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. Author manuscript; available in PMC: 2021 Oct 21.
Published in final edited form as: Pain Pract. 2020 May 12;20(7):769–776. doi: 10.1111/papr.12896

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

Daniel Chun-suk Oh †, Lucas First †, Neal Rakesh †, Hanna Oh †, Amitabh Gulati §
PMCID: PMC8529624  NIHMSID: NIHMS1731524  PMID: 32270598

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 non-oncologic 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 five patients with refractory malignant SIJ pain who underwent US-guided superior or inferior-approach SIJ injection. Using imaging and outcomes, we develop 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 versus 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 where metastatic tumor burden pose otherwise technically-challenging injections.

INTRODUCTION

Sacroiliac joint (SIJ) pain is a common cause of low back and buttock pain given that it presents in many ways1,2. The SIJ is a diarthrodial synovial joint that is maintained by a ligamentous network, connects the sacrum and ilium, and stabilizes the lumbopelvic junction. The posterior sacroiliac ligament is a strong joint stabilizer which extends from the sacrum and forms the thick interosseous sacroiliac ligament in the superoposterior compartment; the anteroinferior compartment is synovial, thus the few inferior centimeters of the SIJ represents a chondral joint from anterior to posterior.

Non-malignant SIJ pain results from inflammatory conditions, pelvic or sacral fractures, diastasis, joint instability, ligamentous laxity, or shearing of the joint capsule3. There are additional pain generators in the oncologic population, including direct or indirect tumor burden causing fracture, ligament damage, nerve compression, and periosteal inflammation. SIJ pain can be a sequela of cancer treatments, including surgical fusion/resection or direct effects of radiation therapy (RT). Tumor and treatment can cause SIJ dysfunction. In SIJ dysfunction or instability, the ligamentous portion of the joint is commonly implicated1,2. Generally, tumors invading the sacrum and/or ilium represent metastatic disease and treatment is targeted toward palliation for better quality-of-life (QOL).

Initial conservative treatments include physical therapy, nonsteroidal anti-inflammatory drugs, systemic corticosteroids, and/or opioids3. However, systemic medications confer significant risk to an at-risk oncologic population. When unsuccessful, more invasive treatments such as SIJ corticosteroid injections, radiofrequency ablation, dorsal column stimulation, sacroplasty, and intrathecal pumps can be considered4,5. In 2017, Hutson et al. introduced a paradigm approach to SIJ pain from extra-articular tumors, proposing treatment should first include SIJ injections prior to proceeding to lateral branch blocks, sacroplasty, intrathecal medication, spinal cord stimulation, or surgery6.

The gold standard for SIJ corticosteroid injections involves accessing the inferior third of the SIJ under fluoroscopic-guidance. In non-malignant SIJ pain, a cadaveric study revealed higher success rates of fluoroscopically-guided injections7. However, clinically, it has been shown that ultrasound (US)-guidance has similar efficacy to fluoroscopic-guidance in patients with SIJ arthritis8. While there are advantages to both, US-guidance is particularly beneficial in the oncologic population by allowing visualization of metastatic disease, neovascularization, and other soft tissue structures. Furthermore, US-guidance does not require the patient to be prone, allowing for more comfortable positioning to undergo injection. Additionally, most patients with metastases have undergone multiple studies/treatments with radiation and US-guidance eliminates radiation exposure.

In the non-malignant population, Do et al. and Park et al. concluded that the superior approach under fluoroscopic-guidance consistently gives good access to the SIJ and achieves pain relief comparable to other methods9,10. In the oncologic population, multiple US-guided approaches to the SIJ are useful to navigate around tumor burden. We highlight five patients with SIJ pain secondary to pelvic tumor burden, persistent pain despite other treatments, or treatment-associated changes, who responded to US-guided SIJ corticosteroid injection. We describe key factors and introduce a framework for approaches to the SIJ depending on tumor location.

METHODS

This retrospective review was approved via waiver for informed consent by Memorial Sloan Kettering Cancer Center’s (MSKCC) Internal Review Board and supported by MSKCC Support Grant (P30 Core Grant) and the Department of Anesthesiology and Critical Care. Chart reviews of patients with pelvis-related pain and histories of oncologic diseases were performed. We reviewed patients’ symptomology, medical history, and pre-/post-procedure pain levels. We reviewed all available imaging.

In preparation, imaging was reviewed to plan the approach to the SIJ to avoid tumor bulk. Then, each patient was placed in prone position. The patient was pre-scanned with the ultrasound device (GE P9TM with either 9L linear or 1–5Hz curvilinear probe) to assess for anatomic anomalies and pre-procedure planning as outlined below. Power doppler was used to avoid vasculature given its high sensitivity of fluid flow and vasculature detection. Then, the patient was cleaned and sterilely prepped. A 25-gauge needle with 1% lidocaine was used for skin anesthesia. Next, a 25-gauge, 2-inch or 3.5-inch Quincke needle was placed under US-guidance into the SIJ (Inferior: Figure 1a, Figure 1b, Figure 1c; Superior: Figure 2a, Figure 2b, Figure 2c). Notably, the SIJ depth will vary based on body habitus. In our healthy model, it ranged from 2.5 to 4-cm. Cachectic patients as we often see in the oncologic population may have depths less than 2.5-cm. After negative aspiration to ensure that the needle tip is not intravascular, the injectate was administered under visualization. The injectate consisted of 0.25% bupivacaine and either triamcinolone or methylprednisolone. Patients were followed post-procedurally, per standard practice at MSKCC.

Figure 1:

Figure 1:

Figure 1:

Figure 1:

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Ultrasound transverse view of the inferior sacroiliac joint (synovial) with the in-plane needle approach. (a) The position of the transducer. (b) Unlabeled and (c) labeled images of the approach. The white arrow indicates the needle. The depth of the needle tip is 2.5-cm. Gmax gluteus maximus; ESM erector spinae muscle; PSIL posterior sacroiliac ligament; I ilium; S sacrum; SIJ sacroiliac joint.

Figure 2:

Figure 2:

Figure 2:

Figure 2:

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Ultrasound transverse view of the superior sacroiliac joint (ligamentous) with the in-plane needle approach. (a) The position of the transducer. (b) Unlabeled and (c) labeled images of the approach. The white arrow indicates the needle. The depth of the needle tip is 4.5-cm. Gmax gluteus maximus; ESM erector spinae muscle; PSIL posterior sacroiliac ligament; I ilium; S sacrum; SIJ sacroiliac joint; NP needle placement.

Inferior Approach:

The transducer was placed over the posterior superior iliac spine (PSIS) and translated medially in the longitudinal view to reveal the S1 foramen (Figure 3a, Figure 3b, Figure 3c). It was then translated inferiorly from the PSIS to reveal the ligamentous portion of the SIJ, which is the target for the superior approach. The probe was further translated inferiorly to reveal the S2 foramen (Figure 4a, Figure 4b, Figure 4c). The transducer was moved further caudad to reveal the cleft at the junction of the distal posterior inferior iliac spine (PIIS) and lateral aspect of the sacrum, which is synovial portion of the SIJ and the target for the inferior approach.

Figure 3:

Figure 3:

Figure 3:

Figure 3:

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Ultrasound transverse view of the SIJ at the level of the S1 neuroforamen (a) The position of the transducer. (b) Unlabeled and (c) labeled images. At this level, the depth of the SIJ is 4-cm. Gmax gluteus maximus; ESM erector spinae muscle; PSIS posterior superior iliac spine; PSIL posterior sacroiliac ligament; I ilium; S sacrum; SIJ sacroiliac joint; S1F S1 foramen; S1LB S1 lateral branch.

Figure 4:

Figure 4:

Figure 4:

Figure 4:

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Ultrasound transverse view of the SIJ at the level of the S2 neuroforamen (a) The position of the transducer. (b) Unlabeled and (c) labeled images. At this level, the depth of the SIJ is 3.5-cm. Gmax gluteus maximus; ESM erector spinae muscle; PSIL posterior sacroiliac ligament; I ilium; S sacrum; SIJ sacroiliac joint; S2F S2 foramen; S2LB S2 lateral branch.

Superior Approach:

The transducer was placed over the PSIS and translated medially in the longitudinal view to reveal the S1 foramen (Figure 3a, Figure 3b, Figure 3c). It was then translated inferiorly from the PSIS to reveal the ligamentous portion of the SIJ, which is the target for the superior joint approach. If the probe was translated inferiorly, the S2 foramen will be visible. Subsequently, the endpoint of the injection was the portion of the SIJ between the S1 and S2 foramen. The target is the ligamentous component of the articular joint which may be intra- or peri-articular.

RESULTS

CASE 1

A patient in their eighties with high-grade metastatic sarcoma with left iliac lymph node involvement status-post RT, immunotherapy as well as sacral melanoma status-post RT presented with left buttock pain, 10/10 on the Numeric Pain Rating Scale (NPRS) that was sharp and stabbing and worse with walking. The patient was taking ibuprofen 400mg every six hours and received a L5-S1 epidural steroid injection that did not improve the pain. An MRI revealed a sacral tumor centered at the left sacral ala with infiltration of the L5-S1 neuroforamen and compression of the exiting left L5 and S1 nerve roots (Figure 5). As the tumor was adjacent to the entirety of the superior SIJ, an US-guided, inferior approach left sacroiliac joint injection with corticosteroids was performed. The injectate consisted of 80mg of methylprednisolone and 4mL of 0.25% bupivacaine. Immediately, the patient’s NPRS reduced to 3/10. The patient was able to ambulate more comfortably and discontinued ibuprofen. The patient returned to normal function and ambulatory status for 5.5 months before re-presenting with increasing difficulty with standing due to pain, with disease progression.

Figure 5:

Figure 5:

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A coronal section of MRI proton density sequence reveals a large sacral metastatic lesion located at the left superior-anterior sacral ala with infiltration of the L5-S1 neuroforamen and with compression of the exiting L5 (not pictured) and S1 nerve roots.

CASE 2

A patient in their sixties with metastatic prostate adenocarcinoma status-post chemotherapy and palliative external beam radiotherapy to L1-L5 presented with worsening low back pain with sitting, improved with ambulation or laying supine. The patient was taking oxycodone 5mg every six hours for pain, without sufficient relief of symptoms. At presentation the patient’s pain was rated as 8/10 on the NPRS. A CT scan revealed multiple diffuse sclerotic metastases in the lower thoracic spine, lumbar spine, sacrum, iliac bones, femurs and lower ribs (Figure 6). Given concern for SIJ instability due to reduced cortical strength and diffuse metastatic disease, a bilateral US-guided, superior approach SIJ injections with corticosteroid was performed, resulting in immediate pain relief. The injectate consisted of 40mg of triamcinolone and 3mL of 0.25% bupivacaine per joint. Post-procedure, pain severity was 4/10 on the NPRS and one day after the procedure, pain severity was 0/10 leading to discontinuation of oxycodone. At 6-month follow-up, patient continued to report good pain control with increased sitting tolerance.

Figure 6:

Figure 6:

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A CT scan in axial view reveals multiple diffuse sclerotic metastases in the sacrum and ilium as well as the lower thoracic spine, lumbar spine, femurs and lower ribs (not pictured).

CASE 3

A patient in their eighties with metastatic anaplastic large cell lymphoma status-post chemotherapy, immunotherapy, and palliative external beam radiotherapy to a lesion in the L5 vertebral body resulting in complete collapse of the L5 vertebra, presented with left low back and buttock pain, radiating to the posterior thigh, that was 8/10 on NPRS. The patient underwent posterior spinal fixation and developed SIJ dysfunction due to altered biomechanics as well as rapid degenerative changes to the joint in the setting of radiation therapy and chemotherapy11,12,13. Pain medication regimen included duloxetine 60mg daily, pregabalin 150mg three times a day, and baclofen 10mg twice a day. Given radicular pain, the patient had received a L5-S1 interlaminar epidural steroid injection without relief. As there was concern for SIJ dysfunction and instability, an US-guided, superior-approach left SIJ corticosteroid injection was performed, leading to immediate pain relief, NPRS was rated at 4/10. The injectate consisted of 60mg of triamcinolone and 3mL of 0.25% bupivacaine. At 3-month follow-up, the patient continued to report significant pain relief. Due to incremental return of pain and patient’s upcoming travel plans, a left SIJ injection was repeated and resulted in sustained pain relief at 4-month follow-up.

CASE 4

A patient in their sixties with metastatic prostate adenocarcinoma status-post hormone therapy, RT to the pelvis and brain, and surgery presented with worsening severe, shooting low back pain. CT scan was notable for bilateral iliac, S1, and S2 sclerotic osseous metastases with bilateral sacral insufficiency fractures (Figure 7). The patient was taking oxycodone extended release 10mg every 12 hours with oxycodone 5mg every 4 hours. As there was concern for SIJ instability in the setting of insufficiency fractures and smaller metastases near the superior joint, an US-guided, superior-approach left SIJ injection was performed, followed by a superior-approach right SIJ injection 1 month later, both resulting in 2 months of relief with return to function. When pain returned, sacroplasty was done with mild improvement of pain, however, given pain persistence, an US-guided, superior-approach bilateral SIJ injections was performed with 40mg methylprednisolone and 3mL of 0.25% bupivacaine that resulted in immediate pain relief to NPRS 0/10. The patient was able to tolerate prolonged sitting and walking for 2 months and decrease oxycodone dosing to as needed.

Figure 7:

Figure 7:

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A CT scan in axial view is notable for bilateral iliac, S1, and, S2 sclerotic osseous metastases with bilateral sacral insufficiency fractures.

CASE 5

A patient in their sixties with metastatic melanoma status-post immunotherapy and RT to the left ilium/femur presented with left buttock and hip pain, worsened with ambulation and activity, requiring use of a cane. A CT scan showed large, lytic metastases in the left lower posterior ilium and sacrum that was abutting the entirety of the inferior SIJ (Figure 8). The patient had been taking oxycodone extended release 10mg every 12 hours, oxycodone 10mg every 4 hours as needed, and duloxetine 20mg daily. Given size of the tumor and proximity to the inferior SIJ, an US-guided, superior-approach left SIJ injection was performed with 20mg triamcinolone and 3mL of 0.25% bupivacaine. The patient’s NPRS immediately reduced with sustained relief for at least 3.5 months, leading to discontinuation of the cane. The patient was able to wean off the extended release oxycodone.

Figure 8:

Figure 8:

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A CT scan in axial view shows large, lytic metastases in the left inferior-posterior ilium and sacrum.

DISCUSSION

Oncologic patients may present with various generators of low back or buttocks pain, including the SIJ. In this population, SIJ pain has multiple other generators including tumor compression of nerves innervating the SIJ joint, direct tumor burden, fracture, SIJ dysfunction or instability, or treatment-associated changes. In these instances, SIJ corticosteroid injection can be a beneficial adjunct pain treatment.

While the gold standard is fluoroscopic-guidance, there are benefits to US-guidance. First, US allows for direct visualization of soft tissue metastases, neovascularization (confirmed by power doppler), and other soft tissue. The SIJ can be approached inferiorly or superiorly to avoid metastatic seeding while guiding the injectate as close to the tumor as possible. Second, patients with metastatic disease may have positional pain which prevents prone positioning for fluoroscopic procedures. US-guidance allows for SIJ injections to be performed in different positions, including sitting. Therefore, this intervention can be performed even within a hospice setting. Third, US-guidance does not subject the patient to additional radiation, which is important in a population that is already at a significantly elevated risk of radiation. Lastly, US machines are more widely accessible, thus this procedure could be routinely performed in outpatient clinical practices, without the need for a fluoroscopy suite and support staff.

In the non-malignant population, the inferior approach has been widely described and is commonly used. However, there are only a few reports of the superior approach using fluoroscopy, not with ultrasound. These studies showed that the superior approach results in viable access to the SIJ9,10. None of these studies describe either approach under US-guidance in the oncologic population in which there are special considerations including metastatic seeding and neovascularized tissue. In the presented cases, there were no immediate or long-term side effects to the injections. However, more recently, we have been using shorter-acting local anesthetic such as lidocaine with particulate steroid because there can be extravasation of injectate14 to unintentionally anesthetize the sacral plexus, causing transient weakness. The SIJ has collateral blood flow, thus the surrounding structures are unlikely to infarct. Previous studies have shown the safety and efficacy of particulate steroid injections in the oncologic population6,15,16.

In this paper, we aimed to adapt these approaches to 5 patients with metastases and develop an algorithm for treating SIJ pain (Table 1). The basis is to inject corticosteroids near the tumor, the site with most inflammation, and to use US-guidance to avoid tumor burden. We recommend using a superior approach through the ligamentous portion of the SIJ if the tumor is in the upper lateral sacrum or upper ilium, near the ligamentous SIJ. If there are diffuse osseous metastases, clinical and/or radiographic evidence of SIJ instability or dysfunction, or metastatic burden that spans the entire inferior SIJ, the superior approach is preferred given that the ligamentous portion is likely the pain generator. Furthermore, the interosseous sacroiliac ligament is one of the strongest ligaments in the body, thus needle puncture through this ligament is unlikely to cause exacerbation of instability. We recommend using an inferior approach through the synovial portion of the SIJ if the tumor is in the lower lateral sacrum or lower ilium, near the synovial SIJ. If the tumor obscures or spans the entirety of the superior SIJ, an inferior approach is also preferred.

Table 1:

Paradigm for using superior versus inferior approach ultrasound-guided SIJ injection depending on location of metastatic burden. The underlying goal is to inject near the tumor site under ultrasound-guidance to avoid injecting into the tumor.

Superior Approach Inferior Approach
1. Superolateral sacrum
2. Superior ilium
3. Diffuse sacrum/ilium
4. SIJ instability/dysfunction
5. Fracture of sacrum or ilium
6. Metastatic disease spanning adjacent to the inferior SIJ (synovial portion)		 1. Inferolateral sacrum
2. Inferior ilium
3. Metastatic disease spanning adjacent to the superior SIJ (ligamentous portion)
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*

If there is radicular pain, first attempt an epidural steroid injection

Notably, there are technical considerations to the US-guide injections in cancer patients as many are cachectic and may have tumor neovascularization near the SIJ. First, while the curvilinear probe may be used for healthy individuals, the linear probe may provide better resolution at the level of the SIJ (<6-cm) given there is less soft tissue overlying the SIJ in cachectic individuals. Additionally, virtual convex may help better visualize the oblique needle trajectory that is often needed to access the joint. Neovascularization, on the other hand, can be avoided by reviewing imaging prior to the procedure, using power doppler, and aspirating before injecting.

All cases had significant benefit with SIJ corticosteroid injections, including functional improvements and/or weaning of oral analgesics. Case 1 had a large osseous tumor at the sacral ala with L5/S1 involvement, adjacent to the entire superior SIJ, thus an inferior approach was taken. Case 2 demonstrated that SIJ pain can be bilateral from diffuse osseous metastatic disease, thus superior approaches were performed. Case 3 suggests that SIJ pain can be due to alterations in SIJ mechanics and development of osteoarthritis from treatments such as chemotherapy and radiation therapy11,12,13. Given joint dysfunction, a superior approach was performed. Case 4 had osseous metastases near the inferior SIJ as well as bilateral sacral insufficiency fractures, thus underwent sacroplasty. However, given that he had persistent pain from metastatic burden and SIJ dysfunction, the superior approach was used with good relief. Lastly, case 5 underwent a superior approach given that his metastatic disease spanned the inferior, synovial aspect of the SIJ. As evidenced by our cases, durable palliation and long-term pain control are important to improve physical activity, mood, ability to engage in vocation, and personal relationships, ultimately for an improved QOL17.

LIMITATIONS

This case series describes a decision framework to approach SIJ pain in the oncologic population. A more thorough study is needed to determine better evidence to support our experiences. This may be difficult to study in the end-of-life setting. Finally, it is possible that there is no difference in efficacy between the two injection approaches as an intra-articular injection into the SIJ may spread to both the ligamentous and synovial parts of joint. Nevertheless, it is useful to have multiple techniques to access the SIJ to navigate tumor burden. In the setting of periosteal inflammation secondary to tumor burden, treatment, or SIJ dysfunction, injection closest to the pathologic portion of the joint is ideal. Our proposed algorithm is intended to be a guideline as accessing the intra- and peri-articular SIJ space in patients with sacral metastatic disease may be technically more difficult than in a healthy person.

Of note, our experiences with fluoroscopically-guided superior approach SIJ injections suggest that the injectate may spread intra- or peri-articular to the SIJ, especially when targeting the posterior sacral ligament. Under ultrasound, we are unable to confirm the flow, however in the setting of SIJ instability or dysfunction, the ligamentous portion is commonly implicated, thus peri-articular spread may confer similar benefit to intra-articular spread as demonstrated by studies18,19. Future head-to-head trials must address the efficacy between intra- and peri-articular SIJ injections for pain secondary to SIJ dysfunction/instability in the setting of cancer and/or treatment.

CONCLUSION

This paper demonstrates a decision framework for inferior versus superior approach US-guided SIJ injections in the oncologic population with SIJ pain from metastases to the pelvis or sacrum. This is particularly important in the oncologic population where metastatic tumor burden pose otherwise technically-challenging injections. However, to clearly demonstrate the efficacy of this technique, a more thorough study and comparison is needed.

ACKNOWLEDGEMENTS

There are no acknowledgements for this manuscript.

Footnotes

Reprints:

Reprints of this manuscript will not be available from the authors.

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