1. 2016;19;E329-E338Fluoroscopy-Guided Sacroiliac Joint Injection: Description of a Modified Technique
   Case Study
   Prasad Jaychand Kasliwal, MBBS, DA, DNB, MNAMS, and Sapana Kasliwal, MBBS, DA.

Sacroiliac joint (SIJ) pathology is a common etiologic cause for 10 – 27% of cases of mechanical low back pain (LBP) below the L5 level. In the absence of definite clinical or radiologic diagnostic criteria, controlled blocks of the SIJ have become the choice assessment method for making the diagnosis of SIJ pain. The SI joint is most often characterized as a large, auricular-shaped, diarthrodial synovial joint. In reality, its synovial characteristic is limited only to the distal third and anterior third. In SIJ interventions, the lateral view has been underutilized. In our technique, we used the lateral view to create a three-dimensional view of the SIJ to aid in gauging the accurateness of the contrast spread and to obtain a precise block. After obtaining appropriate fluoroscopic images, a curved tip spinal needle was directed into the inferior aspect of the SIJ using a posterior approach. As the needle contacts firm tissues on the posterior aspect of the joint, position of the needle tip is checked using lateral fluoroscopy. In the lateral view, the needle tip position is manipulated to keep it in the anterior third of the SIJ and contrast is injected. Our criteria for accurate SIJ block, in posteroanterior (PA) view, is the injection of the contrast medium should outline the joint space and the contrast medium should be seen to travel cephalad along the joint line. In the lateral view, the contrast medium most densely outlines the parameter of the joint. We have utilized this method with good effect in approximately 30 cases over one year. Out of 30 cases, needle position and contrast spread was satisfactory in 28 and 27 cases, respectively. So satisfactory needle placement and contrast spread was in 93% and 87% cases. Pain relief of 80% or more after intra-articular injection of local anesthetic was seen in 50% (15 of 30) patients; pain relief of 50 – 79% was witnessed in 30% (9 of 30) patients. Thus, pain decreased 50% or more in 80% (24 of 30) of the joints. Out of 24 joints where we got satisfactory needle position and contrast spread, 23 joints got more than 50% relief. Thus, if needle position and contrast spread is satisfactory as per the criteria, pain relief of 50% or more was in 96% (23 of 24) of joints. There are few possible limitations with this study like difficulty to go up to the anterior third of the SIJ, it may be more painful as a narrow joint line has to be travelled in depth, sciatic numbness due to drug leak, or injuring the pelvic structure. Advantages of this method are that depth and level of the needle tip for a SIJ block is described for the more precise block. This will reduce false positive and false negative results, i.e., sensitivity and specificity of SIJ blocks and results for diagnostic blocks become more reliable. It will also reduce the chances of a case getting abandoned due to inappropriate contrast spread obscuring the fluoroscopic landmarks. As we know the depth of the needle, the chances of injuring pelvic structures become less and safety improves.