Keep Government Out of Your SIJ

[bedrock]

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Unfortunately many elderly patients on a fixed income cannot afford prp or rfa which may provide 6 months of relief and then need to be repeated, but their Medicare will cover the 27279 and be a permanent fix with limited sequelae for their expected lifespan. I fully admit being a young and impressionable attending but as long as the diagnosis is solid, what am I missing?

long term changes in biomechanics, causing SIJ pain on the other side, and/or amplifying L5-S1 disc issues.
If they don't respond well to an SIJ fusion, the patient no longer has any options other than medications.

 

[PMROralBoards]

long term changes in biomechanics, causing SIJ pain on the other side, and/or amplifying L5-S1 disc issues.
If they don't respond well to an SIJ fusion, the patient no longer has any options other than medications.

Agreed, but don’t you think if most of their pain is the SIJ and they are a motivated patient that they would physically be in a much better position five or ten years down the road than if they continued with severe SIJ pain and were inactive? Again I am speaking about an elderly (>70 year old) patient, not someone in their 50s with right sided lower back pain.

 

[Gnarvin]

Agreed, but don’t you think if most of their pain is the SIJ and they are a motivated patient that they would physically be in a much better position five or ten years down the road than if they continued with severe SIJ pain and were inactive? Again I am speaking about an elderly (>70 year old) patient, not someone in their 50s with right sided lower back pain.

In my experience, I don’t see a lot of elderly people with debilitating SIJ pain. I see a ton of elderly people with significant buttock pain with standing and walking but that is usually stenosis rather than SIJ pain.

In my experience it is rare to find an elderly person with classic SIJ pain history AND actually have 3/5 truly positive provocative maneuvers. When I say truly positive, I mean the maneuvers cause pain in the actual SIJ area rather than vaguely causing pain somewhere in the low back and that the provocative maneuvers reproduce their worst pain.

The one time where I see SIJ pain more commonly is the elderly is after lower lumbar fusion, though.

 

[gaspasser127]

Help me understand SI bone’s angle for a new posterior approach procedure. Seems like a crowded space with questionable reimbursement, not much upside. Maybe bad timing in their part?

There’s no angle. When Painteq and others came out with the posterior allograft they piggy backed off the 27279 code.

To SI Bone’s credit, they really did the leg work to get the code established in the first place and in the beginning they stuck to their guns about not training pain docs and saying SIJ fusion is for surgeons only. I can actually respect that.

Then - In an attempt to protect their code, they put up a massive fight with the CPT committee and got allografts kicked off to a T code. They argued how allografts aren’t true fusion and that it doesn’t work. They criticized Painteq’s studies. i can actually respect that too.

Here’s what I can’t respect. Now that the cats out of the bag and tons of pain docs are doing SIJ fusion and there’s a cat 1 code for posterior allograft, all of a sudden they have new screws they’re willing to train pain docs on and silly allografts even though they created this entire debacle in the first place.

 

[PMROralBoards]

In my experience, I don’t see a lot of elderly people with debilitating SIJ pain. I see a ton of elderly people with significant buttock pain with standing and walking but that is usually stenosis rather than SIJ pain.

In my experience it is rare to find an elderly person with classic SIJ pain history AND actually have 3/5 truly positive provocative maneuvers. When I say truly positive, I mean the maneuvers cause pain in the actual SIJ area rather than vaguely causing pain somewhere in the low back and that the provocative maneuvers reproduce their worst pain.

The one time where I see SIJ pain more commonly is the elderly is after lower lumbar fusion, though.

Fair enough. I think the underlying reason I’m posting so much about this is that I have always read very negative things about these fusions, so I am hesitant to think that my patients are the exception. I make sure that the provocative pain refers back to the same PSIS location for each maneuver. I appreciate all the feedback.

 

[lobelsteve]

Fair enough. I think the underlying reason I’m posting so much about this is that I have always read very negative things about these fusions, so I am hesitant to think that my patients are the exception. I make sure that the provocative pain refers back to the same PSIS location for each maneuver. I appreciate all the feedback.

SIJ fusion is unnecessary 99.9% of the time.