What conditions can an SI (Sacroiliac) joint cortisone injection treat?

Conditions Treatable with SI Joint Cortisone Injections

SI joint cortisone injections are most effective for treating spondyloarthropathy-related sacroiliitis, with moderate evidence supporting their use for short-term pain relief in patients with sacroiliac joint dysfunction who have failed conservative management. 1

Primary Indications

Inflammatory Conditions

• Spondyloarthropathy: The strongest evidence (placebo-controlled RCT) supports SI joint injections for patients with spondyloarthropathy-related sacroiliitis 1, 2
• Inflammatory sacroiliitis: Patients with inflammatory back pain show significant improvement in pain and inflammation as measured by dynamic MRI 2

Non-inflammatory Conditions

• Sacroiliac joint dysfunction/pain: Moderate evidence supports short-term effectiveness for patients with SI joint pain who have failed conservative management 1, 3, 4
• Post-traumatic SI joint pain: Patients with a history of pelvic trauma may benefit from SI joint injections 1
• Post-fusion SI joint pain: Patients who have undergone L5-S1 fusion may develop SI joint pain that responds to injections 1

Patient Selection Criteria

Physical Examination Findings

• Provocative maneuvers: When 3 of 6 specific tests are positive (Patrick's Test, Thigh Thrust, Gaenslen's Test, Distraction, Compression, and Sacral Thrust), the sensitivity is 94% and specificity is 78% for SI joint pain 1, 5
• Lower threshold for specific populations: In patients with predisposing factors (pelvic trauma, spondyloarthritis, prior L5-S1 fusion), 1-2 positive exam maneuvers may be sufficient due to higher prevalence of SI joint pain 1

Pain Characteristics

• Pain duration: Pain present for more than one month 1
• Pain intensity: Pain greater than 4/10 on pain scale 1
• Failed conservative therapy: Over-the-counter medications and physical therapy should be tried first 1

Treatment Efficacy

Short-term Outcomes

• Inflammatory conditions: 83.3% of patients with spondyloarthropathy showed significant improvement in back pain and sacroiliitis at 5.2 months post-injection 2
• General SI joint pain: Moderate evidence supports short-term effectiveness (2-4 weeks) with significant reduction in pain scores 3, 4

Intermediate-term Outcomes

• Duration of relief: Average pain relief lasts 8.9 months in patients with spondyloarthropathy 2
• Six-month efficacy: Significant improvement in pain, provocative tests, and functional outcomes at six months post-injection in patients with SI joint dysfunction 3

Long-term Outcomes

• Variable results: Some studies show return to baseline pain levels by 6 months 6, while others demonstrate continued relief at 6 months 3

Treatment Protocol

Injection Technique

• Image guidance: Fluoroscopic guidance is recommended for accurate needle placement 1, 4
• Alternative guidance: CT and MRI guidance are also effective options 2, 7
• Injectate volume: The SI joint volume is approximately 1.4mL (range 0.6-2.7mL); injections beyond this volume may affect adjacent structures 1

Repeat Injections

• Criteria for repeat injection: Appropriate if there was ≥75% relief from diagnostic injection or ≥50% relief for at least 2 months after the first therapeutic injection 1

Safety Profile

Common Side Effects

• Injection site pain: Most common delayed adverse event 1
• Vasovagal reactions: Reported in approximately 2.5% of patients 1
• Facial flushing/sweating: Related to corticosteroid use 1
• Transient sciatic nerve block: Can occur with local anesthetic in the injectate 1

Serious Complications

• Rare but reported: Joint infection, spinal epidural abscess, meningitis, and endocarditis (particularly in immunosuppressed patients) 1

Alternative Approaches

Injection Targets

• Intra-articular vs. peri-articular: Both approaches show significant pain reduction, with no significant difference in outcomes between the two 1
• Extra-articular contributions: Some providers advocate for lateral branch blocks or neurotomies to address extra-articular pain sources 1

Alternative Injectates

• Prolotherapy: Small RCT showed 64% of patients reporting ≥50% pain relief at 6 months with dextrose water prolotherapy vs. 27% with corticosteroid 1
• Emerging options: Platelet-rich plasma and other regenerative agents are being evaluated 1

Common Pitfalls

• Inaccurate diagnosis: Failed response may be due to incorrect diagnosis; confirmation with anesthetic injection improves success rates 1
• Inadequate physical examination: Using fewer than 3 provocative tests reduces specificity significantly 1
• Overlooking imaging in inflammatory conditions: While imaging adds little value for mechanical SI joint pain, it is important for identifying inflammatory spondyloarthropathy 1
• Improper needle placement: Accurate image guidance is essential for successful outcomes 1, 4