Lumbar Procedures: Indications

and Techniques
Brad Goodman, M.D.
OrthoAlabama
Spine Intervention Society
Lumbar Hands-On Lab
Spain, 2018
Disclosure
Scout “AP” True AP only at L3-4 15 degree right oblique Lateral

How is a true AP, Lateral, and Oblique view defined

Where is the pedicle, lamina, pars interarticularis, SAP, IAP, transverse
process, disc, “Z” joint, foramen, iliopectineal lines?
Where is the dura, cord, segmental nerve, medulo-radicular artery?
Where are multifides, lumborum, iliocostalis, quadratus, psoas, crus?
There is no anatomic structure named “Scotty Dog”!!
Gray’s Anatomy, 35th Ed. 1973
Interventional Pain

Have a plan!

What are you trying to do?

What is your goal? Diagnose?

Treat?

Follow the ISIS protocols

Is it supported by the
literature?

Does it make sense?

 Lumbar Radicular Pain
Low Back Pain

ISIS Algorithms for assessment,

management, and treatment

Bogduk. Practice Guidelines

for Spinal Diagnostic and
Treatment Procedures. 2013

Bogduk and Govind. Acute

Radicular Pain: An Evidence
Based Approach. 1999
We saw it on your X-ray,
so we removed it!
Diagnosis by Imaging

MRIs are just very detailed,

expensive pictures!
Just because there is pathology
on imaging, doesn’t mean it
is clinically significant.
Asymptomatic adults:
64% have HNP or bulge

Correlation of imaging with

the history, symptoms, and
signs

Boden. J Bone Jt Surg, 1990

Boos. Spine 20:2613-2525, 1995
Jensen. NEJM. 1994
Confusion
LBP vs LRP

“Back pain and lumbar radicular pain are different disorders. They
have
Different causes;
They invite different investigations; and
The treatment of each is radically different”.

Bogduk and Govind. Acute Radicular Pain:

An Evidence Based Approach. 1999
Bogduk. Practice Guidelines for Spinal
Diagnostic and Treatment Procedures. 2013
Lumbar Radicular Pain Quality – Shooting,
lancinating, electrical
Not aching or throbbing
Pattern – Narrow band, quassi
segmental
Distribution – Lower Extremity
Distal > Proximal
Depth – Deep and superficial
Cutaneous Dysthesias –
“Spiders crawling”

Cannot differentiate level of

pathology L4, L5, S1
Radicular Pain
Etiology

Most common causes: 98%

Disc protrusion
Lateral recess or foraminal stenosis due to spondylosis
All other causes rare
Pretest probability establishes the diagnosis
Young - HNP, rapid onset
Mature - Foraminal or spinal stenosis, slow onset
Post surgery - Epidural fibrosis with neural involvement
A definitive diagnosis requires imaging.
The imaging must correlate with the symptoms and signs.
Bogduk and Govind. Acute Lumbar Radicular Pain, 1999
Mechanisms of Radicular Pain

• Mechanical compression
• Inflammation

• Ischemia (venous congestion)

Is It Simply Mechanical Compression?

Animal studies show isolated mechanical compression

of a nerve root does not induce radicular pain
Asymptomatic individuals have HNPs
Size of HNP does not always correlate with degree of
pain
Improvement of pain is seen prior to disc resorption
Lumbar Radicular Pain

Treatments with evidence of efficacy

Epidural corticosteroids
Surgery
Which treatment would you want for your:
Saintly grey haired mother?
Mother-in-law?

Epidural Corticosteroids!
Lumbar Radicular Pain
Treatment

Epidural Corticosteroids

First use 1951

Large number uncontrolled case series, varied Dxs
Good pain relief 18-90 % of patients
Epidural Steroids

Interlaminar
Access epidural space via posterior approach through
ligmentum flavum, i.e. transflaval
Needle tip in dorsal epidural space

Corticosteroids deposited in dorsal epidural space

Epidural Steroids
Interlaminar

Advantages
Very safe
Effective in a percentage of patients
Disadvantages
Blind injections have predominated
Epidural space? Level? Side of Pathology? Competence of
injectionist?
Dilute injectate?
Medication may fail to reach ventral epidural space?
Unable to use post surgery at level of pathology
Questionably effective
Overused
Interlaminar Epidural Steroids
Technique

Interlaminar
No visual cues: a “feel” technique (tactile cues)
Larger epidural needles - 18ga
LOR to saline or air. Not contrast
Saline less compressible with dramatic LOR. LOR
Contrast is viscous and does not flow easily through needles. LOR
Small diameter needles: restriction of flow. LOR ( Flow = π r2 )

“Feel the tissues Luke”

“AP” view

Procedure needle (18ga)

introduced and
advanced to ligmentum
flavum

“Large” blunt needles so

you can feel tissue
layers!
18ga Tuohy, Hustead,
Crawford
 Lateral views

Complete lack of visual cues!

This is a “feel” procedure!

Resistance to insertion. LOR to saline + air

Needle tip on ligmentum flavum. Needle tip through LF
 Lumbar Interlaminar
Post contrast
AP and Lateral

Pattern: Heterogeneous,
vacuolated, fuzzy margins,
asymetrical

AP view w/ Contrast Lateral w/ contrast

 Subarachnoid Space

Normal myelogram, subarachnoid space Mixed subarachnoid,

epidural injection
Contralateral Oblique View

Furman, M., Jasper, N. R. and Lin, H. (2012), Fluoroscopic Contralateral Oblique

View in Interlaminar Interventions: A Technical Note. Pain Medicine, 13: 1389–
1396.
Furman MB. Pain Med 2012;13(11):1389–1396
Landers MH. Pain Med. 2012 Jan;13(1):58-65
Furman MB. Pain Med 2012;13(11):1389–1396
Contralateral Oblique View

Courtesy of Josh Rittenberg, MD

Image from Josh Rittenberg
Epidural Steroids
Caudal – S4-5 Interlaminar

Caudal
Access to epidural space via sacral hiatus
Should not be commonly performed
No LOR used
Needles
25ga, 2.0 inch
Caudal Advantage
Drug injected often flows to ventral epidural space
No risk of dural puncture
S/P laminectomy L5
Disadvantage
Blind injections - 30+% non epidural
Placing injectate >4 levels from pathology
Sacral anatomy – In AP, Where is the sacral hiatus?
Sacral anatomy – There it is! Really?
Scout Lateral

Most caudal lamina

Sacral-coccygeal ligament
Lateral

Needle through sacral coccygeal

ligament

No need to advance up canal

Contrast
2.5 cc
Rostral to L5 foramen

Extra-foraminal spread
Interlaminar epidural
Fluoro Guided

Conclusions (Sharma, 2017)

Treating axial pain regardless of etiology – “Lack of effectiveness”

Radicular pain due to HNP and stenosis – “Statistically

significant short term improvement in pain”

Sharma et al. Pain Medicine 18: 239-251. 2017

Radicular Pain
Treatment

Lumbar Transforaminal - Epidural Steroid Injections

Advantages
Close to site of pathology
Concentrated injectate
L1-5 on blood
Thinners.

Bogduk Rauschning
“Safe” triangle “Safe” in regards to the nerve & dura,
NOT the radiculo-medulary artery

Bogduk Rauschning
Lumbar Transforaminal Injections
Technique

Injectates:
Lidocaine Test dose?
Corticosteroid
Solution only. Dexamethasone +/- LA
Suspension (Particulates) (methyprednisolone, betamethasone, triamcinolone)
Radiculo- Medulary artery Cord infarct
Relatively contraindicated. Need to Document medical indication if used
No difference in efficacy (Dreyfuss; Maus; Kennedy)
If you use a particulate suspension and have a problem, you have
no defense!
Reasonably prudent? Disregard of possible consequences?
Blood supply to Cord
Cord infarct
Lumbar Transforaminal

Left L5 TF

Traditional
Subpedicular placement (Supraneural)
 L4

L5

S1

Scout True AP
End plate not squared Endplate closest to target
Area of interest squared
 L4

L5

S1

L oblique L oblique
Target centered Needle in place
 L5 TF

L4
Lateral

Confirms dorsal -ventral

position
L5
Needle in place
Subpedicular
Mid-foramen
S1 Safe

Needle parallel to end plate

closest to target.
 AP Needle

L4 Tip under “6:00” position

Mid-foramen
Safe!

L5

S1
 AP

L4 Contrast ~1.5cc

Epidural? Yes
Covering DRG? Yes
L5

S1
 Lateral

L4 Contrast

L5

S1
S1 TF
Scout AP

End plate closest to target

parallel to beam

Lateral wall S1 nerve canal

AP

S1 Dorsal Foramen
AP

S1 ventral foramen

The wrong one!

Slight oblique

S1 dorsal foramen

The right one!

Slight oblique

Needle in S1 dorsal foramen

Lateral

Needle in S1 nerve root canal

Lateral

Needle in S1 nerve root canal

Dorsal S1 vertebral body

AP and Lateral
Post contrast
 The Effectiveness of Lumbar Transforaminal Injection of
Steroids: A Systematic Review of Outcomes Studies and
Controlled Trials.
MacVicar, Landers, King, Bogduk Pain Medicine 2013

• Useful Information derived from:

• 12 Observational Trials
• 5 Pragmatic (comparative effectiveness) Trials
• 6 Explanatory (randomized controlled) Trials
• Conclusions (disc herniations):
• TFESIs work: up to 70 % achieve ≥ 50% pain relief
• TFESIs are not a placebo
• TFESIs reduce health care consumption, spare surgery
• TFESIs have been shown to be a cost effective
intervention in contained herniations
• TFESIs can be durable: 25-40% have 12 month relief
Courtesy of Tim Maus, MD
Transforaminal Steroids
Efficacy- Seminal literature

Lumbar radicular pain

Confirmed HNP by MRI
LSE without benefit
On surgery schedule
~75% excellent relief up to 10 years
Average ~2 transforaminal injections

Weiner & Fraser, J Bone Joint Surg, 1997

Lutz et al, Arch Phys Med Rehab, 1998
Riew et al, J Bone Jt Surg (Am), 2000
Vad et al, Spine 27:11-16, 2002
Many others more recent
Lumbar Radicular Pain
Epidural Steroid Injections

How many injections are appropriate?

Base on medical reevaluation of patient response:

Pain relief
Increased function
Analgesic usage
Duration of relief
Lumbar Radicular Pain
Epidural Steroid Injections

There is no Mystical Power of Three

What is the maximum number?

Professor Aprill did extensive poling of the ISIS instructors.

But “The Truth” was uncovered in a classic British source:

Epidurals
Is there are maximum?

And the Lord spake, saying, “Then shalt thou count to three, no more.
Three shall be the number thou shalt count, and the number of the
counting shall be three. Four shalt thou not count… Five is right
out.”
Monty Python and the Holy Grail
1975
The Holy Hand Grenade of Antioch
Lumbar Medial Branch Block
Why Perform Lumbar MBBs

Diagnostic procedure
Test the hypothesis that a pain is mediated by the medial branch
Also called zygapophysial joint block
Option A
Option B
Critical Elements for Success

1. Accurate anatomic knowledge

2. Strict diagnostic criteria
3. Validated technique
Critical Elements for Success

1. Accurate anatomic knowledge

2. Strict diagnostic criteria
3. Validated technique
History1911 Joel Goldthwait described Z-joint as a potential pain
generator
1933 RK Ghormely used the term “facet syndrome” to
describe the pain mediated by lumbar Z-joints
1941 Badgley CE also endorsed “articular facets” an active
participant of LBP
1963 Hirsch D injected 11% hypertonic saline in the region
of z-joint and provoked low back and thigh pain
1971 Rees WES described denervation of the Z-joints to
relieve back pain
1974-75 CN Shealy offered RF neurotomy to treat Z-joint
mediated back pain
1976 Moony & Robertson injected intra-articular injection of
hypertonic saline followed by injection of local
anesthetics
1979 Bogduk and Long detailed the enervations of Z-joint
and essentially established the current practice of MBBs
for Z-joint denervation.
 Improved Anatomic Knowledge –
Cadaveric Dissections
• Comprehensive descriptions of the dorsal rami and
medial branches
• Anatomical and neurosurgical significance of the
lumbar MAL
• Modification of facet denervation technique

Courtesy Dr. Bogduk

Bogduk N, Wilson AS, Tynan W. The human dorsal rami. J Anat1982;134:383-397.
Bogduk N. The lumbar mamillo-accessory ligament. Its anatomical and neurosurgical significance. Spine
1981;6:162-7.
Bogduk N, Long D. Percutaneous Lumbar Medial Branch Neurotomy: A Modification of Facet Denervation. Spine
1980;5(2):193-200.
Anatomy

Demondion, et al. Am J Neuroradiol 2005; 26:706-10

Critical Elements

1. Improved anatomic knowledge

2. Accurate diagnosis
3. Validated technique
Lumbar Z Joint Pain
•More common in older
population
•(Depalma 2011)

•Axial wt bearing increases from

18% in the normal z-jt to 47% in
z-jt arthropathy
•(Yang 1984)

Mooney and Robertson 1976

Lumbar Z Joint Pain

No feature of hx, PE, or

imaging can differentiate z-jt
pain from other sources
(Schwarzer 1994, 1995)
(Manchikanti 2000)
Absence of pain rising from
sitting distinguished z-jt pain
from disc or SIJ (Young 2003)
Lumbar Z Joint Pain
Pain with extension and
rotation not predictive of
zygapophysial joint pain
(Jackson 1988)
 Accurate Diagnosis
• A diagnosis of zygapophysial joint pain cannot
definitively be made with history, physical
examination or imaging

• The essential indication for medial branch

neurotomy is complete relief of pain following
controlled diagnostic blocks of the target medial
branches
Critical Elements

1. Improved anatomic knowledge

2. Accurate diagnosis
3. Validated technique
Face Validity (anatomic) of Lumbar MBBs

§ 1st phase: Cadaveric study demonstrating radiographic

locations of MBs. 2 target points over the course of the MBs
were selected

§ 2nd phase: 120 medial branch injections in 15

asymptomatic volunteers performed using 0.5 ml contrast

§ Spread of contrast documented on CT scans following MBBs

Dreyfuss P et al. Spine 1997; 22:895

Face Validity (anatomic) of Lumbar MBBs

Results:
§84% of target medial branches were selectively and
exclusively infiltrated.

§ 8% venous uptake, with negative aspiration before

injection in all cases.

Dreyfuss P et al. Spine 1997; 22:895

Face Validity (physiologic) of Lumbar MBBs

18 asymptomatic volunteers

§Phase 1: Z-joint capsular distension with contrast until

pain or maximal distension without rupture < 2.5 ml.
Subjects with pain were admitted to Phase 2

§Phase 2: MB injection with either saline or 2% lidocaine,

wait ½ hr

§ Phase 3: Repeat capsular distention

Kaplan M et al. Spine 1998; 23:1847-1852
Face Validity (physiologic) of Lumbar MBBs

Results:
89% of MBBs successfully anesthetized the target
joint

Kaplan M et al. Spine 1998; 23:1847-1852

Construct Validity - Controlled MBB

• The false positive(FP) rate of a single,

uncontrolled lumbar MBB is 25-45%

• Controlled MBBs are mandatory to

reduce the likelihood of FP responses
 Triple (Placebo) Blocks

• The most rigorous way of excluding false (+) response:

• 1st block: active agent
• 2nd block: normal saline or active agent
• 3rd block: active agent or normal saline

• Logistic and ethical issues in its application

• Not practical

• Can be used in a research or medico-legal setting

Double (Comparative) Blocks

v Two blocks
v One block with a short acting agent: lidocaine
v usually >2 hrs relief
v One block with a long acting agent: bupivacaine
v usually > 4 hrs relief with marcaine

v More practical
 Definitions
long-acting LA
Comparative
long
Blocks
relief CONCORDANT
short-acting LA short relief

long-acting LA long
relief DISCORDANT

short-acting LA long relief

Barnsley L, Lord S, Bogduk N. Comparative local anaesthetic blocks in the diagnosis of cervical
zygapophysial joints pain. Pain 1993; 55:99-106.
 Stringent Criteria

Only concordant responses are positive

Longer pain relief with bupivacaine than lidocaine

Disadvantages
• Deny treatment to some patients that need it

Advantages
• Increase the success rate of treatment
• Shorten the waiting lists
Expanded Criteria

• Concordant and discordant responses are considered

positive

• Pain relief with either agent irrespective of duration of

relief
Expanded Criteria

• Advantages
• No patients incorrectly denied the RF treatment

• Disadvantages
• Treatment to some patients who do not need it
• Reduces the success rate of treatment
• Prolongs waiting list
Correlation of lumbar medial branch RF
neurotomy results with single vs. double
diagnostic MBBs.

Using single diagnostic block:

47% reported > 50% relief, mean duration 9.9 months

Using double-blocks:
77% reported > 50% relief, mean duration 9.8 months

Derby R. et al, Pain Med 2012

Summary of Prognostic MBBs

Single blocks (MBBs) are not valid due to an

unacceptable occurrence of FP responses
Minimum selection criteria for RF: >80% relief
from comparative MBBs
Conclusion

Symptoms

Accurate diagnosis

Validated treatment

Optimal outcomes
Technique

Int’l Spine Intervention Society

Practice Guidelines, 2nd Ed, 2013
Pre and post MBB
assessment
L1-4 Medial Branch Block
 L2 MBB

Innervates
SAP of L3
IAP of L3
Target at junction
of SAP/TP L3
 L4 SAP

L4 TP
mp
L3mb
L5 SAP Inflexion

mp
L5 TP
L4 mb
How Oblique for MBB?
Medial Branch Blocks – Target Points
Lateral view

Courtesy: Dr. Tim Maus

Suboptimal Needle
Placements

Too low
at MAL
And too medial

Too high

Provided by Dr. Paul

Dreyfuss
Suboptimal Contrast Flow Pattern

Suboptimal flow -
Try to avoid
contrast flow
superiorly towards
the IVF - consider
re-positioning

Provided by Dr. Paul

Dreyfuss
L5 Dorsal Ramus Block
Right L5 Dorsal Ramus
Block

Provided by Dr. Isaac

Cohen
L5 DR
Block

Provided by Dr. Paul Dreyfuss

Decline View for Lumbar MBB

• MBB were originally validated for target

specificity using only AP and oblique views

• 2nd Ed Guidelines describe the utility of the

decline view for lumbar MBB

• Useful for checking needle position and

contrast patterns to ensure coverage of target
nerve

Int’l Spine Intervention Society Practice Guidelines, 2nd Ed, 2013

Declined view
Right L3 Medial Branch Block

Provided by Dr. Isaac Cohen

Right L3 Medial Branch Block

Declined views with contrast

• 8% incidence (Dreyfuss et al. Spine 1997;22:895-902)
• 3.7% incidence (Verrills. Spine 2008; 33: 174-177)
• 6.1% incidence (Lee et al. Anesth Analg 2008;106:1274-8)
 Conclusions

• Prevalence of Z-joint mediated LBP is between 15-40%

• Diagnostic lumbar MBB has both anatomic and physiologic face

validity

• Diagnostic MBB has diagnostic utility

• Single block has a high false positive (25%-45%) rate

• An organized approach to document both pain score and ADL

before and after the procedure is essential for proper interpretation
of the diagnostic MBB.
Thank you!
SIS Multisociety Project
Appropriate Use Criteria (AUC) for SIJ Procedures
Pain Medicine 2017
November 1; 18(11):2081-2095

Convened Representatives
SIS, AAOS, ASA, ACR, AAPM&R, NASS
Goal: To evaluate image-guided injections and RF
procedures for suspected SIJ-mediated pain
Reviewed 10,000 scenarios
SIJ AUC Portal

Clinical Indications
Anticoagulants
Timing of Injections
Number of Injections
Lateral Branch RF Neurotomy
SIJ AUC Clinical Indications

Location of Pain

Physical Exam Findings

• Acute spondyloarthritis
SIJ AUC Clinical Indications

Location of Pain
Pain over SIJ - Yes
Pain over SIJ and referred to leg -Yes
Pain over SIJ and referred to groin - Yes
Maximal pain above L5 vertebra - No
SIJ AUC Clinical Indications

Physical Exam Findings

3 or more (+) SIJ provocation tests
Regardless of remaining scenario details
1 or 2 (+) SIJ provocation tests
Other aspects of scenario (Hx, mech of injury, pain
characteristics) suggestive of SIJ mediated pain
No (+) SIJ provocation tests
Not indicated
Regardless of remaining scenario details
SIJ AUC Injected Materials

Preference is local anesthetic + steroid

Total volume (contrast + LA + steroid)
1.5 cc
2.0 cc Schwarzer ‘95
2.5 cc Aprill ‘92
SIJ AUC Anticoagulants

DO NOT WITHHOLD
Lack of bleeding complications reported in lit
No sensitive neural structures to be damaged if
hematoma were to occur
Greater risk posed by condition for which
anticoagulant prescribed
SIJ AUC Evaluation of Block

Degree of pain relief

< 50% - Negative
50 -75% - Equivocal
> 75% - Positive
Close to 100% - Unequivocal
Sacroiliac Joint Injections - Goal
Diagnostic
Determine whether the sacroiliac joint is the source of
pain
Therapeutic
ID pts who might benefit from treatment targeting the
SIJ
Intraarticular introduction of corticosteroid or other
agent may provide lasting pain relief
Does not ID pts who will benefit From SIJ RF
SIJ Anatomy
True synovial joint with a fibrous capsule
Articular surface irregular depressions and
convexities lock ilium against sacrum
SIJ Anatomy
Wedge-like shape of sacrum + large
ligament complex creates more stability
SIJ Ligaments
The anterior SIJ capsule/ligament is 2 mm thick
(MRI) (Jaovisidha. Invest. Rad.1996;31:532-541)
SIJ Ligaments
The posterior capsule is often rudimentary with the
strong interosseous ligament forming the
posterior SIJ border
SIJ Anatomy
Morphology is variable
between individuals
and between sides in
same individual
Avg adult surface area
is 17.5 sq cm
Auricular, C-shaped
interface
SIJ Innervation

Free nerve endings (pain and thermal

sense) exist in the SIJ capsule and
posterior ligaments (Solonon; Acta Orthop
Scand 1957;27:1-127, Vilensky; Spine;27:1202-1207,
2002, Szadek; Reg Anesth Pain Med; 33:36-43, 2008)
SIJ Innervation
Predominant innervation from dorsal ramus of
S1 (Grob; Zeitschr Rheumatol 1995;27:117-122)
S1 and S2 lateral branches
contributed in 100% of specimens
S3 lat branch in 88%
L5 dorsal rami in 8%
S4 lat branch in 4% (Roberts; Regional
Anesthesia & Pain Medicine 2014; 39(6): 456-464)
SIJ Neuroanatomy

S1, S2, S3, (and variably, S4)

LB nerves found distributed
to SI interosseous ligament
Not all LB nerves progressed to
SI ligaments
Marked variability of path,
location, and number of LB
nerves at each level
SIJ Complex Pain Construct
• Avariety of anatomic pain generators within the
“SIJ complex” account for presence of pain
similar to the shoulder joint complex
Intra-articular (IA) pain: e.g. arthritis (OA),
infection, spondyloarthropathies, metabolic
diseases, idiopathic (movement restriction?,
capsular strain?)
Extra-articular (posterior SIJ complex) pain:
enthesitis, ligamentous
SIJ Complex Pain Construct

Intra-articular (IA) pain injections

70% relief at one month after IA
corticosteroid injection (Maugers; British
Journal of Rheumatology, 1996)

AS - 12/22 good relief at one month

Subsequent phenol injection resulted in a much longer
period of relief
Randomized controlled trial (2 arms)
A maximum of 3 semi-weekly injections – Outcome
evaluated at 15 months

• 50% or > pain relief in • 50% or > pain relief in

17% of Triamcinolone 58% of Dextrose Group
Group
SIJ Pain Etiology

Altered Biomechanics
• Inflammatory • Somatic Dysfunction
• Scoliosis
• Traumatic
• Leg Length Discrepancy
• Osteoarthritic • Gait Abnormality
• Pregnancy – esp 3rd trimester • Spinal Fusion including L5-S1
• Idiopathic - 35% (Chou et al., • Spinal Surgery
2004)
SIJ Prevalence

Schwarzer - 1996

• 217 combined pts with maximal pain below L5 evaluated

• Anatomic controlled (neg z-jt blocks) and/or dual positive (>75% relief)
SIJ blocks performed

• Prevalence of SIJ pain was 10-20% (Schwarzer, Spine, 20:31, 1995,

Maigne, Spine 21,1889, 1996)
SIJ Prevalence

DePalma – 2011 - Sources of LBP

• 40 y.o.
• 50 y.o.
– 70% - Discogenic
– 42% - Discogenic – 18% - Facetogenic
– 31% - Facetogenic – 10% - SIJ
– 18% - SIJ • 65 y.o.
– 18% - Discogenic
– 45% - Facetogenic
– 28% - SIJ
 SIJ Clinical Presentation
Fortin JD, Falco FJ - 1997
SIJ mediated pain:
• ‘Fortin Finger test’ identified 16 patients
• All 16 with a positive finger test subsequently
had a positive SIJ injection.
Fortin JD, Falco FJ. The Fortin finger test: an
indicator of sacroiliac pain. American Journal
Murakami et al1997
of Orthopedics. – 2008
Jul;26(7):447-480
• 25 patients meeting selection criteria identified the main pain at
the PSIS or within 2cm

Murakami E, et al. Diagram specific to sacroiliac joint pain site indicated by one-finger
test. Journal of Orthopedic Science 2008 Nov;13(6):492-7.

B. White
Basic Lumbar
Course
Tampa 3-27-15
Provocative Testing

Patrick Faber Test Gaenslen’s Test

 Provocative Testing

DistractionTest Compression Test

Provocative Testing

Sacral Thrust Thigh Thrust

 SIJ mediated pain
Summary:

In a chronic low back pain population with:

pain below L5
unilateral pain over the SIJ
with 3 positive physical exam maneuvers

There is a high probability of the low back pain

being from the SIJ ( > 50%)
If the physical exam maneuvers are negative then the probability that their
LBP is from the SIJ is: 14%
(But note, in a non-selected all inclusive LBP group the pre-test prob. is about
20% so the Post test (-) prob. would be about 7%)
SIJ Pain: Prevalence S/P fusion
 SIJ Pain: Prevalence S/P fusion
Longo et al – British Medical Bulletin, 2014
• Review article looked at 9 studies
• Overall prevalence of SIJ pain after fusion à 32% - 43%

Maigne – European Spine Journal, 2005

• Prospective study of 61 patients after fusion
• Prevalence of SIJ pain after fusion à 35%

Katz et al – Journal of Spinal Disorders and Tech -

2003
• Prospective study of 34 patients
• Prevalence of SIJ pain after fusion
• 59% of total with >75% relief during anesthetic window
• 34% of total with > 10 days relief
SIJ: Imaging overview
CT imaging – Elgafy et al., 2001
57% sensitivity and 69% specificity for SI joint pain
MRI-
can detect early sacroilitis but not other dysfunction.
85% sensitive for active sacroilitis
Bone scan-
Slipman et al - 1991.
100% specificity and 13% sensitivity
Maigne et al. – 1998
90% specificity and 46% sensitivity
Hancock review article - 2007
low sensitivity but specificity >90%
Results suggest that a positive bone scan is highly consistent with
the SIJ as the source of LBP
However, a negative bone scan provides little information; the
SIJ could still be a source of LBP.

Cohen SP, Chen Y, Neufeld NJ. Sacroiliac joint

SIJ AUC Imaging

Degenerative changes on imaging

No direct correlation
If present, more likely to warrant SIJ
investigation
SIJ Pathology

Ankylosing Spondylitis - XR Osteoarthritis - CT

 SIJ Pain:
Step by Step
 Step By Step
Procedure
Technique
Left SIJ AP view:
Spinous process mid-line

Identify the inferior pole of the targeted SI joint

Laterally imaged joint line,

? Anterior
Medially imaged joint line,
? Posterior

Use approximately 10-15 degrees cephlad tilt of the image intensifier. Modify so that the
superior pubic ramus does not obscure clear visualization.
 Step By Step
Procedure Technique
Slight contralateral
oblique:
Joint margins
approximating
 Step By Step
Procedure Technique
Increasing
contralateral
oblique
Step By Step Procedure
Technique
Mark skin along the medial
aspect of the inferior 1 cm of
the joint or just caudal to the
inferior aspect of the joint.

Skin local weal with lidocaine

1%

Advance procedure needle

towards joint. Needle touch
down onto bone at medial side
of joint space in contralateral
oblique view

Redirect laterally until joint

capsule contacted
Step By Step Procedure
Technique
Needle advanced into joint
space in contralateral oblique
view

Joint space is not smooth,

obstructions will be noted. If
os is contacted, withdraw the
needle 1-2mm, rotate and re-
advance. Save pre injection
image.
 Step By Step
Procedure Technique
Needle advanced into
joint space in lateral
view

A lateral view should

evidence the needle at
~S2-3 and the ventral 1/3
of the sacrum
 Step By Step
Procedure Technique
Initial dye flow in contralateral
oblique

In AP view, with or without

some obliquity, inject a small
volume of contrast using
active fluoroscopy.

If a larger volume is used, and

it is non-intraarticular, further
attempts to visualize the joint
will be difficult if not
impossible.

An arthrogram should be
noted. Contrast is first seen
filling the inferior recess of the
capsule.

Save image
 Step By Step Procedure
Technique
Initial dye flow in AP view

If contrast cannot be
injected, withdraw needle
slightly, or rotate hub, re-
attempt gentle injection;
repeat until arthrogram is
identified

Evaluate AP and lateral

images for possible capsule
disruption
Step By Step Procedure
Technique
Initial dye
flow in
ipsilateral
oblique view
 Step By Step Procedure
Technique
Initial dye
flow in lateral
view
25g needle

Contrast in margins of left SIJ

B. White
Basic Lumbar
Course
Tampa 3-27-15
 Step By Step
Procedure Technique
Initial dye flow
in lateral view

B. White
Basic Lumbar
Course
Tampa 3-27-15
 Step By Step
Procedure Technique
Dye pattern after instillation of injectate

Contralateral oblique Ipsilateral oblique

B. White
Basic Lumbar
Course
Tampa 3-27-15
SIJ: Key Points
A. Sacroiliac pain accounts for ~15% of patients
with LBP. Physical examination and imaging
are unreliable for diagnosis. SI pain is always
below L5.
B. SI injections should never be combined with
other procedures
C. Sedation is not medically necessary in the vast
majority (>95%) of cases
D. Sacroiliac joint access is not always easy, and
failure to enter the joint is common
E. The joint does not hold a large volume, <2.5cc.
If attempting a diagnostic block, use small
volumes 1-1.5cc.
SIJ: Key Points
F. The joint is “leaky” in ~20-30% of patients and the
lumbosacral plexus lies just ventral to the joint. Therefore
selectivity may be in jeopardy.
G. Dorsal osteophytes usually encroach on the joint from
lateral to medial; a slight medial to lateral vector may
increase successful joint entry.
H. Access to the joint is usually at the inferior pole. Access is
possible at the rostral pole; it will require penetrating the
dorsal ligaments.
I. Particulate corticosteroid is appropriate with local
anesthetic at a concentration to assure somatic block after
dilution. Lidocaine 1, 2 or 4%, or bupivacaine 0.25-0.75%
J. When imaging the joint in AP view, the dorsal margin of
the joint is visualized medially to the ventral margin of the
joint