X034T Posterior Sacroiliac Joint Arthrodesis: The Proposed New Code On The AMA May 2022 Panel Meeting
“The CPT® Editorial Panel is engaged in an ongoing process improvement effort which currently includes re-examination of the CPT® Category I and Category III criteria. Based on these efforts periodic changes should be expected.”
How do we make sense of this upcoming AMA panel meeting.
Posterior sacroiliac joint distraction with an allograft placed through the articular surface
What is the treatment rationale for the posterior intra-articular approach?
It appears that if you have two moving surfaces as in the sacrum moving against the ilium, a wedge allograft placed between them would stop movement of the joint. Given enough time, there is an expectation that the wedge allograft would fuse together with the joint surfaces. For this theory to become a reality, you would need to study what size allograft would provide enough distraction of the SI Joint and where would be the ideal location to place the allograft since the surface area of the joints are so large relative to the size of the allograft.
What is the ideal placement for the allograft to truly achieve stability of the SI Joint?
The SI Joint has a large articular surface area but is limited to a width of 4 mm by strong stabilizing ligaments. These ligaments resist distraction of the joint which will lead to instability. Therefore if you place a wedge between the joint there is a high risk of dislodgment or subsidence or erosion through the articular surface from the tremendous pressures on the graft.
Drilling to place a posterior SIJ allograft
What are the risks of using power drills in the joint?
The safety of power drills will depend on the individual physician’s abilities. Drilling in the joint will remove the structural strength of the surface and increase the risk of graft subsidence and migration.
What happens if the allograft does not fuse?
There is a lot that we can learn from spine surgery on intervertebral fusion. When we place a structural allograft between the vertebral endplates to achieve distraction and stability, we also have to add pedicle screws for stability. Often, the graft subsides into the endplates which can lead to a painful non-union/pseudoarthrosis or become dislodged. If the graft fails, there is no instrument to remove it so likely you will refer to an Orthopedic spine surgeon or Neurosurgeon. Alternatively, you can place Sacrix percutaneous threaded screws using the lateral-oblique approach and not worry about the allograft. Maybe even place the Sacrix screws when you place the allograft.
What clinical evidence will the AMA have access to?
There is overwhelming clinical evidence on the effectiveness of a lateral trans-articular approach using SI-Bone triangular titanium implants (TTI). Sacrix has modified this approach to a lateral-oblique trans-articular technique that uses threaded screws to provide immediate SI Joint stability with over 400% stronger in pull-out compared to SI-Bone. This Sacrix technique is easy and can be done safely under fluoroscopy and could be viewed as an alternative to intra-articular allograft.
What FDA considerations?
The posterior intra-articular technique does not use FDA cleared instruments and devices which circumvents the FDA oversights.
What potential legal considerations?
Without FDA requirements and with adoptions by pain management doctors, it would seem daunting for the AMA.
Sacrix is a KICVentures Group portfolio company
Authors
Dr. Kingsley R. Chin MBA is a board-certified Professor of Orthopedic Spine Surgery and honors graduate of Harvard Medical School and the Harvard Combined Orthopedic Residency Program. He did his spine fellowship with Dr. Henry H Bohlman. He was Chief of Spine Surgery at the University of Pennsylvania.
Dr. Jason A. Seale MBA is a medical doctor and entrepreneur. He is the clinical director at the LES Clinic.