Is transection of bilateral S1, S2, and S3 spinal lateral branch nerves under direct visualization and endoscopic neurectomies medically necessary for treating chronic sacroiliac joint pain?

Endoscopic Neurectomy for Sacroiliac Joint Pain is NOT Medically Necessary

This procedure should be denied because endoscopic neurectomy (direct visual rhizotomy/extradural transection of spinal nerves) is explicitly listed as "not covered" and "unproven because of insufficient evidence" for chronic low back pain treatment, and the patient has not completed the evidence-based treatment algorithm that requires radiofrequency ablation before considering any more invasive irreversible surgical procedures. 1

Critical Diagnostic Deficiencies

Multiple untreated pain generators confound the diagnosis:

• The primary diagnosis of "spondylosis without myelopathy or radiculopathy, lumbar region" does not align with isolated sacroiliac joint pain 1
• MRI demonstrates L5-S1 pathology with moderate bilateral neural foraminal stenosis and facet arthropathy—a significant untreated pain source 1
• L3-4 anterolisthesis with pars interarticularis defects has not been adequately addressed as a potential pain generator 1
• Negative medial branch blocks at L4-5 and L5-S1 suggest lumbar facets are not contributing, but the L3-4 level with documented anterolisthesis remains unaddressed 1

Inconsistent diagnostic block results:

• While the patient reports 80-90% relief from sacral lateral branch blocks, there is documented conflicting evidence including only 30% relief from bilateral L5-S1 transforaminal epidural steroid injection 1
• The presence of multiple positive provocative maneuvers (FADIR, Patrick's/FABER, thigh thrust, ASIS distraction) supports SIJ involvement, but when 3 of 6 maneuvers are positive, the specificity is only 78% using dual fluoroscopically guided anesthetic-only injections with ≥80% pain reduction as the comparator 2

Evidence-Based Treatment Algorithm Violation

The established stepwise approach has not been followed:

1. Conservative management (completed appropriately): Physical therapy, medications, activity modification, time, and rest have been attempted 2, 1

2. Diagnostic injections (completed): Sacral lateral branch blocks demonstrated 80-90% relief 1

3. Radiofrequency ablation (NOT attempted): This is the critical missing step. Cooled radiofrequency ablation of bilateral S1, S2, S3 lateral branches is the evidence-based next intervention given the documented 80-90% relief from diagnostic blocks 1, 3

4. More invasive options (inappropriately requested): Endoscopic neurectomy should only be reconsidered after documented failure of multiple RFA attempts 1

The American Society of Anesthesiologists explicitly supports this stepwise approach, recommending medial branch blocks for facet-mediated spine pain as part of multimodal treatment, with radiofrequency ablation as the established therapeutic intervention before any surgical consideration 1, 2

Insufficient Evidence for Endoscopic Neurectomy

Direct visual rhizotomy lacks adequate supporting evidence:

• The 2025 BMJ clinical practice guideline does not support endoscopic neurectomy for sacroiliac joint pain, noting that even radiofrequency denervation requires careful patient selection and has limited evidence 1
• The guideline emphasizes that patients would be disinclined to receive treatment with an interventional procedure for which there is very low certainty of evidence for benefit 1
• CPT 64772 (transection or avulsion of spinal nerve, extradural) is explicitly listed as "not covered" due to insufficient evidence 1

Radiofrequency ablation has substantially stronger evidence:

• RFA of the L5 dorsal ramus and S1-3 lateral branches has been shown to be efficacious in numerous studies, with extensive lesioning strategies (particularly cooled RFA) demonstrating the strongest evidence 3
• Corticosteroid injections and radiofrequency treatment should be considered when conservative treatment fails, not surgical neurectomy 3
• The reported rate of complications for SI joint treatments is low, but this refers to established treatments like RFA, not experimental procedures like endoscopic neurectomy 3

Recommended Next Steps

Proceed with cooled radiofrequency ablation:

• Given the documented 80-90% relief from diagnostic sacral lateral branch blocks, the patient is an appropriate candidate for cooled RFA of bilateral S1, S2, S3 lateral branches 1, 3
• This procedure has moderate evidence for pain relief from the posterior sacroiliac joint complex 1
• Multiple RFA sessions may be attempted before considering more invasive options 1

Address confounding pain generators:

• Evaluate and treat the L3-4 anterolisthesis with pars defects, which remains unaddressed 1
• Consider the contribution of L5-S1 moderate bilateral neural foraminal stenosis to the overall pain presentation 1
• A multimodal and multidisciplinary approach should be maintained throughout treatment 2, 3

Common Pitfalls to Avoid

Skipping established treatment steps:

• Jumping directly to irreversible surgical procedures without attempting RFA violates evidence-based treatment algorithms and exposes patients to unnecessary surgical risks 1, 4
• The permanence of neurectomy makes it inappropriate as anything other than a last-resort option after all reversible interventions have failed 1

Ignoring multiple pain generators:

• Treating only the SIJ when imaging demonstrates significant L5-S1 and L3-4 pathology will likely result in persistent pain and patient dissatisfaction 1
• The negative lumbar medial branch blocks help exclude L4-5 and L5-S1 facets, but do not address the documented structural pathology at these levels 1