What's your favorite algorithm for SIJ Pain? So many options!

[drusso]

Steroid---> ablation---> fusion---> PNS ---> PRP
Steroid---> PRP---> ablation---> PNS---> fusion
PRP---> PNS---> Steroid---> ablation---> fusion
Ablation---> PRP---> Steroid---> fusion---> PNS
Steroid ---> Fusion ---> PRP---> Ablation ---> PNS
PNS---> PRP---> Ablation---> steroid---> fusion

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[callmeanesthesia]

so I’m assuming you’re borderline trolling like most of your posts like this, but I’ll bite.
Depends on the anatomy and cause. Generally though, after trying PT, NSAIDs, SI joint belt, then try injections. Local/steroid first for diagnostic and therapeutic purposes. Then typically ablation. If pain is due to MSK/ligamentous injury such as a fall or pregnancy/childbirth, will suggest PRP, though I have few takers as about 70-80% of my patients are Medicare or Caid. If due to altered biomechanics from fusion, then steroid -> ablation. If no relief from those, double check for other causes that may have been missed, such as L1 radic or hip, and consider diagnostic SI block and SI fusion, vs continued conservative care.

 

[MitchLevi]

Seems SI RFA is becoming harder to get approved by insurance companies.

I only do a few per year but I don't have great success with it.

After PT and conservative Tx I like CSI followed by PRP and that's as far as I take it.

Circle back to PT frequently.

I do not believe in SI fusion or PNS overlying the joint bc that mechanistically makes zero sense to me as to why it would work.

 

[callmeanesthesia]

Seems SI RFA is becoming harder to get approved by insurance companies.

I only do a few per year but I don't have great success with it.

After PT and conservative Tx I like CSI followed by PRP and that's as far as I take it.

Circle back to PT frequently.

I do not believe in SI fusion or PNS overlying the joint bc that mechanistically makes zero sense to me as to why it would work.

I’d say my results from SI RFA are comparable to lumbar and cervical. I do the Palisade technique. Over 50% of my patients are conventional Medicare with a secondary, very few Medicare replacement plans, and the local Caid variety covers it too (they pay about Medicare rates for everything), so it’s covered for most of my patients.

 

[clubdeac]

PT, SIJ mobilization, SI belt, NSAIDs etc. if no better then SIJ injection. If good temporary relief (4-12 weeks) will perform a second. If again good temporary relief will proceed to ablation.

 

[gaspasser127]

PT, SI belt, NSAIDs —> steroid+LA SIJ injection and send home with a pain diary. If >50% pain relief for 3 months then repeat injections. If + diagnostic block but no durable pain relief with steroid then posterolateral fusion. Pretty good results at 12-24 months from what I’ve seen and takes 15-30 min to perform.

OP, what’s your algorithm?

 

[cowboydoc]

Algorithm like deac. Results nowhere near as predictable as cervical or lumbar RF. I do palisade with 18g Stryker venom.

Cervical>lumbar>>SIJ

 

[Taus]

Algorithm like deac. Results nowhere near as predictable as cervical or lumbar RF. I do palisade with 18g Stryker venom.

Cervical>lumbar>>SIJ

While I can’t back it up with literature, my own observation bias shows my younger patients doing better than my older/caid patients. I suspect it’s bc the younger are truly having more ligament/“posterior sacroiliac complex” pain as opposed to old arthritic primarily intraartic pain.

I do same. Palisade with 18g venom.

 

[TIVAndy]

Algorithm like deac. Results nowhere near as predictable as cervical or lumbar RF. I do palisade with 18g Stryker venom.

Cervical>lumbar>>SIJ

can someone show me a reference to this palisade technique?

 

[10KHertz]

Si joint with steroids done correctly. Then rfa done correctly. Then nothing …

 

[nvrsumr]

SI joint belt if prego. If covered sacral lat blocks. If positive then famous nvrsumr rf technique

 

[Crybaby]

Who can you actually get to wear a SI belt?

 

[gaspasser127]

Who can you actually get to wear a SI belt?

practically no one. it's just a check box.

 

[fathead88]

https://www.painphysicianjournal.com/current/pdf?article=MzEwOA%3D%3D&journal=100

It’s a bipolar strip lesion from L5 to s3, 1 cm spacing with a 20g needle

 

[painfree23]

Scs?

 

[drusso]

so I’m assuming you’re borderline trolling like most of your posts like this, but I’ll bite.
Depends on the anatomy and cause. Generally though, after trying PT, NSAIDs, SI joint belt, then try injections. Local/steroid first for diagnostic and therapeutic purposes. Then typically ablation. If pain is due to MSK/ligamentous injury such as a fall or pregnancy/childbirth, will suggest PRP, though I have few takers as about 70-80% of my patients are Medicare or Caid. If due to altered biomechanics from fusion, then steroid -> ablation. If no relief from those, double check for other causes that may have been missed, such as L1 radic or hip, and consider diagnostic SI block and SI fusion, vs continued conservative care.

Did I leave anything out?

 

[MitchLevi]

Anyone doing PNS for SIJ pain please discuss your outcomes and the MoA of pain relief. I keep hearing about this but it doesn't make much sense to me.

 

[drrosenrosen]

https://www.painphysicianjournal.com/current/pdf?article=MzEwOA%3D%3D&journal=100

It’s a bipolar strip lesion from L5 to s3, 1 cm spacing with a 20g needle

I've done 1.5cm spacing with 18ga, with good results. I don't use the guideblock spacer thing, but I do mark with a ruler and marking pen

 

[painfree23]

I've done 1.5cm spacing with 18ga, with good results. I don't use the guideblock spacer thing, but I do mark with a ruler and marking pen

Do you do this in AP?

 

[NJPAIN]

Two questions:

1. How about patients with an obvious inflammatory component such a inflammatory bowel disease associated sacroiliitis? Responds briefly (< 3 months) to CS injection. Would you fuse that patient if they are poorly responsive to RF denervation? I have a patient with this scenario who did well for a year with PRP. We are going to repeat but it’s a financial burden and I’m trying to stay one step ahead with a plan.
2. Anyone have the new SIJ pain book? Is it worth having or is it just KOL BS?

 

[Orin]

But when do I put the pump or cement in?

 

[bedrock]

I onlys

Two questions:

1. How about patients with an obvious inflammatory component such a inflammatory bowel disease associated sacroiliitis? Responds briefly (< 3 months) to CS injection. Would you fuse that patient if they are poorly responsive to RF denervation? I have a patient with this scenario who did well for a year with PRP. We are going to repeat but it’s a financial burden and I’m trying to stay one step ahead with a plan.
2. Anyone have the new SIJ pain book? Is it worth having or is it just KOL BS?

I'd just repeat PRP annually. How much do you charge for PRP? I charge $750. Everyone can find $750 if they know it is coming each year. One of these days I will figure out how to do my own PRP without kits and I will reduce the cost to $5-600 and no patient has a valid excuse not to do that given the cost of deductibles etc.

 

[painfree23]

But when do I put the pump or cement in?

After the stim

 

[Ducttape]

Two questions:

1. How about patients with an obvious inflammatory component such a inflammatory bowel disease associated sacroiliitis? Responds briefly (< 3 months) to CS injection. Would you fuse that patient if they are poorly responsive to RF denervation? I have a patient with this scenario who did well for a year with PRP. We are going to repeat but it’s a financial burden and I’m trying to stay one step ahead with a plan.
2. Anyone have the new SIJ pain book? Is it worth having or is it just KOL BS?

do we fuse things that are inflammed otherwise(i mean besides abcesses and dr pimple popper stuff)?

 

[Agast]

I entered M96.1 while I was charting and “postlaminectomy syndrome of the sacroiliac joint” popped up as a possible diagnosis. So you guys are in the clear! Lol

 

[drrosenrosen]

Do you do this in AP?

I do cephalad tilt so the needles are more perpendicular to the surface of the sacrum, then do bipolar lesions all down the line. Lateral to check, but most of needle placement is in that modified AP. The L5 dorsal ramus I just do like normal

 

[GoBeers]

Two questions:

1. How about patients with an obvious inflammatory component such a inflammatory bowel disease associated sacroiliitis? Responds briefly (< 3 months) to CS injection. Would you fuse that patient if they are poorly responsive to RF denervation? I have a patient with this scenario who did well for a year with PRP. We are going to repeat but it’s a financial burden and I’m trying to stay one step ahead with a plan.
2. Anyone have the new SIJ pain book? Is it worth having or is it just KOL BS?

fusing an autoimmune inflamed joint is not going to make a difference since the problem is the autoimmune component. send back to rheumatology to optimize immunomodulator. steroid injection seems reasonable though.

 

[RoloTomassi]

Two questions:

1. How about patients with an obvious inflammatory component such a inflammatory bowel disease associated sacroiliitis? Responds briefly (< 3 months) to CS injection. Would you fuse that patient if they are poorly responsive to RF denervation? I have a patient with this scenario who did well for a year with PRP. We are going to repeat but it’s a financial burden and I’m trying to stay one step ahead with a plan.
2. Anyone have the new SIJ pain book? Is it worth having or is it just KOL BS?

It's probably the same effectiveness as fusing a severely degenerated L5-S1 disc where there's not much disc left, little mobility, inflammatory Modic changes.