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Brown: Atlas of Regional Anesthesia, 3rd ed., Copyright © 2006 Saunders, An Imprint of Elsevier
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Chapter 40 – Sacroiliac Block

PERSPECTIVE

The sacroiliac block is most often used for patients with chronic low back pain. It is used both diagnostically and therapeutically in these patients. Relief of low back pain after a sacroiliac block in patients referred to chronic pain centers occurs frequently, and pain secondary to sacroiliac arthropathy is a cause of low back pain that is apparently often overlooked by physicians infrequently involved in comprehensive pain programs.

Patient Selection.

Patients undergoing evaluation for low back pain should be evaluated clinically for sacroiliac pain. These patients typically complain of unilateral low back pain, which often radiates into the ipsilateral buttock, groin, or leg. Often these patients have symptoms similar to those characteristic of facet joint syndromes. During the clinical examination, an increase in pain with pressure over the sacroiliac joint suggests sacroiliac pain. If such pain is present, provocative maneuvers that increase sacroiliac joint motion should be performed, including Gaenslen’s test and the Flamingo test (Fig. 40-1 [1] [2]).

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Figure 40-1a  Provocative testing of the sacroiliac joint. A, Gaenslen’s test: Examiner stands behind the patient and hyperextends the leg of the sacroiliac joint being tested while stabilizing the pelvis. Pain with this maneuver may indicate sacroiliac joint involvement but may also indicate a hip lesion or lumbar root problem.


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Figure 40-1b  B, Flamingo test: The patient is asked to stand on the involved leg alone and then hop. Pain in the region of the sacroiliac joint is a positive test result.


Pharmacologic Choice.

During fluoroscopically guided provocative diagnostic sacroiliac joint injection, 1 to 2 mL of radiocontrast solution (e.g., Isovue-300 mixed with an equal volume of isotonic saline solution) should be used. This injection often provokes pain similar to that experienced by the patient with activity. After sacroiliac joint involvement has been confirmed, a therapeutic injection of 5 to 10 mL of 1% lidocaine mixed with 20 to 40 mg of methylprednisolone can be performed. If no fluoroscopy is used and a combined diagnostic/ therapeutic injection is performed empirically, 5 to 10 mL of 1% lidocaine, 0.25% bupivacaine, or 0.2% ropivacaine mixed with 20 to 40 mg of methylprednisolone is used.

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