Refer for SIJ PRP before or after fusion?

[SSdoc33]

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there is no gray area in the online mind of drusso.

i think i learned about this in medical school:

BPD Splitting Can Harm Relationships

Splitting is a symptom of borderline personality disorder where a person is unable to hold opposing thoughts and sees everything as black or white.

www.verywellmind.com

 

[drusso]

You are using big words to insert experience over science and research. Stop saying gamechanger. Nothing in Pain is a gamechanger. Your bashing of kypho is based on politics and nothing to do with the science. The articles written in NEJM 2009 were heartily debunked. The articles showing NNT to save a life of 1:15 are stout. Review from SIS should be out by end of year.

Everything is based on politics. Healthy policies don't change because of science and research. They change because of interests and positions.

I do kyphos. But, I don't do them because SIS says it works. I do it because it actually works. It actually worked even when Up-to-Date said it didn't work. Big difference.

Now, substitute Perc SIJ, Regen, or PNS for Kypho. Same-Same.

When you personalize care for your patients instead of Kow-Towing to the Roger Chou's and David Kallames of the world, a Gamechanger is what ever your patient tells you it is.

 

[lobelsteve]

Weed legal in your state? Put down the bong McConaughey

 

[Orin]

It is like playing Russian roulette with placeboes/therapies. Eventually one of them will work and hopefully you won't maim someone on the way.

I don't mind that approach as long as we're methodical and reasoned in it, as it's still an art/practice issue. I agree that we need to acknowledge that many therapeutic decisions in pain medicine are not made solely on EBM or clinical/patient factors, but often involve politics, local practice standards, financials, reps/providers, etc.

 

[drusso]

Weed legal in your state? Put down the bong McConaughey

Weed?? That's so 2015...

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www.forbes.com

 

[Espn123]

I’ll give up on anyone answering my ? About their experience with it

 

[Ducttape]

All fair and excellent points.

my question to the group is....has anyone done at least 5-10 posterior SI joint bone grafts themselves after working the patient up etc and feel that this procedure is NOT effective?

you need to add - has anyone done these who is not being financially reimbursed for the procedure itself.

Okay, this is what I'm getting at: What's the difference between "innovation" and what people around here characterize as "quackery," "fraud," or "human experimentation" in the field of pain medicine?

7-8 years ago I took ALOT of heat for injecting PRP into appendicular joints and tendons. Now, I don't think anyone thinks that is such an aberration. Some people still think it's quackery.

Despite multiple studies saying it doesn't work and Evicore guidelines saying it's no different from placebo, many people here do vertebral augmentation for VCF. Why? Because they believe in their experience and not the meta-analytic GIGO science.

Perc posterior SIJ fusion could be a gamechanger for our field.

Do we owe it to our patients to set aside our epistemic arrogance (our illusion of knowledge) and actually gain practical experience and find out?

there may be something to PRP. I give you that. at least for tendinopathies.

there is still debate about kypho. I reviewed the data, and like others, I see people who have had kypho and I do advise on kyphoplasty, for the acute pain, but...

since we are using experience - my level V based evidence (ie lowest level there is, even below, say, SSDoc or Espn123) is that people getting kypho have the same amount of pain a year out as those who did not get kypho.


and my experience with SIJ fusion - of the few referred patients so far that I have seen who have had this procedure, 100% have had no benefit whatsoever. (and yes, it is a biased group. but so are post op patients...)

 

[drusso]

there may be something to PRP. I give you that. at least for tendinopathies.

• Tendons/Ligaments with MSCs
  • Cultured MSCs vs LP-PRP for chronic patellar tendinopathy RCT: Effect of Autologous Expanded Bone Marrow Mesenchymal Stem Cells or Leukocyte-Poor Platelet-Rich Plasma in Chronic Patellar Tendinopathy (With Gap >3 mm): Preliminary Outcomes After 6 Months of a Double-Blind, Randomized, Prospective Study - PubMed (nih.gov)
  • Mesenchymal Stem Cells for Treatment of Tendon and Ligament Injuries-clinical Evidence - PubMed (nih.gov)
• Review Articles
  • PRP
    • The application of platelet-rich plasma in the treatment of knee osteoarthritis: A literature review - PubMed (nih.gov)
    • A narrative review of platelet-rich plasma (PRP) in reproductive medicine - PubMed (nih.gov)
    • Platelet-rich plasma vs bone marrow aspirate concentrate: An overview of mechanisms of action and orthobiologic synergistic effects - PubMed (nih.gov)
    • A narrative review of the research progress and clinical application of platelet-rich plasma - PubMed (nih.gov)
    • Platelet-rich plasma injection vs corticosteroid injection for conservative treatment of rotator cuff lesions: A protocol for systematic review and meta-analysis - PubMed (nih.gov)
    • Efficacy of different platelet-rich plasma injections in the treatment of mild-moderate knee osteoarthritis: A systematic review and meta-analysis - PubMed (nih.gov)
    • Pain and functional outcomes of the sacroiliac joint after platelet-rich plasma injection: a descriptive review - PubMed (nih.gov)
    • Platelet-Rich Plasma Applications for Achilles Tendon Repair: A Bridge between Biology and Surgery - PubMed (nih.gov)
  • MSCs
    • Recent Developments in Clinical Applications of Mesenchymal Stem Cells in the Treatment of Rheumatoid Arthritis and Osteoarthritis - PubMed (nih.gov)
    • Intra-Articular Injections of Platelet-Rich Plasma, Adipose Mesenchymal Stem Cells, and Bone Marrow Mesenchymal Stem Cells Associated With Better Outcomes Than Hyaluronic Acid and Saline in Knee Osteoarthritis: A Systematic Review and Network Meta-analysis - PubMed (nih.gov)
    • Autologous bone marrow derived mesenchymal stem cell therapy for osteonecrosis of femoral head: A systematic overview of overlapping meta-analyses - PubMed (nih.gov)
    • Strategies to Identify Mesenchymal Stromal Cells in Minimally Manipulated Human Bone Marrow Aspirate Concentrate Lack Consensus - PubMed (nih.gov)
    • Evidence-based Treatment of Failed Primary Osteochondral Lesions of the Talus: A Systematic Review on Clinical Outcomes of Bone Marrow Stimulation - PubMed (nih.gov)
    • Mesenchymal Stem Cells: A New Choice for Nonsurgical Treatment of OA? Results from a Bayesian Network Meta-Analysis - PubMed (nih.gov)
    • Mesenchymal stem cells in osteoarthritis therapy: a review - PubMed (nih.gov)
    • Mesenchymal Stem Cells in the Treatment of Cartilage Defects of the Knee: A Systematic Review of the Clinical Outcomes - PubMed (nih.gov)
    • Intra-articular Injections of Mesenchymal Stem Cells Without Adjuvant Therapies for Knee Osteoarthritis: A Systematic Review and Meta-analysis - PubMed (nih.gov)
    • The application of bone marrow mesenchymal stem cells and biomaterials in skeletal muscle regeneration - PubMed (nih.gov)

 

[Espn123]

you need to add - has anyone done these who is not being financially reimbursed for the procedure itself.


there may be something to PRP. I give you that. at least for tendinopathies.

there is still debate about kypho. I reviewed the data, and like others, I see people who have had kypho and I do advise on kyphoplasty, for the acute pain, but...

since we are using experience - my level V based evidence (ie lowest level there is, even below, say, SSDoc or Espn123) is that people getting kypho have the same amount of pain a year out as those who did not get kypho.


and my experience with SIJ fusion - of the few referred patients so far that I have seen who have had this procedure, 100% have had no benefit whatsoever. (and yes, it is a biased group. but so are post op patients...)

Do you really think that everyone who does these procedures are paid consultants for a company?

 

[drusso]

Do you really think that everyone who does these procedures are paid consultants for a company?

This is my favorite place to check!

Search Physicians - Open Payments Data - CMS | CMS Open Payments Data

openpaymentsdata.cms.gov

 

[Espn123]

This is my favorite place to check!

Search Physicians - Open Payments Data - CMS | CMS Open Payments Data

openpaymentsdata.cms.gov

Neither here nor there in relation to my ?

 

[Ducttape]

Do you really think that everyone who does these procedures are paid consultants for a company?

no.

you are getting paid to do the procedure. that affects your judgement about the procedure.

 

[callmeanesthesia]

no.

you are getting paid to do the procedure. that affects your judgement about the procedure.

Most of these procedures though do not have a disproportionate impact on income in comparison to other uses of our time. I bet I’d make way more doing caudals in office all day than going to the surgery center to do SI joint fusions and stims. I can tell you though that if I’m not getting paid to do a procedure that will certainly affect my decision on whether to offer it…

 

[cowboydoc]

Do you really think that everyone who does these procedures are paid consultants for a company?

A neurosurgeon colleague who is overall quite conservative claims great success with SI fusion. He is the only one in his group that does them because they are a loss leader for neurosurgeons. He seems as unbiased as anyone with whom I've discussed the procedure. That said, I haven't found anyone to refer to him for SI fusion to this point.

Not coincidentally, the patients I can't get under control with chronic SI dysfunction are almost exclusively multi-level lumbar fusion patients.

 

[SSdoc33]

A neurosurgeon colleague who is overall quite conservative claims great success with SI fusion. He is the only one in his group that does them because they are a loss leader for neurosurgeons. He seems as unbiased as anyone with whom I've discussed the procedure. That said, I haven't found anyone to refer to him for SI fusion to this point.

Not coincidentally, the patients I can't get under control with chronic SI dysfunction are almost exclusively multi-level lumbar fusion patients.

yup

 

[Espn123]

yup

These comments alone kind of make my point....I think many of the people who are commenting with confidence are not even familiar w the posterior approach and think we are talking about open lateral fusions...

there is little evidence and certainly some KOL smear, but this procedure definitely gives patients very good pain relief in most cases

 

[Ducttape]

These comments alone kind of make my point....I think many of the people who are commenting with confidence are not even familiar w the posterior approach and think we are talking about open lateral fusions...

there is little evidence and certainly some KOL smear, but this procedure definitely gives patients very good pain relief in most cases

please post non industry funded studies that are prospective, blinded, and randomized. saying "they are doing great" begets nothing but inflating your own self worth.

 

[Espn123]

please post non industry funded studies that are prospective, blinded, and randomized. saying "they are doing great" begets nothing but inflating your own self worth.

At this point we don’t have those. Would be happy to have others share clinical experience but so far nobody has, good or bad

 

[deleted131481]

Which is exactly my question. I have a small sample size of practical experience. I think it helps patients greatly. Wondering if anyone else has had similar or different experiences after doing some cases.

I don’t feel this article does much for me one way or another...

I have not done it, but while I appreciate your experience I don't think that makes you any more of an authority on the effectiveness of SIJ fusion. I'll acknowledge my not having performed the procedure brings a negative bias like you having done it brings positive bias.

I haven't done a fusion for discogenic pain either but I would not refer my patients for it. If someone wants to offer SIJ fusion for someone who has failed SIJ injection, RFA, and focused PT, then I'm not totally opposed. I just wouldn't for my patients because:

- short term data so far is fairly weak with higher complication rate
- long-term data is absent but reasonable to postulate risk of adjacent segment disease
- i rarely see such debilitating isolated SIJ pain in someone who's exhausted conservative therapy, weight loss etc to warrant a fusion

 

[Espn123]

I have not done it, but while I appreciate your experience I don't think that makes you any more of an authority on the effectiveness of SIJ fusion. I'll acknowledge my not having performed the procedure brings a negative bias like you having done it brings positive bias.

I haven't done a fusion for discogenic pain either but I would not refer my patients for it. If someone wants to offer SIJ fusion for someone who has failed SIJ injection, RFA, and focused PT, then I'm not totally opposed. I just wouldn't for my patients because:

- short term data so far is fairly weak with higher complication rate
- long-term data is absent but reasonable to postulate risk of adjacent segment disease
- i rarely see such debilitating isolated SIJ pain in someone who's exhausted conservative therapy, weight loss etc to warrant a fusion

Fair enough, but in my bias opinion the risk/benefit profile far outweighs many other things we do regularly, including even scs.

to reiterate, the posterior approach bears no resemblance in any way to the lateral fusion we all have seen disasters from