Sacroiliac Joint Injection Procedure Note

Date/Time of Procedure: [Date and time of procedure]
Location: [Facility name], [Room/Suite]
Performing Clinician: [Name, credentials]
Patient Identifiers: [Per facility policy]
Procedure: Sacroiliac (SI) Joint Injection — Laterality: [right / left / bilateral]

Clinical Indication

Pre-procedure diagnosis: [Diagnosis with laterality] (State suspected SI joint–mediated pain with side; include associated diagnoses only if explicitly documented.)

Procedure intent: [diagnostic intra-articular injection / therapeutic intra-articular injection / combined diagnostic and therapeutic] (If combined, state how immediate and delayed responses will be interpreted.)

Target structure: Intra-articular SI joint [right / left / bilateral]

Competing diagnoses: [Statement that alternative pain sources were considered or excluded based on history, exam, and/or imaging]

Pre-Procedure Assessment

Baseline pain and function:
- Baseline pain score: [NRS 0–10 / VAS] [value] (Use same scale pre- and post-procedure.)
- Patient-reported laterality of pain: [right / left / bilateral]
- Functional limitations: [Patient-specific tasks and/or standardized measure with values]
- Prior SI joint injections: [none / yes] (If yes, include percent relief, duration of benefit, and approximate date.)

Pain pattern:
- Maximal pain location: [Description, e.g., posterior pelvis near PSIS/sacral sulcus]
- Radiation pattern: [Description or none]
- Radicular features: [present / absent]

Provocative maneuvers: (Mark each as positive if it reproduces familiar pain, negative, or not performed.)

• FABER/Patrick: [positive / negative / not performed]
• Gaenslen: [positive / negative / not performed]
• Thigh thrust/Posterior shear: [positive / negative / not performed]
• SI compression: [positive / negative / not performed]
• SI distraction: [positive / negative / not performed]
• Yeoman: [positive / negative / not performed]

Summary: [#]/6 positive provocative maneuvers (At least 3 positive maneuvers are typically required to support SI joint as pain generator.)

Imaging reviewed: [Study type, date, and key findings] (If none reviewed, state "Imaging not reviewed today.")

Conservative care to date: [Physical therapy, home exercise program, activity modification, medications, and current rehabilitation plan]

Safety screening:
- Allergies: local anesthetics [none / agent and reaction], corticosteroid [none / agent and reaction], iodinated contrast [none / agent and reaction], chlorhexidine [none / reaction type]
- Active infection (local/systemic): [none / suspected / confirmed] (If present, defer procedure and document plan.)
- Anticoagulant/antiplatelet therapy: [none / agent(s)] — Management: [continued / held / last dose date / bridging plan]
- Pregnancy status: [not applicable / negative / positive / unknown] (If unknown and relevant, document mitigation plan.)
- Diabetes: [no / yes] — Steroid glucose counseling: [completed / not applicable]
(For any high-safety item not assessed, explicitly state "not assessed" with mitigation plan.)

Informed Consent

Informed consent obtained. Risks discussed included bleeding, infection, allergic reaction, pain flare, lack of benefit, nerve injury, and steroid-related side effects. Alternatives reviewed including conservative care, physical therapy, and medication optimization. Patient had opportunity for questions and agreed to proceed.

Time-Out Verification

• Patient identity verified
• Procedure and laterality confirmed
• Site marked per facility protocol [yes / not applicable]
• Allergies reviewed
• Imaging available and functioning
• Team members identified

Time-out completed immediately prior to needle insertion.

Procedure

Positioning and monitoring: Patient positioned [prone / lateral / other]. Monitoring: [vital signs / pulse oximetry / continuous ECG / none]

Sedation: [none / minimal anxiolysis / IV anxiolysis / moderate sedation / MAC] (If sedation beyond minimal anxiolysis, document medical necessity.)

Imaging guidance: [fluoroscopy / CT]. Views obtained: [list views used to confirm placement]. Fluoroscopy time/dose: [time and/or dose metrics, if available]. Images saved to [PACS / medical record].

Sterile technique: Skin prepped with [prep agent], sterile draping performed, appropriate PPE used. Local skin anesthesia: [drug], [concentration], [volume].

Right SI Joint

(Include if right side injected.)

Needle placement: Needle: [gauge], [length]. Approach: [posterior-inferior intra-articular / other]. Technique: Skin wheal placed, needle advanced under imaging guidance into joint space, final position confirmed, negative aspiration.

Contrast confirmation: Contrast: [agent], [volume]. Intra-articular spread: [confirmed / not confirmed]. Vascular uptake: [none observed / suspected]. (If contrast omitted, state reason and alternative confirmation method.)

Injectate: Local anesthetic: [name], [concentration], [volume]. Corticosteroid: [name], [dose in mg], [volume]. Diluent: [if used]. Total volume: [mL]. (For diagnostic-only injection, state "no steroid injected.")

Left SI Joint

(Include if left side injected.)

Needle placement: Needle: [gauge], [length]. Approach: [posterior-inferior intra-articular / other]. Technique: Skin wheal placed, needle advanced under imaging guidance into joint space, final position confirmed, negative aspiration.

Contrast confirmation: Contrast: [agent], [volume]. Intra-articular spread: [confirmed / not confirmed]. Vascular uptake: [none observed / suspected]. (If contrast omitted, state reason and alternative confirmation method.)

Injectate: Local anesthetic: [name], [concentration], [volume]. Corticosteroid: [name], [dose in mg], [volume]. Diluent: [if used]. Total volume: [mL]. (For diagnostic-only injection, state "no steroid injected.")

Tolerance and complications: Procedure [well tolerated / tolerated with concerns]. Complications: [none / vasovagal / intravascular injection signs / allergic symptoms / neurologic changes / bleeding / other].

Post-Procedure Assessment

Post-procedure pain score (same scale as baseline): [NRS 0–10 / VAS] [value]
Targeted neuro check: [normal / findings] (Include if clinically relevant.)
Dressing applied, hemostasis confirmed.
Disposition: [routine discharge / observed then discharged with escort]

Pain Diary and Response Assessment Plan

Baseline anchors captured today: Pain score: [value]. Functional tasks: [task 1], [task 2], [task 3] (Patient-relevant, reproducible activities.)

Diary instructions: Record pain scores hourly for [4–6 hours] during anesthetic window and daily for [number] days thereafter. At each timepoint, record functional task performance and analgesic use.

Response criteria: For diagnostic injection: positive response defined as [≥50% / ≥80%] relief during anesthetic phase with duration consistent with agent used. For therapeutic injection: document onset and magnitude of relief consistent with steroid timeline. Duration of relief must be documented.

Follow-Up Plan

Follow-up timing: [Early follow-up within days for diary review / 1–4 weeks for steroid effect assessment]

• Positive response: Confirm SI-mediated pain; proceed with SI-directed care [continued therapy / repeat injection / consider RF ablation or fusion per guidelines].
• Partial or unclear response: Reassess differential; consider confirmatory strategy [repeat diagnostic block / alternative workup].
• No response: SI joint less likely as primary source; redirect workup and management.

Rehabilitation: [Continue / escalate] active rehabilitation program.
Next appointment: [Date/time / not yet scheduled] (If not scheduled, note that pain diary and functional measures will be reviewed at next visit.)