
==== Front
Interv Pain Med
Interv Pain Med
Interventional Pain Medicine
2772-5944
Elsevier

S2772-5944(23)00207-8
10.1016/j.inpm.2023.100375
100375
Letters to the Editor
The therapeutic effectiveness of fluoroscopically guided intra-articular sacroiliac joint injections in patients with sacroiliac joint dysfunction, an observational study
Kristoff Tyler J.
J. Willis Hurst Internal Medicine Residency Program, Emory University School of Medicine, Atlanta, United States
Sinopoli Jacob T.
Case Western Reserve University School of Medicine, Health Education Campus, 9501 Euclid Ave, Cleveland, OH, 44106, United States
Farley Tyler
Department of Physical Medicine & Rehabilitation, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, United States
Rabah Nicholas
Case Western Reserve University School of Medicine, Health Education Campus, 9501 Euclid Ave, Cleveland, OH, 44106, United States
Thompson Nicolas R.
Department of Quantitative Health Sciences, Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, United States
Goyal Kush goyalk@ccf.org
∗
Center for Spine Health, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, United States
∗ Corresponding author. 1730 West 25 Street, 1E, Cleveland, OH, 44113, United States. goyalk@ccf.org
15 12 2023
12 2023
15 12 2023
2 4 10037520 11 2023
22 11 2023
© 2023 The Authors. Published by Elsevier Inc. on behalf of International Pain & Spine Intervention Society.
2023

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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pmcReply Letter to Editor:

Thank you for your feedback and comments. We will try to provide clarification regarding steroid use and physical therapy (PT).

First, as requested, is our data comparing various corticosteroid efficacy on pain and function after intra-articular sacro-iliac joint (SIJ) injection performed under fluoroscopy (Table 1). Of note, few patients had methylprednisolone 40mg and thus were excluded from statistical analysis.Table 1 Frequency and percent of patients who improved by MCID for each scale, stratified by corticosteroid type after intra-articular sacro-iliac joint (SIJ) injection performed under fluoroscopy.

Table 1	Time Point	Triamcinolone 40 mg	Methylprednisolone 40 mg	Methylprednisolone 80 mg	
N	Improve by MCID
N (%)	N	Improve by MCID
N (%)	N	Improve by MCID
N (%)	
Pain (NRS)
(MCID = 2.5)	1-month follow-up	92	57 (62.0 %)	6	5 (83.3 %)	163	96 (58.9 %)	
3-month follow-up	73	23 (31.5 %)	5	3 (60.0 %)	122	58 (47.5 %)	
6-month follow-up	36	10 (27.8 %)	2	1 (50.0 %)	61	36 (59.0 %)	
1-year follow-up	23	6 (26.1 %)	5	2 (40.0 %)	49	17 (34.7 %)	
PHQ-9 (MCID = 5)	3-month follow-up	58	10 (17.2 %)	3	0 (0.0 %)	94	18 (19.1 %)	
6-month follow-up	46	12 (26.1 %)	2	0 (0.0 %)	57	14 (24.6 %)	
1-year follow-up	41	12 (29.3 %)	0	N/A	71	17 (23.9 %)	
2-year follow-up	22	8 (36.4 %)	1	0 (0.0 %)	59	9 (15.3 %)	
PROMIS-GH
Physical Health (MCID = 5)	3-month follow-up	54	14 (25.9 %)	0	N/A	22	10 (45.5 %)	
6-month follow-up	35	8 (22.9 %)	0	N/A	17	5 (29.4 %)	
1-year follow-up	39	11 (28.2 %)	0	N/A	23	8 (34.8 %)	
2-year follow-up	17	5 (29.4 %)	0	N/A	23	9 (39.1 %)	
PROMIS-GH
Mental Health (MCID = 5)	3-month follow-up	56	11 (19.6 %)	0	N/A	22	10 (45.5 %)	
6-month follow-up	36	7 (19.4 %)	0	N/A	17	5 (29.4 %)	
1-year follow-up	41	12 (29.3 %)	0	N/A	25	6 (24.0 %)	
2-year follow-up	17	3 (17.6 %)	0	N/A	23	3 (13.0 %)	
EQ-5D (MCID = 0.11)	1-month follow-up	42	10 (23.8 %)	2	0 (0.0 %)	109	40 (36.7 %)	
3-month follow-up	45	14 (31.1 %)	3	0 (0.0 %)	88	27 (30.7 %)	
6-month follow-up	37	10 (27.0 %)	1	0 (0.0 %)	63	20 (31.7 %)	
1-year follow-up	45	17 (37.8 %)	1	1 (100.0 %)	84	25 (29.8 %)	
PDQ (MCID = 16)	1-month follow-up	33	5 (15.2 %)	0	N/A	87	33 (37.9 %)	
3-month follow-up	27	9 (33.3 %)	3	0 (0.0 %)	55	14 (25.5 %)	
6-month follow-up	12	4 (33.3 %)	0	N/A	26	11 (42.3 %)	
1-year follow-up	9	1 (11.1 %)	2	0 (0.0 %)	25	5 (20.0 %)	

The frequency and percent of patients who improved by the MCID for each scale, stratified by corticosteroid type, are shown in Table 1. Mixed-effects linear regression modeling revealed that patients who were administered methylprednisolone 80 mg had significantly greater improvement in pain (as measured by NRS) than patients who were administered triamcinolone 40 mg (omnibus p-value <0.001). For change in PROMIS-GH mental health T-score, we found a significant interaction between time point and corticosteroid type (omnibus p-value = 0.014). Compared to patients who were administered triamcinolone 40 mg, patients who were administered methylprednisolone 80 mg had more improvement in PROMIS-GH mental health T-score at 3-month and 6-month follow-up but not at 1-year and 2-year follow-up. There were no significant differences in change in score by corticosteroid type for PHQ-9, PROMIS-GH physical health, EQ-5D, or PDQ (all omnibus p-values >0.05).

While we agree that PT plays an important role in restoring function prior to and after intra-articular SIJ injection, we did not document and analyze PT due to a number of factors.

First, of the many patients that were referred to our tertiary care center, some had performed PT outside our medical system. This made retrospective review of outside records cumbersome and would allow for inconsistency between treatment centers. During follow-up appointments, when discussing PT, we observed varying compliance, quantity of PT sessions, and quality of home exercise program.

Second, in the instances where therapy was documented, evaluating quality of physical therapy is quite subjective. The qualifications and training of the person providing PT can vary based on location and facility.

Lastly, there was significant variability in the patients' utilization of PT. Many were unable to continue PT after injection due to cost, distance and/or lack of time commitment. Some patients stated they preferred to continue with their home exercise program based off their pre-injection PT. Many patients refused further PT after experiencing significant pain relief after injection.

While at our facility, active PT with home exercise program was emphasized both before and after procedure, for the aforementioned reasons, data on PT was not collected or reported in our review.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
