SIJ Arthrodesis 27278 in Non-Facility Settings

[Ronin1]

It’s all in the patient population. I see at least 3-4 a week that I would consider for Intracept. But I have a mainly Medicare age practice.

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[nvrsumr]

There are already docs who do trials in office who drop their stuff on the ground, too cheap to purchase another stim lead, wash it off and stick it in the patient. Their MAs don’t know any better and the reps keep their mouth shut.

haha. Come on. They always give you a free lead if that happens.

Interesting to see ASC owners who have been battling hospitals to bring more surgeries to the ambulatory setting getting a little territorial and slanderous when a cheaper (not yet to be known if equally safe) option presents itself in the office

Breast augmentation is done in plastic surgery office suites so must be some way to maintain sterility, hemostasis and sedation.

 

[RoloTomassi]

i see maybe 100 patients/week (give or take)

i find one that is a reasonable Intracept candidate maybe once or twice a month.

then there are the insurance hurdles, etc. they are out there. but not the "epidemic of modic changes" that drusso would suggest

Saw 12 pts this morning including these 3 candidates

 

[Agast]

haha. Come on. They always give you a free lead if that happens.

Interesting to see ASC owners who have been battling hospitals to bring more surgeries to the ambulatory setting getting a little territorial and slanderous when a cheaper (not yet to be known if equally safe) option presents itself in the office

Slander? Lol this would be the least bad thing this doc has done to a patient.

 

[nvrsumr]

I had to look up slander vs libel. haha. I thought more of a general statement regarding procedures done in office.

 

[SSdoc33]

Saw 12 pts this morning including these 3 candidates

yes on the first 2. the third? meh

 

[Taus]

yes on the first 2. the third? meh

Why meh? Let’s say it’s not facets (exam and mbb negative), prior esi with brief relief, failed PT, DC, non-opioid meds, brace, tens. I’ve done plenty with less impressive MRIs who have done really well. N >90 overall, results still mirror published literature.

What else you can offer here? Suck it up? Scs? Pns? Bmac?

 

[Taus]

Just saw this one back two months postop. 90% relief. Modic being binary is not just a party line from Relievant…..

 

[Ronin1]

Just saw this one back two months postop. 90% relief. Modic being binary is not just a party line from Relievant…..

On this one did you just do 4-5

 

[Taus]

On this one did you just do 4-5

?

 

[drusso]

i see maybe 100 patients/week (give or take)

i find one that is a reasonable Intracept candidate maybe once or twice a month.

then there are the insurance hurdles, etc. they are out there. but not the "epidemic of modic changes" that drusso would suggest

Are they tender to palpation over the iliac crest near the cluneal nerves?

 

[nvrsumr]

@drusso are you considering doing the Si fusions in your "accredited" office procedure room. The sterility requirements for an implant do seem to be a valid issue. Thoughts on how to address?

 

[Espn123]

There are already docs who do trials in office who drop their stuff on the ground, too cheap to purchase another stim lead, wash it off and stick it in the patient. Their MAs don’t know any better and the reps keep their mouth shut.

What?

 

[lobelsteve]

What?

5 second rule.

 

[Ronin1]

?

Did you do two lesions one at L4 and one at L5 or did you do an additional one

 

[Taus]

Did you do two lesions one at L4 and one at L5 or did you do an additional one

I don’t really see where else it would be needed. Pristine spine outside L45

 

[Asclepius186]

Had a bad case of post procedural radiculitis after an intracept that kind of soured me on it for a bit. Probably gonna give it more of a go again soon. I did an ESI at the time of the procedure. Post op MRI showed targeting was spot on. Frustrating to deal with.

 

[BobBarker]

Had a bad case of post procedural radiculitis after an intracept that kind of soured me on it for a bit. Probably gonna give it more of a go again soon. I did an ESI at the time of the procedure. Post op MRI showed targeting was spot on. Frustrating to deal with.

I had one, too. My j stylette chose its own adventure and went straight south out the bottom of the pedicle. It resolved with oral steroids and time.

 

[Asclepius186]

I had one, too. My j stylette chose its own adventure and went straight south out the bottom of the pedicle. It resolved with oral steroids and time.

Yes this one resolved with oral steroids and about 4-6 weeks. Can’t blame a wayward J stylet though. Everything seemed fine procedurally. Best I can guess I attribute it to the fact that the guy had mod to severe foraminal stenosis and with the post op inflammation from the procedure things got squeezed/irritated in an already tight foramen.

 

[MitchLevi]

What do yall think about this? Failed everything else.

 

[Taus]

What do yall think about this? Failed everything else.



5-1, do it

 

[RoloTomassi]

What do yall think about this? Failed everything else.

View attachment 378999View attachment 379000

I'd do it too, but the sclerotic/autofusing look at L5-S1 makes me a little less excited. Make sure to scroll fully left to right on all sequences looking at the other levels, might be something less obvious that we're missing.

 

[MitchLevi]

I'd do it too, but the sclerotic/autofusing look at L5-S1 makes me a little less excited. Make sure to scroll fully left to right on all sequences looking at the other levels, might be something less obvious that we're missing.

That's my hold up too. I've tried everything else and each "thing" I do works for a small amount of time. I think he's ankylosing.

 

[Taus]

That's my hold up too. I've tried everything else and each "thing" I do works for a small amount of time. I think he's ankylosing.

Just saw this one back at 2 weeks out. 60%. Failed all else over a decade. Will see back at three months postop for final result. Agreed re temper expectations some. Most of my 90 to 100% home runs have big type one modic hyperintense on stir, but that’s empirical. Plenty of those also got around 75%, which they are thrilled with

 

[SSdoc33]

Why meh? Let’s say it’s not facets (exam and mbb negative), prior esi with brief relief, failed PT, DC, non-opioid meds, brace, tens. I’ve done plenty with less impressive MRIs who have done really well. N >90 overall, results still mirror published literature.

What else you can offer here? Suck it up? Scs? Pns? Bmac?

i appreciate your expertise and the fact you have put your money where your mouth is in terms of doing an outcomes study.

but this is at least 4 levels of degenerative changes. there are disc bulges everywhere. there has to be a component of facet pain. the outcome from the third example wouldnt be as good as the first two.

and yes, there are many times when i dont offer an injection nor surgery. there are some things a needle can't treat.

i worry that if we expand the types/number of patients that get basivertebral nerve ablation the outcomes wont be as good. they CANT be as good. we cant expand the inclusion criteria to anyone who happens to have an older-looking spine

i am just seeing an MRI and not evaluating the patient, seeing if they are crazy, smoker, fat, etc. so it is obviously hard to say anything definitive

 

[RoloTomassi]

i appreciate your expertise and the fact you have put your money where your mouth is in terms of doing an outcomes study.

but this is at least 4 levels of degenerative changes. there are disc bulges everywhere. there has to be a component of facet pain. the outcome from the third example wouldnt be as good as the first two.

and yes, there are many times when i dont offer an injection nor surgery. there are some things a needle can't treat.

i worry that if we expand the types/number of patients that get basivertebral nerve ablation the outcomes wont be as good. they CANT be as good. we cant expand the inclusion criteria to anyone who happens to have an older-looking spine

i am just seeing an MRI and not evaluating the patient, seeing if they are crazy, smoker, fat, etc. so it is obviously hard to say anything definitive

Why only treat one pain generator? If herniation/stenosis and facet arthropathy present, mixed radicular/facetogenic presentation, you will only treat the facets?

 

[SSdoc33]

Why only treat one pain generator? If herniation/stenosis and facet arthropathy present, mixed radicular/facetogenic presentation, you will only treat the facets?

you are justifying

of course you treat everything. but my point is that BVN in a decrepit looking spine just wont work as well as spines with clearer indications.

give a strong indication for the procedure, not a weak one. "nothing else helped" is not a strong indication

 

[Taus]

i appreciate your expertise and the fact you have put your money where your mouth is in terms of doing an outcomes study.

Ty

but this is at least 4 levels of degenerative changes. there are disc bulges everywhere. there has to be a component of facet pain. the outcome from the third example wouldnt be as good as the first two.

History, exam, and mbb should clarify that for you. If an older patient has L3 to S1 modic and the clinical picture fits, facet ruled out, no leg symptoms, failed all else reasonable, I would do the case. I have done at least 30 such cases, i.e., Medicare, back pain attributed to DDD for decades. Most of these end up 50 to 75% relief categories, not home runs, but a whole lot better than anything else out there.

and yes, there are many times when i dont offer an injection nor surgery. there are some things a needle can't treat.

100% agreed, but this should help more likely than not in this scenario.

i worry that if we expand the types/number of patients that get basivertebral nerve ablation the outcomes wont be as good. they CANT be as good. we cant expand the inclusion criteria to anyone who happens to have an older-looking spine

i am just seeing an MRI and not evaluating the patient, seeing if they are crazy, smoker, fat, etc. so it is obviously hard to say anything definitive

 

[SSdoc33]

Ty


History, exam, and mbb should clarify that for you. If an older patient has L3 to S1 modic and the clinical picture fits, facet ruled out, no leg symptoms, failed all else reasonable, I would do the case. I have done at least 30 such cases, i.e., Medicare, back pain attributed to DDD for decades. Most of these end up 50 to 75% relief categories, not home runs, but a whole lot better than anything else out there.

100% agreed, but this should help more likely than not in this scenario.

valid points

 

[Force440]

Whether or not you agree that an SI joint fusion can help some patients. Let's be clear. Allografts don't reliably fuse SI joints. There is no compression, limited joint preparation and minimal BMP placed. I've always been taught that each of these factors are fundamental to obtaining an adequate arthrodesis.

I've had advocates for allografts tell me that "it really doesn't matter whether or not the joint fuses", but I guarantee that they bill for a fusion every time.

There are better options for posterior access SI joint fusions. . . but no, they can't be done in an office based setting.

 

[MitchLevi]

I'd do it too, but the sclerotic/autofusing look at L5-S1 makes me a little less excited. Make sure to scroll fully left to right on all sequences looking at the other levels, might be something less obvious that we're missing.

You wanna do it? I can't get the company to reply to me.

 

[Ducttape]

i worry that if we expand the types/number of patients that get basivertebral nerve ablation the outcomes wont be as good. they CANT be as good. we cant expand the inclusion criteria to anyone who happens to have an older-looking spine

this exactly.

and the decrease in benefit is expected, as one does more and more and has more reasoned expectations. we have all had that experience with stim coming out of residency, and we will have had that experience again after doing the new and upcoming procedure.

one thing going for intracept, compared to other procedures, is the fact that it is not a big money generator like neuromodulation or fusion procedures, so it seems less likely to be abused purely for profit's sake.

question - are there a lot of Linkd in posts about it?


the other positive is that it is less permanent with no residual material left in that patient's body.

 

[drrosenrosen]

this exactly.

and the decrease in benefit is expected, as one does more and more and has more reasoned expectations. we have all had that experience with stim coming out of residency, and we will have had that experience again after doing the new and upcoming procedure.

one thing going for intracept, compared to other procedures, is the fact that it is not a big money generator like neuromodulation or fusion procedures, so it seems less likely to be abused purely for profit's sake.

question - are there a lot of Linkd in posts about it?


the other positive is that it is less permanent with no residual material left in that patient's body.

As far as money goes, it is a relative drain for people who do most of their stuff in the office, since you have to carve out time to do it in a hospital, and then only collect the pro fee. If you were participating in an ASC I understand that they make a decent profit on the kits. And if you're paid in wrvu widgets, it pays about the same as a kyphoplasty

 

[Espn123]

this exactly.

and the decrease in benefit is expected, as one does more and more and has more reasoned expectations. we have all had that experience with stim coming out of residency, and we will have had that experience again after doing the new and upcoming procedure.

one thing going for intracept, compared to other procedures, is the fact that it is not a big money generator like neuromodulation or fusion procedures, so it seems less likely to be abused purely for profit's sake.

question - are there a lot of Linkd in posts about it?


the other positive is that it is less permanent with no residual material left in that patient's body.

The answer to your question is yes