Chapter 8 Sacroiliac Intraarticular Joint Injections, Posterior Approach, Inferior Entry

This is a relatively safe procedure, and there are no specific structures to avoid. However, care should be taken to not advance the needle beyond the ventral joint capsule and into the pelvis. Hence, the only safety view or consideration is a lateral view with this idea kept in mind. Unlike other procedures with orthogonal imaging (i.e., anteroposterior and lateral), the typical views used here are anteroposterior and various obliques that best visualize the SIJ.

The SIJ is an auricular-shaped diarthrodial joint with a joint capsule and synovial fluid. It has hyaline cartilage on the sacral side and fibrocartilage on the iliac side.

The exact innervation of the sacroiliac joint remains under debate. Some authors have suggested that the joint is innervated both posteriorly and anteriorly;^3,4 however, others argue that the innervation is exclusively posterior from the lateral branches of the sacral dorsal rami.^5,6

The diagnosis of SIJ pain is made by clinical suspicion with the use of the history and physical examination and can be supported by diagnostic intraarticular injections. To date, there are no reliable imaging studies or physical examination maneuvers to accurately diagnose SIJ dysfunction.²

Because of the potential for capsular defects in the sacroiliac joint, the sensitivity and specificity of intraarticular blocks has been called into question.^7,8 The interosseus or dorsal sacral ligaments, both potential pain generators, are not blocked through intraarticular injection. Studies have shown that while multisite, multidepth sacral lateral branch blocks do not block the intraarticular joint, they are potentially useful tool to evaluate extraarticular SIJ pain.¹¹

Note: Please see page ii for a list of anatomical terms/abbreviations used in this book.

Trajectory View

Tilt the fluoroscope cephalad approximately 10 to 15 degrees to elongate the posterior plane of the joint and improve the target lucency.

Oblique the fluoroscope, starting with 5–10 degrees of ipsilateral oblique.

Under live fluoroscopy, move the C-arm to 10–20 degrees contralateral oblique.

Watch for the optimal “hyperlucent” region at the inferior portion of the SIJ.

The target needle destination is the inferior aspect of the medial joint space; this corresponds with the posterior aspect of the SIJ.

Because this is the trajectory view, the needle entry and trajectory should be parallel to the C-arm beam (Figure 8–1).

Figure 8–1 A, Fluoroscopic image of the trajectory view with the needle in position at the medial aspect of the sacroiliac joint. B, Radiopaque structures, trajectory view. There are typically no radiolucent structures that are safety considerations with this trajectory view. Use the other views for needle advancement to best visualize corresponding landmarks.

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