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R E S E A R C H A R T I C L E Open Access
Image guided sacroiliac joint corticosteroid
injections in children: an 18-year single-
center retrospective study
Racha Chamlati
1
, Bairbre Connolly
1
, Ronald Laxer
2
, Jennifer Stimec
3
, Jyoti Panwar
3
, Shirley Tse
2
,
Prakash Muthusami
1
, Joao Amaral
1
, Michael Temple
1
and Dimitri A. Parra
1*
Abstract
Background: Sacroiliitis is commonly seen in enthesitis-related arthritis (ERA), a subtype of juvenile idiopathic
arthritis (JIA). Sacroiliitis is characterized by the inflammation of the sacroiliac (SI) joints (+/−adjacent tissues). The
treatment options include systemic therapy with or without corticosteroid SI joint injections. Image guided SI joint
injections are frequently requested in pediatric patients with sacroiliitis.
The purpose of this study was to evaluate the feasibility and efficacy of SI joint injections in children with sacroiliitis.
Methods: A retrospective study of patients referred to Interventional Radiology (IR) for SI joint corticosteroid
injections (2000–2018). Clinical information was collected from Electronic Patient Charts and procedural details from
PACS. Efficacy was determined clinically, by MRI, or both when available.
Results: 50 patients (13.8 years; M:F = 35:15) underwent image-guided SI joint corticosteroid injections. Most
common indications were JIA (84%) and inflammatory bowel disease (14%). 80% had bilateral injections. 80% were
performed under general anesthesia and 20% under sedation. The corticosteroid of choice was triamcinolone
hexacetonide in 98% of patients. Needle guidance and confirmation was performed using CT and fluoroscopy
(54%), Cone Beam CT (CBCT, 46%), with initial ultrasound assistance in 34%. All procedures were technically
successful without any complications. 32/50 patients had long-term follow-up (2 years); 21/32 (66%) had clinical
improvement within 3-months. Of 15 patients who had both pre- and post-procedure MRIs, 93% showed short-
term improvement. At 2 years, 6% of patients were in remission, 44% continued the same treatment and 47%
escalated treatment.
Conclusion: Image-guided SI joint injections are safe and technically feasible in children. Imaging modalities for
guidance have evolved, with CBCT being the current first choice. Most patients showed short-term clinical and
imaging improvement, requiring long-term maintenance or escalation of medical treatment.
Keywords: Sacroiliac joints, Corticosteroid injections, Juvenile idiopathic arthritis, Children
Background
Juvenile idiopathic arthritis (JIA) is the most common
pediatric rheumatic disease and cause of arthritis in chil-
dren, with an incidence of 1 to 22 in 100,000 and a
prevalence of 7 to 150 in 100,000 [1]. JIA is defined as
persistent arthritis for at least 6 weeks, presenting before
16 years of age, of unknown etiology after excluding
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changes were made. The images or other third party material in this article are included in the article's Creative Commons
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licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence: dimitri.parra@sickkids.ca
1
Division of Image Guided Therapy, Department of Diagnostic Imaging, The
Hospital for Sick Children, University of Toronto, 555 University Avenue,
Toronto, ON M5G 1X8, Canada
Full list of author information is available at the end of the article
Chamlati et al. Pediatric Rheumatology (2020) 18:52
https://doi.org/10.1186/s12969-020-00435-8
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
other causes [2]. The International League of Associ-
ation for Rheumatology (ILAR) classifies JIA into seven
subtypes: systemic arthritis, oligoarthritis (persistent and
extended), polyarthritis rheumatoid factor negative, poly-
arthritis rheumatoid factor positive, enthesitis-related
arthritis (ERA), psoriatic arthritis, and undifferentiated
arthritis [3,4]. An important goal in JIA is early recogni-
tion and management to achieve inactive disease, main-
tain remission, and prevent irreversible joint damage
and deformities [2].
Sacroiliitis can be seen in JIA, especially ERA, and is
characterized by the inflammation of the sacroiliac joint
and adjacent tissues. Sacroiliitis is a common feature of
spondyloarthritis (SpA) with incidences that range from
20% in SpA related to inflammatory bowel disease, to
100% in ankylosing spondylitis [5]. Although frequently
asymptomatic, sacroiliitis can present as lower back or
buttock pain aggravated with movements, such as rising
to stand, walking, running, and climbing. If untreated, it
may lead to fusion of the SI joints. Sacroiliitis should be
suspected if there is a history of inflammatory back pain
or demonstration of positive SI provocation tests [6]. MRI
is considered the gold standard for imaging of SI joints
with a high sensitivity and specificity compared to plain
radiography and bone scanning respectively [7,8]. It dem-
onstrates early features of inflammation and effusion, as
well as chronic changes such as sclerosis, erosions, anky-
losis and bone marrow changes. Although plain radiog-
raphy can still be accepted if patients fulfill the New York
criteria for sacroiliitis [7,8], it can lead to a delay in diag-
nosis as x-rays are often normal at disease onset [9].
Multiple medications are used to treat patients with JIA,
specifically those with ERA, including nonsteroidal Anti-
Inflammatory Drugs (NSAIDs), Disease-Modifying Anti-
rheumatic Drugs (DMARDs), corticosteroids and biologic
agents including anti-tumor necrosis factor-alpha (anti-
TNFα) inhibitors [10]. There are insufficient comparison
studies on the efficacy of different treatment plans for the
management of sacroiliitis in the pediatric population.
NSAIDs are found to be effective in the short term, for
direct symptomatic relief and are particularly effective for
enthesitis in children [11]. Continuous use of NSAIDs in
adults has been shown to achieve improvement radio-
logically, and to slow disease progression, however, their
efficacy has not been determined in children [11]. An
emerging trend is the use of anti-TNFαinhibitors, specif-
ically etanercept, adalimumab and infliximab. They have
shown exceptional clinical results and can be used as first
line treatment for JIA patients with axial involvement [11].
Precautions with anti-TNFαinhibitors are required given
the associated risk of infections, hypersensitivity reactions,
psoriasis, demyelination and malignancy [11].
Another therapeutic option for arthritis in children is
intra-articular (IA) corticosteroid injections, providing
rapid improvement and with minimal systemic risks in
comparison with systemic corticosteroids [12]. Potential
risks of IA injections include infection, bleeding, skin at-
rophy, hypopigmentation, chemical irritation and cal-
cium deposits and focal demineralization [12]. IA
injections are often used in conjunction with systemic
therapy at presentation or during the course of treat-
ment. Corticosteroid injections (IA and tendon sheath)
are performed by many paediatric interventional radi-
ology (IR) practices using image guidance [2]. Image
guided SI joint injections have been performed in our
center for more than 15 years. In the context of new sys-
temic therapies, the current role of IA injections in the
treatment of pediatric patients with sacroiliitis is still to
be determined. The aim of this retrospective study was
to review the feasibility and efficacy of image guided cor-
ticosteroid SI joint injections in children.
Methods
Research Ethics Board approval was obtained. This
retrospective study was conducted at a pediatric tertiary
care hospital. The study population included patients re-
ferred to IR for SI corticosteroid joint injections (Jan
2000 –Jan 2018). Patient demographics and clinical his-
tories were collected from the Electronic Patient Charts
(EPC). Procedural details and imaging were collected
from Picture Archiving and Communication System
(PACS, GE Milwaukee, USA).
Technique
Referral for SI joint injections were done by the rheuma-
tology team. Sacroiliitis was diagnosis based on clinical
symptoms, associated with consistent findings in MRI.
Sedation or anesthetics were given based on patient
preferences and cooperation, which was assessed by the
nurse or anesthesiologist, as well as procedure details
(e.g. number of concomitant joint injections). A staff
pediatric interventionalist performed the procedures
under image guidance. The interventional radiologist
performing the injection obtained informed consent.
Procedures were performed with the patient in the
prone position and using a sterile technique. Needle
guidance and positioning within the joint was performed
and confirmed with CT fluoroscopy, or Cone Beam CT
(available since 2010), depending on availability and/or
radiologist preference (Fig. 1). Cone beam CT is a mo-
dality in which cross sectional images are generated
from a flat panel C arm in the interventional radiology
room. The images generated have a similar quality to
conventional CT and allow procedure guidance with less
radiation exposure. Ultrasound (US) was occasionally
used, according to radiologist preference as well. The
needle was placed in the lower third of the SI joint. The
corticosteroid was prescribed by the rheumatology team
Chamlati et al. Pediatric Rheumatology (2020) 18:52 Page 2 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
based on the patient’s body weight. Triamcinolone hexa-
cetonide was used in most cases and the doses are as fol-
low: 10 to 20 Kg: 20 mg; more than 20 to 40 Kg: 30 mg;
more than 40 Kg: 40 mg. In the case of triamcinolone
acetonide the doses are 40, 60 and 80 mg respectively.
The corticosteroid injection was followed by a similar
volume of lidocaine 1%. Most of the time, no contrast
was used due to the small joint space. A sterile dressing
was applied to the skin. The referring rheumatologist
was informed of the outcome of the procedure. Post-
procedure, the patients were transferred to the post
anesthesia care unit (PACU) and discharged home 2
hours later.
The efficacy of the SI corticosteroid injection was
assessed both clinically and by MR imaging. Patients
with incomplete data and those with IBD were excluded
for this assessment. Medical records were reviewed for
peri- and post-procedural complications. Clinical out-
comes were based on the information available in clin-
ical notes and assessed at two time periods, within 3
months (short term) and 2 years post injection (long
term). Short term response was classified as Good or
Poor; patients rendered asymptomatic or experiencing a
decrease in severity of symptoms such as pain at the
injected joints within a 3 month period as per docu-
mented in the chart were classified as having a good re-
sponse to treatment; patients experiencing the same or
an increase in severity of symptoms within a 3 month
period were classified as having a poor response to treat-
ment. Two radiologists (JS, JP) assessed imaging re-
sponse in patients with both pre- and post-injection
MRI by using the Spondyloarthritis Research Consor-
tium of Canada (SPARCC) scoring system. Both ob-
servers were blinded to clinical information and timing
of the studies and they worked independently. All
examinations were performed on a 1.5-T MRI system
(Magnetom Avanto, Siemens, Erlangen, Germany), using
a dedicated surface coil system and included oblique
coronal short tau inversion recovery (STIR) imaging
(repetition time msecTR/TE/TIecho time msec of 2250/
69/x msec, with a field of view of 25 cm, slice thickness
of 4 mm with a slice gap of 4.5 mm) of the SI joints.
Scoring was performed on six consecutive oblique cor-
onal slices, covering most of the cartilaginous and syn-
ovial portion of the joint, by utilizing three MR indices:
1) presence of bone marrow edema, 2) extent or depth
of edema and 3) intensity of edema [13,14]. Patients ex-
periencing a decrease in SPARCC score post-injection
were classified as having a good response to treatment,
whereas those with an increase in score were classified
as having a poor response to treatment.
Clinical status 2 years post-injection, long term re-
sponse was categorized as inactive disease (remission
and off medications) and ongoing disease activity that
was then divided into 3 subcategories: decreased (de-
crease dose/frequency or removal of drug), maintained
(unchanged dose/frequency of drug) or escalated (in-
crease dose/frequency or addition of drug).
Results
Patient population
Fifty patients with sacroiliitis underwent SI joint injec-
tions during the study period and all injection were tech-
nically successful. Thirty-five (70%) were male and 15
were female (30%), ranging from 8 to 18 years old with a
median age of 14 years, IQR of 4. 32/50 (64%) had a two
year follow up and were included in the clinical response
assessment; 15/50 (30%) had both pre- and post-
injection MRI imaging and were included in the imaging
assessment; 15/50 (30%) had both clinical and imaging
assessment performed (Fig. 2).
The most common etiology was JIA (84%) followed by
inflammatory bowel disease (14%). 26 patients (52%)
were HLA B27 positive, 17 patients (34%) were HLA
B27 negative and 7 patients (14%) were not tested.
Twenty-two out of the 26 HLA B27+ patients (85%)
were diagnosed with ERA, 1 (4%) had psoriatic arthritis
and 3 (11%) had IBD (Table 1). 3/50 (6%) required two
SI joint injections during the study period. Injections
were performed bilaterally in 80% and unilaterally in
20% (40% left and 60% right). General anesthesia was
used in 80% and sedation in 20% (14% nurse sedation,
6% anesthesiologist). Triamcinolone hexacetonide was
used in 49 patients (98%) as this is our preferred intra-
articular corticosteroid. Triamcinolone acetonide was
employed in 1 patient (2%) due to shortage of triamcino-
lone hexacetonide in the country. A 22 G Chiba needle
was most commonly used (17 patients, 40%).The other
Fig. 1 Cone beam CT guided SI joint injection w/o contract
Chamlati et al. Pediatric Rheumatology (2020) 18:52 Page 3 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
needles used were: 22 Spinal (16.6%), 25 Spinal (38.1%),
20 Chiba (2.4%) and 18 Trocar (2.4%). The greater part
of the patients (18 patients, 36%) received a dose of 20
mg (1 ml). CT fluoroscopy (2000–2016) was used for
image guidance and confirmation in 27 patients (54%),
with adjunctive US in 12/27; Cone Beam CT (2010–
2018) was employed in 23 patients (46%), with adjunct-
ive US in 5/23. All procedures were technically success-
ful without any complications.
Of the 32 patients with a short (3-month) and long-
term (2 year) follow-up, 18 patients (56%) had only SI
joint involvement, while the remaining 14 patients (44%)
had multiple joints involved. In the 3-month follow up
period, 21 (66%) patients improved clinically and had no
residual SI joint tenderness, whereas 11/32 (34%)
remained symptomatic with active sacroiliitis (Fig. 3).
Within two years post injection, remission was achieved
in 2/32 patients (6%); treatment was reduced in 1/32 pa-
tient (3%), maintained in 14 patients (44%) and escalated
in 15 patients (47%), with 13/15 starting on biologics.
Among the 13 patients who were escalated to biologics,
7 (54%) had isolated sacroiliitis and 6 (46%) had multiple
joint involvement.
Fifteen out of the 32 patients had a pre- and post-
procedure MRI with a mean of 9.4 months (range 0.25
to 33 months) post injection. 11/15 (73%) had isolated
sacroiliitis and 4/15 (27%) had multiple joint involve-
ment. On post-procedure MRI, 14/15 (93%) showed a
decrease in their SPARCC score, 2 of whom (14%) were
on biologics prior to the injection, 10/14 (66.7%) im-
proved clinically and the remaining 4 patients (26.7%)
reported worsening of symptoms (Fig. 4); 1/15 (6.6%)
had a higher SPARCC score. The median change in
SPARCC score was found to be −14.5 with an inter-
quartile range of 12.5. Out of the 14 patients with a de-
crease in SPARCC score, 12 (86%) met the minimal
clinically important difference of 2.5.
As mentioned before, In the 2-year follow up period,
13 patients had an escalation of treatment starting bio-
logic agents, with a mean initiation time of 6.11 months
(range 0.5 to 18 months) post-injection. When taking
into account joint involvement, in the 11 patients with
isolated sacroiliitis, 1 (9%) achieved remission, 1 (9%) re-
duced treatment, 4 (36%) remained on the same treat-
ment plan and 5 (46%) escalated. Among the 4 patients
with multiple joint involvement, 3 (75%) remained on
the same treatment plan and 1 (25%) escalated to
Fig. 2 Patient flow chart
Table 1 Patient demographics
Mean Age (years) 13.8 (8–18)
Gender F: 15 (30%); M: 35 (70%)
HLA B 27 Status Number of Patients (%)
Positive 26 (52)
Negative 17 (34)
Not Done 7 (14)
Patient Diagnosis Number of Patients (%)
Juvenile Idiopathic Arthritis 42 (84)
Inflammatory Bowel Disease 7 (14)
Isolated Sacroiliitis 1 (2)
Chamlati et al. Pediatric Rheumatology (2020) 18:52 Page 4 of 7
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biologics. Table 2ilustrates the long term follow up in
the group of patients in whom a change of SPARCC
score was assessed.
Discussion
Sacroiliitis is a prominent clinical manifestation of the
ERA sub-type of JIA and is frequently associated with
HLA B27 positivity. It can be treated medically or by SI
corticosteroid joint injections. The management of pa-
tients with JIA requires a multidisciplinary approach as
shown in this study in which rheumatology, diagnostic
imaging and interventional radiology worked together to
provide diagnosis, treatment and follow up. Prior to
image guided techniques, corticosteroid injections were
performed by palpation of anatomical landmarks. How-
ever, this technique lacked specificity or efficiency due
to the complexity of the sacroiliac joint anatomy [15].
With evolving imaging technology, image guided tech-
niques have become increasingly available. Historically,
fluoroscopy was employed. With the advent of cross sec-
tional imaging, conventional CT or cone beam CT has
been used to guide needle placement and ensure suc-
cessful intra-articular injections [15]. US has also been
utilized for needle guidance, on its own or combined
with cross sectional imaging [16]. More recently there
are reports of MRI guided injections [17]. The use of
three needles has been reported in the literature, in the
inferior, middle and superior aspects of the joint [17],
however currently only one needle in the inferior or
middle synovial portion of the joint is preferred [18]. Al-
though two different cross sectional imaging modalities
were used in this study, all cases were successfully com-
pleted without any peri- or post-procedure complication.
US assisted in approximately one third of the SI joint in-
jections. From 2000 to 2009, CT fluoroscopy were the
only cross sectional imaging option available in this IR
practice. In 2010, Cone Beam CT became available and
provided satisfactory image guidance for the procedure.
It eventually replaced CT fluoroscopy in 2016 due to its
adequate performance, ease of use and recognized radi-
ation dose reduction, as has been demonstrated in the
literature [19,20]. The corticosteroid currently used is
triamcinolone hexacetonide as studies have shown that
it is more effective than hydrocortisone succinate and
triamcinolone acetonide in reducing pain and joint in-
flammation [21,22].
Similar to the benefits of injections in other joints, cor-
ticosteroids relieved the symptoms (especially pain) with
SI joint inflammation in the majority of the patients.
This was assessed in two ways: clinically by patient his-
tory/physical exam, and on imaging by assessing and
scoring MRIs before and after the procedure. Most of
the patients with a decrease of inflammation on post in-
jection MRI also reported symptomatic improvement
and met the MCID in the SPARCC SIS of 2.5 [23]. An
interesting finding is that a group of patients despite the
imaging improvement had worsening of symptoms. The
Fig. 3 Post injection short term assessment
Table 2 Long term management Vs. MRI findings
Decrease SPARCC Increase SPARCC
Decrease Treatment 1 (6.7%) 0
Same Treatment 6 (40%) 1 (6.7%)
Escalated Treatment 6 (40%); 5 (33%) started biologics 0
Remission 1 (6.7%) 0
Chamlati et al. Pediatric Rheumatology (2020) 18:52 Page 5 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
reason why this happens is currently unclear to us
and warrants further studies.
Clinical improvements were not sustained in the
majority of patients who received joint injections.
Within 2 years, only two patients achieved remission
and one patient a reduction in treatment. The re-
mainder stayed on the same management plan or es-
calated to a higher level of medical therapy (eg.
biologic agents) within a year. More than half of the
patients who transitioned to biological agents had ex-
clusively SI joint involvement.
There are several limitations with this retrospective
study. Disease severity may have been underestimated as
patient history and complaints were limited to those re-
corded in the rheumatology clinic notes. Radiological re-
ports may not have captured all procedural details or
difficulties encounter during SI joint injections, resulting
in an underestimate. Some patients were transferred to
adult facilities once they came of age or were simply lost
to follow-up. Follow-up MRIs were not consistently per-
formed on a protocol basis, but variably depending on
clinical indication. Due to the complexity of the manage-
ment of sacroiliitis in JIA patients, a comparison of
monotherapy with corticosteroid injections to medical
management alone was not possible.
Conclusion
Image guided SI joints injections are safe and feasible in
pediatric patients. With the evolution of fluoroscopic
systems, CBCT has replaced conventional CT as the im-
aging modality of choice. In our cohort of patients,
intra-articular injections provided short-term symptom
relief, but in the longer term, most of the patients were
maintained or escalated to systemic medical therapy
within months to a year. The lack of standardized man-
agement and follow up protocols makes it difficult to
analyze the clinical evolution of these patients. Collabor-
ation between rheumatology, diagnostic and
interventional radiology is beneficial in their manage-
ment. The role of corticosteroid SI joint injections in the
context of new systemic therapies requires further
investigation.
Abbreviations
ERA: enthesitis-related arthritis; JIA: juvenile idiopathic arthritis;; SI: sacroiliac;
IR: interventional radiology; CBCT: cone beam CT; ILAR: International League
of Association for Rheumatology; SpA: spondyloarthritis; NSAIDs: nonsteroidal
Anti-Inflammatory Drugs; DMARDs: Disease-Modifying Antirheumatic Drugs;
anti-TNFα: anti-tumor necrosis factor-alpha; IA: intra-articular; EPC: Electronic
Patient Charts PACS: Picture Archiving and Communication System; US:
Ultrasound; PACU: post anesthesia care unit; IBD: inflammatory bowel
disease; SPARCC: Spondyloarthritis Research Consortium of Canada; STIR:
short tau inversion recovery; MCID: minimal clinically important differences;
SPARCC SIS: Spondyloarthritis Research Consortium of Canada sacroiliac joint
inflammation score.
Acknowledgements
Not applicable
Authors’contributions
DP was the primary investigator of the paper, supervising, analyzing and
interpreting patient data. RC gathered, analyzed and interpreted the patient data
from charts, as well as wrote the manuscript. JP and JS assessed imaging
response in patients with both pre- and post-injection MRI. All authors read,
edited and approved the final manuscript.
Ethics approval and consent to participate
Research Ethics Board approval was obtained.
Consent for publication
Not Applicable
Competing interests
The authors declare that they have no competing interests.
Author details
1
Division of Image Guided Therapy, Department of Diagnostic Imaging, The
Hospital for Sick Children, University of Toronto, 555 University Avenue,
Toronto, ON M5G 1X8, Canada.
2
Division of Rheumatology, Department of
Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto,
Canada.
3
Department of Diagnostic Imaging, The Hospital for Sick Children,
University of Toronto, Toronto, Canada.
Fig. 4 Post injection SPARCC score assessment
Chamlati et al. Pediatric Rheumatology (2020) 18:52 Page 6 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Received: 2 November 2019 Accepted: 6 May 2020
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