Introduction

Estimates of sacroiliac joint sources of back and leg pain have been estimated to be between 10% and 38% using compared diagnostic injections, with a false-positive rate estimated between 0% and 53.8%.^1–3 Not only have diagnostic provocative tests failed to be accurate,^4,5 but there have been numerous efforts to treat sacroiliac joint pain, including intraarticular injections, extraarticular injections, radiofrequency (RF) treatments, fusion, and prolotherapy^6–9 with level II-3 evidence for both short- and long-term relief.²

Sacroiliac pain or dysfunction has been implicated in diverse patient populations and associated morbidities, including pediatric low back pain, pregnancy, cancer, infection, ankylosing spondylitis, and inflammatory bowel disease.^10–13 Controversy surrounds diagnostic accuracy and technique^14–21 because some advocate intraarticular injections but others advocate extraarticular injections or lateral branch blocks before RF treatment. Summarily, interventions are directed to either the afferent nociceptive nerves supplying the joint or the actual joint itself. A corollary can be drawn to zygapophyseal treatments because intraarticular or median branch blocks are used before RF treatment, just as sacroiliac intraarticular injection or lateral branch blocks are performed before using RF. Although widely accepted clinically, this treatment algorithm has recently been questioned.³

As with any treatment plan, complication avoidance begins with patient selection. Treatment of patients with local infection near the injection site, coagulopathy, allergy to injectate, or comorbidities or conditions that prevent fluoroscopic needle guidance or consent should be avoided. A clear understanding of spinal anatomy and utilization of image guidance is vital to ensure both quality treatment and reduced patient morbidity and mortality. Furthermore, it should be understood that appropriate training within Accreditation Council for Graduate Medical Education accredited programs and mentorship is pivotal to ensure treatment success; interventional hobbyists only serve to undermine accessibility of these valuable therapies to patients.

Before proceeding, readers are directed to the chapters that correspond to sacroiliac joint injections; lateral branch blocks; and traditional (see Fig. 15-2), pulsed, and cooled RF treatments (see Fig. 15-5). A brief review of the differences in RF modalities are listed in Table 16-1, and reviewed elsewhere in the text (see Chapter 7). Other modalities to treat sacroiliac joint pain include fusion and prolotherapy,²² this chapter focuses on complications specific to RF neurotomy.

Even after appropriate safeguards and training, significant complications have been described in scattered case reports. Theoretical risks are listed in Box 16-1, and they are typically localized or systemic in nature.

Selected Complications

Meta-analysis of treatment outcomes is difficult because the treatment arm is highly variable regarding RF technique, inconsistent patient selection, outcome endpoints, and definitions of success. Although there is a plethora of literature describing sacroiliac joint interventions, few describe complications.2–4,9,10,13,23–29