Inferior and Intra‐/Peri‐Articular Superior Sacroiliac Joint Injection Approaches Under Ultrasound Guidance to Treat Metastasis‐Related Posterior Pelvic Bone Pain

Abstract

Background Numerous mechanical and pathologic variables contribute to sacroiliac joint (SIJ) pain. The oncologic population has additional considerations, including tumor burden causing fracture, nerve compression, joint instability, and periosteal inflammation. Post‐treatment changes may also restrict joint mobility, causing transitional pain. Currently, fluoroscopically guided SIJ injections, aimed at the inferior one third of the SIJ, are the gold standard for treatment but have only been described in the nononcologic population. Ultrasound (US) guidance may confer several benefits, including positioning, ease of procedure, lower costs, and, importantly, guidance to avoid neovascularization, metastatic disease, and other soft tissue structures. Objectives We aim to describe the advantages of US‐guided SIJ injections for refractory malignant SIJ pain from extra‐articular tumors. We then describe our technique and decision framework for accessing the superior or inferior SIJ in patients with metastatic sacroiliac pain. Methods A retrospective review was performed on 5 patients with refractory malignant SIJ pain who underwent US‐guided superior or inferior approach SIJ injection. Using imaging and outcomes, we developed a decision framework. Results Patients received either inferior or superior approach SIJ injections depending on location of tumor, extent of tumor invasion, and stability of the SIJ as per our framework. All patients reported improvement in pain and function without complications. Conclusions We propose a decision framework for inferior vs. superior approach US‐guided SIJ injections in the oncologic population with SIJ pain from metastases to the pelvis or sacrum. Having multiple techniques to approach the SIJ is important in the oncologic population, in whom metastatic tumor burden poses a technical challenge to performing these injections.

Transarticular Invasion of Primary Bone Tumors and Tumor-Like Lesions Near the Sacroiliac Joint: an MRI Study in 128 Patients

“…Value of imaging study assessment of transarticular invasion of primary bone tumors and tumor-like lesions near the sacroiliac joint Among imaging techniques (X-ray, CT, MRI and radionuclide scans) for the assessment of bone tumors, MRI has unique advantages with respect to showing the range of intramedullary and surrounding soft tissue invasion of the bone tumor, invasion of the adjacent joints and bone metastasis [7,8]. Abnormal signal changes on MRI can not only clearly reveal the location, size and involved range of bone tumors and tumor-like lesions near the sacroiliac joint but also clearly show that a tumor destroying the ipsilateral cortical bone invades the contralateral bone of the joint across different structures of the sacroiliac joint [9]. According to the literature, the sensitivity and specificity of MRI are 100% and 92% [4,5], respectively, if a strict definition of transarticular invasion of the bone tumor near the sacroiliac joint is used.…”

Image‐guided spinal injection for pain management

“…103 Although ultrasound-guided SIJ injections may be of benefit in oncologic patients with refractory malignant SIJ pain by enabling visualisation of metastatic disease, neovascularisation and other soft tissue structures can make standard procedure technically challenging. 104 Under fluoroscopy, the patient is placed in the prone position with the fluoroscopy tube angled 10-25 degrees in the cephalocaudal plane for better visualisation of the SIJ space. 105 After administration of a local skin anaesthetic, a 22-23-gauge spinal needle is then advanced perpendicular to the skin towards the most distal 1-2 cm of the SIJ.…”