Pain Matters Podcast Network · AAPM - American Academy of Pain Medicine

SI Joint Injections and LCDs: Navigating New Boundaries in Pain Medicine

·45 min·3 clips

The evidence package for sacroiliac joint RFA is described as stronger than many other interventional pain procedures.

Pain Matters opens with the tension between clinical judgment and administrative control. That friction is framed around SI joint injections and the broader issue of overutilization in back pain care. Medicare data are used as one sign of how quickly interventional procedures expanded: while the Medicare population grew by a little over a third between 2000 and 2014, interventional procedures for back pain rose by well over 300%. The speaker also notes that utilization of sacroiliac joint injections kept climbing even as some other procedures leveled off or dipped slightly. At the same time, there seems to be very little correlation between interventional procedures for back pain and disability rates, and non-surgical interventions do not appear to reduce surgical rates. For that reason, the speaker argues that mandates are not the right way to limit overutilization, and instead suggests tying reimbursement to clinical outcomes. The episode then turns to the evidence base for sacroiliac radiofrequency procedures. It stresses that not all techniques are equal, since some have clearer anatomical support than others. Careful categorization is treated as essential if the data are going to mean anything. The speaker points to a systematic review that focused specifically on techniques with anatomical validation for the RF procedure. That review becomes the bridge into the technical literature. The Stout paper is presented as especially elegant because it dissected cadaveric specimens, placed radiopaque wires, imaged them, and modeled where different RF protocols would create lesions. The goal was to test whether those protocols would capture the sacroiliac branches. Bipolar approaches are described as performing very well because they create a strip lesion just lateral to the sacral foramina, making it difficult to miss the nerves that must pass through that tissue path to reach the posterior sacroiliac complex. Some large monopolar cooled techniques are also discussed, and the speaker notes that with enough lesions they can approximate the same strip-lesion logic. The episode argues that, for these validated techniques, the evidence looks very strong, with level one evidence and more RCT support than spinal medial branch RFA. Across the discussion, the tone stays clinical and procedural rather than dramatic, with emphasis on how data, anatomy, and payment policy intersect in real pain practice.

As heard by us

A focused look at SI joint injections, overuse, and where policy drifts ahead of evidence.

Pain medicine is treated here as both a clinical question and a payment problem, with SI joint injections, overuse data, and who gets to shape care plans all pulled into the same frame.

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Why you'd press play

If you want the evidence-and-reimbursement fight around SI joint injections laid out clearly, start here.

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