Clinical Facts about the SI Joint, SI Joint Diagnosis and SI Joint Treatment

Patient Education

  1. The SI joint is a common cause of LBP (low back pain) complaints (Bernard1, Maigne2, Schwarzer3, Sembrano4)
    1. SIJ (sacroiliac joint) is a true synovial joint (Vanelderen5)
    2. SIJ does move (Sturesson6)
    3. SIJ does not typically ankylose with age (Dar7)
    4. The SIJ is highly innervated and can be painful (Szadek8, Fortin9, Ikeda10)
    5. The pain arising from the SI joint can be effectively diagnosed (Fortin11, Bogduk12)
    6. The painful SI joint can be safely and effectively treated with MIS SIJ fusion (Graham Smith13, Duhon14, Miller15, Ledonio16)
  2. Patients with SIJ pathology including degenerative sacroiliitis (DS) and sacroiliac disruptions (SD) have significant pain and significant functional limitations.
    1. The burden of disease of patients with (DS) and (SD) is similar to the burden of patients with severe DJD of the knee or hip (Cher17).
    2. Cost of non-surgical treatment of SIJ pathology is quite significant in both the Medicare and the non-Medicare population (Ackerman18, Ackerman19)
    3. Surgical treatment of appropriate patients with SIJ pathology may actually result in a cost savings for both Medicare and non-Medicare patients (Ackerman20, Ackerman21)
  3. MIS SIJ fusion is an accepted treatment for some patients with SIJ pathology
    1. Widely accepted procedure (ISASS survey results22)
    2. Standard of care for appropriately selected patients (ISASS position statement23)
    3. Accepted diagnostic and non-surgical treatment algorithm (ISASS algorithm23)
  4. Non-surgical treatment for SIJ pathology has been shown to be only marginally effective
    1. No published clinical data on efficacy of medical treatment with narcotics or other medications. Known problems with chronic medication use.
    2. No clinical studies on efficacy of PT treatment for SIJ patients.
    3. Steroid injections provide only temporary relief in a subset of these patients (Maugar24, Hawkins25)
    4. RF treatment provides partial relief for 3 to 6 months, but symptoms return. (Cheng26, Cohen27)
  5. Coding history
    1. SI fusion originally coded as 27280 as there was only 1 code for SIJ fusion
    2. AMA CPT Panel determined that prior code is no longer appropriate for MIS SIJ fusion and assigned Category III code (0334T) effective July 1, 2013, to track utilization and resources.
    3. Category III code does not indicate experimental or investigational
    4. Category III code does not indicate that procedure should not be reimbursed
    5. The AMA states, “…the assignment of a CPT Category III code to a service/procedure does not indicate that it is experimental or of limited utility, but only that the service or technology is new and is being tracked for data collection.” Please see AMA website: http://www.aaos.org/member/coding/Current_Procedural_Terminology.asp
    6. The AMA CPT Editorial Panel voted at its February 2014 meeting to grant MIS SI joint fusion a Category I CPT code effective January 1, 2015. Please see AMA website:  http://www.ama- assn.org/ama/pub/physician-resources/solutions-managing-your- practice/coding-billing-insurance/cpt.page
    7. AMA CPT Panel decision was based on the strength of clinical evidence in peer reviewed journals.
    8. Current evidence includes Level IIB (Duhon14) and Level III evidence (Graham Smith13, Ledonio16)
    9. Level of evidence as determined by Center for Evidence Based Medicine (CEBM) http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence- march-2009/
  6. Reimbursement
    1. Two Medicare MACs have removed MIS SIJ fusion from non-covered lists, Palmetto GBA effective (Jan 2014) and Novitas Solutions, effective (May 2014)
    2. Several major health plans including United Health Care are approving 0334T on a case by case basis

References

  1. Bernard TN, Kirkaldy-Willis WH. Recognizing specific characteristics of nonspecific low back pain. Clin Orthop 1987;(217): 266–80.
  2. Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996; 21: 1889–92.
  3. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995; 20: 31–7.
  4. Sembrano JN, Polly DW. How often is low back pain not coming from the back? Spine 2009; 34: E27-32.
  5. Vanelderen P, Szadek K, Cohen SP, et al. Sacroiliac Joint Pain. Pain Pract 2010; 10: 470–8.
  6. Sturesson B, Selvik G, Udén A. Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine 1989; 14: 162–5.
  7. Dar G, Peleg S, Masharawi Y, et al. Sacroiliac joint bridging: demographical and anatomical aspects. Spine 2005; 30: E429–432.
  8. Szadek KM, Hoogland PV, Zuurmond WW, de Lange JJ, Perez RS. Nociceptive nerve fibers in the sacroiliac joint in humans. Reg Anesth Pain Med 2008; 33: 36–43.
  9. Fortin JD, Kissling RO, O’Connor BL, Vilensky JA. Sacroiliac joint innervation and pain. Am J Orthop Belle Mead NJ 1999; 28: 687–90.
  10. Ikeda R. [Innervation of the sacroiliac joint. Macroscopical and histological studies]. Nihon Ika Daigaku Zasshi 1991; 58: 587–96.
  11. Fortin JD, Falco FJ. The Fortin finger test: an indicator of sacroiliac pain. Am J Orthop Belle Mead NJ 1997; 26: 477–80.
  12. Bogduk N. Pain provocation tests for the assessment of sacroiliac joint dysfunction. J Spinal Disord 1999; 12: 357–8.
  13. Graham Smith A, Capobianco R, Cher D, et al. Open versus minimally invasive sacroiliac joint fusion: a multi-center comparison of perioperative measures and clinical outcomes. Ann Surg Innov Res 2013; 7: 14.
  14. Duhon B, Cher D, Wine K, Lockstadt H, Kovalsky D, Soo C-L. Safety and 6-month effectiveness of minimally invasive sacroiliac joint fusion: a prospective study. Med Devices Evid Res 2013; 6: 219–29.
  15. Miller L, Reckling WC, Block JE. Analysis of postmarket complaints database for the iFuse SI Joint Fusion System®: a minimally invasive treatment for degenerative sacroiliitis and sacroiliac joint disruption. Med Devices Evid Res 2013; 6: 77–84.
  16. Ledonio C, Polly D, Swiontkowski MF, Cummings J. Comparative effectiveness of open versus minimally invasive sacroiliac joint fusion. Med Devices Evid Res 2014; 2014: 187–93.
  17. Cher D, Polly D, Berven S. Sacroiliac Joint pain: burden of disease. Med Devices Evid Res 2014; 7: 1–9.
  18. Ackerman SJ, Polly DW Jr, Knight T, Holt T, Cummings J Jr. Nonoperative care to manage sacroiliac joint disruption and degenerative sacroiliitis: high costs and medical resource utilization in the United States Medicare population. J Neurosurg Spine 2014; 20: 354–63.
  19. Ackerman S, Polly DW, Holt T, Cummings JT, Knight T. Management of sacroiliac joint disruption and degenerative sacroiliitis with nonoperative care is medical resource-intensive and costly in a United States commercial payer population. Clin Outcomes Res 2014; 2014: 63–74.
  20. Ackerman S, Cummings J, Polly D, Knight T, Schneider K, Holt T. Comparison of the costs of nonoperative care to minimally invasive surgery for sacroiliac joint disruption and degenerative sacroiliitis in a United States Medicare population: potential economic implications of a new minimally-invasive technology. Clin Outcomes Res 2013; 2013: 575–87.
  21. Ackerman S, Knight T, Schneider K, Holt T, Cummings J, Polly D. Comparison of the costs of nonoperative care to minimally invasive surgery for sacroiliac joint disruption and degenerative sacroiliitis in a United States commercial payer population: potential economic implications of a new minimally invasive technology. Clin Outcomes Res 2014; 2014: 283–96.
  22. Lorio MP, Polly DW Jr, Ninkovic I, Ledonio CGT, Hallas K, Andersson G. Utilization of Minimally Invasive Surgical Approach for Sacroiliac Joint Fusion in Surgeon Population of ISASS and SMISS Membership. Open Orthop J 2014; 8: 1–6.
  23. ISASS.org - Advocacy: ISASS Statement on Coding Changes for Minimally Invasive SI Joint Fusion 2014. ISASS. 2014. http://www.isass.org/public_policy/2014-03-31-coding-changes-for-minimally-invasive- si-joint-fusion-2014.html (accessed 28 May2014).
  24. Maugars Y, Mathis C, Berthelot JM, Charlier C, Prost A. Assessment of the efficacy of sacroiliac corticosteroid injections in spondylarthropathies: a double-blind study. Br J Rheumatol 1996; 35: 767–70.
  25. Hawkins J, Schofferman J. Serial therapeutic sacroiliac joint injections: a practice audit. Pain Med Malden Mass 2009; 10: 850–3.
  26. Cheng J, Pope JE, Dalton JE, Cheng O, Bensitel A. Comparative outcomes of cooled versus traditional radiofrequency ablation of the lateral branches for sacroiliac joint pain. Clin J Pain 2013; 29: 132–7.
  27. Cohen SP, Hurley RW, Buckenmaier CC, Kurihara C, Morlando B, Dragovich A. Randomized placebo- controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology 2008; 109: 279–88.

For comprehensive information about iFuse and some causes of SI Joint pain and dysfunction, please visit

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