Poll: Stimming & Fusing Vs Fusing & Stimming...A Clinical Conundrum

[drusso]

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A lot of thoughtful discussion on the merits of fusing and stimming versus stimming and fusing...untangling a Gordian Knot for frontline clinicians...

 

[deleted131481]

Generally I find postlami --> SCS salvaged by vertiflex first for the adjacent level disease. Then, with the increased stress on the SIJ they are primed for an SI fusion. This can give another 18 months and we can finally land with a pain pump on prialt then convert to hydromorphone + clonidine when the prialt stops working. If they still have any pain at this point usually send them to pain psych and monthly Butrans visits with the NP.

 

[pmrmd]

I really don’t feel that to be worthy of publication.

 

[RoloTomassi]

I really don’t feel that to be worthy of publication.

Right. Why is one a salvage for the other? Why not just diagnose the pain generators correctly and as they evolve?

 

[lobelsteve]

Lamborghini

 

[drusso]

Generally I find postlami --> SCS salvaged by vertiflex first for the adjacent level disease. Then, with the increased stress on the SIJ they are primed for an SI fusion. This can give another 18 months and we can finally land with a pain pump on prialt then convert to hydromorphone + clonidine when the prialt stops working. If they still have any pain at this point usually send them to pain psych and monthly Butrans visits with the NP.

Compelling algorithm.

 

[deleted472101]

These are different diagnoses and shouldn’t have the term salvage in it.

 

[drusso]

These are different diagnoses and shouldn’t have the term salvage in it.

There’s no rule in life that says you can’t have more than one thing wrong with you!

 

[Agast]

My patient told me her husband was going to have his SI joint fused by a neurosurgeon. On further discussion it seems he has never had a sacroiliac joint injection before. He is going to have one done and then get his SI joint fused. I hope she's confused but she seemed pretty certain the fusion was already planned.

 

[NJPAIN]

These are different diagnoses and shouldn’t have the term salvage in it.

The only “ salvage” aspect of this is that the patient looks like a salvage yard on x-ray.

 

[deleted472101]

SI bone protocol that is two injections gets a fusion.

they Have mid levels ‘diagnosis’ and order injections.

Some injectionologist does injection no questions asked.

then fuse

 

[oreosandsake]

Lamborghini

And Ferrari and mclaren and boat

 

[deleted875186]

I don’t trust anything with Deer on it

 

[TIVAndy]

I don’t trust anything with Deer on it

santa comin' to you on a rain'deer' ...

 

[Propofool123]

I don’t trust anything with Deer on it

He’s on almost everything that’s published these days if it’s interventionally focused, though

 

[RoloTomassi]

Ethos labs came by my office to try to sell me on urine tests for pain biomarkers. Showed me a paper, and sure enough Deer was on it. Has hands in everything.

 

[Propofool123]

I just read this paper while trying to put my kid down for a nap lol. So it’s interesting… a retrospective study and basically seems like the patients included in the study were essentially hand selected. They just had to meet their inclusion criteria but they don’t describe any exclusion criteria.

It would also be worthwhile to know how long they’ve had the SCS, IDDS, ISS, etc system in place and how much improvement in pain they were previously getting with those therapies and for how long.

 

[Espn123]

You guys are harsh!

this is just a proof of concept, not meant to be groundbreaking

 

[Ferrismonk]

My patient told me her husband was going to have his SI joint fused by a neurosurgeon. On further discussion it seems he has never had a sacroiliac joint injection before. He is going to have one done and then get his SI joint fused. I hope she's confused but she seemed pretty certain the fusion was already planned.

Please tell me the surgeon isn't the one "doing the injection"

 

[Orin]

I really don’t feel that to be worthy of publication.

ASPN has been providing a lot of CV padding lately in their newly claimed journal, but these retrospective pieces are a little better than the opinion pieces.

 

[callmeanesthesia]

Please tell me the surgeon isn't the one "doing the injection"

Probably with 5-10 mL of Marcaine and 120 of depo.

 

[10KHertz]

And Ferrari and mclaren and boat

Lamborghini makes a boat. Dilemma solved

 

[oreosandsake]

Probably with 5-10 mL of Marcaine and 120 of depo.

and still nowhere close to the intended target

 

[Ducttape]

TIMOTHY DEER,​

2018 Payments At a Glance​

306 payments $281,621 payment total 8 companies paid this doctor​

TIMOTHY DEER,​

Yearly Payment Breakdown: 2016 Data for this year is as provided by the federal government.​

2016 Payments At a Glance​

278 payments $881,186 payment total 6 companies paid this doctor​

2 listings, the first for the most recent year, the 2nd for the one that has actual data from the feds

DAWOOD SAYED,​

Yearly Payment Breakdown: 2018​

2018 Payments At a Glance​

251 payments $235,617 payment total 10 companies paid this doctor​

his numbers from 2016 are a lot less...

DAWOOD SAYED,​

Yearly Payment Breakdown: 2016 Data for this year is as provided by the federal government.​

2016 Payments At a Glance​

222 payments $114,787 payment total 11 companies paid this doctor​

(edited severely to save space and provide better perspective)

 

[drusso]

2 listings, the first for the most recent year, the 2nd for the one that has actual data from the feds

his numbers from 2016 are a lot less...

(edited severely to save space and provide better perspective)

What are you trying to say?

 

[BobLoblaw78]

From what I have seen the SI fusions have not progressed enough to be a great option for patients needing 1-2 SI injections per year. I only refer if they get great relief and pain returns within 1-2 months AND it is severe debilitating pain. Are other people seeing good results with SI fusion after 1 year? (I see many that are actually worse)

 

[lobelsteve]

From what I have seen the SI fusions have not progressed enough to be a great option for patients needing 1-2 SI injections per year. I only refer if they get great relief and pain returns within 1-2 months AND it is severe debilitating pain. Are other people seeing good results with SI fusion after 1 year? (I see many that are actually worse)

Never seen one that worked (inherent bias in a pain clinic).

 

[drusso]

Never seen one that worked (inherent bias in a pain clinic).

Can cluneal nerve PNS be salvage here? Stim & Fuse vs Fuse & Stim?

 

[lobelsteve]

Can cluneal nerve PNS be salvage here? Stim & Fuse vs Fuse & Stim?

Meh. In those when this much care has been done, I think it is best for the doc and not the patient.

 

[Espn123]

Can cluneal nerve PNS be salvage here? Stim & Fuse vs Fuse & Stim?

Meh. In those when this much care has been done, I think it is best for the doc and not the patient.

Steve, have you seen a patient after a posterior bone graft SI joint procedure?

 

[lobelsteve]

Steve, have you seen a patient after a posterior bone graft SI joint procedure?

I have seen screws, SI-fuse, cornerloc, and maybe one other weird (less known to me brand).

 

[drusso]

Steve, have you seen a patient after a posterior bone graft SI joint procedure?

Have you been having a good experience with the SIJ fusions?

 

[bedrock]

From what I have seen the SI fusions have not progressed enough to be a great option for patients needing 1-2 SI injections per year. I only refer if they get great relief and pain returns within 1-2 months AND it is severe debilitating pain. Are other people seeing good results with SI fusion after 1 year? (I see many that are actually worse)

If good but brief relief after SIJ injections, then do SIJ RFA. Even if cash procedure that is 100x better for patient than a fusion because it is reversible.

I’d never send a patient for an SIJ fusion

 

[drusso]

If good but brief relief after SIJ injections, then do SIJ RFA. Even if cash procedure that is 100x better for patient than a fusion because it is reversible.

I’d never send a patient for an SIJ fusion

What's your technique for reversing/regenerating the ablation? PRP versus Platelet lysate? I degenerate M,W,F's and regenerate on T/Th's...

 

[Espn123]

I have seen screws, SI-fuse, cornerloc, and maybe one other weird (less known to me brand).

I’ve done over 50 cases of posterior single bone allograft to the si joint.

the mechanism of pain relief seems more related to distraction than fusion. People walk into my office 3 days later doing great at least 80% of the time.

overall, the results have been far better than expected and the risk/benefit ratio for this procedure is very favorable. I don’t use those other products interchangeable when discussing it since it’s just not the same procedure, recovery, etc.

I’m ready to be criticized now…

 

[bedrock]

What's your technique for reversing/regenerating the ablation? PRP versus Platelet lysate? I degenerate M,W,F's and regenerate on T/Th's...

As you know an ablation isn’t permanent. That would be a more anal and specific way to describe the difference between that and a fusion.

 

[Propofool123]

I’ve done over 50 cases of posterior single bone allograft to the si joint.

the mechanism of pain relief seems more related to distraction than fusion. People walk into my office 3 days later doing great at least 80% of the time.

overall, the results have been far better than expected and the risk/benefit ratio for this procedure is very favorable. I don’t use those other products interchangeable when discussing it since it’s just not the same procedure, recovery, etc.

I’m ready to be criticized now…

this has been my experience in fellowship as well. SI joint RFA has essentially fallen out of favor for most of my attendings.

 

[NJPAIN]

this has been my experience in fellowship as well. SI joint RFA has essentially fallen out of favor for most of my attendings.

Is that because SI joint lateral branch RFN doesn't work or it not getting reimbursed?

 

[Propofool123]

Is that because SI joint lateral branch RFN doesn't work or it not getting reimbursed?

is SI joint RFA not getting reimbursed anymore or is it that the reimbursement has just gone down?

the patients I’ve seen who have had SIJ fusion have good pain control even at >1 year mark. Last one i saw in clinic had the fusion done 14 months ago.

 

[NJPAIN]

I’ve done over 50 cases of posterior single bone allograft to the si joint.

the mechanism of pain relief seems more related to distraction than fusion. People walk into my office 3 days later doing great at least 80% of the time.

overall, the results have been far better than expected and the risk/benefit ratio for this procedure is very favorable. I don’t use those other products interchangeable when discussing it since it’s just not the same procedure, recovery, etc.

I’m ready to be criticized now…

Is there any evidence that the distraction systems provide more relief than the compression (screw) systems? Seems like the big boys are using compression screws (LEGO) not distraction (DUPLO).

 

[drusso]

this has been my experience in fellowship as well. SI joint RFA has essentially fallen out of favor for most of my attendings.

Has anyone ever tried PRP into the SIJ?

Cureus. 2021 Mar 23;13(3):e14062. doi: 10.7759/cureus.14062.

Platelet-Rich Plasma Versus Corticosteroid Injection for Lumbar Spondylosis and Sacroiliac Arthropathy: A Systematic Review of Comparative Studies

Jeremiah F Ling 1, Austin E Wininger 1, Takashi Hirase 1
Affiliations expand
PMID: 33898145 PMCID: PMC8061754 DOI: 10.7759/cureus.14062
Free PMC article

Abstract
This systematic review compares clinical outcomes between platelet-rich plasma (PRP) and corticosteroid injections for the treatment of lumbar spondylosis and sacroiliac arthropathy. A systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Pubmed, SCOPUS, and Ovid MEDLINE databases. All level I-III evidence comparative studies published in the English language investigating the clinical outcomes between PRP and corticosteroid injections for the treatment of lumbar spondylosis and sacroiliac arthropathy were included. Five studies (242 patients, 114 PRP, 128 corticosteroid) were analyzed. One randomized study was level I evidence, two randomized studies were level II, and two non-randomized studies were level III. Final follow-up ranged from six weeks to six months. Four studies found that both PRP and corticosteroid treatment led to a statistically significant reduction in the visual analog scale (VAS). One found that only the PRP group led to a statistically significant reduction in VAS. Three studies found more significant improvements in one or more clinical outcome scores among PRP patients as compared with corticosteroid patients at the three- to six-month follow-up. Two studies found no difference in outcome score improvements between the two groups at six- to 12-week follow-up. There were no reports of major complications. There were no significant differences in minor complication rates between the two groups. In conclusion, both PRP and corticosteroid injections are safe and effective options for the treatment of lumbar spondylosis and sacroiliac arthropathy. There is some evidence that PRP injection is a more effective option at long-term follow-up compared with corticosteroid injection. Further randomized controlled trials with longer-term follow-up are necessary to compare its long-term efficacy.

Keywords: corticosteroid; injection; lumbar spondylosis; pain management; platelet-rich plasma; sacroiliac arthropathy.

 

[Espn123]

Is there any evidence that the distraction systems provide more relief than the compression (screw) systems? Seems like the big boys are using compression screws (LEGO) not distraction (DUPLO).

Certainly not that I’m aware of.

my point in mentioning is that patients get relief very quickly, much sooner than it would take fusion to occur.

 

[Espn123]

this has been my experience in fellowship as well. SI joint RFA has essentially fallen out of favor for most of my attendings.

Out of those two options which procedure do you think works better in your observational experience?

 

[Propofool123]

Out of those two options which procedure do you think works better in your observational experience?

more sustained pain relief with fusion.
RFA seems to have diminishing returns after a while.

 

[Dr. Ice]

Has anyone ever tried PRP into the SIJ?

Cureus. 2021 Mar 23;13(3):e14062. doi: 10.7759/cureus.14062.

Platelet-Rich Plasma Versus Corticosteroid Injection for Lumbar Spondylosis and Sacroiliac Arthropathy: A Systematic Review of Comparative Studies

Jeremiah F Ling 1, Austin E Wininger 1, Takashi Hirase 1
Affiliations expand
PMID: 33898145 PMCID: PMC8061754 DOI: 10.7759/cureus.14062
Free PMC article

Abstract
This systematic review compares clinical outcomes between platelet-rich plasma (PRP) and corticosteroid injections for the treatment of lumbar spondylosis and sacroiliac arthropathy. A systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Pubmed, SCOPUS, and Ovid MEDLINE databases. All level I-III evidence comparative studies published in the English language investigating the clinical outcomes between PRP and corticosteroid injections for the treatment of lumbar spondylosis and sacroiliac arthropathy were included. Five studies (242 patients, 114 PRP, 128 corticosteroid) were analyzed. One randomized study was level I evidence, two randomized studies were level II, and two non-randomized studies were level III. Final follow-up ranged from six weeks to six months. Four studies found that both PRP and corticosteroid treatment led to a statistically significant reduction in the visual analog scale (VAS). One found that only the PRP group led to a statistically significant reduction in VAS. Three studies found more significant improvements in one or more clinical outcome scores among PRP patients as compared with corticosteroid patients at the three- to six-month follow-up. Two studies found no difference in outcome score improvements between the two groups at six- to 12-week follow-up. There were no reports of major complications. There were no significant differences in minor complication rates between the two groups. In conclusion, both PRP and corticosteroid injections are safe and effective options for the treatment of lumbar spondylosis and sacroiliac arthropathy. There is some evidence that PRP injection is a more effective option at long-term follow-up compared with corticosteroid injection. Further randomized controlled trials with longer-term follow-up are necessary to compare its long-term efficacy.

Keywords: corticosteroid; injection; lumbar spondylosis; pain management; platelet-rich plasma; sacroiliac arthropathy.

Yup..it works, that is, if you actually get into the SIJ...

 

[RoloTomassi]

Has anyone ever tried PRP into the SIJ?

Yes my algorithm is steroid, then PRP, then RFA. I don't get great results with RFA, very hit or miss with either lateral foramen or palisade technique. Not quite sold on fusion yet and don't like the idea of any type of fusion unless last resort.

 

[Ferrismonk]

I’ve done over 50 cases of posterior single bone allograft to the si joint.

the mechanism of pain relief seems more related to distraction than fusion. People walk into my office 3 days later doing great at least 80% of the time.

overall, the results have been far better than expected and the risk/benefit ratio for this procedure is very favorable. I don’t use those other products interchangeable when discussing it since it’s just not the same procedure, recovery, etc.

I’m ready to be criticized now…

Maybe they just need to develop a mini vertiflex?

 

[Ferrismonk]

Is that because SI joint lateral branch RFN doesn't work or it not getting reimbursed?

I'm sure it's the latter.

 

[SageCraft]

I've had PRP into my SIJ twice. First one lasted 5-6 months. Repeat has lasted >1.5 years. I've been very impressed. Corticosteroid would last maybe 6 weeks max. I can't imagine considering a fusion.

 

[bedrock]

Yes my algorithm is steroid, then PRP, then RFA. I don't get great results with RFA, very hit or miss with either lateral foramen or palisade technique. Not quite sold on fusion yet and don't like the idea of any type of fusion unless last resort.

My protocol is also steroid then PRP then RFA. PRP works as well or better than RFA in many patients. Is generally cheaper than cash RFA as well.

though both my steroid and PRP protocol include injecting both the SIJ and the SIJ ligaments, as the ligaments are very frequently a pain generator.