Computed tomography, ultrasound and fluoroscopy guidance in intra-articular sacroiliac joint injections: A systematic review

Introduction: Fluoroscopy and Computed Tomography (CT) are the reference standards for verifying needle placement when undertaking an Intra-articular (IA) Sacroiliac Joint (SIJ) injection. The use of Ultrasound (US) for performing SIJ injections has become a focus in recent years, as it eliminates radiation exposure. This systematic review aimed to compare the efficacy of US, CT, and Fluoroscopy when undertaking SIJ injections. Methods: A systematic search was conducted using the databases Embase, PubMed, CINAHL, and Scopus. The included studies were published in English (January 2003 to March 2025) and assessed adult patients who had undergone SIJ injections and the efficacy of one or more modalities using diagnostic accuracy measurements or patient pain and function scores. Results: There were 509 papers identified in the search. Following application of the inclusion and exclusion criteria, eight papers were included in the review. Needle placement accuracy ranged from 40 % to 100 %. CT accuracy ranged from 76 % to 100 %, US from 40 % to 96 %, and Fluoroscopy from 65 % to 92 %. Conclusion: While CT guidance provides precise anatomical detail and high accuracy, and fluoroscopy is accessible and accurate, both involve radiation exposure. US guidance provides real-time visualisation without radiation exposure. Further assessment is required to determine the exact role of US. Implications for practice: Current guidelines recommend fluoroscopy or CT guidance for SIJ injections, but US has merit in this area without the use of ionising radiation exposure. Image fusion could be a feasible alternative guidance for SIJ injections. It combines a previous CT scan with real-time US guidance for precise IA placement, reducing a patient's radiation exposure.