Symphyseal cleft injection

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Symphyseal cleft injections (symphysography) are performed as both diagnostic and therapeutic measures for patients with (suspected) osteitis pubis, usually under CT or fluoroscopy.

Indications

  • suspected or confirmed osteitis pubis

Contraindications

  • factors to be considered as per any musculoskeletal injection, e.g. anticoagulation, local skin infection

Procedure

Preprocedure evaluation

Most patients with athletic pubalgia will have undergone imaging, usually MRI, to identify signs of osteitis pubis.

Positioning/room set-up
  • can be performed under fluoroscopy or CT, or less commonly ultrasound
  • the patient lies supine on the table
Equipment
  • sterile wash and drapes, sterile gloves
  • 5 mL syringe; 25G hypodermic needle; short-acting local anesthetic (e.g. lidocaine)
  • 3 mL syringe x 2, 22G spinal needle
  • iodinated contrast
  • steroid (e.g. methylprednisolone, triamcinolone); long-acting local anesthetic (e.g. bupivacaine)
  • dressing
Technique
Fluoroscopy / CT

A commonly used technique is :

  • skin markers placed over the pubic symphysis
  • preprocedure planning image acquisition
  • needle track plan, aiming for the midpart of the pubic symphysis between upper and lower margins
  • mark skin entry point
  • sterile prep and drape
  • 2-3 mL short-acting local anesthetic to skin and subcutaneous tissue
  • advance 22G spinal needle to the fibrous capsule of pubic symphysis then advanced a further 1 cm into the symphyseal cleft
  • injection 0.5-1 mL iodinated contrast to outline symphyseal cleft (also allows to asses contrast extending into primary/secondary clefts as well as rectus abdominis insertional injuries)
  • note whether iodinated contrast injection provokes usual symptoms
  • injection steroid (e.g. 20 mg methylprednisolone) and 1 mL long-acting local anesthetic
  • withdraw needle and apply dressing

Complications

Outcomes

Evidence of effectiveness is limited to small case series, which have reported short-term symptom relief and successful return to play but a substantial percentage of non-responders with ongoing symptoms .