Sonoanatomy and

Injection Technique of
the
Iliolumbar Ligament

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

AUTHORS
Dominic Harmon, MD, FCARCSI
Vladimir Alexiev, MD, FCARCSI
Department of Anesthesia and Pain
Medicine, Mid-Western
Regional Hospital, Dooradoyle,
Limerick, Ireland
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

Iliolumbar ligament
The iliolumbar ligament is a strong
ligament passing from the tip of
the transverse process of the fifth
lumbar vertebra to the posterior
part of the inner lip of the iliac
crest

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

The iliolumbar ligament plays an

important biomechanic role in
anchoring
the spine to the pelvic ring and
stabilizing the sacroiliac joint

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

The iliolumbar ligament is one of the

common sources of low back pain

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Iliolumbar syndrome
Iliolumbar syndrome is a back pain
condition caused by pathology of the
iliolumbar ligament
Injection of local anesthetic into the
structure considered to be diagnostic
of the source of the pain (i.e. the
iliolumbar ligament)

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

 Iliolumbar syndrome, also known as iliac

crest pain syndrome,or multifidus
triangle syndrome involves an
inflammation or tear of the iliolumbar lig.
The pain is localized to the
posterior/medial portion of the iliac crest,
might be constant, and is aggravated by
activity (especially bending to the
contralateral side)
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

Injury to the iliolumbar ligament occurs

:
1-repeated bending and twisting, as in
a sport like golf or volleyball
Trauma, such as a car accident, can
also cause iliolumbar syndrome

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

lifting heavy loads while rotating

laterally (manual workers, golf
players, etc)
The pathology is believed to be
ligament strain

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Symptoms of iliolumbar
syndrome
Recurrent attacks of acute low back
pain in the area referred to as the
"multifidus triangle"

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

 Pain can be referred to the groin with

an increase in discomfort after
prolonged siting or standing
Aggravated by repetitive extensionflexion activity

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Physical examination
One iliac crest is frequently lower
than the other (Usually the painful
iliac crest is the higher one)
lateral bending away from the
painful side produces or increases
LBP

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

 The most typical sign is tenderness

on palpation of the iliac crest on the
involved side
Tenderness is usually limited to the
insertion of the iliolumbar ligament

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Treatment:
Injection:
local anesthetics with or without
steroids/ prolotherapy

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Differential Diagnoses
Quadratus lumborum muscle
Erector spinae muscle
The facet joints
The sacroiliac joint
The hip

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Case report

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

 A 46-year-old male patient

Persistent, debilitating right-sided
lower back pain
The onset of pain was associated
with lifting a heavy weight 12 months
previously

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

 NRS: 7/10
The pain was centered on the right
iliac crest, and was associated with
tenderness to palpation in this region
Pain also in the right lateral hip region
and the medial aspect of the right
groin

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Lumbar lateral flexion to the left

exacerbated the pain
X-ray and MRI of the lumbar spine
were normal
Conservative measures of antiinflammatory drugs and physical
therapy had failed to resolve
symptoms
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

 The patient gave consent

placed in the prone position
skin was disinfected with antiseptic
solution and draped
low frequency (2-5 MHz), curvilinear
ultrasound transducer

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Transducer was placed over the right

iliac crest and oriented in the caudad
cephalad direction

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

The
iliac crest
was
identified

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

The transducer was moved medially

and caudad while the orientation was
changed to oblique

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

This allowed visualization of the erector

spinae muscle
The hyperechoic structure below this
muscle is the iliolumbar ligament
An aseptic injection technique was used
In-line approach from the medial side of
the
transducer, i.e. the needle was advanced
laterally andcephalad
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

The patients pain intensity decreased

to 2/10
Increased range of movement
A diagnosis of iliolumbar
syndrome was made

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

The patient was referred to

physiotherapy with this diagnosis.
Subsequently the patient underwent
ultrasound-guided prolotherapy to
the right iliolumbar ligament
He obtained persistent pain relief
and returned to full work duties

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Our findings suggest that an

ultrasound-guided
iliolumbar ligament injection is a
viable option compared to the
classic blind injection technique

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

As compared with other imaging

modalities ultrasound has significant
advantages:
In terms of accessibility
Ease of use
Safety
Cost
Quality of visualization of the soft
tissues in real time
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

The procedure may be performed

under fluoroscopy, specifically when
fluoroscopy is being utilized for other
techniques
Fluoroscopy does not visualise the
ligamen

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

THANK
YOU
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist