SIJ Fusion Under Attack?

[drusso]

There's some chatter that a group of surgeons is planning an attack on the minimally invasive SIJ fusion code at the next RUC meeting. This would be tantamount to an insurrection against MIS SIJ procedures performed by pain physicians. Can anyone confirm or deny this?

It's past time to mobilize the specialty's resources. This is our Fort Sumter...let's show them what we've got...

"The submitted application recommends that a separate and unique Category III code should be given for MIS SI fusion for the dorsal and posterior approach. We strongly disagree with his assessment. We contend that the existing 27279 code, which has been coded for several years for posterior and posterior/dorsal approach, does not require a specific code. CPT code 27279 further states “percutaneous or minimally invasive” by a description of CPT. The existing code is accurately represented within the current descriptor of 27279. The steps for a posterior MIS SI Fusion approach are equivalent in scope and complexity to the lateral approach except a different angle to approach the joint is used. This code has been utilized and accepted by payers and societies for MIS SI fusions by multiple devices/implants over the last several years utilizing the posterior, posterior/dorsal approach with well-documented clinical outcomes. If the AMA were to limit 27279 CPT code as suggested by Mr. Twetten, only one manufacturer would be represented under the current 27279 CPT code. The open arthrodesis code for sacroiliac joint 27280 does include multiple approaches, as with most codes that can be done either through a percutaneous/minimally invasive vs. open procedure. If the CPT Committee were to issue a code for every procedure that could be performed at a different angle/approach for any existing procedure; this would set a dangerous precedent for coding."

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[lobelsteve]

If none of them work, none of them should get paid for.

 

[Ducttape]

of all the procedures to mobilize resources over and fight for, SI fusion would be near or at the very bottom of the list...

 

[drusso]

of all the procedures to mobilize resources over and fight for, SI fusion would be near or at the very bottom of the list...

We stand together or we will be picked off.

 

[NJPAIN]

There's some chatter that a group of surgeons is planning an attack on the minimally invasive SIJ fusion code at the next RUC meeting. This would be tantamount to an insurrection against MIS SIJ procedures performed by pain physicians. Can anyone confirm or deny this?

It's past time to mobilize the specialty's resources. This is our Fort Sumter...let's show them what we've got...

"The submitted application recommends that a separate and unique Category III code should be given for MIS SI fusion for the dorsal and posterior approach. We strongly disagree with his assessment. We contend that the existing 27279 code, which has been coded for several years for posterior and posterior/dorsal approach, does not require a specific code. CPT code 27279 further states “percutaneous or minimally invasive” by a description of CPT. The existing code is accurately represented within the current descriptor of 27279. The steps for a posterior MIS SI Fusion approach are equivalent in scope and complexity to the lateral approach except a different angle to approach the joint is used. This code has been utilized and accepted by payers and societies for MIS SI fusions by multiple devices/implants over the last several years utilizing the posterior, posterior/dorsal approach with well-documented clinical outcomes. If the AMA were to limit 27279 CPT code as suggested by Mr. Twetten, only one manufacturer would be represented under the current 27279 CPT code. The open arthrodesis code for sacroiliac joint 27280 does include multiple approaches, as with most codes that can be done either through a percutaneous/minimally invasive vs. open procedure. If the CPT Committee were to issue a code for every procedure that could be performed at a different angle/approach for any existing procedure; this would set a dangerous precedent for coding."

This is exactly what was was talking about. Either we work in concert with the surgeons or we work against them. I don't know the correct answer but I do thinks its one or the other. No one wants to be on the receiving end of "scope creep". Endoscopic discectomy, interspinous "fusion", facet fusion, SI joint fusion, kyphoplasty. Surgeons were not going to be silent on this forever. It think this is one of the reasons ortho groups are hiring their own pain docs; to limit what they do or at least profit from their intrusion into the surgical lane.

 

[Agast]

FWIW I don't think surgeons are against pain doctors doing this because of turf, I think there is some genuine concern that people are doing the wrong kind of procedures or inappropriate procedures to treat pain and therefore are preventing patients from getting more appropriate care from a real spine surgeon. At least that's what I gleaned from the LinkedIn commentary crowd.

 

[drusso]

FWIW I don't think surgeons are against pain doctors doing this because of turf, I think there is some genuine concern that people are doing the wrong kind of procedures or inappropriate procedures to treat pain and therefore are preventing patients from getting more appropriate care from a real spine surgeon. At least that's what I gleaned from the LinkedIn commentary crowd.

Kettle...pot...black...

 

[Agast]

Kettle...pot...black...

As long as kettles and pots both agree to keep paper cups out of the kitchen

 

[Ducttape]

We stand together or we will be picked off.

you must choose an appropriate position to stand and fight.

get the high ground. that's not SI fusion.

 

[drusso]

you must choose an appropriate position to stand and fight.

get the high ground. that's not SI fusion.

First, they came for the SIJ fusions
And I did not speak out
Because I was not a fusionist

Then they came for the stem cells
And I did not speak out
Because I was not a regenerative medicine doctor

Then they came for the SCS
And I did not speak out
Because I was not a neuromodulator

Then they came for me
And there was no one left
To speak out for me

 

[Agast]

^^you had SDN withdrawal during site maintenance didn’t you lol

 

[deleted472101]

I do agree with drusso.

I don’t do SI fusion but from what I hear it’s a good procedure that can help a few.

I think we should take up our field as an interventional field. The understanding of pain and the ability to treat with interventions and other advanced procedures makes us different from a PCP.

if we just roll over everyone just because it’s not what I do then we will lose in general

 

[SSdoc33]

i appreciate the sentiment, but i have NEVER seen a successful SIJ fusion. this is not the hill we want to die on

 

[deleted472101]

I wonder the same question. If we don’t see a good response to SI fusion does that mean they don’t exist?

if we pool our patient population lumbar surgery, PT, time, chiropractic care never works.

 

[swamprat]

I've done a few SI fusions with pain teq - a few non responders despite good relief with SI injections and a few excellent , pain free patients. It's just like everything else we do - and surgeons for that matter (how many failed backs have you seen that were electrive surgeries where patients didn't even have epidurals and went straight to surgery). The argument surgeons know better at this stuff is BS. Also IMO SI fusion at least on professional side isn't exactly a home run money wise .. discectomy pays wayy better. I am all for pushing the field forward we are physicians after all not mid levels.

 

[Ducttape]

1. the data on SI fusion is poor.
2. Medicare LCD for SI fusion document that it is to be performed by trained orthopedic or neurosurgeon. no comment on my LCD on pain physician or interventionalist.
3. SI fusion goes against the very premise of a multidisciplinary program to improve functional outcomes - fusing limits movement and activity.

please tell me - what other body part does better after it is fused and unable to move?


tell me why i would want to defend SI fusions, besides the fact that a few of my colleagues perform this procedure?


your poem - as it were - also belies the fact that one is not eliminating the doctors who perform the procedure, only the procedure, so it is not a concordant example.

 

[drusso]

1. the data on SI fusion is poor.
2. Medicare LCD for SI fusion document that it is to be performed by trained orthopedic or neurosurgeon. no comment on my LCD on pain physician or interventionalist.
3. SI fusion goes against the very premise of a multidisciplinary program to improve functional outcomes - fusing limits movement and activity.

please tell me - what other body part does better after it is fused and unable to move?


tell me why i would want to defend SI fusions, besides the fact that a few of my colleagues perform this procedure?


your poem - as it were - also belies the fact that one is not eliminating the doctors who perform the procedure, only the procedure, so it is not a concordant example.

It's not about data. It's about freedom.

 

[cowboydoc]

It's not about data. It's about freedom.

-said the antivaxxer, refusing to wear a mask.

 

[pmrmd]

I wouldn’t call the SI joint mobile, so the pain/motion paradigm does not apply IMO. It may be the joint is too mobile in some of these people with large lumbar fusion constructs into the sacrum. I’ve never been a huge believer in SIJ pain and especially fusion but in a few cases it is absolutely indicated and there has been marked improvement. I only have 1 LinQ under my belt but a few of my patients had SI Bone and did well.

 

[SommeRiver]

Am I the only person who has seen a pt with a fused SIJ at year 5 or greater?

SIJ fusion shouldn't exist.

What is the pathophysiology being treated?

 

[NJPAIN]

FWIW I don't think surgeons are against pain doctors doing this because of turf, I think there is some genuine concern that people are doing the wrong kind of procedures or inappropriate procedures to treat pain and therefore are preventing patients from getting more appropriate care from a real spine surgeon. At least that's what I gleaned from the LinkedIn commentary crowd.

Perhaps you are correct on that. I’ve seen plenty of patients get an interspinous spacer followed by an endoscopic discectomy only to go on to have a laminectomy in the end.
I’m all for advancing the field as well but I do think we have to play nice in the sand box and keep focused on what is best for the patient. I also think that our most important battle is with the midlevels trying to be MDs and we need the help of other specialties including surgeons to fight that battle.

 

[Ducttape]

It's not about data. It's about freedom.

as physicians and scientists, we should be looking objectively at data to guide what we recommend and what procedures we perform,.

yes, we use data in combination with the art of medicine.



if we don't use data, then we are snake oil salesmen. it cant be all about $$$$$.

 

[BobBarker]

The SI fusion products really work quite well. They are more consistently successful than SCS.

 

[Ducttape]

The SI fusion products really work quite well. They are more consistently successful than SCS.

please post data/studies.

 

[bedrock]

The SI fusion products really work quite well. They are more consistently successful than SCS.

I hope that you first do a very thorough SIJ ablation before you ever consider a fusion.

 

[drusso]

as physicians and scientists, we should be looking objectively at data to guide what we recommend and what procedures we perform,.

yes, we use data in combination with the art of medicine.



if we don't use data, then we are snake oil salesmen. it cant be all about $$$$$.

I didn't say $$$$$. I said freedom.

 

[drusso]

The SI fusion products really work quite well. They are more consistently successful than SCS.

Can you elaborate?

 

[NJPAIN]

The SI fusion products really work quite well. They are more consistently successful than SCS.

So what's your algorithm? Are you fusing every SI joint after failure of conservative therapy, a "positive" diagnostic block and then a therapeutic block lasting less than 3 months?

 

[lobelsteve]

Can you elaborate?

Nope, elaboration would be only on bias/financial interest.
Literature is a mess.

 

[gaseous_clay]

i appreciate the sentiment, but i have NEVER seen a successful SIJ fusion. this is not the hill we want to die on

I’ve had a few successful ones. Just like stim, it’s about patient selection.

 

[gaseous_clay]

as physicians and scientists, we should be looking objectively at data to guide what we recommend and what procedures we perform,.

yes, we use data in combination with the art of medicine.



if we don't use data, then we are snake oil salesmen. it cant be all about $$$$$.

Have you seen the data on facets/RFA, ESIs, and SCS? Long term efficacy is not that great.

 

[gaseous_clay]

Am I the only person who has seen a pt with a fused SIJ at year 5 or greater?

SIJ fusion shouldn't exist.

What is the pathophysiology being treated?

Which type of SI fusion did they have? The transacral screws?

 

[drusso]

Nope, elaboration would be only on bias/financial interest.
Literature is a mess.

...this is why we can't have nice things. Bias and financial interests don't stop spine surgeons and other specialists from innovating their craft.

 

[SommeRiver]

Which type of SI fusion did they have? The transacral screws?

Never seen any of the newer SIJ fusion options, but no one knows if those will turn any different than screws right?

It's like asking about L4-S1 DRG leads at 8 yrs...No one knows.

I have no reason to think the outcomes will be any different long term (new vs old approach) bc the final common pathway is identical right? You're fusing the SIJ - Screw or cement surely doesn't matter at year 3 or 8 or 15 right?

 

[Ducttape]

Have you seen the data on facets/RFA, ESIs, and SCS? Long term efficacy is not that great.

at least for facets, we are not placing a permanent construct in to a patients back that limit movement.

one can argue whether ESI s have long term effects on the spine (debatable re arachnoiditis), but there are no permanent irreversible effects with RFA that has been documented.

 

[Ducttape]

...this is why we can't have nice things. Bias and financial interests don't stop spine surgeons and other specialists from innovating their craft.

so we should "stoop" to their level and let financial interests dominate our treatments.


sorry I'm slow to seeing the light of day. I gotta start doing more pumps and peripheral stims, what ASPN Pain recommends...

 

[gaseous_clay]

at least for facets, we are not placing a permanent construct in to a patients back that limit movement.

one can argue whether ESI s have long term effects on the spine (debatable re arachnoiditis), but there are no permanent irreversible effects with RFA that has been documented.

Agreed, however, this still doesn’t address the issue of poor long term efficacy of these procedures, yet we still perform them. Spine surgeons have this same mentality.

 

[gaseous_clay]

Never seen any of the newer SIJ fusion options, but no one knows if those will turn any different than screws right?

It's like asking about L4-S1 DRG leads at 8 yrs...No one knows.

I have no reason to think the outcomes will be any different long term (new vs old approach) bc the final common pathway is identical right? You're fusing the SIJ - Screw or cement surely doesn't matter at year 3 or 8 or 15 right?

Same can be said for lumbar fusion surgery and adjacent segment disease that inevitably happens after 3-5 years, requiring another fusion.

 

[SommeRiver]

Same can be said for lumbar fusion surgery and adjacent segment disease that inevitably happens after 3-5 years, requiring another fusion.

Hey man, I'm not a fan of those either!

Take a 9mm slip with radiculitis and LBP...I'm not against fusing that if nothing works. I have objective evidence there's a problem and it makes physiological sense to stabilize that pathology. I just can't make sense of SIJ fusion at the anatomical level.

 

[deleted131481]

Rarely do I see isolated SIJ pain that is as severe as someone with severe lumbar stenosis/neurogenic claudication. I can't really think of any off the top of my head.

The only RCT I'm aware of for SIJ fusion is iFuse. This from their 2019 article 2 year data:

"Severe events unrelated to the device or procedure included 14 events in the low back (e.g., disc herniation, lumbar facet pain), 3 events in the hip (e.g., trochanteric bursitis), 10 events in the pelvis (primarily sacroiliac joint or contralateral sacroiliac joint pain), and 8 events unrelated to the pelvis, spine, or hip. "

With an n=52, I consider this quite high. If you 'cured' their SIJ pain and they have back/hip pain, then I think it's either poor diagnosis or adjacent disease.

 

[Ducttape]

Same can be said for lumbar fusion surgery and adjacent segment disease that inevitably happens after 3-5 years, requiring another fusion.

not really comparable to compare repeating an RFA with reopening a patient to extend and/or remove a fusion.

you leave scar tissue and foreign objects and change anatomic structures with the first, not with the latter. one requires hours to recover, the other requires months.


would you rather buy a used car that had tranmission fluid changes a few times or one with a rebuilt transmission?



I think it is better to compare efficacy of RFA with the efficacy of medications. most of my patients agree an oxy only lasts for 4 hours.

 

[gaseous_clay]

not really comparable to compare repeating an RFA with reopening a patient to extend and/or remove a fusion.

you leave scar tissue and foreign objects and change anatomic structures with the first, not with the latter. one requires hours to recover, the other requires months.


would you rather buy a used car that had tranmission fluid changes a few times or one with a rebuilt transmission?



I think it is better to compare efficacy of RFA with the efficacy of medications. most of my patients agree an oxy only lasts for 4 hours.

You’re taking my statement out of context. My response was related to the post about long term efficacy of SI joint fusion, not comparing RFA with lumbar fusion. Morbidity and recovery from fusion vs RFA is incomparable, so you’re stating the obvious. Both procedures have diminishing returns with time, and the latter should be done in conjunction with some home exercise and/or PT for best results.

 

[Laryngospasm]

The reality of spine generated pain treatments is it’s a huge mess and we all do the best we can with the treatments that are available and that can be paid for. Unfortunately for patients the spine from and engineering standpoint is incredibly complex. I think it will be quite some time before really good stuff happens such as being able to regrow the patients disc and regenerate healthy facets.

 

[Agast]

Absent scoliosis and compression fractures, the worst facetogenic pain I see is in people who could stand to lose 50+ lbs. They don’t need fancy regenerative medicine. They need accountability. They need to participate in their own care.

 

[lobelsteve]

Absent scoliosis and compression fractures, the worst facetogenic pain I see is in people who could stand to lose 50+ lbs. They don’t need fancy regenerative medicine. They need accountability. They need to participate in their own care.

Same for DM, HTN, CAD, COPD, cholesterol. Such is the practice of all medicine since industrialization.

 

[drusso]

If none of them work, none of them should get paid for.

Minimally Invasive and Maximally Destructive - Regenexx

Regenexx offers non-surgical, regenerative orthopedic treatment options for pain related to osteoarthritis, joint injuries, overuse conditions, spine pain, and common sports injuries.

regenexx.com

 

[SSdoc33]

Minimally Invasive and Maximally Destructive - Regenexx

Regenexx offers non-surgical, regenerative orthopedic treatment options for pain related to osteoarthritis, joint injuries, overuse conditions, spine pain, and common sports injuries.

regenexx.com

he is officially a hack at this point.

just a blogger with an enormous COI.

this nonsense he posts detracts from what may otherwise be reasonable treatment options

less centeno, more malanga

 

[drusso]

he is officially a hack at this point.

just a blogger with an enormous COI.

this nonsense he posts detracts from what may otherwise be reasonable treatment options

less centeno, more malanga

How many SIJ fusions are you doing?

 

[SommeRiver]

Minimally Invasive and Maximally Destructive - Regenexx

Regenexx offers non-surgical, regenerative orthopedic treatment options for pain related to osteoarthritis, joint injuries, overuse conditions, spine pain, and common sports injuries.

regenexx.com

What a BS statement. His pts got "worse and worse after the RFA wore off."

Dude...He no longer has that problem eh? He uses PRP or BMAC or whatever and his pts no longer "get worse and worse" after his shots wear off?

What about when his pts run out of money? Then what?

He also mentions his RFA lasted 1-2 yrs...His shots last how long? I'd give anything to say my RFA routinely lasts 1-2 yrs. That's amazing...HE'S AMAZING!

 

[SSdoc33]

How many SIJ fusions are you doing?

none. i think it a BS procedure with better, less invasive treatments