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DR TIM GRICEINFORMATION SHEET AND CONSENT FOR SACROILIAC JOINT INJECTION WITH OR WITHOUT SEDATION

The Sacroiliac joint (SIJ)

The Sacroiliac joint is the joint between the Spine (Sacrum) and the Pelvis (Ilium) and hence its name. It is a fibrous joint (no cartilage) that has a small amount of movement and is responsible for transferring the weight of the upper body to the pelvis and legs. Its innervation (nerve supply) is complex and variable. It is important during Standing, walking and sitting.

Figure1 Bone of the sacroiliac joint (SIJ) Figure N3rves to SIJ pain

The joint is small joint with little movement, but transmits the weight of the upper body to the pelvis. Irritation or inflammation may occur in these joints, which may cause pain. This may be felt in the back, buttocks or legs as shown in figure 2 above.

Diagnosis of sacroiliac joint dysfunction causing pain

Sacroiliac joint pain is one of the many causes of low back, pelvic and leg pain. The diagnosis is made from a combination of history and distribution of the pain as well as radiological imaging such as CT and MRI scans, along with clinical examination.

One method to confirm the diagnosis is the injection of the joint with local anaesthetic and steroids.

This serves two purposes

1. Confirm the source of the pain should the injection relieve the patients pain and discomfort.2. Treat the underlying inflammation in the joint

While it is not possible to predict or guarantee the effectiveness of any treatment, this procedure may give good long-term relief, partial relief or exclude the SIJ as the primary cause of pain.

Possible results of the procedure

It may treat the pain and the pain does not return It may treat the pain for a short period of time (weeks to months) and then the pain returns

either less or the same as before. In this case a repeat injection or radiofrequency neurotomy may be considered.

There may be no effect on the pain

How is the Procedure performed?

The procedure will be done as a day patient procedure at a Private Hospital, or more often in clinic. You will be advised of the time and place when the appointment is sent to you.

You will need to be fasted for at least six hours before the procedure if sedation is being used. This usually means nothing to eat from midnight the night before a morning procedure, or if your procedure is in the afternoon you may have a light breakfast before 7am.

You should take all your usual painkillers and other medication unless specifically advised otherwise. People on medication for diabetes should discuss what to do regarding insulin and oral hypoglycaemic drugs prior to the procedure

If you are on any blood thinning agents such as warfarin, clopidogrel (Plavix) or Asasantin please let the pain specialist know well in advance as special arrangements will have to be made. This may include stopping these medications up to ten days before the procedure otherwise the injection may have to be rescheduled. You may also need to change onto other blood thinning injections for the period leading up to the procedure.

Please bring a list of your medications and mention any allergies.

You will need someone to drive you home after the procedure and care for you for the next twenty four hours.

This procedure can be performed under sedation by the anaesthetist present, via an IV cannula in the hand, as well as oxygen provided via nasal prongs along with the standard anaesthetic monitoring

An X-ray machine can be used to guide the placement of the injection after the patient is positioned face down on the bed with pillows placed underneath for support.

The area to be injected is then uncovered and sterilized with pink skin preparation usually containing alcohol (and sometimes chlorhexadine) to reduce the risk of infection.

A small needle is placed near the SIJ under radiological guidance and a small volume of local anaesthetic and often steroid. This is to numb the nerve supply to the joint. This may also bring relief if the SIJ is the cause of the pain.

What happens after the procedure?

You will be moved to the recovery area and will be monitored until you have recovered from the sedation and procedure.

You will then move to the second stage of the recovery process before being discharged into the care of a support person.

Wherever possible, the pain specialist performing the procedure will review you before you have been discharged.

You will also receive a follow-up phone call over the next few working days to discuss any benefits or side effects and arrange your next appointment with the pain specialist.

This document provides information on who to contact should you have any questions or complications.

Should the pain specialist be unavailable to immediately review and/or treat a complication, then the second point of contact would normally be your own GP.

If they are unavailable then you should present to the nearest emergency department if you have any major complications or concerns.

COMPLICATIONS

This procedure is usually safe and uneventful. However, as with any procedure there is always a small degree of risk.

Common Complications Continuing pain / no benefit

Minor bleeding in the area injected Bruising in the area injected Temporary weakness or numbness from the local anaesthetic Brief increased pain that may fluctuate in intensity

More Serious Side Effects Damage to surrounding structures Infection Permanent nerve injury Allergy to the anaesthetic drugs used as part of the procedure Increase of any pre-existing medical condition such as cardiac conditions Bruising around the area from needle trauma Aspiration during sedation Eye injury while lying prone (face down) Serious anaesthetic / procedural complications and very rarely death Increased lifetime risk of cancer due to X-rays exposure Very rare risk of surgery due too injuries from the procedure

Please discuss with your doctor any other questions you may have about this procedure or this information sheet. If you agree to have the procedure, you will be asked to sign a consent form.If you notice –

Any swelling from the site, Any bleeding from the site, or Have any other concerns,

Please contact your General Practitioner, Queensland Pain Clinic, or the Emergency Department of your local hospital.

Dr Tim GriceSpecialist Pain Medicine PhysicianQueensland Pain DoctorSuite 4, Level 4123 Nerang StSouthport, QLD 4215Phone: 07 5532 0468Fax: 07 5528 3850Email: admin@qpdr.com.au

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DR TIM GRICEPAIN SCORE CHARTBRING THIS TO YOUR NEXT CONSULTATION WITH DR TIM GRICE

RECORD YOUR PAINIn the table below, record your pain level in the area that has been treated. Please note –

Record your pain every 2 hours, Record your pain for 48 hours following your procedure, Record whether you were active or inactive at the time you recorded your pain.

DATE TIME SCORE ACTIVE INACTIVE

CONSENT

I have had time to read and I understand the information and instructions provided to me regarding the Sacroiliac Joint Injection procedure and post-procedural care Common Complications:- Continuing pain / no benefit, Minor bleeding in the area injected, Bruising in the area injected, Temporary weakness or numbness from the local anaesthetic, Brief increased pain that may fluctuate in intensityMore Serious Complications:- Damage to surrounding structures, Infection , Permanent nerve injury, Allergy to the anaesthetic drugs used as part of the procedure, Increase of any pre-existing medical condition such as cardiac conditions, Bruising around the area from needle trauma, Aspiration during sedation, Eye injury while lying prone (face down), Serious anaesthetic / procedural complications and very rarely death, Increased lifetime risk of cancer due to X-rays exposure, Very rare risk of surgery due too injuries from the procedure

I understand that I have the right at any stage to change my mind even after I have signed this document.

I have had time to ask any questions and raise any concerns I have regarding this procedure and its risks with Dr Tim Grice.

I understand that there are alternatives to this procedure including; no –treatment, medication and psychological support.

I understand that if there were any immediate life threatening Incidents happen during the procedure that they will be treated as part of the procedure.

I understand and agree that a sample of my blood can be taken and tested should a member of staff have exposure to my bodily fluids as part of the procedure.

I believe that all my questions have been discussed and answered to my satisfactionI

I understand that I may need further procedures to get a longer lasting benefit should the injections prove to be beneficial

I understand that this is not a permanent treatment and the pain may return but repeat

treatments or Radiofrequency Neurotomy can be performed in the future. I consent to this procedure with / without sedation (delete not applicable) in the Pain Specialist’s rooms / Operating Theatre (delete one option)

Patient Name: ___________________________________ Date: _________

Patient Signature: ________________________________

Doctor Name: ___________________________________

Doctor Signature: ________________________________

CONTACT DETAILS

Dr Tim Grice Specialist Pain Medicine Physician Queensland Pain DoctorSuite 4, Level 4, 123 Nerang St, Southport, QLD 4215Phone: 07 5532 0468 Fax: 07 5528 3850 Email: admin@qpdr.com.au