Anesthesia Billing Inc
1715 Medical Pkwy
Newton KS 67114
July 1, 2011
Effective Date: July 27, 2011
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Sacroiliac joint arthrography using fluoroscopic guidance with injection of an anesthetic has been explored as a diagnostic test for sacroiliac joint pain. Duplication of the patient’s pain pattern with the injection of contrast medium suggests a sacroiliac etiology, as does relief of chronic back pain with injection of local anesthetic.
Similar to other structures in the spine, it is assumed that the sacroiliac joint may be a source of low back pain. In fact, prior to 1928, the sacroiliac joint was thought to be the most common cause of sciatica. In 1928, the role of the intervertebral disc was elucidated, and from that point forward the sacroiliac joint received less research attention. Research into sacroiliac joint pain has been thwarted by any criterion standard to measure its prevalence and against which various clinical examinations can be validated. For example, sacroiliac joint pain is typically without any consistent, demonstrable radiographic or laboratory features and most commonly exists in the setting of morphologically normal joints. Clinical tests for sacroiliac joint pain may include various movement tests, palpation to detect tenderness, and pain descriptions by the patient. Further confounding the study of the sacroiliac joint is that multiple structures, such as posterior facet joints and lumbar discs, may refer pain to the area surrounding the sacroiliac joint.
A. Injection into the sacroiliac joint for diagnostic or therapeutic purposes may be considered medically necessary when all of the following conditions are met:
B. Sacroiliac injections are considered experimental / investigational for all other indications.
C. Arthrography of the sacroiliac joint is considered experimental / investigational.
The use of diagnostic blocks to evaluate sacroiliac joint pain builds on the experience of use of diagnostic block in other joints to evaluate pain. Blinded studies with placebo controls (although difficult to conduct when dealing with invasive procedures) are ideally required for scientific validation of sacroiliac joint blocks, particularly when dealing with pain relief, well-known to respond to placebo controls. In the typical evaluation of a diagnostic test, the results of sacroiliac diagnostic block would then be compared to a gold standard. However, there is no current gold standard for sacroiliac joint injection. In fact, some authors have positioned sacroiliac joint injection as the gold standard, against which other diagnostic tests and physical exam may be measured. (1) Finally, one would like to know how the results of a diagnostic test will be used in the management of the patient, and whether the subsequent treatment plan results in beneficial health outcomes.
There is minimal literature regarding sacroiliac joint blocks. Schwarzer and colleagues reported on a case series of 43 patients with unexplained low back pain below L5-S1. (2) These 43 patients were chosen opportunistically from a larger group of patients referred for discography or zygapophyseal joint blocks. Thus all patients underwent multiple procedures. A total of 13 of the 43 patients (30%) reported relief of their pain with sacroiliac joint blocks. There were no blinded controls, although the authors felt that the use of pain blocks at the zygapophyseal joints functioned as internal controls. The authors concluded that these results refuted the null hypothesis that sacroiliac joint pain does not exist and that sacroiliac joint blocks should be further investigated as a criterion standard for the diagnosis of sacroiliac joint pain. Maigne and colleagues reported on a series of 54 patients with low back pain who received double sacroiliac joint block. (3) The first block used lidocaine, a short-acting anesthetic. If the patient reported pain relief, a second, confirmatory block was performed 1 week later using a long-acting anesthetic. If similar relief was obtained with the second block, it was concluded that the sacroiliac joint was the source of the pain. A total of 18% of patients met these criteria. Similar to the Schwarzer et al. study, this study was designed primarily to demonstrate that sacroiliac pain exists and to assess its prevalence.
At the time this policy was created, there were no studies that described how the results of sacroiliac joint arthrography might be used in the management of the patient.
Searches of the literature were performed on the MEDLINE database through July 2008. One publication focused on the technique of sacroiliac joint injection. (4) Several other retrospective case series have been reported. (5-7) One case series reported results of diagnostic/therapeutic blocks in patients who were referred for low back pain and disc herniation without claudication or neurologic abnormalities. (7) Fifty patients who had at least 3 positive pain provocation tests for sacroiliac joint dysfunction received sacroiliac injection of bupivacaine and betamethasone. Pain, assessed by visual analogue scores (VAS), improved from 7.8 to 1.3 at 30 minutes after the injection. At a 12-week follow-up, 46 patients (92%) reported VAS scores of 3 or less. Four patients required hospitalization for an unanticipated motor block. A placebo-controlled randomized trial examined the effect of lateral branch radiofrequency denervation in 28 patients with injection-diagnosed sacroiliac joint pain. (8) Two of 14 patients (14%) in the placebo-control group reported pain relief at 1-month follow-up. None reported benefit at 3-month follow-up. Of the 14 patients treated with radiofrequency denervation, 11 (79%) reported pain relief at 1 month, 9 (64%) at 3 months, and 8 (57%) at 6 months. Questions remain about intra-articular versus peri-articular sources of sacroiliac pain. One prospective comparison found that periarticular lidocaine injections (25 of 25 patients) were more effective than intra-articular injection (9 of 25 patients). (9) Another study found that sacroiliac joint injections were ineffective in the management of patients with inflammatory spondyloarthropathy. (10)
An updated literature search using the MEDLINE database in October 2009 identified 2 new guidelines based on systematic reviews. (11-14) The American Society of Interventional Pain Physicians (ASIPP) derived their updated guideline on a systematic review of sacroiliac injections by Manchikanti et al. and Rupert et al. (11,12) This systematic review included 13 studies utilizing fluoroscopically guided controlled diagnostic blocks (i.e., placebo-controlled or comparative local anesthetic) in patients with chronic low back and/or lower extremity pain for greater than 3 months in duration. Five studies, considered level II-2 evidence (well-designed cohort or case-control studies), were reviewed on the topic of diagnosis of sacroiliac joint pain using a double-block paradigm (comparative controlled local anesthetic blocks). The false-positive rate for use of a single, uncontrolled, sacroiliac joint injection was 20% to 54%. With a double-block paradigm, the prevalence of sacroiliac joint pain was estimated to range between 10% and 38% in patients with a high likelihood of sacroiliac joint pain. Interpretation of these results is limited by the lack of a “gold” standard for reference comparison. ASIPP concluded that sacroiliac joint blocks appear to be the evaluation of choice to provide appropriate diagnosis, due to the inability to make the diagnosis of sacroiliac joint-mediated pain with noninvasive tests. (11) For therapeutic intra-articular sacroiliac joint interventions, 4 randomized trials were excluded from review due to a lack of a valid diagnosis prior to therapeutic interventions. None of the 14 observational reports met the inclusion criteria, due to lack of controlled diagnostic blocks to establish diagnosis, evaluating only patients with spondyloarthropathy, or not following patients for 6 months. Limitations were noted as a paucity of literature evaluating the role of both diagnostic and therapeutic interventions and widespread methodologic flaws.
Practice guidelines from the American Pain Society (APS) were based on a systematic review that was commissioned by the APS and conducted at the Oregon Evidence-Based Practice Center. (13,14) The systematic review concluded that no reliable evidence existed to evaluate validity or utility of diagnostic sacroiliac joint block as a diagnostic procedure for low back pain with or without radiculopathy, with a resulting guideline recommendation of insufficient evidence. Data on sacroiliac joint steroid injection were limited to 1 small controlled trial, resulting in a recommendation of insufficient evidence for therapeutic injection of this joint.
A search of the literature using the MEDLINE database was conducted in January 2011. Manchikanti and colleagues published critical reviews of the APS guidelines (13,14, referred to earlier) for interventional techniques, including sacroiliac injections. (15,16) Evidence for diagnostic sacroiliac injections was considered to be fair to poor, and no additional literature was identified since the 2009 systematic review by Rupert and colleagues (12) that found limited evidence for therapeutic sacroiliac injections.
Clinical Input Received through Physician Specialty Societies and Academic Medical Centers
While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.
In response to requests, input was received from 4 physician specialty societies (6 responses) and 3 academic medical centers (5 responses) while this policy was under review in 2010. Clinical input was mixed. There was general agreement that the evidence for sacroiliac joint injections is limited, although a majority of reviewers considered sacroiliac injections to be the best available approach for diagnosis and treatment in defined situations.
There is limited prospective or controlled evidence for sacroiliac joint arthrography or injection therapy. It should be noted that, in general, the literature regarding injection therapy on other joints in the back is of poor quality. Overall, sacroiliac arthrography and injection have not been adequately evaluated. Evidence is insufficient to permit conclusions regarding the effect of this procedure on health outcomes.
Technology Assessments, Guidelines, and Position Statements
In 2007, ASIPP published Systematic Review and Practice Guidelines, including sacroiliac joint interventions. (17,18) Evidence was determined to be moderate (level III, non-randomized comparative trials) for the accuracy of sacroiliac joint diagnostic injections for the diagnosis of sacroiliac joint pain. The authors report that “even though short-term relief from sacroiliac joint injection is considered as a gold standard for the diagnosis of sacroiliac joint pain, there was no blinded comparison of the test or reference standard in evaluation of these investigations.” The evidence for intra-articular sacroiliac joint injections for short- and long-term relief was found to be limited (level IV, case series).
The ASIPP Interventional Pain Management guidelines were updated in 2009. The guidelines for diagnostic and therapeutic sacroiliac joint injections were based on the systematic review by Manchikanti et al. and Rupert et al. described earlier.(11,12) Evidence for sacroiliac joint injections was considered to be level II-2 (evidence obtained from at least 1 properly designed small diagnostic accuracy study). The guidelines indicate that sacroiliac joint blocks appear to be the evaluation of choice to provide appropriate diagnosis, due to the inability to make the diagnosis of sacroiliac joint-mediated pain with non-invasive tests. Evidence was determined to be unavailable to establish efficacy of intra-articular sacroiliac joint injections for therapeutic purposes.
Common indications for sacroiliac joint injections were listed as follows:
Recommended frequency of interventions was also described.
2009 practice guidelines from the APS were based on a systematic review that was commissioned by the APS and conducted at the Oregon Evidence-Based Practice Center. (13,14) The APS guideline states that there is insufficient evidence to evaluate validity or utility of diagnostic sacroiliac joint block as a diagnostic procedure for low back pain with or without radiculopathy and that there is insufficient evidence to adequately evaluate benefits of sacroiliac joint steroid injection for nonradicular low back pain.
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07-27-2011 Policy added to the bcbsks.com web site.
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