Sacroiliac Joint Injection

• The sacroiliac joint (SIJ) is a true

diarthrodial joint with the articular
surfaces of the sacrum and ilium
separated by a joint space enclosed in a
fibrous capsule
• a synovial joint, especially in the
superoanterior and inferior aspects
superoposterior joint surface lacks a
joint capsule and contains the
interosseous ligament.
• The anterior joint capsule gives origin
to the anterior sacroiliac ligament. The
posterior aspect also contains the
posterior sacroiliac, sacrotuberous, and
sacrospinous ligaments that stabilize
the joint
• The muscular and fascial support of the SIJ
is derived from the gluteus maximus and
medius, the erector spinae, the latissimus
dorsi and thoracolumbar fascia, the biceps
femoris, the piriformis and oblique
muscles, and the transversus abdominis.
• The gluteus maximus, biceps, and
piriformis attach to the sacrotuberous
ligament while the thoracodorsal fascia
connects to the remaining muscle groups.
• The anteroposterior and superoinferior
wedge-shaped sacrum (forming a keystone
configuration) and this extensive muscular
support account for reduced mobility but
high stability of the SIJ
• The posterior SIJ is predominantly
innervated by lateral branches of
the L4-S2 nerve roots with
contributions from S3 and the
superior gluteal nerve. The
anterior SIJ innervation is from
the L2-S2 segments
• The synovial capsule and
ligaments contain free nerve
endings as well as
mechanoreceptors that transmit
proprioceptive and pain sensation
from the joint
 Indications
• Diagnostic SIJ injections are used to identify pain
stemming from the SIJ. Most provocative tests
for diagnosing SIJ pain are not definitive, and SIJ
injections remain the gold standard. There are
also no imaging studies that consistently provide
findings to diagnose the SIJ as the source of pain.
• Therapeutic SIJ injection is used after failure of
conservative treatment, including anti-
inflammatory medications and physical therapy
• The placement of the
ultrasound probe over
the sacroiliac joint (SIJ)
to obtain a short axis
view is shown
• The patient is placed in the prone position with a pillow underneath the
abdomen to minimize lumbar lordosis.
• Usually a low-frequency curvilinear transducer is used, especially in
obese patients to increase penetration
• The transducer is placed transversely over the lower part of the sacrum
(at the level of the sacral hiatus), and the lateral edge of the sacrum is
identified. hen the transducer is moved laterally and cephalad till the
bony contour of the ileum is clearly identified
• The cleft seen between the medial border of the ileum and the lateral
sacral edge represents the SI joint, and the inferior-most point is targeted
• A 22-gauge needle is then inserted at the medial end of the transducer
and advanced laterally under direct vision in plane with the ultrasound
beam until it is seen entering the joint
• Short-axis sonogram
showing the needle (in
plane) inside the SIJ
(arrowheads).
• The dotted lines outline
the bony surface of the
ilium and the arrows
point at the dorsal
surface of the sacrum
• Anteroposterior
radiograph showing
intravascular spread of
• the contrast agent
during SIJ injection. (
 Limitations
• The potential for periarticular rather than intra-
articular injection may be increased compared
to fluoroscopic or CT-guided SIJ injections
because an arthrogram with contrast agent
injection can be reliably obtained in most cases
with the latter technique.
• Ultrasound is not very reliable in detecting
intravascular injection while performing SIJ
injections