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Does the presence of cranial contrast spread during a sacroiliac joint injection predict short-term outcome?
  1. Wout Vandervennet1,
  2. Koen Van Boxem1,
  3. Laurens Peene1,
  4. Dieter Mesotten1,2,
  5. Klaas Buyse1,
  6. Pieter Devooght1,
  7. Roel Mestrum1,
  8. Martine Puylaert1,
  9. Astrid Vanlantschoot1,
  10. Thibaut Vanneste1 and
  11. Jan Van Zundert1,3
  1. 1 Anesthesiology, and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Lanaken, Limburg, Belgium
  2. 2 Hasselt University, Faculty of Medicine and Life Sciences and Limburg Clinical Research Center, Diepenbeek, Belgium
  3. 3 Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
  1. Correspondence to Dr Koen Van Boxem, Anesthesiology and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Lanaken, Belgium; koen.vb{at}


Background The innervation of the sacroiliac joint (SIJ) is complex, with a dual innervation originating from the lumbosacral plexus anteriorly as well as the sacral lateral branches posteriorly. Nociceptors are found in intra-articular structures as well as periarticular structures. In patients with SIJ pain, a fluoroscopy-guided SIJ injection is usually performed posteriorly into the bottom one-third of the joint with local anesthetic and corticosteroids, but this does not always reach all intra-articular structures. The correlation between a cranial contrast spread and clinical success is undetermined in patients with SIJ pain.

Methods In a tertiary referral pain center, electronic medical records of patients who underwent an SIJ injection were retrospectively analyzed. Only patients with at least three positive provocation maneuvers for SIJ pain were selected. Contrast images of the SIJ were classified as with or without cranial spread on fluoroscopy as a marker of intra-articular injection. Clinical success was defined as ≥50% improvement in the patient’s global perceived effect after 3–4 weeks. The primary outcome was defined as the correlation between cranial contrast spread and clinical success after an SIJ injection.

Results 128 patients in total were included. In 68 patients (53.1%) fluoroscopy showed cranial contrast spread. Clinical success was higher in patients with cranial spread of contrast (55 of 68, 81%) versus those without (35 of 60, 58%) (p=0.0067). In a multivariable analysis with age, gender, presence of rheumatoid arthritis, side, and number of positive provocation maneuvers, the cranial spread of contrast remained the only independent factor of clinical success (p=0.006; OR 3.2, 95% CI 1.4 to 7.7).

Conclusion In patients with SIJ pain, identified by positive pain provocation maneuvers, cranial contrast spread as a marker of intra-articular injection, with subsequent injection of 3 mL of local anesthetic and methylprednisolone 40 mg, was significantly correlated with clinical success up to 4 weeks. Therefore, attempts should be made to reach this final needle position before injecting local anesthetic and corticosteroids. This result needs to be confirmed in a high-quality prospective trial.

  • injections
  • spinal
  • nerve block
  • pain management

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  • Contributors WV: evaluation of the radiographic images, literature search, drafting of the manuscript. KVB: concept of the study, final review of the images and final review of the manuscript. LP: evaluation of the radiographs. DM: supervision of statistical analysis and review of the manuscript. PD: review of the manuscript. KB: review of the manuscript and interpretation of the literature. RM: participation in study concept and review of the manuscript. MP: review of the manuscript. AV and TV: retrieval of patient files and review of the manuscript. JVZ: supervision of the analysis and review of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The protocol for this retrospective study was reviewed and approved by the ethical committee of Ziekenhuis Oost-Limburg (reference number: 20/0077R).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. The data consist, on the one hand, of information retrieved from patients’ record cards. On the other hand, the fluoroscopic images were read online in the hospital computer system. Individuals who want to consult this information can address the request to the corresponding author.