SI fusion

[paindoc007]

I have a neurosurgeon near me that has been sending me a lot of diagnostic si injections for possible fusion recently. Up until now I’ve not been a big fan of the concept of fusing the si joint. I’m wondering if I should be a team player, do the shot, and send them back, or talk with the patient and give my honest opinion about si fusion. Wondering what everyone’s experience is with this, and if they’ve seen good outcomes from surgical si fusions

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[willabeast]

I have a neurosurgeon near me that has been sending me a lot of diagnostic si injections for possible fusion recently. Up until now I’ve not been a big fan of the concept of fusing the si joint. I’m wondering if I should be a team player, do the shot, and send them back, or talk with the patient and give my honest opinion about si fusion. Wondering what everyone’s experience is with this, and if they’ve seen good outcomes from surgical si fusions

I look at it this way. These are the surgeon's patients. Do what is asked and do not editorialize. The problem is when the patient asks you your opinion. Unless you think an SI joint fusion will work well, say something neutral. Like - have not seen enough fusions to know, etc. You never want to burn a referral source unless you plan on never getting another referral. Personally, i had bad luck sending people for si joint fusions. With an excellent surgeon by the way.

 

[Timeoutofmind]

I look at it this way. These are the surgeon's patients. Do what is asked and do not editorialize. The problem is when the patient asks you your opinion. Unless you think an SI joint fusion will work well, say something neutral. Like - have not seen enough fusions to know, etc. You never want to burn a referral source unless you plan on never getting another referral. Personally, i had bad luck sending people for si joint fusions. With an excellent surgeon by the way.

Gross

What if that was your family member?

Same story?

Just do the shot and send them along to get a useless piece of metal shoved in their pelvis?

I have burnt plenty of referral sources. Who cares. Greedy docs everywhere out there. Keep your practice clean.

 

[RoloTomassi]

There's liability on your part if you don't do your due diligence in assessing appropriateness. Low risk in this case but don't just be a mindless robot.

If history and exam is consistent, go ahead, but definitely do a follow up visit to talk about all the options--re-injection, RFA, PRP, and fusion. Also go into other possible contributing pain generators, and their options.

You might burn that bridge but those happy patients will spread the word.
Good surgeon shouldn't knock you for fixing the patient less invasively anyway.

 

[willabeast]

Gross

What if that was your family member?

Same story?

Just do the shot and send them along to get a useless piece of metal shoved in their pelvis?

I have burnt plenty of referral sources. Who cares. Greedy docs everywhere out there. Keep your practice clean.

I think that works if you are in a really good practice environment, where everyone's consistent focus is on quality care. Probably always a good strategy in the long run.

 

[Laryngospasm]

I typically tell patients something along the lines of “surgery doesn’t always go well” and “do plenty of research and get a second opinion before making big decisions”… if I feel super strongly about a given situation I will tell them it’s not a good idea.

 

[deleted131481]

I have a neurosurgeon who I work well with that sends plenty of referrals. He sends SI diagnostic injections elsewhere though as I suspect he knows I'm not a big believer.

I'm ok with this arrangement and I still think he's a good surgeon and send referrals.

 

[lobelsteve]

How good is he if he fuses SIJ?

 

[paindoc007]

Has ANYONE here seen good outcomes after SI fusions?

 

[Ducttape]

a less loaded question - has anyone ever seen good outcomes after an SI fusion that they did not personally perform?

 

[RoloTomassi]

Yes but seems like a high NNT

 

[kstarm]

The only ones I have seen work are for people with pelvic fractures almost always related to trauma. Usually the people doing the fusions for chronic pain have significantly different patient selection criteria than I would. I also imagine that I only see patients with issues, so there is likely some bias there, presumably the patients that do well are not seeking further treatments.

 

[Ferrismonk]

a less loaded question - has anyone ever seen good outcomes after an SI fusion that they did not personally perform?

I have, but it's only after SIJ injections don't last and insurance won't let me burn.

That being said, I've seen a lot more failed fusions (for pain) than successful ones.

 

[lobelsteve]

a less loaded question - has anyone ever seen good outcomes after an SI fusion that they did not personally perform?

Have not.
n=100.

 

[bedrock]

I have, but it's only after SIJ injections don't last and insurance won't let me burn.

That being said, I've seen a lot more failed fusions (for pain) than successful ones.

I would highly suggest you offer PRP to those patients who failed SIJ injections. Likely a similar cost the deductible for surgery, but far less risk and works most of the time. I would recommend PRP of both the joint and ligaments in most cases.

 

[Ferrismonk]

I would highly suggest you offer PRP to those patients who failed SIJ injections. Likely a similar cost the deductible for surgery, but far less risk and works most of the time. I would recommend PRP of both the joint and ligaments in most cases.

I've done a few SI PRP and they've all been a homerun. This patient couldn't afford it. Medicaid.

Honestly, if I had my way, I would replace steroids with PRP for basically everything I do.

 

[Dr. Ice]

I've done a few SI PRP and they've all been a homerun. This patient couldn't afford it. Medicaid.

Honestly, if I had my way, I would replace steroids with PRP for basically everything I do.

Glut tendon, partial rotator cuff, Achilles’ tendon, common extensor, hip labrum, all scream yes yes yes PRP

 

[Orin]

We're numerator doctors. We wouldn't see the positive cases where SI fusion helped. I haven't seen one of the lateral fusions help either, but I haven't seen a posterior fusion in clinic yet.

 

[swamprat]

Im 5/7 for SI fusion. I try to be very specific with patients that the diagnostic block needs to relieve a significant portion of QOL improving pain for duration of anesthetic if the SI fusion will work.

 

[gaspasser127]

We're numerator doctors. We wouldn't see the positive cases where SI fusion helped. I haven't seen one of the lateral fusions help either, but I haven't seen a posterior fusion in clinic yet.

I’ve seen good results in about 75% of patients at the one-year mark for the posterior approach.

For the people who are doing the posterior fusion, if patients re-present with same SIJ pain a few months or a year down the road, what’s your algorithm? Imaging to evaluate integrity of the fusion? Diagnostic or steroid SIJ injections?

 

[soccrwz]

CT scan evaluate for osseous bridge; I've heard other patients with lateral fusion from outside, and some pain docs doing PNS for medial cluneal with benefit

 

[Taus]

CT scan evaluate for osseous bridge; I've heard other patients with lateral fusion from outside, and some pain docs doing PNS for medial cluneal with benefit

Medial cluneal pns, to me, seems like another treatment being done for same reason dogs lick their balls….

 

[Crybaby]

For those of you offering prp for SI joints, what type of preparations are you using? How much into joint and how much around supporting ligaments?

 

[Dr. Ice]

For those of you offering prp for SI joints, what type of preparations are you using? How much into joint and how much around supporting ligaments?

30 Pure, 2-3cc inside, 1-2 cc outside

 

[RoloTomassi]

Emcyte PurePRP 60 mL double spin, concentrated to 3-4 mL, inject 2-3 inside, and if any left over and it's full, the rest as I withdraw sightly

 

[Dr. Ice]

Emcyte PurePRP 60 mL double spin, concentrated to 3-4 mL, inject 2-3 inside, and if any left over and it's full, the rest as I withdraw sightly

I find I can get just about 5 cc from a 30 kit..you’re probably able to get at least 8 from a 60..what are you doing with all the extra volume?

 

[Crybaby]

Are you guys happy with accellerated? What is their pricing per kit? Currently looking at Apex and it is around 200. Arthrex is the only other I have any experience with and was higher and a bit more cumbersome

 

[RoloTomassi]

I find I can get just about 5 cc from a 30 kit..you’re probably able to get at least 8 from a 60..what are you doing with all the extra volume?

Normally it makes 7-8 mL but you can tilt and skim off more platelet poor plasma before you swirl if you only need small volume, higher concentration.

 

[RoloTomassi]

Are you guys happy with accellerated? What is their pricing per kit? Currently looking at Apex and it is around 200. Arthrex is the only other I have any experience with and was higher and a bit more cumbersome

Yeah I'm happy with it. I think around 225

 

[Dr. Ice]

Yeah I'm happy with it. I think around 225

I’m ok with accelerated..rep is accessible in my area. Didn’t care too much for arthrex, haven’t dealt with apex. Agree cost about 200 bucks or so for kits

 

[Agast]

I had a patient come to me saying Insurance needs him to do a pain log and blocks before his surgeon can do an SI joint fusion, and the SI joint injection with steroid does not fulfill the requirement because it was done and still denied. What injection are they asking for?

 

[callmeanesthesia]

I had a patient come to me saying Insurance needs him to do a pain log and blocks before his surgeon can do an SI joint fusion, and the SI joint injection with steroid does not fulfill the requirement because it was done and still denied. What injection are they asking for?

Local only, sometimes the volume injected my be limited by their criteria too - I think 2 mL to play it safe.

 

[macman]

I havent seen too many pts happy with SI fusion, that being said I haven't seen to many pts cured with SI RFA either.

Referred >> primary pain at SI I suspect

The pts that seem to do really well with SIJ steroid injections:

1) elderly with Rheum hx

2) pts with lumbar fusions

 

[drusso]

CT scan evaluate for osseous bridge; I've heard other patients with lateral fusion from outside, and some pain docs doing PNS for medial cluneal with benefit

We're seeing epidemic levels of cluneal neuralgia.

 

[Nodolor]

We're seeing epidemic levels of cluneal neuralgia.

think weekly PRP would help

 

[Multimodal]

I would love to know what others are charging for PRP. I just bought a machine and am coming up with a plan to roll out to patients. I have heard up to 2k at some clinics for a single PRP session or as low as 900 in others. Im thinking of cutting the difference somewhere in the middle but am not too sure what will be the best balance to capture patients.

 

[Dr. Ice]

I would love to know what others are charging for PRP. I just bought a machine and am coming up with a plan to roll out to patients. I have heard up to 2k at some clinics for a single PRP session or as low as 900 in others. Im thinking of cutting the difference somewhere in the middle but am not too sure what will be the best balance to capture patients.

For SIJ or just in general?

 

[lobelsteve]

I would love to know what others are charging for PRP. I just bought a machine and am coming up with a plan to roll out to patients. I have heard up to 2k at some clinics for a single PRP session or as low as 900 in others. Im thinking of cutting the difference somewhere in the middle but am not too sure what will be the best balance to capture patients.

I charge based on where the injection is going. So it’s usually the cost of 20610 or 20551. I don’t MusicKit but I have a full lab in the office. Just a couple of test tubes and the centrifuge

 

[BobBarker]

I charge $800 for unilateral, $1000 bilateral.

 

[nvrsumr]

$499 plus half off for second site. I make them pay for a consult with their insurance first though.

 

[drusso]

I would love to know what others are charging for PRP. I just bought a machine and am coming up with a plan to roll out to patients. I have heard up to 2k at some clinics for a single PRP session or as low as 900 in others. Im thinking of cutting the difference somewhere in the middle but am not too sure what will be the best balance to capture patients.

 

[Multimodal]

clearly raised by belgians to be......evil

to everyone else. thanks for the response!