2026 多学会共识建议：皮质类固醇注射治疗关节突关节和骶髂关节疼痛

ABSTRACT

Background Corticosteroid injections (CSIs) are widely employed in facet and sacroiliac joint pain. Similar to CSIs at other sites (peripheral nerve blocks, joints, epidural), these injections are associated with potential adverse events. These multisociety consensus recommendations aim to develop evidence-based statements and recommendations on the safe use of CSIs in facet joint and sacroiliac joint injections.

Methods Development of the consensus recommendations was approved by the American Society of Regional Anesthesia and Pain Medicine Board of Directors and several other societies that agreed to participate. The scope of statements and recommendations was agreed on to include safety of the injection technique (landmark-guided, ultrasound, or radiology-aided injections); effect of the addition of the corticosteroid on effectiveness (vs local anesthetic or saline); and adverse events related to the injection. Experts were assigned topics to perform a comprehensive literature review and draft statements and recommendations, which were refined and voted for consensus (>75% agreement) using a modified Delphi process. A modified version of the US Preventive Services Task Force grading of evidence and strength of recommendation was followed.

Results All statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Boards of Directors of the participating societies also approved all statements and recommendations. Injection of corticosteroid into the facet joint in patients with joint inflammation may relieve pain and improves function. Intra-articular, extra-articular (periarticular), and combined administration are effective for sacroiliac joint injections. No dose-response studies exist, but CSIs containing 10 mg of methylprednisolone or triamcinolone per facet joint and 40 mg per sacroiliac joint (SIU) (or their respective pharmacologic equivalents) are reasonable.

Conclusions In this practice recommendation, we provide statements and recommendations on facet and sacroiliac micro工 CSIs, the optimal doses, and intervals and criteria for repeating the CSIs in patients with facet joint and sacroiliac joint pain.

# WHAT IS ALREADY KNOWN ON THIS TOPIC

⇒ Corticosteroid injections into the facet and sacroiliac joints provide mainly short-term (up to 3 months) pain relief.

WHAT THIS STUDY ADDS

⇒ In patients with positive single photon emission CT, relief from facet joint intra-articular corticosteroid injections may last 3-6 months. We identified the lowest effective dose for intra-articular facet injection (10 mg methylprednisolone/triamcinolone). Both intra-articular and extra-articular sacroiliac joint corticosteroid injections appear to be effective, and combined intra-articular and extra-articular injections are at least as effective as intraarticular administration for sacroiliac joint pain.

# HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

⇒ If a patient experiences prolonged pain relief after facet joint or medial branch blocks with corticosteroid and local anesthetic injections, clinicians should wait for pain to return to >50% of baseline before performing an abitative procedure. Extra-articular or combination injections are at least as effective in most patients as intra-articular sacroiliac joint blocks.

INTRODUCTION

Facet joint pain and sacroiliac joint pain are common causes of mechanical low back and sacroiliac pain.$^{1-4}$ Corticosteroid injections (CSIs) are often employed in these conditions.$^{3-9}$ There are issues related to their use: advisability of cortico-steroid use in medial branch blocks (MBBs), effectiveness of intra-articular (IA) facet injections, IA versus extra-articular (ie, periarticular) sacroiliac joint injections versus their combination, adverse events related to their administration, and recommended doses.

Check for updates

© American Society of Regional Anesthesia & Pain Medicine 2026. No commercial re-use. See rights and permissions. Published by BMJ Group.

To cite: Benzon HT, Doshi TL, Maus T, et al. Reg Anesth Pain Med Epub ahead of print: [please include Day Month Year], doi:10.1136/rapm-2025-107347

Original research

|Grade|Definitions|Suggestions for practice| |---|---|---| |A|The Multisociety Corticosteroid Safety Work Group recommends the service. There is high certainty that the net benefit is substantial.|Offer or provide this service.| |B|The Multisociety Corticosteroid Safety Work Group recommends the service. There is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial.|Offer or provide this service.| |C|The Multisociety Corticosteroid Safety Work Group recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.|Offer or provide this service for selected patients depending on individual circumstances.| |D|The Multisociety Corticosteroid Safety Work Group recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.|Discourage the use of this service.| |I|The Multisociety Corticosteroid Safety Work Group concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.|If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.| |Adapted from Harris et al.$^{14}$|||

# Development of the consensus statements on facet and sacroiliac joint CSIs and the safety of vaccine in the presence of CSIs

In this practice recommendation (PR), we discuss the safe use of CSI in or around facet joint and sacroiliac joint. This is the third PR in a series describing the safe use of corticosteroids, with previous guidelines addressing peripheral nerve blocks and trigger point injections, and peripheral joint and soft tissue injections.$^{10}$ $^{11}$

The rigorous development and approval of the statements and recommendations (SRs) are the same as in the previous two guidelines.$^{12}$ $^{13}$ The topics were identified by a Work Group and assigned to participants who had written on the subject matter or expressed interest in the issue. Each topic author performed an extensive literature search using PubMed, Embase, and/

or Cochrane Clinical Trials with appropriate medical subject headings (MeSH) terms on each topic (see online supplemental appendix). Based on qualitative evidence synthesis, SRs were created and evaluated based on US Preventive Services Task Force (USPSTF) methodologies,$^{14}$ noted in tables 1 and 2. Each recommendation was assigned a grade based on the available evidence (table 1). The level of certainty regarding the net benefit was based on the available literature outlined in table 2. The SRs were unanimously approved by the participants using a modified Delphi process after four rounds of voting. Subsequently, these SRs were approved by the Board of Directors of the participating societies.

Similar to other PRs in this series, this project was sponsored by the American Society of Regional Anesthesia and Pain Medicine (ASRA PM), with participating societies including the

|Level of certainty|Description| |---|---| |High|The available evidence usually includes consistent results from well-designed, well-conducted studies in representative care populations with facet or sacroiliac joint pain. These studies assess the effects of the service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies. Examples—Randomized Controlled Trials or large-scale observational studies with control groups| |Moderate|The available evidence is sufficient to determine the effects of the intervention on health outcomes, but confidence in the estimate is constrained by such factors as: ► The number, size, or quality of individual studies. ► Inconsistency of findings across individual studies. ► Limited generalizability of findings to individuals with facet or sacroiliac joint pain ► Different etiologies and phenotypes in the study subjects with joint pain. ► Lack of coherence in the chain of evidence. As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion. Examples: A single large-scale observational study without control groups (multisite or single-site); multiple (>2) large retrospective studies (>20 subjects) or cohort studies.| |Low|The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of: ► The limited number or size of studies. ► Important flaws in study design or methods. ► Inconsistency of findings across individual studies. ► Gaps in the chain of evidence. ► Findings not generalizable to individuals with facet or sacroiliac joint pain, or generalizable only to a small proportion of those with facet or sacroiliac joint pain. ► Lack of information on important health outcomes or those related to vaccine injection. More information may allow estimation of effects on health outcomes. Examples: Case series or case reports or consensus-based recommendations from other sources| |The USPSTF defines certainty as "the likelihood that the USPSTF assessment of the net benefit of a service is correct." The net benefit is the benefit minus the harm of the service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a service.||

Original research

American Academy of Pain Medicine (AAPM), North American Spine Society, and International Pain and Spine Intervention Society. The North American Spine Society affirmed the educational benefit of the guideline but did not officially endorse it, per their organization's policy. The American Society of Interventional Pain Physicians (ASIPP) and its members participated in the development of SRs. However, they objected to two sentences in the introduction on facet injections and withdrew from the guideline. The American College of Rheumatology (ACR), American Academy of Orthopaedic Surgeons, and the AAPM and Rehabilitation (AAPM&R) identified members with content expertise (JF, JR, and AN, respectively) who helped create the SRs, participated in the discussions, and voted on the SRs.

This PR is not intended to limit or deny care, affect the rights of patients or providers, nor does it define the standard of care. It is not intended to replace clinical judgment. In the imperfect setting of heterogeneous data, limited data, controversial topics, and bias inherent to expert opinion, compliance with our recommendations may or may not result in improved outcomes compared with personalized medicine.

FACET INJECTIONS (IA AND MBBs)

Facet joint injections are one of the most common pain procedures performed in the USA. Facet injections include IA facet joint injections and MBBs. Similar to other pain medicine interventions, facet injections may serve several roles: diagnostic, prognostic, predictive, facilitative, and therapeutic. Diagnostic refers to identifying or confirming a particular disease or condition. Although prognostic and predictive are often used interchangeably, prognostic involves forecasting the likely course of a condition regardless of therapy. In contrast, predictive refers to using specific information (ie, response to an injection) to foretell the potential effect of a therapeutic intervention (eg, radiofrequency ablation, RFA). Facitative refers to the ability of an intervention to enable or improve the outcomes of a more definitive treatment, such as performing an injection to increase engagement in physical therapy or taking a medication preemptively for either the same reason or to enable a definitive procedure to be safely performed. Given the substantial but conflicting evidence for anything besides short-term (3 months) benefit for non-ablative facet interventions, the value of MBBs may be considered primarily prognostic (predictive), while IA injections may serve both a prognostic and facilitative role. However, some studies suggest better predictive value for MBBs. ASIPP and its members (Laxmaiah Manchikanti, Salahadin Abdi, Joshua Hirsch, Shalini Shah, Alaa Al Ab-ElSayed) disagreed with the previous two statements, declined to endorse the outcome of the vote, and ultimately requested removal from the entire project. The remaining participants endorsed the statements with 18 voting members agreeing, one voter dissenting, and two committee members abstaining; three did not respond.

Indications and contraindications

Facet injections are indicated for non-radicular, axial low back and neck pain lasting at least 3 months that has not responded to more conservative treatments (eg, physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs)). The pain should be organic, that is, with positive symptoms and signs, and localized to the targeted facet joint (eg, paraspinal tenderness) without a predominant, poorly controlled behavioral health component.

In general, relative and absolute contraindications to facet injections include allergy to any injected medication, including

local anesthetics (LAs) and contrast, infection at the puncture site, coagulopathy, the presence of a neurological disorder which the procedure might mask, pregnancy, an acute fracture in which corticosteroids might impair healing, and systemic infection.$^{15-17}$

Evidence for facet injections

MBBs are typically performed using LA alone. Multiple studies by the same investigators have evaluated the addition of cortico-steroids to MBBs, finding no significant difference in outcomes with or without corticosteroids.$^{18-21}$

Published data regarding corticosteroid efficacy in spinal facet joint pathology are very heterogeneous. Several randomized controlled trials (RCTs) have demonstrated a lack of long-term efficacy from lumbar IA facet joint injections.$^{22-26}$ Overall, there is mixed evidence for facet injections as therapeutic procedures. Based on ASIPP grading of evidence,$^{27}$ therapeutic IA facet joint CSIs are considered to have level IV (limited) evidence in the lumbar spine, level III (fair) evidence in the thoracic spine, and level IV (limited) evidence in the cervical spine, all with a weak recommendation.$^{3}$ For therapeutic MBBs, the authors concluded there was level II (moderate) evidence to support them and provided a moderate recommendation. A recent systematic review of 21 studies evaluated the effectiveness of fluoroscopically guided lumbar IA facet joint CSIs on pain relief and functional improvement at >1 month after the injection.$^{28}$ The overall mean improvement ranged from 11% to 59% for pain relief and 8%–58% for function at >1 month. The quality of evidence was very low; hence, the actual effect of facet IA injection is unclear. The authors concluded that pragmatic and observational studies reduced pain and disability, while sham-controlled trials have not demonstrated efficacy.$^{28}$

Comprehensive international multispecialty consensus guidelines for both lumbar and cervical facet interventions have concluded that neither IA facet injections nor MBBs, with or without corticosteroids, will likely confer any meaningful intermediate-term relief beyond those performed with LA alone.$^{12}$ These practice guidelines advise against the routine use of corticosteroids in facet injections. However, they may be considered in patients at risk of adverse consequences from RFA or who received prolonged relief from previous diagnostic injections (see also our discussion on single proton emission CT, SPECT-positive patients).$^{1}$ Although the conclusion by the international working group was based on detailed reviews of the literature, there are instances of prolonged duration of relief after IA CSI or MBB with LA alone.$^{29}$ $^{30}$ A small prospective observational study of 40 patients showed significant pain relief (>50%) up to 6 months in 65% of patients who had IA injections and in 40% of patients who had MBBs with LA and corticosteroid (0.5 mL bupivacaine with 10 mg dexamethasone).$^{29}$ A retrospective study of 104 patients who had MBB (5 mg triaminolone and 0.25% bupivacaine) after cervical spine surgery showed over 50% (57% for 6 months and 53% for 3 months) had a favorable response requiring no further treatment during their follow-up.$^{30}$ The varied duration of relief from MBBs with corticosteroids (and IA) may be partly due to the measurement tool used in the study. In a randomized study performed in 58 patients with chronic LBP, Civelek et al compared MBBs (40 mg MP in 2 mL bupivacaine) with RFA. They reported better results with RF for pain at 1, 6 and 12 months; no difference at 1, 6 and 12 months in quality of life; no difference at 1 month and 6 months, but better satisfaction with RF at 12 months.$^{31}$ Therefore, in cases with a favorable response, the clinician should wait

Original research

for the recurrence of pain (>50% of preinjection level) before doing an RFA.

The multispecialty international working group guidelines and other organizations have recommended MBB as the preferred predictive tool before lumbar and cervical medial branch (MB) RFA, rather than IA facet injections, with or without cortico-steroid.$^{1 2 32}$ These recommendations were based on: MBB having better face validity than IA injections as a predictive tool before RFA; the high technical failure rate for IA injections; the observation that some individuals have non-MB innervation to their facet joints; and several clinical studies demonstrating superior outcomes when MBBs were used to identify candidates for RFA or cryodervation compared with IA or periarticular injections.$^{33-37}$

Facet joint injections in SPECT-positive patients and patients with post-traumatic injury

Distinctions have been made for patients suffering from inflammatory facetogenic pain or patients with acute injury. Positive results from facet joint CSIs have been reported in two prospective, randomized trials$^{38}$ $^{39}$ and an observational study.$^{40}$ The two prospective, randomized studies were performed in patients with abnormal joint findings on SPECT.$^{38}$ $^{39}$ Previously, in a non-randomized, prospective trial, Dolan et al compared 22 patients with facet-positive findings on SPECT to 36 patients without facet abnormalities on SPECT, reporting that 94% of SPECT-positive patients experienced significant pain improvement at 1 month (vs 47% in the SPECT-negative patients) and 79% reported improvement in pain at 3 months (vs 42% in SPECT-negative patients); however, no differences between groups were observed at 6 months.$^{40}$ Only 3 of 22 patients with positive SPECT had tenderness corresponding to the location of increased uptake.$^{40}$ Although the authors reported that each joint was treated with 40 mg of methylprednisolone, there is no

description of the average dose per patient or the number of joints injected per patient.$^{40}$ In one of the subsequent randomized trials, Pneumaticos et al reported significantly greater pain relief 1 month after facet joint injections in SPECT-positive patients compared with patients whose injection level(s) was determined by clinical exam or who had negative facet SPECT findings.$^{39}$ In this study, each joint was injected with 3 mg of betamethasone, and each patient received, on average, four joint injections,$^{39}$ for approximately 12 mg of betamethasone per patient or an equivalent dose of 64 mg of methylprednisolone.$^{41}$ In a prospective, randomized study comparing IA facet joint injections to MBB in patients with positive facet abnormalities on SPECT, Ackerman and Ahmad reported that pain relief (61%) and disability (53%) were significantly reduced at 12 weeks in patients who received IA injections when compared with those who received MBB.$^{38}$ More recent studies have also reported improved outcomes from facet injections in SPECT-positive patients.$^{42,43}$ Koh et al showed better >50% pain relief in SPECT-positive patients at 2 weeks (86% vs 20%) and at 4 weeks (79% vs 0%) after lumbar MBBs, although there were no significant postinjection changes in the Oswestry Disability Index$^{42}$ (see table 3).

Nolan et al noted that patients who were SPECT-positive had a better response to cervical MBBs with LA or IA injections with corticosteroid and LA than those who were SPECT-negative: 54 of 89 SPECT-positive patients (60.7%) had at least 80% reduction of their pain, compared with four of 23 patients (17.4%) (see table 4).$^{43}$ Other studies have not observed significant differences in outcomes between SPECT-positive and SPECT-negative patients (see table 3).$^{44}$ $^{45}$ Garcia et al found no difference in pain relief between SPECT-positive and SPECT-negative patients, but the study contained no power analysis and combined the results of cervical, lumbar, and thoracic facet injections.$^{44}$ Similarly, Scholten et al evaluated 43 cervical MBBs and found no significant differences in pain outcomes based on SPECT; this study

|Study|Dose injected|Comments| |---|---|---| |Studies with SPECT|Studies with SPECT|Studies with SPECT| |Dolan et al, 1996; P: C: 58 patients, 32 SPECT+ and 36 SPECT-received IA injections$^{40}$|0.5 mL lidocaine +40 mg methylprednisolone per joint|LBP at least 3 m. Pain scores significantly improved at 1 m and 3 m in the SPECT+ patients vs SPECT-| |Pneumaticos et al, 2006; P: R, C: Group A1 (SPECT+), A2 (SPECT-), (no scan)$^{39}$|2.5 mL bupivacaine +0.5 mL betamethasone (3 mg) per joint|Change in pain score at 1 m and 3 m significantly greater in Group A1 compared with A2 and B.| |Ackerman and Ahmad, 2008; P: R, D8; 46 patients, SPECT+: IA (L2-3, 13-4, 14, 5 joints) vs MBB (12, 13, 14, 15), both groups had 51 dorsal ramus injections with LA+CS; 23 per group$^{38}$|0.5 mL LA-CS solution (0.5 mL 1% lidocaine and 0.2 mL (8 mg) of tramcinolone|Mean duration of pain 46 m ≥50% relief at 12 w greater in IA CS group (61% vs 26%) CS group (61% vs 26%)| |Koh et al. 2011: Prospective cohort study evaluating lumbar MBB in SPECT+ (n=28) and SPECT- (n=5) patients.$^{42}$|2.4 mL 1% lidocaine +30 mg tramcinolone, each level|24 (85.7%) experienced >50% pain relief at 2 w in the SPECT+ group vs 20% in the SPECT- group. At 4 weeks, responder rates were 78.6% and 0%, respectively.| |Nolan et al. 2022: Retrospective study of IA cervical facet injections or MBB in 89 SPECT+ and 23 SPECT- patients.$^{43}$|Either facet joint injection with LA and Cs or MBB with LA is performed at the discorrelation of the interventionalist. La and Cs, dose and volume not specified.|Did not stratify IA injections vs MBB. 61 (68.5%) and 6 (26.1%) of SPECT+ and SPECT- patients, respectively, had >50% pain relief within 24 hours.| |Garcia et al. 2022: Retrospective study in 340 pts who received intra-articular cervical (n=114), lumbar (n=207), or thoracic (n=21) facet intra-articular injections after SPECT$^{44}$|Triamcinolone, betamethasone, dexamethasone used, with bupivacaine or lidocaine, doses of corticosteroids and volumes injected not noted.|61.2% of SPECT+ vs 70.0% of SPECT- pts had >50% immediate pain relief, with no difference between groups. 2 weeks after injection, the median reduction in 0–10 pain score was 3 in both groups.| |Scholten et al. 2024: Retrospective study in 43 patients with cervical SPECT-concordant (+, 25%) and SPECT– discordant (-, 75%, MBB$^{45}$|0.5 mL of 0.5% bupivacaine or 2% lidocaine, per level|Both groups experienced significant pain reduction with no difference in postblock outcomes (≥50% and ≥80% relief). difference in postblock outcomes (≥50% and ≥80% relief).| |Barnsley et al., 1994; P: R, C study in patients with chronic neck pain after a motor vehicle accident; 41 patients; 21 (CS group), 20 (LA group) received IA cervical facet injection$^{48}$|1 mL betamethasone, 5.7 mg vs bupivacaine 0.5%|Median duration of pain –52 m for the CS group and 46.5 m for the LA group. Entry criteria: Relief from diagnostic 2 MBBs. Median time to 50% of preinjection level: 3d in betamethasone group and 3.5d in bupivacaine group| |Note: The lowest effective doses were used by Lee et al$^{49}$ and Klessinger$^{30}$: These injectates were 0.5 mL 0.5% bupivacaine with 10 mg dexamethasone injected intra-articularly or during MBBs,$^{29}$ and 0.25% bupivacaine with 5 mg tramcinolone (1 mL of mixture injected) for MBBs, respectively.$^{30}$|Dididase�in et al. 35 in the duxinase and duxinase and duxinase and duxinase and duxinase and duxinase and duxinase and duxinase and duxinase and duxinase and duxinase and duxinase and duxinase and duxinase and duxinase and duxinase and duxinase and duxinase and duxinas||

Original research

|Study|Technique and evaluation|Results|Effectiveness of IA vs EA/Peri-articular (PA) or Combined IA/EA| |---|---|---|---| |Nacey et al, 2016 Retrospective, 113 injections (20 mg TA in 0.5 mL 0.25% or 0.5% bupivacaine) in 99 patients.$^{133}$|Fluoroscopic guidance. Needle injected into the inferior portion of SIJ. IA or PA injection based on whether contrast medium coursed within the sacrolliac joint.|IA injections in 55 patients, PA in 58 patients. Combined IA and PA in 29 patients (most cases had IA, with minimal PA injections). Reduction of preinjection pain was significant in both groups.|No significant difference in pain relief between IA and PA groups at 1 week. No comparisons were made between IA or PA with combined IA and PA.| |Hartung et al, 2010 Prospective study, 20 SJ injections in 20 patients (40 mg TA and 0.78 mg gadolinium).$^{111}$|Ultrasound guidance, 'needle injected into SIJ cleft', MRI after injection. Outcome measure: numerical pain rating scale, 24 hours and 28 days after injection.|IA injections in 8, PA injections in 12 patients. No patient had combined IA and PA.|Similar pain relief between IA and PA, at 28 days.| |Murakami et al, 2007 Prospective, 25 patients; 13 patients PA, 12 patients IA. 1–2.5 mL lidocaine and contrast injected (no corticosteroid).$^{134}$|Fluoroscopic guidance, PA—needles inserted peri- artically into four sections along the posterior margin of SIJ, superior to inferior; IA—needle inserted into caudal portion of joint. Outcome measure: Activities of daily life, IA (Oma maximum 12 points). Effectiveness: score of 10.5 points or higher. Evaluation before and 5 min after injection.|PA effective in 100% of patients, IA in 36% of patients.|PA more effective than IA.| |Murakami et al, 2018 Prospective, 72 patients; PA injections first, IA if PA not effective; 0.5 mL 2% lidocaine and contrast (non corticosteroid)$^{132}$|Fluoroscopic guidance. PA—same techniques as above: IA—neede inserted into distal 1 cm of SIJ. Effectiveness: ≥70% pain relief 15–30 min after injection, confirmed the day after.|72 of 85 patients had an 'effective injection': 58 (81% of 72 patients had benefit with PA and 14 (19%) had benefit IA injections. 13 (15%) had benefit with neither.|PA is more effective than IA.| |Cohen et al, 2019 P, R, DB, 125 patients. Fluoroscopic- (64 patients) vs landmark-guided (61 patients) SI injections (1 mL 40 mg MP+2 mL 0.5% bupivacaine).$^{101}$|Fluoroscopic-guided vs landmark-guided injections. Needle inserted into the inferior one-third of the joint. Categorized injections as IA (2.50% within joint, EA (no joint spread visible or both (<50% IA). Injection EA in 60, IA in 29, and combined in 35.|At 1 m follow-up, all groups improved, but there was no difference in pain relief between the two groups. At 3 months, significant improvement in a few but not most outcome measures favoring the fluoroscopy group.|All three groups had significant relief. No difference between EA, IA, and combined EA/IA injections.| |Khalil et al, 2022 Two-center prospective study: patients with right-sided pain had IA (22+24 patients) injections, patients with left-sided SUI pain given PA (23+27 patients) injections (2 mL containing 40 mg MP with 1 mL 2% lidocaine).$^{135}$|Fluoroscopic-guided, IA injections: Needle inserted into the SIJ, mostly midportion, fluoroscopy confirmed location. PA: Needle inserted into three different portions of the joint capsule; upper, middle, and lower. Outcome measure: Numerical Pain Rating Scale,|PA injections were superior in terms of pain relief to IA injections at 1 m, 3 m and 6 m after injections.|PA injections were superior to IA injections.| |Borowsky and Fagen Retrospective; 120 patients: 40 patients—IA, 1.5 mL 0.5% bupivacaine+80 mg MP; 80 patients - PA, 2 mL 4 0.5% bupivacaine+40 mg MP IA, same dose PA.$^{125}$|Fluoroscopic-guided. Needle inserted into the SIJ; PA—needle directed into SI and posterior interosseous ligament bathing S1–3 lateral branches. Outcome measures: AIAT at 3w and 3m; change in pain scores: response: ≥75% relief; success: ≥50% relief.|Relief immediate post-block and at 3 months: better with PIA vs IA alone. Improvement in AIAT was better at 3 months in the combined group.|Combined PA/IA better than IA.| |Tantawy and Nazim, 2024 Randomized; IA—30 patients, 40 mg MP+LA; Combined—30 patients. Dose not clear: Abstract—'same dose of MP given in both groups'; Methods: 40 mg given IA, same dose given PA.$^{136}$|Outcome measures: VAS pain score at 1 w, 1 m and 6 m|Significant improvement in both groups at 1 w, 1 m, and 6 m after injection. 1 month and 6-month follow-up: Significantly better pain relief in the combined group compared with the IA-only group.|Combined PA and IA are better than IA alone. It is not clear whether the doses were the same in both groups (authors did not respond to queries).| |AIAT, Activities of Daily Living Improvement Assessment Tool; IA, intra-articular; JOA, Japanese Orthopedic Association; LA, local anesthetic; m, months; MP, methylprednisolone; SIJ, sacroiliac joint; TA, triamcinolone; w, weeks.||||

also had no power analysis.$^{45}$ However, the authors recommended a rational approach to using SPECT to help identify the levels to be injected.

Taken together, these favorable reports in patients with positive SPECT $sc^{38-40}$ $^{42}$ $^{43}$ along with basic science studies demonstrating inflammatory mediators in degenerated facet joints$^{46}$ $^{47}$ suggest that a subset of patients may respond well to CSIs in and around the facet joints.

In contrast, a study involving IA cervical facet injections with corticosteroid (betamethasone 5.7 mg) versus LA alone (bupiva-caine 0.5%) in post-traumatic neck pain (whiplash injury) found that less than half the patients in each arm reported pain relief lasting longer than 1 week, concluding that IA injections of corticosteroid or LA are not effective for cervical facet pain following whislaph injury, which was presumed to be at least partially inflammatory in nature.$^{48}$ The median duration of pain was 52 months (range: 33–60.5) after a whislaph injury, so inflammatory changes may have dissipated at the time of injection.

From the studies described above, one may conclude that evidence of an inflammatory contribution to facet pain (acute injury, SPECT-positive) identifies patients who will likely benefit from IA facet joint CSI.$^{44}$

Response to facet joint injections according to severity of facet arthritis

One study that grouped patients into three facet osteoarthritis severity groups (least to most severe) compared IA “dexamethane-10 mg (0.25 mL)” to 0.125% bupivacaine (0.25 mL) in each group. The authors reported statistically significant benefits in Numerical Rating Scale (NRS) pain scores across all severity groups, but no intergroup differences in pain scores.$^{49}$

Role of fluoroscopy, CT, and ultrasound

Some professional societies and insurance companies in the USA recommend a specific imaging modality for certain

Original research

procedures.$^{150}$ Image guidance should be chosen based on clinical experience, patient characteristics, and an overall risk-benefit assessment. Competency in ultrasound-guided injections may vary widely depending on experience, training, and equipment availability. Thus, for clinicians who are limited in their familiarity with ultrasound, fluoroscopy should be used alone to confirm appropriate needle placement.

Gofeld et al performed 50 ultrasound-guided lumbar facet joint injections in 5 cadavers and confirmed contrast spread with fluoroscopy. IA spread was observed in 44 of the 50 cases (88%).$^{51}$ In another cadaveric study that used CT to confirm needle placement, 40 out of 42 ultrasound-guided lumbar facet injections were placed in the joint.$^{52}$ These investigators subsequently randomized 40 patients to undergo either CT-guided or ultrasound-guided lumbar facet joint injections, confirming correct needle tip placement by CT imaging in 17 out of 18 patients in the ultrasound group (94%).$^{53}$ In 2 of the 20 patients randomized to ultrasound-guided injections, the facet joints could not be visualized solely with ultrasound, so they were excluded from analysis. The joints not visualized occurred in a female patient with a body mass index (BMI) of 28.3 kg/m$^{2}$ and a male patient with a BMI of 32.9 kg/m$^{2}$.$^{53}$ In a similar but more recent study evaluating ultrasound-guided injections confirmed by CT scan, 64 of 74 injections (86.5%) were successfully deposited into the lumbar facet joint; notably, all patients in this study had a BMI <25 kg/m$^{2}$.$^{54}$ These observations suggest that ultrasound-guided injections risk reduced visibility in patients with a specific body habitus. Another equally important issue is the possibility of targeting the wrong segment when ultrasound guidance is used. In a study performed in the thoracic spine, the authors reported that the correct level was identified in 56.8% and 84.1% of the procedures, depending on whether the starting landmark was the 12th rib or C7, respectively.$^{55}$ It should be noted that even using fluoroscopy, lumbar and cervical facet injections are associated with high technical failure rates (ie, no clear arthrogram), estimated at 24% for cervical facet inject injections and 33% for lumbar procedures.$^{156}$

In a randomized, prospective trial, Yun et al compared clinical outcomes of ultrasound-guided versus fluoroscopy-guided facet injections in 57 patients.$^{57}$ In the technique description, the authors described “bony contact” as the endpoint for needle placement in both groups, which is more consistent with pericular placement. There were no clinical differences in pain or disability at 1 and 3 months, but there were statistically significant differences in procedure times favoring fluoroscopy.$^{57}$ Two studies also noted no differences in outcomes (pain relief and functional improvement) between ultrasound and fluoroscopy-guided facet joint injections, but in contrast to the study by Yun et al$^{57}$, found shorter procedure times with ultrasound.$^{58}$ 59 A meta-analysis comparing the effectiveness of ultrasound-guided facet injections to fluoroscopy or CT-guided procedures that included 202 patients found no significant differences in pain or functional parameters.$^{60}$ In summary, although ultrasonography provides a radiation-free alternative for lumbar and cervical facet joint injections, fluoroscopy-guided procedures are associated with lower technical failure rates and are superior for accurate vertebral level identification and confirmation of IA placement through contrast administration. Differences in procedure times are likely related to the specific expertise of the clinician with ultrasound compared with other imaging modalities. The clinical outcomes after ultrasound-guided and fluoroscopy-guided IA facet injections appear to be similar.

Particulate versus non-particulate steroids

For lumbar facet joint injections or after RFA, there are no RCTs or consensus recommendations regarding the efficacy and/or safety of particulate versus non-particulate corticosteroids. Our recommendations on the type of corticosteroid for facet joint injections are based on data for corresponding epidural CSIs, particularly transforaminal injections, which are near the facet joints and MBs. The use of particulate corticosteroids offers the theoretical advantage of a longer duration of action, but with a potential increased risk of neurological complications.$^{61}$ Based on the available evidence, there appears to be only a slight difference en efficacy between particulate and non-particulate corticosteroids. In contrast, particulate corticosteroids may carry an increased risk of complications, such as neurological injury and perhaps adrenal suppression. Neurologic injury is mitigated by adherence to proper technique, that is, assurance that the needle tip is in the facet joint, confirmed by imaging. For preventing post-RFA neuritis, there is extrapolated evidence to support the use of non-particulate corticosteroids in the cervical spine and low-level evidence for particulate corticosteroids in the lumbar spine.$^{12}$

Nature of injectate in facet joint injections

Although some studies have shown analgesic benefits from IA LA or corticosteroid, many studies have reported no significant differences between IA saline, corticosteroid, or LA for facetogenic pain.$^{22-24}$ 38 48 62-64 Two early studies from the 1990s showed better relief with LA compared with saline. A 1995 prospective study compared lumbar facet IA performed with up to 1.5 mL 0.5% bupivacaine versus IA saline.$^{62}$ Among 63 patients studied, 57 completed the study; 23 (40%) obtained at least 50% relief with at least one LA injection but not with saline. A 1998 RCT performed in 80 patients with mechanical LBP showed greater pain relief with IA LA than with saline.$^{64}$ In this study, either 1 mL lidocaine or 1 mL saline was injected. The investigators injected 2 mg cortivazol (equivalent to 30 mg prednisone “near the joint”, rendering the results inconclusive. (Of note, the authors asserted that the effect of the CSI was not evaluated because it was administered outside the joint.)

Other studies have shown similar efficacy between LA and saline. A 1989 randomized study conducted in 109 patients reported similar improvements after the injection of 8 mL of LA into two lumbar facet joints, saline into two facet joints, or LA administered around two facet joints. In the 70 of 109 patients who experienced immediate relief after the injection, pain relief persisted in 36% at 3-month follow-up.$^{24}$ An RCT compared lumbar facet IA with MPA versus saline in 190 patients.$^{23}$ Either methylprednisolone 20 mg in 1 mL NS or 2 mL NS was injected IA. No significant differences were observed between the two groups in pain level, functional status, or back flexion, with 42% of the corticosteroid group reporting improvement versus 33% of the saline group at 1 month following injection, with similar results up to 3 months postinjection. After 6 months, both IA saline and IA corticosteroid were equally ineffective. A randomized DB trial by Barnsley et al compared 1 mL IA bupivacaine versus 1 mL 5.7 mg betamethasone injected into the cervical facet joints.$^{48}$ These patients previously responded to MBBs. The time from treatment to 50% return of pain was 3 days in the corticosteroid group versus 3.5 days in the LA group (p=0.42). Another prospective DB study compared lumbar IA corticosteroid (triaminolone 20 mg in 0.5 mL) to saline (0.5 mL) in patients with lumbar facetogenic pain, confirmed via two positive in terms of need for MB RF ablation.$^{25}$ The need for RF was

Original research

similar between the two groups (75% in the saline group vs 91% for the CS group), with mean time before RF also being similar (6.1 and 6.5 weeks for the saline and CS groups, respectively).

A prospective, DB, RCT of 30 patients comparing IA triamcinol 1 mL (10 mg/mL) to an injectate consisting of hyaluronate 1 mL (8 mg Hylan GF-20) found modest benefit in functional status and pain improvement, but no significant differences between groups. The Synvisc-One group experienced significant short-term improvement in pain and short-term and long-term (6 months) functional improvement, while the CS group showed significant short-term functional improvement but no significant short-term or long-term relief.$^{65}$ The authors concluded that for patients with axial LBP suggestive of facetogenic etiology, IA hyaluronate and corticosteroid provide comparable benefit.

In summary, most studies showed similar results between IA LA and IA CSI, with scant evidence comparing IA corticosteroid and other injectates such as hyaluronic acid. Whereas saline appears to have the same intermediate-term effect as LA, most clinicians would not inject saline alone intra-articularly.

Dose-response and the effect of volume in facet joint injections

The relatively high rate of false-positive and false-negative IA facet joint blocks further obfuscates understanding facet dose-response studies. Based on comparative LA blocks, the estimated false-positive response rates vary between 17% and 41%.$^{1276}$⁻$^{70}$ In studies that use a placebo injection, the false-positive (ie, placebo response) rate ranges from 12% to over 30%.$^{1}$

The estimated capacity of the lumbar facet joint is 1.0–2.0 mL. Yet, the lumbar facet IA injectate volume in the literature varies from 0.25 mL to 8.0 mL, thus increasing the risk of either false-negative blocks due to inadequate anesthetization of the joint or false-positive blocks due to extravasation of LA and/or facet joint capsule rupture with resultant spread to non-facet pain generators.$^{71}$ Similarly, the cervical facet joint capacity is estimated at 1 mL$^{72}$.$^{73}$ but reported injectate volumes used for IA injections range from 0.5 mL to 2.0 mL.$^{72}$.$^{73}$ One study in the lumbar spine found that if the IA injection did not rupture the capsule, only 17% of patients experienced pain relief.$^{74}$ Another study found that lumbar facet capsule rupture commonly occurred with 1.0 and 3.0 mL injectate volumes.$^{17}$ Thus, IA injectate volumes above 1.0, and especially above 3.0 mL, could significantly skew prevalence and outcome studies toward false-positive results above and beyond the robust placebo effect.$^{75}$ Injectate viscosity may also contribute to a false-positive block, as LA agents typically have lower viscosities than contrast media, which could result in spread beyond the fluoroscopically visible contrast.$^{76}$

Given the relationship between injectate volume/spread and analgesic efficacy, confirmation of IA versus periarticular facet injection is essential in establishing appropriate injectate dosing. However, the manner in which IA injections are confirmed and what constitutes IA spread are also quite variable. Kershen et al conducted a retrospective review of 77 patients who received 205 facet joint injections, comparing fluoroscopically guided IA to peri-articular facet joint injections.$^{77}$ The injectate consisted of 0.5–1 mL of contrast solution (confirming IA vs periarticular spread), 0.5 mL of LA (0.25% bupivacaine vs 0.5% bupivacaine vs 1% lidocaine), and 0.5 mL of corticosteroid (20 mg methyl-prednisolone vs 3 mg betamethasone vs 20 mg triaminolone), for a total injectate volume of 1.5–2 mL.$^{77}$ The authors found statistically significant pain relief in both groups (IA vs periarticular), but no difference between groups,$^{77}$ which aligns with

the findings of the international multispecialty lumbar facet consensus guidelines.$^{1}$

Whereas dose-response studies evaluating peripheral joint IA injections are voluminous (see our PG on joint injections),$^{11}$ there is a paucity of corticosteroid dose-finding studies specific to facet joints. The commonly employed doses were 40 mg methylprednisolone (MP), 8 and 10 mg triamcinolone (TA), 3 and 5.7 mg betamethasone (BTM), and 10 mg dexamethasone (DEX) (see table 3). There are no dose-response studies below 40 mg of MP or TA or their corticosteroid equivalents. Based on the minimum dose found to be effective (8 mg TA),$^{38}$ commonly employed doses, and available evidence in similar small-capacity joints (elbow, wrist) where 20–40 mg of methylprednisolone equivalents was injected,$^{11}$ corticosteroid doses of 10 mg methylprednisolone or triaminolone or their equivalent, per facet joint, seem reasonable. Dose-response studies are needed to confirm these estimates.

Number of levels

Determining the levels to be treated can be complicated, as there seems to be no pathognomonic physical examination or historical findings that reliably predict response to facet joint injections.$^{1}$ The selection of treatment levels should be based on clinical presentation, radiologic findings, and possibly point of maximal tenderness verified via fluoroscopic guidance.$^{12}$ Recent coverage guidance from the Centers for Medicare and Medicaid Services (CMS) states, “One to two levels, either unilateral or bilateral, are allowed per session per spine region.” (“Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L38803)”). In one systematic review that evaluated lumbar facet joint injections (IA and MBB) stratified by the number of levels treated, only 1 of 3 studies found a positive correlation (0 of 2 for IA CS injections, 1 of 1 for MBB.$^{78}$

Frequency of injections and duration of relief

Studies by Manchikanti et al compared lumbar, thoracic, and cervical MBBs with LA alone (bupivacaine) to LA with cortico-steroid (betamethasone 0.15 mg/mL) to LA with sarapin, alone or in combination with corticosteroids.$^{8}$ They injected 0.5–1 mL per targeted nerve did not provide information on frequency besides stating that the decision to repeat the injections was based on patient response. Their studies showed no differences between MBB done with LA alone versus LA with corticosteroid.$^{8}$ $^{20}$ On average, patients in these studies received 3–4 injec- tions per year, regardless of the assigned treatment group. After cervical MBBs, patients received an average of 5.7 treatments for 2 years with a mean duration of significant pain relief from each procedure of 17–19 weeks.$^{19}$ After thoracic MBBs, the average number of treatments was 3.5 per year, with an average duration of relief of 15.8±1.5 weeks.$^{18}$ After lumbar MBBs, the average duration of relief was 19 weeks per treatment episode.$^{20}$

In a non-randomized study by Campos et al evaluating bilateral IA lumbar facet joint injections with ropivacaine and betamethasone, the authors reported significant pain reduction (74.4%) and improvement in disability (62.8%) at 6 months postinjection. These results suggest that 6-month intervals between injections may be appropriate.$^{79}$ In the randomized trial by Pneumaticos et al which showed a better response in SPECT-positive patients, the relief lasted up to 3 months after injections.$^{39}$ However, at 6 months postinjection, the difference in responder rates fell shy of statistical significance.$^{39}$ Ackerman and Ahmad's prospective study compared IA facet injections with LA and corticosteroid to MBB with LA and corticosteroid in patients with positive SPECT

Original research

scans; the authors found a greater proportion of responders in the IA group than the MBB group (61% vs 26%) at 12-week follow-up.38 The randomized comparative-effectiveness study by Lee et al found that 13 of 20 (65%) patients who underwent thoracic IA facet CSI experienced meaningful pain relief (relief >50%) 6 months after injection, compared with 7 of 20 (40%) in the MBB group.29) As discussed previously, Klessinger found that 53% (46 of 87) of patients with persistent neck pain after surgery who underwent MBBs experienced relief lasting for at least 6 months.30 These studies demonstrate that IA CSIs may provide at least 3 months of relief when carefully selecting patients with an acute inflammatory component, with a lower percentage of responders reported after MBB.

Interval between CSIs and annual cumulative dose

Unsurprisingly, no definitive data provide insight into the appropriate dose or interval of CSIs in or around the facet joints. As with other authors,$^{13279}$ we do not recommend the routine use of IA facet joint CSIs for chronic low back or neck pain. We also do not recommend a series of facet joint injections. As discussed above, there may be situations where IA or periarticular CSI provide short-term to intermediate-term relief (3–6 months) to a small subset of patients with acute injuries or evidence of acute inflammation (ie, SPECT-positive patients).$^{40}$ In these cases, there is insufficient evidence to make recommendations on the optimal corticosteroid dosing interval or cumulative annual dose,$^{80}$ and the interval for repeat injections in responders should be based on clinical benchmarks (see recommendation 6 in box 1) rather than a rote algorithm. This recommendation includes waiting for the pain to reach >50% of preinjection levels in patients who responded favorably.

The cumulative annual dose of corticosteroid, not to exceed 200 mg methylprednisolone equivalent per year, or 400 mg over 3 years,$^{80}$ should include all corticosteroid administration from all sources.

Pharmacokinetic study after facet joint CSI

A study of five patients showed that peak serum concentrations occur within 24 hours after IA facet injections of triamcinolone, with an elimination half-life of 213 hours. Baseline cortisol suppression lasted an average of 4.4 days.$^{81}$ Determining a more precise estimate of peak levels is limited by the authors' collection of the first set of samples at 24 hours.

Adverse events related to facet CSIs

Facet CSIs may have local and systemic adverse effects, which are a direct consequence of systemic absorption (which is a function of injection location), genetics, and drug metabolism. Although rare, cases of infection after facet CSI have been reported in various surrounding structures, including spondylo-discitis,$^{82}$ septic arthritis,$^{83}$ $^{84}$ paraspal or psoas abscess,$^{85}$ $^{87}$ or epidural abscess.$^{88}$ Data from a single institution over 10 years found an overall incidence of IA facet injection-related adverse events of 0.84% (101/11,980); of the eight cases determined to be procedure-related, there were seven cases of infectious spondylutides and one case of systemic aspergillosis to the spine.$^{89}$ Most of these patients had risk factors that may have increased susceptibility to infectious complications, including age over 60 years, diabetes mellitus, prior history of infection, and chemotherapy. However, infectious complications are not unique to IA facet CSIs. A recent case report described an epidural abscess after lumbar MBBs performed with LA only.$^{90}$ Notably, the patient was on a daily systemic corticosteroid and a disease-modifying

Box 1 Statements and recommendations on facet joint corticosteroid injections

Facet joint injections

Statements

1. Significant pain relief following cervical and lumbar medial branch blocks with local anesthetic (LA) is predictive of long-term pain relief with medial branch radiofrequency ablation (RFA), with no supplemental gain achieved with the addition of corticosteroids.

Level of certainty: Moderate

2. Intra-articular (IA) facet corticosteroid injections may provide significant pain relief and improved function in a subset of patients with active facet joint inflammation.

Level of certainty: Low

3. In patients with facetogenic pain who experience analgesic benefit from IA facet joint injections, the relief is usually but not always short-term.

Level of certainty: Low

4. For IA facet joint injections, there are insufficient data to establish a minimum effective corticosteroid dose. When employed, the most common doses are 10 mg methylprednisolone or triamcinolone, 3 mg betamethasone, or a pharmacologically equivalent nonparticulate corticosteroid (2 mg dexamethasone), per facet joint.

Level of certainty: Low

5. In patients with chronic facetogenic pain who experience analgesic benefit from medial branch blocks (MBBs), the relief may be intermediate-term. The addition of corticosteroids to an MBB confers unclear benefit.

Level of certainty: Low

6. Image guidance is required for confirmation of an accurate IA facet injection. Fluoroscopy and CT are associated with radiation exposure; radiation dose can be mitigated using techniques conforming to the radiation dose "As Low as Reasonably Achievable" principle.

Level of certainty: High

7. There may be reduced visibility during ultrasound-guided lumbar facet injections in patients with certain body habitus, and there is a risk of targeting the wrong spinal segment.

Level of certainty: Moderate

8. There is little to no additional benefit in the magnitude of pain relief with particulate compared with non-particulate corticosteroids in facet joint injections.

Level of certainty: Low

9. Particulate corticosteroids may carry a slightly increased risk of neurological injury (with incorrect needle placement) compared with non-particulate corticosteroids, but this can be mitigated with proper technique.

Level of certainty: Low

10. Cervical IA facet interventions carry increased anatomical risk of inadvertent intravascular or intrathecal injection compared with lumbar IA facet interventions.

Level of certainty: Moderate

11. The small capacity of the facet joint, along with a high extracapsular leakage rate and proximity of the facet joints to other potential pain generators, contributes to high rates of false-positive IA facet injections. Difficulty accessing the joint (ie, periarticular spread, increased pain) is a source of false-negative blocks.

Level of certainty: Moderate

Continued

Original research

Box 1 Continued

Recommendations

1. IA facet corticosteroid injections may be considered in patients with inflammatory facet pain or in those for whom medial branch RFA may not be possible or appropriate.

Strength of recommendation: C

2. Either particulate or non-particulate corticosteroids may be used for lumbar IA facet injections.

Strength of recommendation: C

3. Non-particulate corticosteroids are recommended for cervical IA facet injections due to more serious risks if there is inadvertent intravascular injection.

Strength of recommendation: C

4. If used for IA facet injections, the corticosteroid dose per facet joint should not exceed 10 mg methylprednisolone or triamcinolone, 3 mg betamethasone, or their nonparticulate equivalent (2 mg dexamethasone).

Strength of recommendation: I

5. MBBs with LA only are recommended as the preferred predictive tool for medial branch RFA.

Strength of recommendation: A

6. If relief from IA facet joint injection or MBBs lasts beyond the immediate post-procedural period, clinicians should wait until diminution of pain relief (eg, return to >50% of baseline) before proceeding to medial branch RFA.

Strength of recommendation: A

7. For IA facet injections, it is recommended to use fluoroscopy or CT guidance with techniques to minimize radiation exposure. Ultrasound may be used to guide injections if the patient's anatomy permits safe and reliable performance of the procedure.

Strength of recommendation: C (fluoroscopy and CT)/I (ultrasound)

anti-rheumatic drug (DMARD) for rheumatoid arthritis and had undergone a sacroiliac joint injection with corticosteroid 2 months prior to the injection. These observations highlight that complications can occur with facet interventions even without corticosteroid administration, but clinical factors related to corticosteroid and other immunosuppressant exposure contribute to increased risk.

Whereas IA injections are intended to provide localized pain relief, systemic effects do occur; thus, facet, IA, and epidural CSIs have been associated with an increased risk of immunosuppression$^{81}$,$^{93}$ and adrenal insufficiency.$^{92}$ It is difficult to ascertain the degree to which suppression of the hypothalamic-pituitary-adrenal (HPA) axis by facet CSIs corresponds to an increased risk of the above complications in clinical practice. This topic is addressed in the upcoming PR on vaccines.

Facet injections are considered to carry a low risk for bleeding complications.$^{93}$ $^{94}$ While the risk is small, interventionalists should be familiar with the ASRA and ASIPP guidelines.$^{93}$ $^{94}$

SRs on facet joint CSIs are in box 1.

SACROILIAC JOINT INJECTIONS

Pain in the sacroiliac joint area can be mechanical or inflammatory in etiology. Inflammatory sacroiliac pain, sacroiliitis, may be a component of a more diffuse axial spondyloarthropathy that affects the peripheral joints and organs such as the skin, eyes, and gastrointestinal tract.$^{95}$ It involves inflammation-induced bone loss with abnormal new bone formation at specific sites in the

skeleton, including the sacroiliac, facet, and peripheral joints. It usually responds to disease-modulating agents and NSAIDs. This PR focuses mainly on sacroiliac joint pain secondary to mechanical causes and its management with sacroiliac joint CSIs.

The sacroiliac joint is the largest spinal joint in the body, and the innervation of different segments and pain referral patterns is complex and variable. The lateral branches from L5-S3 or S4 have been shown to innervate the dorsal ligaments (extra-articular component of the joint) and posterior bone, while the ventral rami innervate the SI joint capsule and ventral ligaments, including the IA synovial component.$^{96-98}$ In general, extra-articular pathology is more prevalent in younger patients, those with unilateral pain after trauma, and in those with more prominent tenderness, while IA pathology is more common in older patients, individuals with osteoarthritis or inflammatory arthritis, and those with bilateral symptoms.$^{98}$ These differences have implications for treatment. As with facet injections, sacro-iliac joint (SIJ) blocks may be diagnostic, predictive, prognostic, or facilitative, and the same principles apply. However, there are distinct differences between SIJ and facet joint blocks, mainly due to information.

Indications and contraindications for sacroiliac joint

injections

SIJ injections are indicated for the treatment of pain suggestive of SIJ etiology based on history and physical examination, pain lasting at least 3 months, and in those who experience inadequate relief following more conservative treatments (eg, physical therapy, NSAIDs).$^{99}$ $^{100}$ Low-volume (1–2.5 mL) IA injections can also provide optimum diagnostic, prognostic, and predictive value for identifying surgically amenable pathology; unfortunately, many studies utilized high volumes that lack specificity. As with other pain injections, relative and absolute contraindifications to SIJ injection include allergy to any medication used in the procedure, active local or systemic infection, coagulopathy, and acute fracture in the sacroiliac region.$^{16}$

Role of fluoroscopy and ultrasound

Although some evidence indicates that fluoroscopic versus landmark guidance for SIJ injections may yield comparable clinical outcomes,$^{101}$ it seems intuitive that visualizing the target of an injection would provide the best diagnostic (ie, identifying which parts of the joint are pain generators), predictive (extra-articular injections for RFA, IA for fusion), and possibly therapeutic outcomes while decreasing the risk of inadvertent injection into undesirable sites. Even for ‘blind’ injections, imaging holds diagnostic value (ie, identifying which structures were anesthetized). Various imaging modalities have been used to visualize the SIJ, including fluoroscopy, CT, and ultrasound. CMS guidance stipulates that procedure codes for IA SIJ injections should only be used with fluoroscopy or CT confirmation of IA needle positioning; otherwise, the injection must be coded as a trigger point injection (Local Coverage Article for Billing and Coding: Pain Management (A52863)). In some circumstances, CT-guided SIJ injections may decrease procedure time, offer better visualization of the synovial compartment, and improve the joint penetration success rate in patients with challenging anatomy.$^{102-104}$ Studies suggest that ultrasound guidance for IA SIJ injections remains technically challenging, especially in patients with a large body habitus. A recent small RCT found that both CT-guided and fluoroscopically guided SIJ injections were associated with significant improvements in pain and disability up to 12 months postprocedure, with patients in the CT group having slightly

Original research

improved outcomes at 6 months compared with the fluoroscopic group.$^{104}$ However, fluoroscopy is more widely available, entails less radiation exposure compared with CT, and remains the most common imaging modality for SIJ injections.

Stelzer et al investigated fluoroscopically guided or ultrasound-guided SIJ injections in 20 cadavers for a total of 40 injections with contrast combined with red-colored latex. The joints were later dissected and revealed that IA latex was present in 1 of 20 (5%) ultrasound-guided injections compared with 10 of 20 (50%) fluoroscopy-guided injections.$^{105}$ In two retrospective studies, cranial contrast spread within the capsule correlated with improved short-term (2–4 weeks) clinical outcomes, but no long-term (greater than 8 weeks) benefit.$^{106}$ $^{107}$

A prospective study by De Luigi et al in 50 patients undergoing ultrasound-guided SIJ injections by a single physician using arthrogram confirmation found that 48 of 50 patients (96% had successful arthrograms.$^{108}$ The two patients with unsuccessful arthrograms were morbially obese. In one patient, vascular contrast uptake was noted on fluoroscopy, so the needle was repositioned before the injection of corticosteroid, and a successful arthrogram was appreciated.$^{108}$ In a prospective, randomized trial comparing ultrasound-guided and fluoroscopically guided as SIJ injections, 48 of 55 (87.3%) ultrasound-guided injections were technically successful versus a 98.2% accuracy rate using a fluoroscopically guided approach.$^{109}$ A successful IA injection was confirmed using contrast spread within the joint, as assessed by postprocedure radiography. It should be noted that there were no statistically significant differences in pain or disability between groups at 2 and 12 weeks after the procedure.$^{109}$ In a prospective, randomized trial comparing pain scores at 1 month in 40 patients randomized to either fluoroscopically guided or ultrasound-guided sacroiliac joint injections, Soneji et al found that 50% of ultrasound-guided injections were confirmed to be IA versus 65% of fluoroscopically guided injections, but no statistical differences in pain or disability scores were observed between groups.$^{110}$ The study also found that ultrasound-guided injections (in-plane or out-of-plane approach as per clinician's preference) took significantly longer to perform compared with fluoroscopically guided injections (561 vs 323 s, p<0.01).$^{110}$ Hartung et al performed ultrasound-guided sacroiliac joint injections in 14 patients (20 joints) and confirmed IA placement by gadolinium spread on postprocedure MRI.$^{111}$ They found that 8 of 20 (40%) ultrasound-guided injections had contrast deposited inside the joint, while the remaining 12 injections missed the SI joint entirely. Despite the low rate of IA placement, there were no significant differences in clinical outcomes between groups.$^{111}$ These findings are consistent with a systematic review and meta-analysis comparing US and fluoroscopically guided CS injections for back pain (n=8 studies) in general that found no differences in pain outcomes or complication rates, but a very slight benefit for function favoring fluoroscopy (SMD with 95% CI 0.13 (-0.00 to 0.25), p=0.05).$^{112}$

Although it appears that IA localization is better with fluoroscopy-duided injections compared with US guidance, the comparative effectiveness between the two is similar. While image guidance is recommended to minimize the risk of intravascular uptake with SIJ injection, no definitive recommendations can be made regarding the superiority of ultrasound versus fluoroscopy with contrast.

Particulate versus non-particulate corticosteroid

Similar to other joint injections, there are no RCTs or consensus recommendations regarding the efficacy and/or safety of

particulate versus non-particulate corticosteroid in SIJ injections. All randomized trials and nearly all observational studies evaluating SIJ injections have used particulate corticosteroids. In one observational study involving 1327 CT-guided spinal injections, of which 35 involved the SIJ, Brandle et al found no difference between the type and dose of corticosteroids or the addition of LA.$^{113}$

Clinical trials and dose-response studies

Interpreting dose-response studies of SIJ IA and extra-articular CSIs requires consideration of diagnostic protocols (single block vs dual block and controlled vs uncontrolled blocks), anatomical injection sites (IA vs extra-articular, cephalad vs caudad), and whether the pain is inflammatory (ie, spondyloarthropathy) or non-inflammatory.

False-positive and false-negative blocks

The incidence of false-positive SIJ injections with a single diagnostic block is significantly higher (29%–63%) than with dual or confirmatory blocks (10%–33%), though this fluctuates with the pain relief cut-off threshold.$^{114}$⁻$^{117}$ In one systematic review, the authors found the evidence for diagnostic accuracy to be ASIPP Level III (fair) for single diagnostic blocks with at least 75% pain relief and Level II (moderate) for dual diagnostic blocks with at least 70% pain relief.$^{118}$

The IA capacity of the SIJ is estimated to be between 0.8 mL and 2.7 mL in symptomatic individuals (slightly smaller in asymptomatic individuals), with capsular distention evident between 1.08 mL and 1.6 mL.$^{119}$¹¹⁹ However, extravasation ventral capsular disruption can lead to false-positive blocks from extravasation anesthetic.$^{114}$ $^{119}$ $^{120}$ However, extravasation outside the IA space resulting in pain relief does not necessarily signify a false-positive block, as numerous structures comprising the periarticular space can be sources of SIJ pain.$^{121-123}$ Given these considerations, IA SIJ injections should be conducted with a maximum of 2.5 mL, though volumes exceeding 3 mL can be used for EA and combined IA and EA injections.$^{124-126}$

IA corticosteroids for spondyloarthropathy

An inflammatory component to SI joint pain can be confirmed by the presence of subchondral marrow edema on MRI.$^{127}$ Whereas corticosteroids are theoretically superior to placebo for inflammatory SIJ pain, evidence for the efficacy of IA corticosteroids for SIJ pain in spondyloarthropathy based on RCTs is limited. Maugars et al examined 42 IA CSIs consisting of 1.5 mL cortivazol (particulate corticosteroid available in France, equivalent to 62.5 mg prednisone) mixed with 1–2 mL contrast for SIJ pain in 22 sonegative spondyloarthropathy patients. The authors reported that 86% experienced >70% pain relief for at least 1 month, with the mean duration of benefit being 8.5 months.$^{128}$ The group then performed a placebo-controlled, double-blind study in 10 patients (13 joints) with spondyloarthropathy, comparing IA injections of 1.5 mL cortivazol in a water-soluble contrast medium to saline.$^{129}$ The authors found that 83% of patients in the corticosteroid group experienced a successful outcome at 1 month (defined as >70% pain relief) versus 0% in the placebo group. Patients in the placebo group were then given the option to receive a CSI, to which 6 of 7 agreed. Among the 14 total joints injected with corticosteroid, the success rate was 85.7% at 1 month, 62% at 3 months, and 58% at 6 months.$^{129}$ These studies suggest intermediate-term benefits for high-dose SIJ corticosteroid in treating inflamatory SIJ pain.

Original research

IA corticosteroids for non-spondyloarthropathy

For non-inflammatory SIJ pain, IA SIJ CSI results are less consistent. Liliang et al performed a prospective observational study in 150 patients with a clinical presentation consistent with non-inflammatory SIJ pain.$^{130}$ All patients underwent a screening diagnostic block with LA only, resulting in at least 75% pain relief in 88 patients, 20 of whom did not report a recurrence of SIJ pain. A confirmatory block was positive in 39 patients, making those patients eligible for injection of 0.5–1 mL contrast mixed with 1 mL of 0.5% bupivacaine or 2% lidocaine and 1 mL of 40 mg/mL triamcinolone. Among patients receiving SIJ CSIs, 26 out of 39 (67%) experienced ≥50% pain reduction lasting more than 6 weeks.$^{130}$ Visser et al performed a single-blind, randomized comparative-effectiveness study comparing physical therapy, manual therapy, and IA injections with lidocaine (30 mg) and triamcinolone (40 mg in 51 patients diagnosed with non-inflammatory SI joint pain based on physical exam. A successful outcome, defined as complete pain relief 6 weeks after treatment or any decrease in pain 12 weeks after treatment, was reported in 20% of physical therapy patients, 72% of those who received manual therapy, and 50% of patients who underwent injections.$^{131}$ In a systematic review on the effectiveness of IA SIJ injections with corticosteroids, three of the four studies included in the section on duration of benefit reported that less than half of the subjects experienced benefit lasting at least 1 month.$^{114}$

Luukkainen et al performed a randomized controlled study in 20 patients with clinically diagnosed SIJ pain in the setting of seronegative spondyloarthopathy, comparing extra-articular injections with 1.5 mL of 2% lidocaine and 1.5 mL of 40 mg/mL methylprednisolone versus injections with the same volume of lidocaine mixed with saline. Two months postinjection, the corticosteroid group experienced a mean pain reduction of 26.5 points on a 0–100 Visual Analog Scale versus 1.5 in the saline group.$^{122}$ 3 years later, the group performed a double-blind controlled study in 24 patients with clinically diagnosed non-spondylarthropathic SIJ pain comparing extra-articular CSIs versus saline using the same injectate composition as in their first study.$^{123}$ At 1-month follow-up, the authors reported 75% pain reduction in the corticosteroid group versus 25% in the saline group. These two studies from the same group of investigators suggest that even patients with radiologically confirmed SIJ pathology may benefit from periarticular injections, and that in these patients, the benefits last at least 1 month.

Sacroiliac joint injections: IA, extra-articular, combined IA and extra-articular CSIs

Both IA and extra-articular SIJ structures may act as pain generators, with IA pathology being more common in elderly patients, those with bilateral symptoms, with evidence of pathology on imaging, and in those whose pain began insidiously. As noted previously, extra-articular pathology may be more common in younger individuals with unilateral pain, prominent tenderness, and following an inciting event such as falls, motor vehicle collisions, sports injuries, and pregnancy.$^{98}$ $^{122}$ $^{123}$ $^{132}$ Interpreting the results of IA versus extra-articular studies is challenging due to inadequate descriptions of the technique (see technique in the studies, table 4) and the various combined patterns of (unintentional) injectate spread. For example, in one study, not all patients (3 of 20 patients) had contrast injections, yet the authors presumed that all their injections were periarticular.$^{122}$

There is little information on the clinical significance of contrast spread within the SIJ. In a retrospective study, Scholten et al found that patients with cephalad spread of contrast

experienced significantly greater improvement in pain scores at 2 weeks postprocedure compared with patients without cephalad contrast spread, but no difference was observed at 8 weeks. Both groups had statistically significant pain relief at 2 and 8 weeks compared with baseline.$^{107}$ In a recent retrospective analysis to determine whether cephalad spread of contrast correlated with clinical outcome, Vandervennet et al evaluated injections in 128 patients with presumed SIJ pain, confirmed by at least 3 positive provocative maneuvers.$^{106}$ They found that contrast spread cephalad in 68 out of 128 patients (53.1%). Clinical success, defined as 50% or greater improvement in global perceived effect after 3-4 weeks, was reported in 55 of 68 (81%) patients with cephalad spread vs 35 of 60 (58%) in the group without cephalad spread.$^{106}$

Studies have yielded mixed results regarding the relative effectiveness of intra-articular and extra-articular (also called periarticular) injections and combined IA and extra-articular injections. The technique of extra-articular injections has been different across studies, making interpretation challenging (see table 4). One retrospective study showed no difference between IA and EA injections; the authors did not evaluate combined IA/ EA injections.$^{133}$ One small study that sought to determine the accuracy of ultrasound-guided injections reported comparable results for IA and extra-articular (60% of 20 blocks) injections through 4 weeks.$^{111}$ In one of the earliest studies to compare periarticular and IA SI injections, Murakami et al compared immediate-term outcomes between 25 peri-articular SIJ injections and 25 IA injections, using hypertonic saline to provoke pain before both types of procedures. The injectate consisted of a mixture of lidocaine and contrast in both groups. 5 min post-injection, 100% of the periarticular group versus 36% of the IA group experienced a positive outcome based on pain relief using various measurement tools.$^{134}$ Based on their results, the authors recommended periarticular injections at the midportion of the periarticular area based on observations that this part is exposed to greater stress than the other areas.$^{134}$ In a later prospective observational study by the same group of investigators that evaluated outcomes after periarticular injections, and if negative, IA injections in 85 patients, the authors found that 68% responded to periarticular injections with >70% pain relief, 16% responded to IA injections, and 15% responded to neither$^{132}$ (table 4).

In a double-blind, randomized study comparing the effectiveness of fluoroscopy-guided versus landmark-guided SIJ injections in 125 patients with a clinical presentation suggestive of SIJ pain, Cohen et al noted 91% of the fluoroscopically guided injections were IA or IA and EA (combination), while only 8% of the landmark-guided injections had any IA penetration.$^{101}$ The percentages of responders, defined as ≥50% pain relief immediately after the injection, were 62% in the IA group, 57% in the EA group, and 69% in the IA and EA combination group. At 1 month postprocedure, there were no significant differences in any outcome measure. Responder rates, defined as a 2-point or greater decrease in average pain coupled with positive satisfaction, in the IA and EA groups were 48% and 41%, respectively. At 3 months, trends were observed whereby the IA group experienced greater reductions in pain scores than the EA group, though most differences fell shy of statistical significance. The differences in respondent rates between IA, EA, and combined IA/EA did not reach statistical significance.$^{101}$

A recent combined study from Jordan and Germany compared IA versus periarticular corticosteroid SIJ injections.$^{135}$ 90 patients were given IA injections if their SIJ pain was right-sided and a periarticular injection if left-sided. The injectate consisted of 1 mL of 40 mg methylprednisolone with 1 mL 2% lidocaine;

Original research

Box 2 Statements and recommendations on sacroiliac joint (SIJ) corticosteroid injections

SIJ injections

Statements

1. Both intra-articular (IA) and extra-articular SIJ corticosteroid injections can provide short-term to intermediate-term (1 to 3 months) pain relief in patients who clinically present with SIJ-associated pain.

Level of certainty: Moderate

2. Image guidance using fluoroscopy or CT provides greater accuracy for IA SJ injections compared with ultrasound.

Level of certainty: Moderate

3. Fluoroscopically guided and ultrasound-guided SIJ corticosteroid injections provide comparable degrees of pain relief. This is probably due to the presence of both IA and EA nociceptors, a high likelihood of concomitant pain generators, and the strong placebo response for procedures.

Level of certainty: Low

4. Extra-articular (also called periarticular) and combined intra-articular and extra-articular corticosteroid injections are at least as effective as intra-articular-only injections.

Level of certainty: Low

5. Most published studies on the clinical outcomes from SIJ corticosteroid injections used particulate formulations.

Level of certainty: High

6. There are no dose-finding studies establishing the minimum effective dose for SIJ corticosteroid injection. Data from joints as hip and knee joints suggest increased effectiveness with methylprednisolone or triamcinolone 40 mg compared with 20 mg, with little additional benefit above 40 mg. A retrospective study showed that 40 mg methylprednisolone was equally effective as 80 mg in reducing pain scores.

Level of certainty: Low

7. Risk factors for infectious or inflammatory complications following SIJ corticosteroid injection include immunocompromised status and poor infection control practices.

Level of certainty: Moderate

8. Risks of SIJ corticosteroid injections are dose-dependent and include local and systemic infection, immunosuppression, hyperglycemia, decreased bone mineral density and increased fracture risk, and adrenal suppression in susceptible patients (eg, patients on protease inhibitors).

Level of certainty: Moderate

Recommendations

1. IA, EA, or combined IA/EA SJ corticosteroid injections are indicated for patients with pain consistent with SIJ etiology based on history and physical examination (and imaging if indicated), lasting at least 3 months, and with inadequate relief following more conservative treatments.

Strength of recommendation: C

2. To confirm IA spread during an SIJ injection, image guidance using fluoroscopy or CT is recommended.

Strength of recommendation: C

3. Either particulate or non-particulate corticosteroid may be used for SIJ injections, with the published literature supporting the former.

* Recommendation: C

4. A reasonable dose for SIJ corticosteroid injection is 40 mg methylprednisolone or triamcinolone, or an equivalent dose of betamethasone (7.5–8 mg) or dexamethasone (7.5 mg) per SIJ.

Box 2 Continued

Strength of recommendation: I

5. If there is significant relief after an SIJ corticosteroid injection, clinicians should wait until the diminution of pain relief (ie, return to >50% of baseline) before performing subsequent corticosteroid injections.

Strength of recommendation: A

Note: Recommendation #7 in the facet joint injection section relating to the use of fluoroscopy, CT, or ultrasound also applies to SIJ injections.

pain was assessed by VAS and NRS. Periarticular injections were superior to IA injections at all time points (1 week, 1 month, and 3 months) after injection.

Several studies have compared combination EA and IA injections to IA-only, suggesting superiority for combined procedures. A retrospective study by Borowsky and Fagen found superior outcomes for combined IA and EA injections compared with IA-only.$^{125}$ In the IA-only group (n=40), patients received 80 mg methylprednisolone and 1.5 mL 0.5% bupivacaine, whereas the combination group (n=80) received 2 mL containing 40 mg methylprednisolone and 0.5% bupivacaine injected intra-articularly, and the same dose injected under the posterior ligaments to bathe the S1-S3 lateral branches. In the immediate postblock period, the response rate (defined as >75% pain relief) was 62.5% in the combined injection group versus 42.5% in the IA group. The success rates (defined as >50% pain relief) in the combination and IA-only groups were 42.5% and 27.5% at 3 weeks, and 31.25% and 12.5% at 3 months, respectively (table 4).$^{125}$ The combined group also experienced better improvement in their Activities of Daily Living Improvement Assessment Tool (AIAT) at 3-month follow-up. In a recent randomized trial by Tantawy and Nazim$^{136}$ in 60 patients, the authors reported superiority for combined injections over IA-only blocks through 6-month follow-up, using the same dose of steroids in both groups.

In summary, the published trials indicate that IA, EA (or peri-articular), and combined IA and EA SIJ CSIs all provide relief in a substantial percentage of patients (see table 4). In terms of comparative effectiveness, three studies showed no difference between IA versus EA,$^{101}$ $^{133}$ $^{137}$ while three studies showed EA to be superior.$^{132}$ $^{134}$ $^{135}$ Two of the three studies showing EA to be more effective injected LA only,$^{132}$ $^{134}$ while the one study that used corticosteroid and LA was pseudo-randomized (type of injection was based on the side of pain) and injected “mostly” into the mid-portion of the SIJ.$^{135}$ Finally, two studies showed better results with combined IA/EA,$^{125}$ $^{136}$ while in another study, the higher responder rate in the combined group (67%) was not significantly greater than the IA (62%) or EA (57%) groups.$^{101}$ The two studies that directly compared combination injections to IA-only reported superiority for the former.$^{125}$ $^{136}$

Medicare coverage determination statements acknowledge the extra-articular portion of the SIJ as a potential pain generator, and while it mandates image guidance, similar to most major payor coverage determinations (eg, AETNA, Tricare, United Healthcare), they do not require a specific injection location. However, it is possible that some insurance carriers may deny payment for non-IA SIJ injections.

Site of extraarticular (periarticular) injections

Aktas et al questioned whether PA injections involve injection into the ligamentous portion of the SIJ, retroarticular area, or

Original research

Box 3 Key statements and recommendations on facet and sacroiliac joint (SIU) corticosteroid injections

Facet corticosteroid injections

1. The addition of a corticosteroid to medial branch blocks (MBBs) confers unclear benefits. MBBs with local anesthetic only are recommended as the preferred predictive tool for medial branch radiofrequency ablation.

2. Image guidance is required for confirmation of an accurate intra-articular (IA) facet injection, that is, fluoroscopy or CT. Ultrasound may be used to guide injections if the patient's anatomy permits safe and reliable performance of the procedure.

3. Either particulate or non-particulate corticosteroids may be used for lumbar IA facet injections. Non-particulate corticosteroids are recommended for cervical IA facet injections.

4. If used for IA facet injections, the corticosteroid dose per joint should not exceed 10 mg methylprednisolone or triamcinolone, 3 mg betamethasone, or their nonparticulate equivalent (2 mg dexamethasone).

2. If relief from IA facet joint injection or MBBs lasts beyond the immediate postprocedural period, clinicians should wait until diminution of pain relief (eg, return to >50% of baseline) before proceeding to medial branch radiofrequency ablation.

SIC corticosteroid injections

1. To confirm IA spread during an SIJ injection, image guidance using fluoroscopy or CT is recommended. Fluoroscopy or CT provides greater accuracy for IA SIJ injections compared with ultrasound.

2. Extra-articular (also called periarticular) and combined intra-articular and extra-articular corticosteroid injections are at least as effective as intra-articular-only injections.

3. Either particulate or non-particulate corticosteroids may be used for SIJ injections, though most published literature reported the use of particulate corticosteroids.

4. A reasonable dose for SIU corticosteroid injection is 40 mg methylprednisolone or triamcinolone, or an equivalent dose of betamethasone (7.5–8 mg) or dexamethasone (7.5 mg) per joint.

5. If there is significant relief after an SIJ corticosteroid injection, clinicians should wait until the diminution of pain relief (ie, return to >50% of baseline) before performing subsequent corticosteroid injections.

posterior tissue.$^{121}$ We reaffirm the recommendations of Aktas et al that injection techniques into the synovial and ligamentous portions of the SIJ need to be better described, and their comparative effectiveness should be examined in RCTs. Notably, in a study in cats, mechanosensitive receptors were noted mainly in the posterior sacroiliac ligaments, with few in the nearby muscles.$^{137}$

Sacral lateral branch blocks and RFA

In individuals who obtain meaningful but only short-term benefit from sacral lateral branch blocks, RFA has been shown in most$^{138-141}$ but not all$^{142}$ randomized trials to provide at least 3 months of relief. Since the lateral branches innervate the posterior extra-articular part of the SIJ, lateral branch blocks without corticosteroid should theoretically provide prognostic value before RFA. Among the RCTs that evaluated lateral branch RFA, studies used a positive response to sacral lateral branch blocks without corticosteroid as an inclusion criterion.$^{139-141}$

Dose-response summary

There are no studies comparing different doses for SI CSIs. Most studies evaluating corticosteroids used doses equivalent to 40 mg methylprednisolone or triamcinolone.$^{101}$ $^{111}$ $^{125}$ $^{135}$ $^{136}$ Data on other similarly sized joints (ie, shoulder, knee, hip) suggest that doses of 40 mg triamcinolone or methylprednisolone may be better for pain reduction compared with 20 mg, with 40 mg providing similar pain relief to 80 mg, and possibly a longer duration of benefit with higher doses in some studies.$^{143}$⁻$^{146}$ A recent retrospective study showed that 40 mg methylprednisolone was equally effective as 80 mg in reducing pain scores.$^{147}$ Thus, corticosteroid doses equivalent to methylprednisolone or triamcinolone 40 mg per joint are reasonable for the SIJ.

Interval between CSIs and annual cumulative dose

A long-term retrospective audit of all patients receiving SIJ CSIs at a single tertiary care spine center found that 120 out of 164 (77%) had a positive response, defined as ≥50% pain relief lasting at least 2 weeks, with two patients lost to follow-up.$^{148}$ The 118 responders received an average of 2.7 injections, with a mean duration of benefit of 9.3 months per injection for those receiving more than one injection.

There is insufficient evidence to recommend specific dosing intervals or dose limits for SIJ injections. As with other injections for low back pain, the frequency should be based on the duration of response (see below).$^{149}$

Based on the available evidence, SIJ CSIs are expected to provide 1–3 months of significant relief in about half of patients meeting clinical criteria for SIJ pain, although some patients may experience longer duration of benefit depending on SIJ pathology, injectate location, and improvement in other parameters that may provide long-term benefit such as sleep, mood, and function. Similar to facet IA injection, if there is a positive response to an initial SIJ injection, it is reasonable to consider another injection when there is a reduction of pain relief and return to >50% of baseline (see box 2). Additional injections should consider the annual cumulative dose, ie, a maximum of 200 mg methylprednisolone equivalent, annually and 400 mg over 3 years,$^{80}$ which includes corticosteroid from all sources.

Adverse effects

Given anatomical variations and the different procedural approaches to the SIJ, the risk of inadvertent intravascular injection and neurological injury is theoretically lower than for epidural or facet injections. SIJ injection is a low-risk procedure; the clinician should adhere to the ASRA and ASIPP guidelines on interventional procedures in patients on anticoagulants.$^{93}$ $^{94}$

The risks of adrenal and immunosuppression are likely similar regardless of the injection site. Reports of infectious or inflammatory complications following SIJ injection in immunocompromised patients$^{150-152}$ and the setting of poor infection control practices$^{153}$ have all involved particulate corticosteroids. There are no cases of similar complications following SIJ injection with dexamethasone, although this may be more a reflection of prevailing clinical practice patterns favoring the use of particulate over non-particulate corticosteroids for pain procedures, rather than an actual increased risk of infectious complications.

SRs are in box 2.

Overall summary and recommendations and concluding comments

The previous two international multispecialty consensus PGs on facet injections dealt with pain patterns, imaging criteria, MBBs,

Original research

effect of sedation, RF, clinical trials versus practice, with minimal discussion of SPECT and IA CSIs.$^{12}$ In these consensus recommendations, we focused on facet and SIJ CSIs.

Injection of corticosteroid into the facet joint in patients with joint inflammation can provide pain relief and improve function. Image guidance is recommended in facet joint injections; either a particulate or non-particulate steroid may be used. The most commonly used dose is 10 mg methylprednisolone or triamcinolone or 2 mg dexamethasone, or their equivalent. For sacroiliac joint injections, extra-articular (peri-articular) or combined extra-articular and periarticular administration is as effective as IA injections. Similar to facet joint injections, image guidance is recommended. The lowest effective dose for intra-articular facet joint injections is 10 mg, and 10-20 mg of methylprednisolone or triamcinolone is reasonable. There are no dose-response studies for SI joint injections, but 40 mg of methylprednisolone, triamcinolone, or their equivalent is reasonable. The maximum corticosteroid dose per year is the same for joint, neuraxial, and other injections and should take into consideration corticosteroid from all sources. In patients receiving multiple injections (eg, epidural corticosteroid and joint injections), the cumulative corticosteroid dose should be the same (or the cumulative corticosteroid dose may be increased based on personalized medicine and a shared-decision model) (box 3).

Our SRs reflect the distillation of data on the effects of IA CSIs in patients with an inflammatory component to their facet joint pain, extra-articular and IA CSJ in the SAJ dissection, duration of response, and associated adverse events. High-quality cost-effectiveness analyses are lacking for fac and SIJ CSIs, but are intimately tied to patient selection, that is, rigorous selection favors cost-effectiveness but may reduce access to care. A limitation of this PR is that potential stakeholders such as patient advocacy groups, regulatory bodies, and payors were not included in the development. Additionally, high-quality placebo-controlled trials using standardized diagnostic criteria and measurement tools are needed to establish the definitive efficacy of facet and sacroiliac joint CSIs.$^{28}$ $^{154}$ Additionally, dose-response studies conducted for facet and sacroiliac joint CSs should be performed; these studies should focus on doses below 40 mg in SI CSIs.

Clinical PRs represent a roadmap to guide physicians on best practices meant to optimize clinical outcomes and safety. Although some recommendations may represent standards of care (e.g. not performing cervical facet injections blindly), they are not meant to supplant physician judgment regarding the best course of action for an individual patient, which should always take into consideration their realistic goals and expectations.

Author affiliations

$^{1}$Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA $^{3}$Anesethology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA

$^{3}$Radiology, Mayo Clinic, Rochester, Minnesota, USA $^{4}$Medicine (Rheumatology), UCLA, Los Angeles, California, USA

"Medicine (Endocrinology), Walter Reed National Military Medical Center, Bethesda, Maryland, USA

$^{6}$Anesthesiology, Clement J Zablocki VA Medical Center, Milwaukee, Wisconsin, USA

$^{1}$Anesthesiology, The University of Texas Health Science Center, San Antonio, Texas, USA

$^{8}$Anesthesiology, The University of Kansas Medical Center, Kansas City, Kansas, USA $^{7}$Department of Anesthesiology, University of Chicago Medical Center, Chicago, Illinois, USA $^{8}$Anesthesiology - Pain Medicine, Mayo Clinic, Rochester, Minnesota, USA $^{11}$PM&R, Medical University of South Carolina, Charleston, South Carolina, USA $^{12}$Department of Anesthesiology and Perioperative Medicine, University of California $^{13}$Virne, California, USA

$^{10}$Anesthesiology - Pain Medicine, Mayo Clinic, Rochester, Minnesota, USA

$^{11}$PM&R, Medical University of South Carolina, Charleston, South Carolina, USA

$^{13}$Aesthesiology and Perioperative Medicine, University of California $^{14}$Invine, California, USA

$^{13}$Anesthesiology, Naval Medical Center San Diego, San Diego, California, USA

$^{14}$Orthopedic Surgery, LSUHSC, New Orleans, Louisiana, USA

$^{15}$PM&R, Vanderbilt University Medical Center, Nashville, Tennessee, USA $^{16}$Pain Medicine, Western Reserve Hospital Partners, Cuyahoga Falls, Ohio, USA $^{17}$Physical Medicine and Rehabilitation, Cleveland Clinic Neurological Institute, Cleveland, Ohio, USA

$^{14}$Anesthesia, McMaster University, Hamilton, Ontario, Canada

$^{19}$University Hospitals of Cleveland, Cleveland, Ohio, USA

$^{20}$University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA $^{21}$Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania, USA

$^{22}$Department of Anesthesiology, Physical Medicine & Rehabilitation, Neurology, Psychiatry and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA

Acknowledgements The American Society of Interventional Pain Physicians and its representatives (Laxmaiah Manchikanti, Salahadin Abdi, Alaa Ab-ElSayed, Joshua Hirsch, and Shalini Shah) were involved in the development of the Statements and Recommendations. Copyediting and formatting were performed by Emma Hitt Nichols, PhD, on behalf of Nascent Medical.

Contributors All authors were involved in the modified Delphi process, approval of the statements and recommendations, and approval of the manuscript. The primary author, HZT guarantees the contributorship statement.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

Competing interests HTB: NIH NIAMS P30AR072579 TLD, MHS: Research support: Biohaven, NIH; Consultant: Guidepoint Global; Speaker; Honorarium: Remedy Health Media TPM: Consultant, Interventional AnalesgiX TDH: Acella: Advisory board, speaker: Acella MM: Consultant: Juris Medicus ALC: Consultant: Swing Therapeutics, Axsome Therapeutics, Tonix Pharmaceuticals MSE: Funded research: SPR Therapeutics; Consultant: Avanos, Abbott CLH: Research grant: Nevro, Inc ASN: Speaker: Averitas Pharmaceuticals; Research: Saol Therapeutics CAP: Royalties, UpDate BJS: Consultant: State Farm, CDS: Advisory Board, Funded research: Scilex; Speaker: AAS: NIH R34AR080279 SN: Consultant, Shiratonics, CADW: Consultant, Vertex Pharmaceuticals and SEIKAGAKU North America; Medical Director, Glimmer Health; Founder and CEO, Personalized Pain Treatment, LLC DAP: Consulting: Avanos, Boston Scientific, Medtronic, Brixton, and SI Bone. Research support: Avanos, Boston Scientific, Brixton, Medtronic SPC: Consulting (past 2 years): Avano, Sclex (ended), SPR, SWORD, Releviate (ended), Clearing (ended), Persica; Research funds paid to institution: Scilex, Avanos.

Patient consent for publication Not applicable.

Ethics approval Not applicable.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, cloud drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

ORCID iDs

Honorio T Benzon https://orcid.org/0000-0003-1376-8003

Tina L Doshi https://orcid.org/0000-001-5011-3298

Hariharan Shankar https://orcid.org/0000-0002-1567-3887

Andrea Chadwick https://orcid.org/0000-0002-0570-9997

Christine Hunt https://orcid.org/0000-0002-0507-7889

Ameet Nappal https://orcid.org/0000-0001-5642-3465

Ariana M Nelson https://orcid.org/0000-0003-1575-1635

Carlos Pino https://orcid.org/0000-0002-7560-8403

Samer Narouze https://orcid.org/0000-0003-1849-1402

David Anthony Provenzano https://orcid.org/0002-002147-3523

Steven Paul Cohen https://orcid.org/0000/0000-0001-5928-2127

REFERENCES

1. Cohen SP, Bhaskar A, Bhatia A, et al. Consensus practice guidelines on interventions for lumbar facet joint a from a multispecialty, international working group. Reg Anesth Pain Med 2020;45:424-67.

2 Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions interventions for cervical spine (facet) joint pain from a multispecialty international working group. Regn working group. Reg Anesth Pain Med 2022;47:3-59.

Original research

3. Manchikanti L, Kaye AD, Soin A. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Phys 2020;35:23:51–17. 4: Janapala RN, Knezevic E, Knezevic NN, et al. Systematic Review and Meta-Analysis of Effectiveness of Therapeutic Sacroiliacilian Injections. Pain Physician 2023;26:43:14–35. 5. Manchikanti L, Abd-Elsayed A, Kaye AD, et al. Escalating Growth to Rapid Decline of Utilization Patterns of facet Joint Interventions in Managing Spinal Pain in the Medicare Population: Updated Analysis of the Effect of Multiple Factors from 2000 To 2022. Pain Physician 2024;27:E979–82. 6. Manchikanti L, Kaye AD, Latchaw RE, et al. Impact of the COVID-19 Pandemic on Utilization Patterns of Facet Joint Interventions in Managing Spinal Pain in a Medicare Population. Pain Ther 2023;12:50:57. 7. Manchikanti L, Pampati V, Sanapati M, et al. Eventinal Decline of 28.9% in Utilization of International Pain Management Techniques Namigc� Medicare Beneficiaries From 2019 to 2022: Updated Analysis on the Ongoing Effects of COVID-19, Economic Decline, the Affordable Care Act (ACA), and Medical Policies. Pain Physician 2024;27:455–67. 8. Manchikanti L, Pampati V, Bell et al. The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents. Curr Rev Pain 2000;4:337–44. 9. Manchikanti L, Simopoulos TT, Campati V, et al. Impact Of COVID-19 Pandemic and Updated Utilization Patterns of Sacroiliac Joint Injections from 2000 to 2020 in The Fee-For-Service (FFS) Medicare Population. Pain Physician May 2022;25:239–50.

10. Benzon HT, Elmofty D, Shankar H, et al. Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections guidelines from the American Society of Regional Anesthesia and Paian Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, and the International Pain and Spine Intervention Society. Reg Aneshin Pain Med 2025. 11. Benzon HT, Provenzano DA, Nagpal A, et al. Use and safety of corticosteroid injections in joints and musculoskeletal soft tissue: guidelines from the American Society of Regional Anesthesia and Paian Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, and the International Pain and Spine Intervention Society. Reg Aneshin Pain Med 2025. 12. Benzon HT, Josji GP, Gan TI, et al. Development, Reporting, and Evaluation of Clinical Practice Guidelines. Aneshin Analys (2019; 12:19:129;17:17–7). 13. Josji GP, Benzon HT, Gan TI, et al. Consistent Definitions of Clinical Practice Guidelines, Consensus Statements, Position Statements, and Practice Alerts and Anesthesia & Analesia 19:29;12:176–70. 14. Harris RP, Helfand M, Woolf SH, et al. Current methods of the US Preventive Services Task Force: a review of the process. Am J Prev Med 2001;20:21–35. 15. Peh W, Image-guided facet joint injection. Biomed Imaging Interv / 2011;7:4e. 16. Tuite M. Facet joint and sacroiliac joint injection. Semin Roentgenol 2004;39:37–51. 17. Dory MA. Arthography of the lumbar facet joints. Radiology 1981;140:23–7. 18. Manchikanti L, Singh V, Falco FJE, et al. Comparative effectiveness of a one-year follow-up of thoracic medial branch blocks in management of chronic thoracic pain: a randomized, double-blind active controlled trial. Pain Physician 2010;13:535–48. 19. Manchikanti L, Singh V, Falco FJE, et al. Comparative Outcomes of a 2-Year Follow-Up of Cervical Medical Branch Blocks in Management of Chronic Neck Pain: A Randomized, Double-Blind Control. Pain Physop 2010;5:13:43–50. 20. Manchikanti L, Singh V, Falco FJE, et al. Evaluation of lumbar facet joint nerve blocks in managing chronic low back pain: a randomized, double-blind, controlled trial with a 2-year follow-up. Int J Med Sci 2010;7:124–35. 21. Manchikanti L, Singh V, Falco FJE, et al. The role of thoracic medial branch blocks in managing chronic mid and upper back pain: a randomized, double-blind, active control trial with a 2-year followup. Aneshin Resolae Res Pract 2012;20:585806. 22. Cohen SP, Doshi T, Constantines OC, et al. Effectiveness of Lumbar Facet Blocks and Predictive Value before Radiofrequency Denervation. Anesthesiology 2018;129:517–35. 23. Carette S, Marcoux S, Truchon R, et al. A Controlled Trial of Corticosteroid Injections into Facet joints for Chronic Low Bank. A. N Engl J Med 1991; 32:55:1002;74. Lilius G, Laasonen EM, Myllynen P, et al. Lumbar facet joint syndrome. A randomised clinical J. Huonj SR (Huvn, L Wong, J er al. etc. Corticosteroid Injections into Lumbar Facet Joints: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial. Am J Phys Med behal. 2019;787–41–6. 25. Kennedy DJ, Fraiser Rh, Zeng P, et al. Intra-articular Steroids vs Saline for Lumbar Z-Joint Pain: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial. Pain Physop 2010;20:246–51. 26. Manchikanti L, Boswell MV, Singh V. Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Pain Phys 2009;4:12–699–802. 27. Fogarty AE, Butner JA, Duszynski B, et al. The effectiveness of fluoroscopically guided lumbar facet steroid joint injections: A systematic review. Interventional Pain Medicine 2025;4:100587.

29 Lee DG, Ahn SH, Cho YW, et al. Comparison of Intra-articular Thoracic Facet Joint Steroid Injection and Thoracic Medial Branch Block for the Management of Thoracic Facet Joint Pain. Spine (Phil Pa 1986) 2018;43:76–80. 30 Klessinger S. The benefit of therapeutic medial branch blocks after cervical operations. Pain Physician 2010;13:527–34. 31 Civelek E, Cansever T, Kabatas S, et al. Comparison of effectiveness of facet joint injection and radiofrequency denervation in chronic low back pain. Turk Neurosurg 2012;22:200–6. 32 Bogduk N, ed. Lumbar medial branch blocks. In: Practice Guidelines for Spinal Diagnostic and Treatment Procedures. 2nd edn. International Spine Intervention Society, 2013. 33 Kaplan M, Dreyfuss P. Halbrook B, et al. The ability of lumbar medial branch blocks to anesthetize the zygapophysial joint. A physiologic challenge. Spine (Phila Pa 1976) 1998;23:1847–52. 34 Lynch MC, Taylor J.F. Facet joint injection for low back pain. A clinical study. J Bone Joint Surg Br 1986;68:138–41. 35 Bureau NI, Moser TP. Gouvion A, et al. CT fluoroscopy-guided transforaminal and intra-articular facet steroid injections for the treatment of cervical radiculopathy: injectate distribution patterns and association with clinical outcome. Eur Radiol 2020;30:5933–41. 36 Cohen SP, Moon JY, Brumnett CM, et al. Medial Branch Blocks or Intra-Articular injections as a Prognostic Tool Before Lumbar Facet Radiofrequency Denervation: A Multicenter, Case-Control Study. Reg Anesth Pain Med 2015;40:376–83. 37 Birkenmaier C, Veihelmann A, Trouillier H-H, et al. Medial branch blocks versus pericapsular blocks in selecting patients for percutaneous cryodenvation of lumbar facet joints. Reg Anesth Pain Med 2007;32:27–33. 38 Ackerman WE III, Ahmad M. Pain Relief With Intraarticular or Medial Branch Nerve Blocks in Patients With Positive Lumbar Facet Joint SPECT Imaging: A 12-Week Outcome Study. South Medical J 2008;101:931–4. 39 Pneumaticos SG, Chatzioannou SN, Hipp JA, et al. Low back pain: prediction of short-term outcome of facet joint injection with bone scintigraphy. Radiology 2006;238:693–8. 40 Dolan AL, Ryan PJ, Arden NK, et al. The value of SPECT scans in identifying back pain likely to benefit from facet joint injection. Br J Rheumatol 1996;35:1269–73. 41 Elovic A, Pourmand A. MDCalc Medical Calculator App Review. J Digit Imaging 2019;32:682–4. 42 Koh WU, Kim SH, Hwang BY, et al. Value of Bone Scintigraphy and Single Photon Emission Computed Tomography (SPECT) in Lumbar Facet Disease and Prediction of Short-term Outcune of Ultrasound Guided Medial Branch Block with Bone SPECT. Korean J Pain 2011;24:81–6. 43 Nolan JE III, Sundet AD, Kagan BD, et al. The positive prediction of single photon emission computed tomography/ computed tomography (SPECT/CT) in the outcome of intervention for cervical facet pain. Spine J 2022;22:1622–7. 43 Garcia D. Sousa-Pinto B, Akinduro OO, et al. SPECT-CT as a Predictor of Pain Generators in Patients Undergoing Intra-Articular Injections for Chronic Neck and Back Pain. World Neurosurg 2022;164:e1243–50. 45 Scholten P, Sheikh M, Atchison J, et al. Correlating SPECT-CT activity in cervical facet joints with positive response to cervical medial branch blocks. Interv Pain Med 2024;3:100393. 46 garashi A, Kluch S., Konno S, et al. Inflammatory Cytokines Released from the Facet目 Tissue in Degerative Lumbar Spinal Disorders. Spine (Phila Pa 1986) 2004;29:2091–51. 47 Kim J-S, Ali MH, Wydra E, et al. Characterization of degenerative human facet joints and facet joint capsular tissues. Osteoarthritis Cartilage 2015;23:2242–51. 48 Barnsley L, Lord SM, Wallis B, et al. Lack of effect of intraarticular corticosteroids for chronic pain in the cervical zygapophyseal joints. N Engl J Med 1994;330:1047–50. 49 Kwak DG, Kwak SG, Lee AY, et al. Outcome of intra-articular lumbar facet joint corticosteroid injection according to the severity of facet joint arthritis. Exp Ther Med 2019;18:4132–6. 50 Sconfienza LM, Dalili D, Adriaensen M, et al. Image-guided injections for facet joint pain: evidence-based Delphi conjoined consensus paper from the European Society of Musculoskeletal Radiology and European Society of Neuroradiology. Eur Radiol 2025;35:6958–66. 50 Gofeld M, Bristow SI, Chiu S. Ultrasound-guided injection of lumbar zygapophyseal joints: an anatomic study with fluoroscopy validation. Reg Anesth Pain Med 2012;37:228–31. 52 Galian K, Obwegeser AA, Bodner G, et al. Ultrasound guidance for facet joint injections in the lumbar spine: a computed tomography-controlled feasibility study. Aneshat Analg 2005;101:579–83. 53 Galian K, Obwegeser AA, Walch C, et al. Ultrasound-guided versus computed tomography-controlled facet joint injections in the lumbar spine: a prospective randomized clinical trial. Reg Anesth Pain Med 2007;32:317–22. 54 Ye L, Wen C, Liu U. Ultrasound-guided versus low dose computed tomography scanning guidance for lumbar facet joint injections: same accuracy and efficiency. BMC Anesthesol 2018;18:160. 55 Heo JY, Lee JW, Kim CH, et al. The Validation of Ultrasound-Guided Target Segment identification in Thoracic Spine as Confirmed by Fluoroscopy. Clin Orthop Surg 2017;9:472–9.

Original research

56 Von H-S, Jang H-Y, Moon H-S, et al. Fluoroscopic Findings of Extra-Cervical Facet Joint Flow and Its Incidence on Cervical Facet Joint Arthograms. J Clin Med 2020;9:39:19.79. Yun DH, Kim H-Y, Soo SD, et al. Efficacy of Ultrasonography-Guided Injection in Patients with Facet Syndrome of the Low Lumbar Spine. Ann Rehabil Med 2012;36:66.58. Park KD, Lim DJ, Lee WY, et al. Ultrasound versus fluoroscopy-guided cervical medial branch for the treatment of the chronic cervical facet joint pain: a retrospective comparative study. Skeletal Radiol 2017;46:81–91.59. Han SH, Park KD, Cho KR, et al. Ultrasound versus fluoroscopy-guided medial branch block for the treatment of lower lumbar facet joint pain. Medicine (Abingdon) 2017;9:66655.65.70.199. 2017;6:66655.65.70.199. 2017;6:66655.65.70.199. 2017;6:66655.65.70.199. 2017;6:66655.65.70.199. 2017;6:66655.65.70.199. 2017;6:66655.65.70.199. 2017;6:66655.65.70.199. 2017;6:66655.65.70.199. 2017;6:66655.65.70.199. 2017;6:66655.65.70.199. 2017;6:66655.65.70.199. 2017;6:66655.65.70.199. 2017;6:66655.65.70.199. 2017;6:66655.65.70.199. 2017;6:66655.65

83 Weingarten TN, Hooten WM, Huntoon MA. Septic facet joint arthritis after a corticosteroid facet injection. Pain Med 2006;7:52–6. 84 Orpen NM, Birch NC. Delayed presentation of septic arthritis of a lumbar facet joint after diagnostic facet joint inject in injection. J Spinal Disord Tech 2003;16:285–7. 85 Cook NJ, Hanrahan P, Song S. Paraspinal abscess following facet joint injection. Clin Rheumatol 1999;18:52–3. 86 Magee M, Kannangara S, Dennien B, et al. Paraspinal abscess complicating facet joint injection. Clin Nucl Med 2000;25:71–3. 87 Balletlero MFM, Carneiro, Luz Lima JP, et al. Psoas Abscess After Lumbar Facet Joint Injection: Case Report and Literature Review. Cureus 2020;12:e9559. 88 Alcock E. Regaard A, Browne J. Facet joint injection: a rare form cause of epidural abscess formation. Pain 2003;103:209–10. 89 Kim BR, Lee JW, Lee E, et al. Intra-articular facet joint steroid injection-related adverse events encountered during 11,980 procedures. Eur Radiol 2020;30:150–17. 90 Onyima C, Chinn M, Chin M. Epidural abscess after lumbar medial branch blocks in a patient on disease-modifying anti-rheumatic drug and corticosteroid. Reg Anethast Pain Med 2021;46:923–5. 91 Stout A, Friedly J, Standaert CJ. Systemic Absorption and Side Effects of Locally Injected Glucocorticoids. PM&R 2019;11:409–19. 92 Williams D, Reicher I, Mohammed H, et al. Secondary adrenal insufficiency from steroid use and co-prescribing of cytochrome p450 3A4 inhibitors. HIV Med 2019;20:e10–1. 93 Narouze S, Benzon HT, Provenzano D, et al. Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition). Reg Anethain P Med 2017;1. 94 Manchikanti L, Sanapati MR, Nampiaparampl D. Perioperative Management of Antiplatelet and Anticoagulant Therapy in Patients Undergoing Interventional Techniques: 2024 Updated Guidelines from the American Society of Interventional Pain Physicians (ASIPPP). 20/24:27:51–94. Bittar M, Deodhar A. Axial Spondyloarthritis. JAMA 2025;333:408. 96 Poliott A, Zwirner J, Doyle T, et al. A Systematic Review of the Normal Sacroiliac Joint Anatomy and Adjacent Tissues for Pain Physicians. Pain Physician 2019;22:E274–74. 97 Dreyfuss P, Henning T, Malladi N, et al. The ability of multi-site, multi-depth sacral lateral branch blocks to anesthetize the sacroiliac joint complex. Pain Med 2009;10:679–88. 98 Cohen SP, Chen Y, Neufeld NJ. Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment. Expert Rev Neurother 2013;13:99–116. 99 Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Man Manip Ther 2008;16:142–52. 100 Lassett M, April CrN, McDonald B, et al. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther 2005;10:207–18. 100 Cohen SP Bicket M, Kurihara C, et al. Fluoroscopically Guided vs Landmark-Guided Sacroiliac Joint Injections: A Randomized Controlled Study. Mayo Clin Proc 2019;94:628–42. 102 Braun I, Bollow M, Seyrekbasan F, et al. Computed tomography guided corticosteroid injection of the sacroiliac joint in patients with spondyloarthropathy with sacroiliitis: clinical outcome and followup by dynamic magnetic resonance imaging. J Rheumatol 1996;23:659–64. 103 Bollow M, Braun J, Taupitz M, et al. CT-Guided Intraarticular Corticosteroid Injection into the Sacroiliac Joints in Patients with Spondyloarthropathy: Indication and Follow-Up with Contrast-Ehanced MRI. J Comput Assist Tomogr 1996;20:512–21. 104 Bessar AAA, Arnaout MM, Basha MAA, et al. Computed tomography versus fluoroscopic guided-sacroiliac joint injection: a prospective comparative study. Insights Imaging 2021;12:38. 105 Stelzer W, Stelzer D, Stelzer E, et al. Success Rate of Intra-articular Sacroiliac Joint injection: Fluoroscopy vs Ultrasound Guidance—A Cadaveric Study. Pain Med 2019;20:189–80. 106 Vandervennet W, Van Boxem K, Peene L, et al. Does the presence of cranial contrast spread during a sacroiliac joint injection predict short-term outcome? Reg AnethPain Med 2021;46:217–21. 107 Scholten PM, Patel SI, Christos PJ, et al. Short-term efficacy of sacroiliac joint corticosteroid injection based on arthrographic contrast patterns. PM R 2015;7:385–91. 108 De Luigi AL Sain V, Arthur R, et al. Assessing the Accuracy of Ultrasound-Guided Needle Placement Sacroiliac Joint Injections. Am J Phys Med Rehabil 2019;98:666–70. 109 Jee H, Lee JH, Park KD, et al. Ultrasound-guided versus fluoroscopy-guided sacroiliac joint intra-articular injections in the noninflammatory sacroiliac joint dysfunction: a prospective, randomized, single-blinded study. Arch Phys Med Rehabil 2014;95:333–7. 110 Sonej N, Bhatia A, Seib R, et al. Comparison of Fluoroscopy and Ultrasound Guidance for Sacroiliac Joint Injection in Patients with Chronic Low Back Pain. Pain Pact 2016;16:537–44. 111 Hartung W, Ross CI, Straub R, et al. Ultrasound-guided sacroiliac joint injection in patients with established sacroiliitis: precise IA injection verified by MRI scanning does not predict clinical outcome. Rheumatology (Oxford) 2010;49:1479–82.

Original research

112 Viderman D, Aubakirova M, Aryngazin A, et al. Ultrasound-Guided vs. Fluoroscopy-Guided Interventions for Back Pain Management: A Systematic Review and Meta-Ancalysis of Randomized Controlled Trials. Diagnostics (Basel) 2023;13:3474. 133 Brände K, Stienen MN, Neff A, et al. Ten-Day Response to CT-Guided Spinal Infiltration Therapy in More Than a Thousand Patients. J Neurol Surg A Cent Eur Neurosurg 2016;77:181-94. 114 114. Kennedy DJ, Engel A, Kreiner DS, et al. Fluoroscopically Guided Diagnostic and Therapeutic Intra-Articular Sacroiliac Joint injections: A Systematic Review. Pain Med 2015;16:1500–18. 115 115. Schneider BI, Huynh L, Levin J, et al. Corrigendum to: Does Immediate Pain Relief after an Injection into the Sacroiliac joint with Anesthetic and Corticosteroid Predict Subsequent Pain Relief? Pain Med 2022;23:1197. 116. Boody B, Caballero J, Macadaeg C, et al. Intra-Articular Sacroiliac Joint Injection. Clin Spine Surg 2021;34:14–6. 117. Simopulos TT, Manchikanti L, Singh A. V A Systematic Evaluation of Valence and Diagnostic Accuracy of Sacroiliac Joint Interventions. Pain Phys 2012;3:15:E305–44. 118. Simopoulos TT, Manchikanti L, Gupta S. Systematic Review of the Diagnostic Accuracy and Therapeutic Effectiveness of Sacroiliac Joint Interventions. Pain Phys 2015;5:18:E13–56. 119. Jung MW, Schellhas K, Johnson B. Use of Diagnostic Injections to Evaluate Sacroiliac Joint Pain. Int J Spine Surg 2020;14:30–4. 120. van der Wuff R, Buis EJ, Groen GI. A multtest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Arch Phys Med Rehabil 2006;87:10–4. 121. Aktas L, Unilu Okan F, Sari K. Comment on "Local sacroiliac injections in the treatment of spondyloarthritis. What is the evidence?" by Wendling et al. Joint Bone Spine 2020;87:209-213. Joint Bone Spine 2021;88:105083. 122. Luukkainen R, Nissilä M, Asikainen E, et al. Periarticular corticosteroid treatment of the sacroiliac joint in patients with seronegative spondylarthropathy. Clin Exp Rheumatol 1999;17:88–90. 123. Luukkainen RK, Wenennendt PV, Kautainen Ht, et al. Efficacy of periarticular corticosteroid treatment of the sacroiliac joint in non-spondylarthropathy patients with chronic low back pain in the region of the sacroiliac joint. Clin Exp Rheumatol 2002;20:52–4. 124. Yin W, Willard F, Carreiro J, et al. Sensory Stimulation-Guided Sacroiliac Joint Radiofrequency Neurotomy: Technique Based on Neuroanatomy of the Dorsal Sacral Plexus. Spine (Phila Pa 1986) 2003;28:2419–25. 125. Borowsky CD, Fagen G. Sources of Sacroiliac Region Pain: Insights Gained From a Study Comparing Standard Intra-Articular Injection With a Technique Combining Intra- and Peri-Articular Injection. Arch Phys Med Rehabil 2008;89:2048–56. 126. McCormick ZL, Hurley RW, Kohan L, et al. d. Multispecialty guidelines on the diagnosis and treatment of sacroiliac joint complex pain. Joint submission to Pain Med and Reg Anesth Pain Med. 127. Pereira PL, Günäylin, T. Brütenb J, et al. Interventional MR imaging for injection of sacroiliac joints in patients with sacroiliitis. AIR Am J Roentgenol 2000;175:265–6. 128. Maugars Y, Mathis C, Vilon P, et al. Corticosteroid injection of the sacroiliac joint in non-spondylartrophathies: a double-blind study. Br J Rheumatol: 1996;35:367–70. 130. Liliang PC, Lu K, Weng HC, et al. The Therapeutic Efficacy of Sacroiliac Joint Blocks With Triamcinolone Acetonide in the Treatment of Sacroiliac Joint Dysfunction Without Spondyloarthropathy. Spine (Phila Pa 1986) 2009;34:896–900. 131. Visser LH, Woudenberg NP, de Bont J, et al. Treatment of the sacroiliac joint in patients with leg pain: a randomized-the-articular joint-related pain at or around the posterior superior iliac spine. Clin Neurol Neurosurg 2018;165:43–6. 133. Nacey NC, Patrie JT, Fox MG. Fluoroscopically Guided Sacroiliac Joint Injections: Comparison of the Effects of Intraarticular and Periarticular Injections on Immediate and Short-Term Pain Relief. AIR Am J Roentgenol 2016;207:1055–61.

134 Murakami E, Tanaka Y, Aizawa T, et al. Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: prospective comparative study. J Orthop Sc 2007; 12:274-80. 135 Khalila IH,an Porn, Kanaan A, et al. Efficacy of Peri-Articular Versus Intra-Articular Sacroiliac Joint Blocks under Fluoroscopy Guidance: A Multicentric Study. Chron Pain Manag 2022;6:141. 136 Tantawy MF, Nazim WM. Comparison between intra-articular and combined intra- and periarticular sacroiliac injection: a prospective randomized controlled clinical trial. J Neurosurg Sci 2024;68:294-300. 137 Sakamoto N, Yamashita T, takebayashi T, et al. An Electrophysiologic Study of Mechanoreceptors in the Sacroiliac Joint and Adjacent Tissues. Spine (Phila Pa 1986) 2001;26:E468-71. 138 Cohen SP, Hurley RW, Buckenmaier CC, et al. Randomized Placebo-controlled Study Evaluating Lateral Branch Radiofrequency Denervation for Sacroiliac Joint Pain. Anesthesiology 2008;109:279-88. 139 Juch JNS, Maas ET, Ostelo RWJG, et al. Effect of Radiofrequency Denervation on Pain Intersity Among Patients With Chronic Low Back Pain. JAMA 2017;318:68. 140 Patel N, Gross A, Brown L, et al. A Randomized, Placebo-Controlled Study to Assess the Efficacy of Lateral Branch Neurotomy for Chronic Sacroiliac Joint Pain. Pain Med 2012;13:383-98. 141 Cohen SP, Kapural L, Kohan L, et al. Cooled radiofrequency ablation versus standard medical management for chronic sacroiliac joint pain: a multicenter, randomized comparative effectiveness study. Reg Anesth Pain Med 2024;49:184-91. 142 van Tilburg CWJ, Schuurmans FA, Stronks DL, et al. Randomized Sham-controlled Double-Blind Multicenter Clinical Trial to Ascertain the Effect of Percutaneous Radiofrequency Treatment for Sacroiliac Joint Pain. Clin J Pain 2016;32:921-6. 143 Cushman DM, Bruno B, Christiansen J, et al. Efficacy of Injected Corticosteroid Type, Dose, and Volume for Pain in Large Joints: A Narrative Review. PM R 2018;10:48-745. 144 Cushman DM, Ofek E, Syed RH, et al. Comparison of Varying Corticosteroid Type, Dose, and Volume for the Treatment of Pain in Small- and Intermediate-Size Joint Injections: A Narrative Review. PM R 2019;11:758-70. 145 Popma JW, Snel FW, Haagsma CJ, et al. Comparison of 2 Dosages of Intraarticular Traminicolone for the Treatment of Knee Arthritis: Results of a 12-week Randomized Controlled Clinical Trial. J Rheumatol 2015;42:1865-8. 146 Robinson P, Keenan AM, Conaghan PG. Clinical effectiveness and dose response of image-guided intra-articular corticosteroid injection for hip osteoarthritis. Rheumatology (Oxford) 2007;46:285-91. 147 Naber WI, Scorbner D, Kalpakjian CZ, et al. Association Between Corticosteroid Dose and Pain Reduction After Sacroiliac Joint Injections. Am J Phys Med Rehabil 2025;104:152-4. 148 Hawkins J, Schofferman J. Serial therapeutic sacroiliac joint injections: a practice audit. Pain Med 2009;10:850-3. 149 Matt Miller, DC, Smith C. Annual Maximum Dose of Epidural Steroid Injection. Pain Med 2019;20:2069-70. 150 Kurnutala LN, Ghatol D, Upadhyay A. Clostridium Sacroiliitis (Gas Gangrene) Following Sacroiliac Joint Injection--Case Report and Review of the Literature. Pain Physician 2015;18:E629-32. 151 Rosenstock T, Hermann K-GA. Septic Sacroiliitis Following Corticosteroid Injection in a Patient Under Anti-Tumor Necrosis Factor Therapy. J Clin Rheumatol 2015;21:320-1. 152 Nagpal G, Flaherty JP, Benzon HT. Diskitis, Osteomyelitis, Spinal Epidural Abscess, Meningitis, and Endocarditis Following Sacroiliac Joint Injection for the Treatment of Low-Back Pain in a Patient Therapy for Hepatitis C Virus. Reg Anesth Pain Med 2017;42:517-7. 153 Wong MR, Del Rosso P, Heine L, et al. An Outbreak of Klebsiella pneumoniae and Enterobacter aerogens Bacteremia After Interventional Pain Management Procedures, New York City, 2008. Reg Anesth Pain Med 2010;35:496-9. 154 Wang X, Martin G, Sadeghirad B, et al. Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials. BMJ 2025;388:e079971.