Evaluation of Landmark-Based and Fluoroscopic-Guided Sacroiliac Joint Injections-A Pilot Series

Sacroiliac joint (SIJ) dysfunction is a frequently underdiagnosed contributor to chronic low back pain. Although fluoroscopic-guided SIJ injections remain the gold standard for both diagnostic and therapeutic purposes, their availability may be limited by insurance barriers or logistical constraints. In such cases, alternative approaches such as ultrasound-guided or landmark-based injections may offer practical, rapid solutions in outpatient settings. This case series aims to compare outcomes between landmark-based and fluoroscopic-guided SIJ injections in patients presenting with clinical findings suggestive of SIJ-related pain.

Ten patients with suspected SIJ-related pain were identified based on a positive Fortin's Finger Test and FABERs examination. Five patients underwent landmark-based SIJ injections, performed by palpating the posterior superior iliac spine (PSIS) and directing the needle slightly inferior to this landmark. The remaining five patients received fluoroscopic-guided SIJ injections using standard imaging protocols. All injections consisted of 2 mL of 0.25% bupivacaine combined with 40 mg of triamcinolone. Pain relief was assessed at a 2-week follow-up using patient-reported percentage improvement.

Among patients who underwent landmark-based injections, reported pain relief at two weeks was 50%, 40%, 50%, 90%, and 50%, with an average relief of 56%. In contrast, patients receiving fluoroscopic-guided injections reported pain relief of 80%, 50%, 75%, 100%, and 75%, with an average relief of 76%. No procedural complications were reported in either group.

Fluoroscopic-guided SIJ injections were associated with greater and more consistent pain relief at short-term follow-up. However, landmark-based injections provided meaningful clinical benefit in the majority of patients and may serve as a practical option when immediate intervention is needed, particularly when imaging resources are unavailable or delayed due to insurance approval. The absence of complications in either group supports the relative safety of both approaches when performed by trained interventionalists. Notably, we maintain that fluoroscopic-guided injections remain the gold standard and should be utilized to confirm sacroiliac joint pain or when assessing patients for potential advanced interventions.

While fluoroscopic guidance offers superior accuracy and therapeutic efficacy for SIJ injections, landmark-based techniques can be a viable solution in specific clinical scenarios. Fluoroscopic-guided injections remain the gold standard and should be utilized to confirm sacroiliac joint pain or when assessing patients for potential advanced interventions.