Ultrasound guided corticosteroids sacroiliac joint injections (SIJIs) in the management of active sacroiliitis: a real-life prospective experience

Abstract

Introduction: Active sacroiliitis represents the hallmark of axial spondyloarthritis (axSpA) and manifests as inflammatory low back pain associated with morning stiffness (MS). Sometimes, the combination of non-steroidal anti-inflammatory drugs (NSAIDs) and biological disease modifying drugs (bDMARDs) proves unsatisfactory in achieving a remission.

Materials and methods: We enrolled patients affected with active sacroiliitis confirmed via magnetic resonance imaging (MRI) and treated with a corticosteroid sacroiliac joint injection (SIJI) via ultrasound guidance. After SIJI, we evaluated visual-analogue scale (VAS) and MS pain changes. As controls, we selected axSpA patients starting bDMARDs.

Results: We enrolled 26 patients (mean age 55 ± 14 years; 25 females and 1 male; > 95% treated with NSAIDs; 46% on bDMARDs; 75.82 ± 123 months) and examined a total of 47 treated joints. We detected a 48% reduction in VAS pain after 24 h. Moreover, we observed a significant reduction (p < 0.0001) of VAS pain between the baseline and every subsequent follow-up visit. Further, a significant difference in VAS pain compared to the baseline in the controls was observed starting from week 12. There was a significant reduction in MS after 1 week due to SIJIs, while in the controls the first significant change from the baseline in MS was detected after 12 weeks. The efficacy of infiltrative therapy lasted up to 6 months: persistent VAS as well as MS pain reduction was observed.

Conclusions: US-guided SIJI represents an effective and safe technique for patients who have active sacroiliitis yet are ineligible for biologic treatment or who experience unsatisfactory disease control despite receiving therapy.

Keywords: Active sacroiliitis; AxSpa; Morning stiffness; Pain; Sacroiliac joint injections; Ultrasound.

Fig. 1

A Anatomical scheme of the posterior region of the right sacroiliac joint showing the short posterior sacroiliac ligament (superficial plane, red arrow) and the first dorsal sacral foramen (red asterisk). B Ultrasound scan of the posterior region of the right sacroiliac joint showing the short posterior sacroiliac ligament (superficial plane, red arrow) and the first dorsal sacral foramen (red asterisk)

Fig. 2

A Anatomical scheme of the posterior ligamentous apparatus showing intrinsic and extrinsic ligament with the short posterior sacroiliac ligament (superior and superficial plane, red arrow), the sacro-tuberous ligament (black arrow) and the sacro-spinous ligament (black dotted arrow). B Ultrasound anatomy of the posterior region of the sacroiliac joint with posterior sacroiliac ligament (superficial plane, red arrow)

Fig. 3

Injection technique displaying the medial-to-lateral free hand approach

Fig. 4

VAS pain reduction (Visuo-analogic pain scale) after SIJIs. Fig. = figure; ****p < 0.0001

Fig. 5

VAS pain reduction (Visuo-analogic pain scale) in controls. Fig. = figure; ****p < 0.0001; **p < 0.05

Fig. 6

Morning stiffness (MS) reduction after SIJIs. Fig.: figure; ****p < 0.0001

Fig. 7

Morning stiffness (MS) reduction in controls. Fig. = figure; ****p < 0.0001; ***p = 0.003

Fig. 8

Non-steroidal anti-inflammatory (Nsaids) drug intake reduction after SIJIs. Fig.: figure; **p < 0.001; *p < 0.05