<p begin="00:00:09.437" end="00:00:12.693" style="s2">- Today I'm gonna demonstrate<br />the sacroiliac joint injection</p>
<p begin="00:00:12.693" end="00:00:15.489" style="s2">as facilitated by ultrasonography.</p>
<p begin="00:00:15.489" end="00:00:19.498" style="s2">The anatomic considerations<br />are the posterior superior</p>
<p begin="00:00:19.498" end="00:00:24.366" style="s2">iliac spine, the sacrum,<br />and the insertion formed</p>
<p begin="00:00:24.366" end="00:00:26.366" style="s2">of the sacroiliac joint.</p>
<p begin="00:00:28.084" end="00:00:33.060" style="s2">The C60 probe is placed in<br />the transverse orientation.</p>
<p begin="00:00:33.060" end="00:00:36.908" style="s2">After anesthetizing the<br />skin the needle enters</p>
<p begin="00:00:36.908" end="00:00:41.075" style="s2">out of plane into the joint,<br />thusly performing the block.</p>
<p begin="00:00:42.658" end="00:00:45.801" style="s2">The sacroiliac joint injection<br />is useful specifically</p>
<p begin="00:00:45.801" end="00:00:49.537" style="s2">to diagnose issues within the<br />sacroiliac joint that might</p>
<p begin="00:00:49.537" end="00:00:51.699" style="s2">be causing hip pain to the patient.</p>
<p begin="00:00:51.699" end="00:00:55.458" style="s2">Typically on physical examination,<br />there might be a positive</p>
<p begin="00:00:55.458" end="00:01:00.148" style="s2">FABER or flexion abduction<br />external rotation test,</p>
<p begin="00:01:00.148" end="00:01:02.029" style="s2">also known as Patrick's sign,</p>
<p begin="00:01:02.029" end="00:01:04.435" style="s2">or a positive Gaenslen's maneuver.</p>
<p begin="00:01:04.435" end="00:01:07.582" style="s2">This can also occur when the<br />patient has a pelvic tilt</p>
<p begin="00:01:07.582" end="00:01:10.152" style="s2">or a leg-length discrepancy.</p>
<p begin="00:01:10.152" end="00:01:12.726" style="s2">The injection is useful<br />both diagnostically</p>
<p begin="00:01:12.726" end="00:01:14.316" style="s2">and therapeutically.</p>
<p begin="00:01:14.316" end="00:01:17.711" style="s2">Traditionally, fluoroscopy is<br />utilized to place the needle</p>
<p begin="00:01:17.711" end="00:01:21.275" style="s2">within the sacroiliac joint space.</p>
<p begin="00:01:21.275" end="00:01:24.556" style="s2">The sacroiliac joint is a<br />very complicated joint in that</p>
<p begin="00:01:24.556" end="00:01:28.637" style="s2">it is a fibrous insertion<br />superiorly and a traditional</p>
<p begin="00:01:28.637" end="00:01:32.753" style="s2">articulating joint in<br />the lower portion of it.</p>
<p begin="00:01:32.753" end="00:01:36.020" style="s2">On fluoroscopy, issues<br />arise such as parallax</p>
<p begin="00:01:36.020" end="00:01:39.654" style="s2">and it is well-documented<br />that sometimes the injection</p>
<p begin="00:01:39.654" end="00:01:43.000" style="s2">is not placed within the joint<br />but rather periarticularly</p>
<p begin="00:01:43.000" end="00:01:45.850" style="s2">and, therefore, not providing the coverage</p>
<p begin="00:01:45.850" end="00:01:48.077" style="s2">or the response that is expected.</p>
<p begin="00:01:48.077" end="00:01:50.000" style="s2">To perform this particular block,</p>
<p begin="00:01:50.000" end="00:01:52.899" style="s2">the following equipment is necessary.</p>
<p begin="00:01:52.899" end="00:01:56.047" style="s2">Chlorhexidine for sterile technique.</p>
<p begin="00:01:56.047" end="00:02:00.214" style="s2">Local anesthetic syringe<br />containing 1% buffered lidocaine.</p>
<p begin="00:02:01.556" end="00:02:06.097" style="s2">And then a syringe containing<br />5cc of bupivacaine,</p>
<p begin="00:02:06.097" end="00:02:10.264" style="s2">one-half percent mixed with<br />5cc of one percent lidocaine.</p>
<p begin="00:02:11.154" end="00:02:15.112" style="s2">And then 40-80 milligrams<br />of triamcinolone kenalog</p>
<p begin="00:02:15.112" end="00:02:18.008" style="s2">which is a particulate steroid.</p>
<p begin="00:02:18.008" end="00:02:21.199" style="s2">A 3 1/2 inch, 25 gauge spinal<br />needle will also be utilized</p>
<p begin="00:02:21.199" end="00:02:22.699" style="s2">for the procedure.</p>
<p begin="00:02:23.571" end="00:02:26.876" style="s2">There will be sterile 4 x 4s<br />necessary to clean the area</p>
<p begin="00:02:26.876" end="00:02:28.261" style="s2">at the conclusion.</p>
<p begin="00:02:28.261" end="00:02:31.947" style="s2">And a simple band-aid will<br />suffice to cover the wound.</p>
<p begin="00:02:31.947" end="00:02:34.556" style="s2">The patient is placed in the<br />traditional prone position.</p>
<p begin="00:02:34.556" end="00:02:38.514" style="s2">There is a bolster within<br />and under the abdomen</p>
<p begin="00:02:38.514" end="00:02:41.559" style="s2">to facilitate opening of<br />the sacroiliac joints.</p>
<p begin="00:02:41.559" end="00:02:46.344" style="s2">And then I utilize the C60<br />probe with its curvy linear</p>
<p begin="00:02:46.344" end="00:02:50.507" style="s2">structure to better visualize<br />the interface between</p>
<p begin="00:02:50.507" end="00:02:53.121" style="s2">the sacrum and the iliac crest.</p>
<p begin="00:02:53.121" end="00:02:56.992" style="s2">The depth is usually set<br />to 7 - 9 centimeters,</p>
<p begin="00:02:56.992" end="00:02:59.643" style="s2">depending on the patient's habitus.</p>
<p begin="00:02:59.643" end="00:03:02.984" style="s2">Additionally, I utilize the<br />muscoloskeletal, or the MSK,</p>
<p begin="00:03:02.984" end="00:03:06.695" style="s2">setting because it provides<br />enhancement of the bony</p>
<p begin="00:03:06.695" end="00:03:11.105" style="s2">structures and the enhancement<br />of the joint space.</p>
<p begin="00:03:11.105" end="00:03:15.767" style="s2">The probe is placed on the<br />patient in the transverse</p>
<p begin="00:03:15.767" end="00:03:19.934" style="s2">orientation approximately<br />a centimeter or two above</p>
<p begin="00:03:20.840" end="00:03:22.966" style="s2">the beginnings of the gluteal folds.</p>
<p begin="00:03:22.966" end="00:03:27.003" style="s2">And I've found the anatomic<br />midline by identifying</p>
<p begin="00:03:27.003" end="00:03:30.032" style="s2">the spinous process of the sacral plate.</p>
<p begin="00:03:30.032" end="00:03:34.199" style="s2">As I roll the probe laterally,<br />the posterior superior</p>
<p begin="00:03:35.698" end="00:03:39.403" style="s2">iliac spine comes into view<br />very clearly at the top</p>
<p begin="00:03:39.403" end="00:03:41.320" style="s2">of the screen, up here.</p>
<p begin="00:03:42.394" end="00:03:46.561" style="s2">The space between the<br />posterior superior iliac spine</p>
<p begin="00:03:47.414" end="00:03:52.184" style="s2">and the shadow cast by the<br />iliac crest and the sacrum</p>
<p begin="00:03:52.184" end="00:03:55.932" style="s2">as it dives down represents<br />the sacroiliac joint.</p>
<p begin="00:03:55.932" end="00:03:58.774" style="s2">And you can see that in<br />the center of the screen.</p>
<p begin="00:03:58.774" end="00:04:02.941" style="s2">It's important to remember<br />that the iliac crest and ilium</p>
<p begin="00:04:03.953" end="00:04:07.912" style="s2">folds and cantilevers towards the sacrum.</p>
<p begin="00:04:07.912" end="00:04:12.392" style="s2">Therefore, the needle angle<br />needs to track from medial</p>
<p begin="00:04:12.392" end="00:04:15.012" style="s2">to lateral into the space identified</p>
<p begin="00:04:15.012" end="00:04:16.829" style="s2">in the center of the screen.</p>
<p begin="00:04:16.829" end="00:04:19.416" style="s2">Local anesthetic is placed.</p>
<p begin="00:04:19.416" end="00:04:23.583" style="s2">And as a finder needle, this<br />injectate using hydrodissection</p>
<p begin="00:04:24.908" end="00:04:27.486" style="s2">demonstrates the needle tip at all times.</p>
<p begin="00:04:27.486" end="00:04:30.667" style="s2">The needle is going in<br />the short axis, therefore,</p>
<p begin="00:04:30.667" end="00:04:33.780" style="s2">it won't be completely<br />visualized on the screen.</p>
<p begin="00:04:33.780" end="00:04:37.090" style="s2">However, hydrodissection<br />can help notice where</p>
<p begin="00:04:37.090" end="00:04:39.090" style="s2">the tip is at all times.</p>
<p begin="00:04:40.113" end="00:04:43.975" style="s2">Then I'll utilize the 3 1/2<br />inch spinal needle, 25 gauge,</p>
<p begin="00:04:43.975" end="00:04:46.913" style="s2">and enter that track that I have placed</p>
<p begin="00:04:46.913" end="00:04:48.614" style="s2">local anesthetic with it.</p>
<p begin="00:04:48.614" end="00:04:51.094" style="s2">The needle tip will then<br />be placed within that joint</p>
<p begin="00:04:51.094" end="00:04:53.663" style="s2">identified in the center<br />of the screen, right here.</p>
<p begin="00:04:53.663" end="00:04:57.903" style="s2">At this point, I attach my<br />syringe containing the local</p>
<p begin="00:04:57.903" end="00:05:00.736" style="s2">anesthetic steroid and saline mix.</p>
<p begin="00:05:02.236" end="00:05:06.403" style="s2">And then I could utilize<br />color flow Doppler to actually</p>
<p begin="00:05:07.546" end="00:05:10.403" style="s2">visualize perturbations of the liquid</p>
<p begin="00:05:10.403" end="00:05:12.320" style="s2">as it enters the joint.</p>
<p begin="00:05:15.174" end="00:05:17.454" style="s2">- [Voiceover] The view is in<br />the short axis, therefore,</p>
<p begin="00:05:17.454" end="00:05:19.662" style="s2">the needle is not visible.</p>
<p begin="00:05:19.662" end="00:05:22.684" style="s2">The iliac crest is visible<br />as the large hyperechoic</p>
<p begin="00:05:22.684" end="00:05:25.337" style="s2">structure on the right of the screen.</p>
<p begin="00:05:25.337" end="00:05:28.926" style="s2">The lateral crest of the<br />sacrum is visible below.</p>
<p begin="00:05:28.926" end="00:05:31.290" style="s2">The target is the void<br />between the lateral crest</p>
<p begin="00:05:31.290" end="00:05:34.187" style="s2">of the sacrum and the iliac crest.</p>
<p begin="00:05:34.187" end="00:05:36.791" style="s2">This helps solidify understanding<br />of the three-dimensional</p>
<p begin="00:05:36.791" end="00:05:39.624" style="s2">structure of the sacroiliac joint.</p>
<p begin="00:05:40.952" end="00:05:44.864" style="s2">- At this point the probe is removed.</p>
<p begin="00:05:44.864" end="00:05:48.364" style="s2">I utilize the 4 x 4s to clean the area.</p>
<p begin="00:05:52.208" end="00:05:55.223" style="s2">And a band-aid is placed over the wound.</p>
<p begin="00:05:55.223" end="00:05:58.404" style="s2">This successfully completes<br />the ultrasonographic</p>
<p begin="00:05:58.404" end="00:06:02.237" style="s2">facilitation of a<br />sacroiliac joint injection.</p>