Sacral Lateral Branch RFA (SI Joint) needle size?
Started by CarabinerSD
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Did a cooled rf using Medtronic setup today. 17g 5cm
As big as you can get. I use 18g 10mm active tip, length depending on body habitus…. as that is what I have for all of my other RF. I would ideally use 16 gauge. Bipolar palisade technique.
However, don’t forget that just about no insurances cover this and it is either done as charity or self-pay.
I would also use cooled if I worked in a hospital and they would eat the cost of the kit.
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I think I’m still getting paid for traditional Medicare, most employer plans, uhc dual complete. Please correct me if I’m wrong and just haven’t been pinched yet.
Not covered by Medicare
Billing 64625?
I don’t think you’re getting paid for SIJ RFA by any insurer for the past 18 months.
You should post your SIJ RFA technique for the group as it is different from standard.
But sounds like it works for your patients and with less post procedural pain.
Sounds like a palisade technique?
My technique has evolved over time to use fewer needles and fewer lesions. Also no grounding pad needed due to bipolar technique. However I rarely do it anymore since Medicare stopped covering it. I use 18g needles.
I make a vertical line of dots 1 cm apart, starting lateral to the S1 foramen and about 1 cm superior to the top edge. I direct the top 2 needles to the sacral ala and the lower 2 straight down coaxial. I motor test the top set and numb and burn bipolar between 1/2 and 3/4 (90 degrees, 2 minutes). Then I remove the top needle and insert it coaxial below the others and redirect what’s now the top needle to also be coaxial. This results in a smaller version of the traditional palisade setup but I already did a burn between the middle 2 with the first set. Then I numb and burn between 1/2 and 3/4 and I’m done.
This will typically cover at least down through the S2 level, often S3, depending on the size and angle of the sacrum.
I got paid around $600 from an bcbs employer plan on one I did in June.
Needle insertion caudal to get cannulae tips parallel to os in nal placement.
I have a cephalad tilt to the II and oblique as necessary to see S1, S2 and S3
posterior foramina and groove the nerve exits in laterally. From anatomical
pictures the branching of the of the nerves is less medially and inferiorly for S1,
midline S2 and superior S3. This is where I put the tips of the needles. Snug
against OS ventral, tip firmly against superior wall of the groove for S3 and
usually S2. S1 I am inferior for placement.
Go to lateral. Often looks a bit different than the below images.
The sacrum is triangle in lateral view and usually S2 and S3 are lower on the
slope so your needle appears to be almost in sacral canal. If I see this at SI I am
too ventral and not a safe placement. This allows me to place more medial
safely in AP for S1 which gets me closer to where it branchs. I believe S1 is
largest and provides most innervation to joint so I am particular about
placement.
As far as lesion size a 22g lesion is 6x10 versus 7.5x12mm for 18g.
Cash…
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Parrallel pallisade with 2 needles works well. Reduces margin of error wrt needle placement
Is the LBB (SI joint block) covered at all by any insurance (Medicare, PPO)?
Other peripheral nerve block generic code has been approved/paid regularly in my area, even if RFA is not.
