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6 Articles in this Series
Introduction
A Challenging Case of Postoperative Hyperalgesia
Are Serum Bupivacaine Levels a Concern During Postoperative Analgesia?
Postoperative Shoulder Pain: Which Analgesic Block Is Best?
TAP Block Could Help Diagnose Nerve Entrapment Syndrome
Ultrasound-Guided Injections for Pregnant Women with Sacroiliac Joint Pain
Using Intrathecal Patient-Controlled Analgesia in the Postop Setting: Case Report

Ultrasound-Guided Injections for Pregnant Women with Sacroiliac Joint Pain

For pregnant women suffering from sacroiliac joint (SI) pain, ultrasound-guided SI joint injections could be a promising alternative to the standard fluoroscopic technique. A new case study reported successful SI pain relief using bilateral SI joint injections administered through ultrasound to a woman at 20 weeks gestation.1

The typical fluoroscopic method for SI injection is contraindicated for pregnant women due to ionizing radiation, noted the researchers from the University of Oklahoma College of Medicine. The use of ultrasound could also reduce costs because ultrasound can be done outside the operating room, without the need of any fluoroscopic equipment, the authors noted.

“Physical therapy [PT] and NSAIDS [nonsteroidal anti-inflammatory drugs] are the hallmark for initial treatment of SI joint pain, however anatomical changes related to pregnancy may limit specific PT modalities and there are recognized fetal risks linked to NSAIDs, including increased risk of spontaneous abortion and fetal malformations, as well as cause premature closure of the ductus arteriosis and oligohydramnios when used after 30 weeks gestation,” the authors noted.

Almost all women report some level of musculoskeletal discomfort with pregnancy. Managing SI joint pain is a significant aim for clinicians, given that such pain, left untreated, could lead to chronic pain issues postpartum.2-3

Treating SI Paint Through Ultrasound-Guided Injection

In this case, a 30-year-old G2P1 female patient presented with a pain symptoms localized to the lower back and centered over both sides of the posterior superior iliac spine (PSIS). The woman, who was at 20 weeks gestation, had been suffering from the pain for 3 months prior to her visit, and there was no inciting event to the pain.

SI joint pain can be a common source of pain for pregnant women, and its causes multifactorial. Hyperlordosis of the back, weight gain, and increased ligament laxity all can lead to increased stress on the lower back and pelvis. Oftentimes, the interspinous and iliolumbar ligaments can be affected by the strain pregnancy puts on the body. The pain also can be variable among patients, with pain intensifying in various static positions.4

Indeed, the patient reported she had experienced similar pain issues during her first pregnancy. At that time, she had responded well to conservative treatments, including PT and NSAIDs.

The patient reported exacerbated pain from sitting on hard surfaces for an extended period of time. Upon physical exam, doctors found a tenderness to palpation present over the PSIS and various maneuvers to the SI joint evoked significant pain, including distraction, thigh thrust, and sacral thrust.

After receiving consent from the patient, she was placed in a prone position with a pillow underneath her abdomen to correct the lordosis. “Under direct visualization using a low frequency, curvilinear ultrasound transducer, the sacroiliac joints were injected under sterile technique with a combination of 5 mL of local anesthetic and steroid,” the authors reported.

The treatment appeared to be successful, with the patient reporting minimal discomfort and having no difficulty performing work-related activities 2 weeks following the procedure.

According to the authors, there may be some limitations to consider with ultrasound-guided SI joint injections. For instance, it may be difficult to identify musculoskeletal structures when using ultrasound on obese patients, as well as failure to demonstrate intravascular injection.

Regardless, the use of interventional procedures has been showing to improve recovery for women suffering from SI joint pain, and since some women may be contraindicated for certain maneuvers related to PT, the use of NSAIDS, or fluoroscopic-guided injections, the use of ultrasound-guided injections could be a practical alternative for clinicians treating this chronic pain issue.

References

1.     Vincent R, Blackburn J, Wienecke G, et al. Management of SI joint pain in pregnancy. Poster presented at: Regional Anesthesiology and Acute Pain Medicine Meeting. April 6-8, 2017; San Francisco, CA. Poster 3862.

2.     Borg-Stein J, Dugan SA, Gruber J. Musculoskeletal aspects of pregnancy. Am J Phys Med Rehabil. 2005;84(3):180-192.

3.     To WW, Wong MW. Factors associated with back pain symptoms in pregnancy and the persistence of pain 2 years after pregnancy. Acta Obstet Gynecol Scand. 2003;82(12):1086-1091.

4.     Sipko T, Grygier D, Barczyk K, et al. The occurrence of strain symptoms in the lumbosacral region and pelvis during pregnancy and after childbirth. J Manipulative Physiol Ther. 2010;33(5):370-377.

Next summary: Using Intrathecal Patient-Controlled Analgesia in the Postop Setting: Case Report
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