SI RFA

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
B

Bsb2015

Full Member
2+ Year Member
Joined
Mar 21, 2019
Messages
68
Reaction score
9
I have a 33 year old patient 6 months post delivery with classic SI joint pain. Has been trying PT when she can-new baby. Gave SI belt to use prn. She does use when she remembers. Doesn’t want po meds. Did SI joint injection with good relief-75% however short term about 3 weeks. Thinking next step would be SI RFA, however imo not “slam dunk” like cervical or lumbar RFA. Would you repeat SI joint injection (knowing short term benefit) or go for RFA as the next step?
Members don't see this ad.
 
TENS and time + ice and heat. HEP when not at formal PT. Repeat SI - Good luck getting RF paid for by insurance. Try Pennsaid, Voltaren, or diclofenac gel.
 
Adjust nsaids. Consider Repeat SIJ. Consider referral for chiropractic or osteopathic manipulation. Buy her time to let this resolve. Wait on the rfa
 
Members don't see this ad :)
My billers have told me you can bill 64640 x3 for sacral lateral branches. May or may not be approved by insurance. You can do an L5 dorsal ramus plus s1-s3 lateral branch blocks x2, bill for L5-S1 RFA and basically throw in the sacral nerves for free. I have been using the Cosman pallisade technique (but without the plastic guide). I used Simplicity in fellowship. Have had some successes with both.

Agree with what others have said about giving it time to resolve though, this soon postpartum. I would repeat SI injection. Refer to a pelvic physical therapist and encourage her to use the SI joint belt more.
 
When they're young, I generally shy away from that. I echo everyone else's ideas. PRP, PT, Re-trying injection, etc.
 
Thanks for all the great input. Doesn’t seem a lot of patients are happy with “give it some time” Or when I encourage them to actually do the PT at home I feel like I’m talking to a brick wall. What’s your verbiage on this (PT, exercise) ? I try to explain my needles aren’t the cure, but sometimes I feel I jump to it quickly, hence my question
 
Your job is not to make ppl happy. Took me a while to learn that, bc early on I wanted to be friends with my pts. I'm cordial and fun with my pts, but I am not shy about telling them the truth. For some reason ppl in 2019 expect that they will NEVER experience pain. That isn't reality.
 
Bsb2015 said:
Thanks for all the great input. Doesn’t seem a lot of patients are happy with “give it some time” Or when I encourage them to actually do the PT at home I feel like I’m talking to a brick wall. What’s your verbiage on this (PT, exercise) ? I try to explain my needles aren’t the cure, but sometimes I feel I jump to it quickly, hence my question
Click to expand...
I’d explain why it’s hurting first (relaxin hormone released during pregnancy causes ligamentous laxity which helps delivery, but can allow abnormal movement of the SI joint), then explain the the steroid injection is only a band aid that reduced inflammation but doesn’t get rid of the movement, and the most effective way to get rid of the movement, short of seeing a surgeon to get the joint fused, is to brace and stabilize the joint by increasing strength of the pelvic stabilizing muscles.
 
I would agree with avoiding permanent issues for a temporary problem but the new baby/demands complicate things. I normally explain that I can mask the issue for a while, but hiding it carries risks, and in some scenarios will cause changes I cannot reverse.

Are they lactating/breastfeeding? That can prolong the hormonal effects but once they stop that, it'll get better.

Pain coping and education is the best thing if they don't want injection related issues and refuse oral medications. NSAID patches/creams are an option. I would consider a Butrans patch but not excited.
 
When I do SI RFA I usually request an L4 L5 S1 S2 and it gets approved. For the RFA I essentially do several strip like burns down the medial aspect of the SIJ where I think the lateral branches lie. I’ve had good results. It does take extra time however
 
swamprat said:
When I do SI RFA I usually request an L4 L5 S1 S2 and it gets approved. For the RFA I essentially do several strip like burns down the medial aspect of the SIJ where I think the lateral branches lie. I’ve had good results. It does take extra time however
Click to expand...

Can you send pics of that? Do you do a contralateral oblique to 15-20 like how we do to get into the SI joint and then go along the medial SIJ or do you do it from AP?
 
Members don't see this ad :)
I changed my technique after the last study by Stout and Burnham, Pain Medicine 2018. I still do bipolar but drop a few extra needles. response rate has gone up from 50-60% to around 80%

bipolar from 7-9 oclock on S1 and then along S1-2-3. takes some time but patients are happy
 
oreosandsake said:
I changed my technique after the last study by Stout and Burnham, Pain Medicine 2018. I still do bipolar but drop a few extra needles. response rate has gone up from 50-60% to around 80%

bipolar from 7-9 oclock on S1 and then along S1-2-3. takes some time but patients are happy
Click to expand...
Could you share that article? Couldn’t find it on pubmed, and I’d be very interested in trying it.
 
Is your patient breastfeeding? I try to limit anything interventional/steroid while either pregnant or breastfeeding. If not breastfeeding, would likely do a second SI injection hoping for longer relief. If she's the got the funds, PRP is a better option in my opinion. Either way, SI RFA is a good choice if the SI injections aren't working, but I reserve this for if they are miserable and two SI joint injections have proven to be helpful but worn off before 3 months-ish. I do dorsal ramus L5 and lateral S1, S2, S3 branches. Venom needle. I haven't had any denials that I know of. I usually bill 64640x3, although I think you can do x4, and 77003.
 
painfree23 said:
Can you send pics of that? Do you do a contralateral oblique to 15-20 like how we do to get into the SI joint and then go along the medial SIJ or do you do it from AP?
Click to expand...

That’s what I’ve been doing- CLO opening up the joint and going medial to it with bipolar burn. Results don’t seem to be as impressive compared to lumbar or cervical RFA. How do you do your SI RFA?
 
Ferrismonk said:
Is your patient breastfeeding? I try to limit anything interventional/steroid while either pregnant or breastfeeding. If not breastfeeding, would likely do a second SI injection hoping for longer relief. If she's the got the funds, PRP is a better option in my opinion. Either way, SI RFA is a good choice if the SI injections aren't working, but I reserve this for if they are miserable and two SI joint injections have proven to be helpful but worn off before 3 months-ish. I do dorsal ramus L5 and lateral S1, S2, S3 branches. Venom needle. I haven't had any denials that I know of. I usually bill 64640x3, although I think you can do x4, and 77003.
Click to expand...

No, she never breast fed. She’s been dealing with it during and now after her pregnancy and is “getting tired of the pain” very nice patient.
 
oreosandsake said:
I changed my technique after the last study by Stout and Burnham, Pain Medicine 2018. I still do bipolar but drop a few extra needles. response rate has gone up from 50-60% to around 80%

bipolar from 7-9 oclock on S1 and then along S1-2-3. takes some time but patients are happy
Click to expand...
I read the article Cowboydoc posted. I currently do the palisade technique, without the guide, 18g needles x7, 1 cm apart, 85 degrees x2.5 m per burn, plus L5 dorsal ramus 80dx90s. Will have to try as you’ve described with an extra burn in the inferiorlateral quadrant of S1. I could do it without adding much time by running that at the same time as L5
What time/temp/needle size do you use?
 
SI RFA is not a covered option under Medicare.

if you have a private insurance, no fault, WC, you might be more fortunate in terms of getting it covered. unfortunately, some LCD such as Evicore directly follow Medicare "guidelines"...

if you are getting those covered under medicare, it is probably because your biller asked for lumbar facet RFA, which medicare does cover, esp. L5S1.
 
callmeanesthesia said:
I read the article Cowboydoc posted. I currently do the palisade technique, without the guide, 18g needles x7, 1 cm apart, 85 degrees x2.5 m per burn, plus L5 dorsal ramus 80dx90s. Will have to try as you’ve described with an extra burn in the inferiorlateral quadrant of S1. I could do it without adding much time by running that at the same time as L5
What time/temp/needle size do you use?
Click to expand...
I do a palisade type technique with Stryker 18g venom bipolar to "carpetbomb" from L5 DR down lateral to the sacral foramen. 90 deg for 90 sec each location.
 
Here's a few views of today's RF. She got about 2 years last time. Ventured a bit further casual than her last one. Laterals don't look great, but are on os.
 

Attachments

  • image.jpg
    image.jpg
    127.2 KB · Views: 248
  • image.jpg
    image.jpg
    161 KB · Views: 247
  • image.jpg
    image.jpg
    130.9 KB · Views: 234
  • image.jpg
    image.jpg
    90.7 KB · Views: 241
  • image.jpg
    image.jpg
    108.3 KB · Views: 239
cowboydoc said:
Here's a few views of today's RF. She got about 2 years last time. Ventured a bit further casual than her last one. Laterals don't look great, but are on os.
Click to expand...

So you do these on straight AP?
 
painfree23 said:
So you do these on straight AP?
Click to expand...
I start with 10 degrees ipsilateral oblique, 25-30 caudal tilt and drop into the regular L5 DR position. Then keep caudal angle, lose the obliquity and do the others sequentially. Check the AP and lateral and will adjust in either view.

I'm interested in refinement. The paper I posted helps visualize location of nerves, but I'm still doing a palisade.
 
cowboydoc said:
I start with 10 degrees ipsilateral oblique, 25-30 caudal tilt and drop into the regular L5 DR position. Then keep caudal angle, lose the obliquity and do the others sequentially. Check the AP and lateral and will adjust in either view.

I'm interested in refinement. The paper I posted helps visualize location of nerves, but I'm still doing a palisade.
Click to expand...
Not to be critical but I will be. Think your needles need to be down to os on lateral. No?
 
In the parenting question how is she carrying the baby around? A lot of new moms are repeatedly injuring themselves with carrying the car seat and sticking a hip out to the side because of the weird way you have to carry them which worsens back pain. This might be impacting her ability to heal that area and with the relaxin still present it seems to cause more issues.

I’m family medicine but I try to get people to only use the car seats in the car for this issue for parents and plagiocephaly for the kids.
 
Keona said:
In the parenting question how is she carrying the baby around? A lot of new moms are repeatedly injuring themselves with carrying the car seat and sticking a hip out to the side because of the weird way you have to carry them which worsens back pain. This might be impacting her ability to heal that area and with the relaxin still present it seems to cause more issues.

I’m family medicine but I try to get people to only use the car seats in the car for this issue for parents and plagiocephaly for the kids.
Click to expand...
264136

This way of carrying it helps some, though wearing the baby is much more ergonomic (google new way to carry car seat for videos of it).
 
Any tips on how to better visualize the PSF. I always have a fear I may be too close and burn a spinal nerve.

Do you guys do any testing prior to lesioning?
 
You must log in or register to reply here.

Similar threads

C
Sacral Lateral Branch RFA (SI Joint) needle size?
Replies
17
Views
1K
cowboydoc
cowboydoc
J
Lumbar RFA Temperature
Replies
24
Views
1K
Taus
T
D
Testing for RFA
2
Replies
66
Views
3K
Ferrismonk
Ferrismonk
P
RFA with pacer/defib
Replies
24
Views
1K
Laryngospasm
Laryngospasm
A
Inspire device and RFA
Replies
2
Views
513
Agast
Agast
Top