In a patient with hip and buttock pain, lumbar MRI showing moderate left‑sided and mild right‑sided L2‑L3 neuroforaminal narrowing with Modic type 1/2 changes, and a recent ineffective sacroiliac joint steroid injection, should the management plan be changed?

Management After Ineffective SI Joint Steroid Injection

Yes, a recent ineffective SI joint steroid injection should fundamentally change your management plan—you must now redirect your diagnostic and therapeutic focus away from the SI joint and toward the lumbar pathology evident on MRI, specifically the L2-L3 neuroforaminal narrowing and Modic changes. 1, 2

Why the Failed Injection Changes Everything

The failed SI joint injection serves as a negative diagnostic test that effectively rules out the SI joint as the primary pain generator. 1, 2 Here's the critical evidence:

• When patients fail to achieve ≥75% pain relief from an image-guided SI joint injection, they are unlikely to benefit from repeat SI joint interventions 1, 2
• The false-positive rate for SI joint injections already ranges between 11-63%, meaning even "positive" results can be misleading 1, 2, 3
• If injection provides no relief, other causes such as lumbar disc pathology and facet joint disease should be evaluated rather than repeating SI joint injections 1

Redirect Focus to the Lumbar Pathology

Your patient's MRI findings are highly significant and likely represent the true pain source:

Modic Type 1/2 Changes Are Inflammatory and Treatable

The Modic type 1/2 changes at L2-L3 represent active inflammatory end-plate changes that respond specifically to targeted steroid therapy. 4

• Patients with inflammatory end-plate changes (Modic Type 1) show significantly greater improvement with spinal steroid injections compared to those without these changes 4
• Intradiscal steroid injections into discs with inflammatory end-plate changes led to significant improvement in all outcome scales 4
• Modic Type 1 changes correspond to reversible local inflammation that can switch to Type 2 after successful treatment 5

L2-L3 Neuroforaminal Narrowing

The moderate left-sided and mild right-sided L2-L3 neuroforaminal narrowing may be contributing to radicular symptoms that could mimic SI joint pain 6

Revised Management Algorithm

Step 1: Reassess the Clinical Picture

• Document whether pain is truly axial (discogenic) versus radicular (nerve root compression) 6
• The Modic changes suggest discogenic pain, while neuroforaminal narrowing suggests radicular pain 4

Step 2: Consider Targeted Lumbar Interventions

For the Modic changes: Epidural steroid injection (ESI) or intradiscal steroid injection (ISI) targeting L2-L3 4

• Patients with inflammatory end-plate changes had greater improvement in disability scores in the first 6 months 4
• ESI is effective for short-term improvement in pain and function 4

For neuroforaminal narrowing: Selective nerve root blocks at L2-L3 if radicular symptoms predominate 6

Step 3: Do NOT Repeat SI Joint Injection

Repeat SI joint injection is only appropriate if there was ≥75% relief lasting ≥2 months from the initial injection 1, 2

• Your patient had an ineffective injection, making repeat injection medically unnecessary 1, 2
• The therapeutic effect of SI joint injections is typically short-term even when successful 1, 7

Critical Pitfalls to Avoid

• Do not assume the SI joint is the problem based on physical exam alone—the failed injection is more definitive than provocative maneuvers 1, 2
• Do not ignore the MRI findings—Modic changes and neuroforaminal narrowing are objective pathology that correlates with pain 4
• Do not repeat ineffective interventions—this wastes time and delays appropriate treatment 1

Comprehensive Pain Management

While pursuing targeted interventions for the lumbar pathology, maintain:

• NSAIDs as first-line pharmacotherapy 6
• Physical therapy focused on lumbar stabilization rather than SI joint mobilization 6, 8
• Consider cognitive-behavioral therapy if chronic pain persists 8