Dr. Kube discusses seven points on minimally invasive sacroiliac joint fusions.
1. Patients most at risk for SI joint dysfunction. Women at childbearing age, patients who have undergone previous lumbar fusions or patients with arthritis are at an increased risk of experiencing sacroiliac joint dysfunction. When patients with lower back pain arrive at the office, physicians can identify whether the sacroiliac joint could be the problem during physical examinations and can help confirm the diagnosis with diagnostic injections. “If we are able to perform a diagnostic injection and numbing the sacroiliac joint with local anesthetic relieves the pain, then we have our diagnosis,” says Dr. Kube.
2. Minimally invasive surgical intervention. If non-surgical intervention doesn’t relieve the pain, there are minimally invasive procedures available for patients with sacroiliac joint dysfunction. There are a few companies, such as SI-Bone, that produce devices to stabilize the joint with implant placement through a small incision. Dr. Kube was recently the first physician to use Zyga Technology’s new system, SImmetry, for stabilization. SImmetry is the only system that allows a traditional fusion during the minimally invasive procedure.
“The unique part of the system is that it allows us to minimally invasively prepare the joint for fusion,” says Dr. Kube. “We go through the pelvis and insert a 1 ½ centimeter tube to access the sacroiliac joint. We’re able to go in through the tube, clean the joint surface and prepare it for fusion. From there, we are able to perform a traditional fusion with traditional fixation, but with a minimally invasive technique.”
3. A long-term alternative to sacroiliac joint pain management. Pain management interventions, such as ablation or neurostimulation, might relieve pain well for a short period of time, but after a while the pain often recurs. “I thought the traditional sacroiliac joint fusion was too invasive and I used to refer these patients to interventional pain management,” says Dr. Kube. “Now that there’s a less invasive way for surgeons to provide a permanent solution to these patients, this procedure could help improve the outcomes for a large portion of the population.”
4. Peri- and post-surgical advantages of the less invasive procedure. With the traditional open procedure, surgeons damage a significant amount of the patient’s anatomy to access the surgical site. This damage means the patient must spend several weeks recovering from surgery. However, minimally invasive procedures keep the soft tissue and ligaments attached and decrease the recovery and rehabilitation time. “By being able to do this procedure less invasively, my first patient was able to stand up and walk within an hour or two after surgery and go home that same day,” says Dr. Kube. “Within a week, the patient reported less pain than was reported preoperatively. We saw this patient at three weeks postoperatively and her pain was gone.”
Since the procedure preserved much of the anatomy, if it fails there are other treatment options, Dr. Kube says. “As a surgeon, we always know that we’re not going to have 100 percent success with any procedure,” he says. “When we have patients with incomplete pain relief, we hope that we have additional options for treatment. This procedure does not burn any bridges, so patients who have continued pain can still have the traditional interventional pain management techniques we currently use. Hence, they have an opportunity for long term pain relief with SI fusion without having to give up the traditional short term options.”
5. Achieving a traditional fusion. Achieving a fusion is very important because if the spinal structure is only stabilized with implants, complications can occur over time. The spine can shift and when the implants loosen, the pain will return. “Once the joint is fused, you have living bone creating the stability for the joint,” says Dr. Kube. “We do insert implants during the procedure, but over time they are essentially no longer needed because the bone is providing stability.”
6. Maximizing reimbursements. The minimally invasive procedures are billable as a spinal fusion using the typical codes in hospitals. For ambulatory surgery centers, capturing the appropriate CPT codes for a sacroiliac fusion, instrumentation, bone graft and C-arm are important. “As with any procedure in the ASC, it’s important for you to negotiate the carve-outs with respect to the implants,” says Dr. Kube. “With this as an outpatient procedure, facilities with those contracts in place can add this to their list of spine surgeries.”
The instrumentation and bone graft required for the minimally invasive sacroiliac joint fusion are less expensive than for a typical one-level lumbar fusion, so they are more likely affordable procedures for spine ASCs. “This is an opportunity for spine surgeons to bring a greater volume of cases to an ASC because they won’t have to refer away these patients to pain management,” he says.
7. Incorporating the procedure into your practice. Spine surgeons with a background in orthopedics can transition to performing the minimally invasive procedure without much difficulty because the fixation is similar to the sacroiliac joint instability fixation they already do, says Dr. Kube. After training, surgeons with a neurosurgery background should also be able to pick up the procedure very well. The procedure doesn’t require extra equipment beyond the manufacturer’s tools for hospitals already performing spine surgery.
“For a hospital adding this as a service line, it’s fairly easy,” says Dr. Kube. “Most already have a C-arm and the only other thing they need is surgeon involvement.”
Learn more about Dr. Richard Kube.
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