Is endoscopic neurectomy medically indicated for chronic, refractory posterior sacroiliac joint complex pain?

Endoscopic Neurectomy for Sacroiliac Joint Pain: Not Medically Indicated

Endoscopic neurectomy (CPT 64772) for chronic sacroiliac joint pain is NOT medically indicated because this procedure is considered unproven due to insufficient evidence of effectiveness, and the patient has not exhausted appropriate evidence-based interventional treatments.

Primary Rationale for Non-Certification

Procedure Classification

• CPT 64772 (transection or avulsion of spinal nerve, extradural) is explicitly listed as "not covered" and "unproven because of insufficient evidence" for chronic low back pain treatment 1
• Direct visual rhizotomy (extradural transection) lacks adequate evidence supporting its effectiveness for sacroiliac joint pain 1
• The unlisted code 64999 requested for endoscopic neurectomy cannot be approved when the primary procedure itself does not meet medical necessity criteria 1

Incomplete Conservative Treatment Pathway

The patient has NOT completed the appropriate stepwise interventional approach:

• While the patient had successful diagnostic sacral lateral branch blocks (80-90% relief), the standard next step is radiofrequency ablation (RFA), not surgical neurectomy 2, 3
• The American Society of Anesthesiologists supports medial branch blocks for facet-mediated spine pain as part of a multimodal treatment approach, with RFA as the established therapeutic intervention 4
• Radiofrequency ablation of sacral lateral branches provides moderate evidence for pain relief from the posterior sacroiliac joint complex 2
• Studies demonstrate RFA provides 82 days mean duration of pain relief for SIJ pain, establishing it as the appropriate next intervention 5

Evidence-Based Treatment Algorithm Not Followed

The correct treatment sequence for refractory SIJ pain should be:

1. Conservative management (completed: physical therapy, medications, activity modification) 4
2. Diagnostic intraarticular SIJ injections (completed: 10/07/2025 with significant relief) 4, 3
3. Diagnostic sacral lateral branch blocks (completed: 11/4/25 with 80-90% relief) 2, 3
4. Therapeutic radiofrequency ablation of sacral lateral branches (NOT completed - this is the missing step) 2, 3, 5
5. Only after RFA failure would more invasive options be considered

Specific Evidence Against Endoscopic Neurectomy

• There is no guideline support for proceeding directly to surgical neurectomy without first attempting RFA 4, 2, 3
• The single study on endoscopic RFA (not neurectomy) was a small preliminary feasibility study of only 17 patients, insufficient to establish standard of care 6
• A 2023 comparative study showed navigation-assisted endoscopic rhizotomy versus cooled RFA, but this compared two RFA techniques, not surgical neurectomy 7
• The evidence for radiofrequency neurotomy in managing chronic SIJ pain is limited but present; evidence for surgical neurectomy is essentially absent 3

Clinical Concerns with Proposed Approach

Diagnostic Inconsistency

• The patient's diagnosis is "spondylosis without myelopathy or radiculopathy, lumbar region" - this does not align with isolated SIJ pain 4
• MRI shows L5-S1 pathology with facet arthropathy and moderate bilateral neural foraminal stenosis, plus L3-4 anterolisthesis with pars defects 4
• The patient has multiple potential pain generators that have not been adequately differentiated 4

Incomplete Diagnostic Workup

• Negative medial branch blocks at L4-5 and L5-S1 suggest facet joints are not the primary pain source 4
• Only 30% relief with bilateral L5-S1 TFESI indicates limited discogenic contribution 3
• However, the presence of L3-4 anterolisthesis with pars defects has not been adequately addressed 4

Recommended Alternative Pathway

The patient should undergo the following before any consideration of neurectomy:

1. Proceed with cooled radiofrequency ablation of bilateral S1, S2, S3 lateral branches - this is the evidence-based next step given 80-90% relief from diagnostic blocks 2, 3, 5
2. Expected duration of relief: approximately 82 days based on comparative data 5
3. If RFA provides significant but temporary relief, repeat RFA is appropriate (can be performed multiple times) 2, 5
4. Only after documented failure of multiple RFA attempts (typically at least 2-3 cycles) would more invasive options be reconsidered 2, 3

Additional Considerations

• The patient's concern about "short-term relief" from steroid injections (1-2 months) actually aligns with expected duration and does not justify bypassing RFA 5
• RFA typically provides longer relief than intraarticular injections (82 vs 38 days mean duration) 5
• The patient's desire for "permanent solutions" does not override evidence-based treatment algorithms 4, 2, 3

Common Pitfalls to Avoid

• Do not skip RFA and proceed directly to surgical neurectomy - this violates established treatment algorithms 4, 2, 3
• Do not perform invasive procedures based solely on patient preference for "permanent" solutions - evidence-based stepwise approach must be followed 4, 3
• Do not ignore concurrent lumbar pathology (L3-4 anterolisthesis, L5-S1 stenosis) that may be contributing to symptoms 4
• Recognize that 80-90% relief from diagnostic blocks predicts good RFA response, making RFA the logical next step 2, 5