is only modest for this technique and may lead to other problems such as with the facet
joints. SI fusion is not performed in Indiana.
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