Thoughts on SI RFA?

[spinedoc1337]

Wondering if anyone does RFA for SI mediated pain, I haven't seen this at all yet.

If anyone does/has done it, what are your outcomes?

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[SommeRiver]

My reality - Not a great procedure. I avoid them, but sometimes cannot.

I get a few weeks to a few months on avg.

 

[paindoc007]

I’ve been doing in for a few years now. I have Coolief which makes the procedure pretty straightforward. I walk down from SA to s3 is a straight line medial to si but lateral for foramen. Create a “wall” so to speak. Get solid results. Like everything we do, good patient selection is key.

 

[callmeanesthesia]

I do it with the Palisade technique (L5 dorsal ramus conventional RF, then bipolar RF in sequence down a row of needles lateral to the S1-S3 foramina). As long as you are careful about patient selection it works well. I do it a lot for patients with lumbosacral fusions. Seems to be equivalent efficacy to conventional RF.

 

[painfree23]

I’ve been doing in for a few years now. I have Coolief which makes the procedure pretty straightforward. I walk down from SA to s3 is a straight line medial to si but lateral for foramen. Create a “wall” so to speak. Get solid results. Like everything we do, good patient selection is key.

when you do this, do you line up SI joint (contralateral oblique with cephalad tilt) or do u do it in straight AP?

 

[bigyihoroi]

Just received notification from major insurances like BS, BC, United, etc... in cali that they are no longer authorizing this procedure

 

[paindoc007]

when you do this, do you line up SI joint (contralateral oblique with cephalad tilt) or do u do it in straight AP?

Slight CL oblique. Not all the way as I would doing an siji

 

[painfree23]

Slight CL oblique. Not all the way as I would doing an siji

Ah ok, any tilt?

 

[Ferrismonk]

Just received notification from major insurances like BS, BC, United, etc... in cali that they are no longer authorizing this procedure

Yep. I see good relief from this procedure, but new code equals an easy way to deny this one.

I swear insurance companies must be stocked with surgeons...

 

[paindoc007]

Ah ok, any tilt?

Nope

 

[chibadriver]

I do it with the Palisade technique (L5 dorsal ramus conventional RF, then bipolar RF in sequence down a row of needles lateral to the S1-S3 foramina). As long as you are careful about patient selection it works well. I do it a lot for patients with lumbosacral fusions. Seems to be equivalent efficacy to conventional RF.

Same palisade/leapfrog. I found the guide block cumbersome and just place the needles parallel to one another, lining them up using the cm marks on an epidural needle before I start. 90/90 for L5 DR then 90/120 for bipolar. Still covered by medicare (WPS), BCBS (locally), and all the company-owned health plans.

 

[callmeanesthesia]

Same palisade/leapfrog. I found the guide block cumbersome and just place the needles parallel to one another, lining them up using the cm marks on an epidural needle before I start. 90/90 for L5 DR then 90/120 for bipolar. Still covered by medicare (WPS), BCBS (locally), and all the company-owned health plans.

Me too. The 18g needle I use as a marker is about 6 cm long so I lay it on the skin along the path and mark both ends, then use a ruler to mark off 1 cm intervals. I think they charge about $80 for the single-use template.

 

[Agast]

I do them and I'm always shocked when patients feel better afterwards. I went back to the strip lesion approach using the venom probes. Haven't heard yet about payment being denied since my biller is pretty good about check before we do the procedure but I'm always waiting for that shoe to drop.

 

[painfree23]

Same palisade/leapfrog. I found the guide block cumbersome and just place the needles parallel to one another, lining them up using the cm marks on an epidural needle before I start. 90/90 for L5 DR then 90/120 for bipolar. Still covered by medicare (WPS), BCBS (locally), and all the company-owned health plans.

So do you put the fluoroscope in slight contralateral oblique , no tilt and drop the needles straight down (not at an angle) when you do this? My results are not as great, wonder if it’s my technique.

Do you use the SI joint as a reference at all or just go next to the foramenae? My needles aren’t always parallel when I go next to the foremen and sometimes have to cranially tilt a lot to see them ( esp S1).

 

[soccrwz]

ive started doing a bipolar technique 4 needles, pick up, then move the 4 needles down, parallel to each other

 

[chibadriver]

So do you put the fluoroscope in slight contralateral oblique , no tilt and drop the needles straight down (not at an angle) when you do this? My results are not as great, wonder if it’s my technique.

Do you use the SI joint as a reference at all or just go next to the foramenae? My needles aren’t always parallel when I go next to the foremen and sometimes have to cranially tilt a lot to see them ( esp S1).

I square up S1 and so long as I have adequate space between the joint line and the foramina, I go straight AP dropping the needles on the sacrum in trajectory view, with a little angle on either end for parallax (keep needle tips approximated for bipolar). I’ll CLO if I don’t have ~1.5cm of space all the way down. If I’m going to have trouble seeing any of the foramen it’s S1, the anterior foramen are more lateral anyway, so you can use them or the struts as a guide. I’ll assemble some step-by-step pictures as I do the next one.

 

[DODOCSS]

IMO, Juice not worth the squeeze

 

[lonelobo]

IMO, Juice not worth the squeeze

Thanks for nothing as usual

 

[chibadriver]

IMO, Juice not worth the squeeze

Well, it is a huge pain in the ass.