Protocol. Diagnosis and Treatment of Sacroiliac Joint Pain

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1 Prtcl Diagnsis and Treatment f Sacriliac Jint Pain Medical Benefit Effective Date: 07/01/18 Next Review Date: 03/19 Preauthrizatin Yes Review Dates: 09/09, 05/10, 05/11, 01/12, 01/13, 03/13, 01/14, 09/14, 09/15, 09/16, 09/17, 03/18 Preauthrizatin is required. The fllwing prtcl cntains medical necessity criteria that apply fr this service. The criteria are als applicable t services prvided in the lcal Medicare Advantage perating area fr thse members, unless separate Medicare Advantage criteria are indicated. If the criteria are nt met, reimbursement will be denied and the patient cannt be billed. Please nte that payment fr cvered services is subject t eligibility and the limitatins nted in the patient s cntract at the time the services are rendered. Ppulatins Interventins Cmparatrs Outcmes Individuals: With sacriliac jint pain Individuals: With sacriliac jint pain Individuals: With sacriliac jint pain Individuals: With sacriliac jint pain Interventins f interest are: Therapeutic crticsterid injectins Interventins f interest are: Radifrequency ablatin Interventins f interest are: Sacriliac jint fusin/fixatin with a triangular implant Interventins f interest are: Sacriliac jint fusin/fixatin with a cylindrical threaded implant Cmparatrs f interest are: Physical therapy Cmparatrs f interest are: Cnservative therapy Cmparatrs f interest are: Cnservative therapy Cmparatrs f interest are: Cnservative therapy Relevant utcmes include: Symptms Functinal utcmes Quality f life Medicatin use Treatment-related mrbidity Relevant utcmes include: Symptms Functinal utcmes Quality f life Medicatin use Treatment-related mrbidity Relevant utcmes include: Symptms Functinal utcmes Quality f life Medicatin use Treatment-related mrbidity Relevant utcmes include: Symptms Functinal utcmes Quality f life Medicatin use Treatment-related mrbidity Descriptin Sacriliac jint (SIJ) arthrgraphy using flurscpic guidance with injectin f an anesthetic has been explred as a diagnstic test fr SIJ pain. Duplicatin f the patient s pain pattern with the injectin f cntrast medium suggests a sacriliac etilgy, as des relief f chrnic back pain with injectin f lcal anesthetic. Treatment f Page 1 f 9

2 SIJ pain with crticsterids, radifrequency ablatin (RFA), stabilizatin, r minimally invasive SIJ fusin has als been explred. Summary f Evidence Fr individuals wh have SIJ pain wh receive therapeutic crticsterid injectins, the evidence includes small RCTs and case series. Relevant utcmes are symptms, functinal utcmes, quality f life, medicatin use, and treatment-related mrbidity. In general, the literature n injectin therapy f jints in the back is f pr quality. Results frm tw small RCTs shwed that therapeutic SIJ sterid injectins were nt as effective as ther active treatments. Larger trials, preferably using sham injectins, are needed t determine the degree f benefit f crticsterid injectins ver placeb. The evidence is insufficient t determine the effects f the technlgy n health utcmes. Fr individuals wh have SIJ pain wh receive RFA, the evidence includes fur small RCTs using different radifrequency applicatins and case series. Relevant utcmes are symptms, functinal utcmes, quality f life, medicatin use, and treatment-related mrbidity. Fr RFA with a cled prbe, the tw small RCTs reprted shrt-term benefits, but these are insufficient t determine the verall effect n health utcmes. The RCT n palisade RFA f the SIJ did nt include a sham cntrl. Anther sham-cntrlled randmized trial shwed n benefit f RFA. Further high-quality cntrlled trials are needed that cmpare this prcedure in defined ppulatins with sham cntrl and with alternative treatments. The evidence is insufficient t determine the effects f the technlgy n health utcmes. Fr individuals wh SIJ pain wh receive SIJ fusin/fixatin with a triangular implant, the evidence includes tw nnblinded RCTs f minimally invasive fusin and tw case series with mre than 85% fllw-up at tw t three years. Relevant utcmes are symptms, functinal utcmes, quality f life, medicatin use, and treatmentrelated mrbidity. Bth RCTs reprted superir shrt-term results fr fusin, hwever, a preferable design fr assessing pain utcmes wuld be independent, blinded assessment f utcmes r, when feasible, a shamcntrlled trial. Lnger term fllw-up frm these RCTs has indicated that the results btained at six mnths persist t tw years. An additinal chrt study and case series, with sample sizes ranging frm 45 t 149 patients and lw drput rates (< 15%), have als shwn reductins in pain and disability at tw years. One small case series shwed utcmes that persisted t five years. The chrt studies and case series are cnsistent with the durability f treatment benefit. Analysis f an insurance database reprted an verall incidence f cmplicatins t be 16.4% at six mnths and cumulative revisin rate at fur years f 3.54%. The evidence is sufficient t determine that the technlgy results in a meaningful imprvement in the net health utcme. Fr individuals wh have SIJ pain wh receive SIJ fusin/fixatin with a cylindrical threaded implant, the evidence includes a prspective chrt. Relevant utcmes are symptms, functinal utcmes, quality f life, medicatin use, and treatment-related mrbidity. The prspective chrt study will fllw patients fr tw years fllwing implantatin f sltted screws filled with autlgus bne. Results at ne year are cnsistent with findings frm the studies using a triangular implant. Hwever, lnger fllw-up and cntrlled trials are needed t evaluate this type f implant. The evidence is insufficient t determine the effects f the technlgy n health utcmes. Plicy Arthrgraphy f the sacriliac jint is cnsidered investigatinal. Radifrequency denervatin f the sacriliac jint is cnsidered investigatinal. Sacriliac (SI) jint injectin using flurscpic guidance* may be medically necessary in the absence f signifi- Page 2 f 9

3 cant lumbar spine (LS) disease and/r hip disease which may cause back, buttck r hip pain, if ALL f the fllwing have been dne: Histry and physical findings, including three r mre psitive prvcatin tests (see Plicy Guidelines), AND A trial f physical therapy/exercise therapy/chirpractic treatment fr fur t six weeks with n imprvement, AND A trial f nnsteridal anti-inflammatry medicatins (NSAIDS) fr fur t six weeks with n imprvement. SI jint injectin using flurscpic guidance* may be medically necessary, in the presence f significant lumbar spine disease and/r hip disease which may cause back, buttck r hip pain, if ALL f the fllwing have been dne: Histry and physical findings, including three r mre psitive prvcatin tests (see Plicy Guidelines), AND A trial f physical therapy/exercise therapy/chirpractic treatment fr fur t six weeks with n imprvement, AND A trial f anti-inflammatry medicatins (NSAIDS) fr fur t six weeks with n imprvement, AND Epidural spinal injectin (ESI) if significant LS spine findings fr which the injectin is indicated r lumbar spine surgery if indicated. After therapy, patient must have persistence f pain r a cmpnent f pain attributable t pssible SI disease rather than LS spine disease, AND/OR Intra-articular injectin f hip r hip surgery if indicated. After therapy, patient must have persistence f pain r a cmpnent f pain attributable t pssible SI disease rather than hip disease. If the abve criteria are nt met, then sacriliac jint injectin is cnsidered investigatinal. Sacriliac jint injectin perfrmed withut flurscpic guidance is cnsidered investigatinal. Minimally invasive fusin/stabilizatin f the sacriliac jint using a titanium triangular implant may be cnsidered medically necessary when ALL f the fllwing criteria have been met: Pain is at least five n a zer t 10 rating scale that impacts quality f life r limits activities f daily living; AND There is an absence f generalized pain behavir (e.g., smatfrm disrder) r generalized pain disrders (e.g., fibrmyalgia); AND Patients have undergne and failed a minimum six mnths f intensive nnperative treatment that must include medicatin ptimizatin, activity mdificatin, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, sacriliac jint, and hip, including a hme exercise prgram; AND Pain is caudal t the lumbar spine (L5 vertebra), lcalized ver the psterir sacriliac jint, and cnsistent with sacriliac jint pain; AND A thrugh physical examinatin demnstrates lcalized tenderness with palpatin ver the sacral sulcus (Frtin s pint) in the absence f tenderness f similar severity elsewhere; AND There is a psitive respnse t a cluster f three prvcative tests (e.g., thigh thrust test, cmpressin test, Gaenslen sign, distractin test, Patrick test, psterir prvcatin test); AND Diagnstic imaging studies include ALL f the fllwing: Imaging (plain radigraphs and cmputed tmgraphy r magnetic resnance imaging) f the sacriliac jint excludes the presence f destructive lesins (e.g., tumr, infectin) r inflammatry arthrpathy f the sacriliac jint; AND Page 3 f 9

4 Imaging f the pelvis (anterpsterir plain radigraph) rules ut cncmitant hip pathlgy; AND Imaging f the lumbar spine (cmputed tmgraphy r magnetic resnance imaging) is perfrmed t rule ut neural cmpressin r ther degenerative cnditin that can be causing lw back r buttck pain; AND Imaging f the sacriliac jint indicates evidence f injury and/r degeneratin; AND There is at least a 75% reductin in pain fr the expected duratin f the anesthetic used fllwing an image-guided, cntrast-enhanced intra-articular sacriliac jint injectin n tw separate ccasins; AND A trial f a therapeutic sacriliac jint injectin (i.e., crticsterid injectin) has been perfrmed at least nce. Fusin/stabilizatin f the sacriliac jint fr the treatment f back pain presumed t riginate frm the sacriliac jint is cnsidered investigatinal when the abve criteria are nt. Plicy Guidelines *Sacriliac jint injectins must be dne with flurscpic guidance as nt using guidance results in a successful injectin nly 22% f the time. Nte: T ensure the integrity f results, ther diagnstic and therapeutic injectins (such as ESI) shuld nt be administered at the same time as a diagnstic r therapeutic SI jint injectin. This prtcl des nt address treatment f pain in the sacriliac jint due t infectin, trauma, r neplasm. Pain prvcatin tests include: Cmpressin Test With the patient in a side-lying psitin, dwnward pressure is applied t the uppermst iliac crest, directed tward the ppsite iliac crest. It is intended t stretch the psterir sacriliac ligaments and cmpress the anterir SI jint. Pain in the SI jint is felt t represent a psitive test. But this test has a sensitivity and specificity f nly abut 60 70%. Thigh Thrust Test This is mre sensitive (~ 90%) but has similar specificity t the cmpressin test. With the patient supine, the hip is flexed t 90 and the knee is bent. The examiner applies psterir shearing stress t the SI jint thrugh the femur. Excessive adductin f the hip is avided, as cmbined flexin and adductin is nrmally painful. Gaenslen s Test With the patient supine, the hip is maximally flexed n ne side, and the ppsite hip is extended. This maneuver stresses bth SI jints simultaneusly by cunterrtatin at the extreme range f mtin. This test als stresses the hip jints and stretches the femral nerve n the side f hip extensin, s care is taken t ensure nrmal hip findings and the absence f neurlgic cnditins affecting the femral nerve. Distractin Test This test is perfrmed with the patient supine. A psterir and lateral frce is applied t bth anterir superir iliac spines t stretch the anterir sacriliac ligaments and synvium. Patrick s Sign Patrick s sign is elicited by stressing the hip and SI jint by flexin, abductin, and external rtatin f the hip. A psitive test reprduces back r buttck pain, whereas grin pain is mre indicative f hip jint pathlgy. Page 4 f 9

5 Medicare Advantage Sacriliac (SI) jint injectins wuld be cnsidered medically necessary fr the diagnsis and/r treatment f chrnic lw back pain that is cnsidered t be secndary t suspected sacriliac jint dysfunctin. (See Medicare Advantage Plicy Guidelines) Diagnstic blcks f a sacriliac jint can be medically necessary t determine whether it is the surce f lw back pain. (See Medicare Advantage Plicy Guidelines) Therapeutic sacriliac (SI) jint injectins f an anesthetic and/r sterid t blck the jint fr immediate, and ptentially lng lasting, pain relief are cnsidered medically necessary if it is determined that the SI jint is the surce f pain in the lwer back. If previus diagnstic r therapeutic SI injectins f an anesthetic and/r sterid t blck the jint fr immediate, and ptentially lng lasting, pain relief have nt effectively relieved the pain, further injectins wuld nt be cnsidered medically necessary. Minimally-invasive surgical (MIS) fusin f the sacriliac (SI) jint is cnsidered medically necessary when ALL f the fllwing criteria are met: Have mderate t severe pain with functinal impairment and pain persists despite a minimum six mnths f intensive nnperative treatment that must include medicatin ptimizatin, activity mdificatin, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ and hip including a hme exercise prgram Patient s reprt f typically unilateral pain that is caudal t the lumbar spine (L5 vertebrae), lcalized ver the psterir SIJ, and cnsistent with SIJ pain A thrugh physical examinatin demnstrating lcalized tenderness with palpatin ver the sacral sulcus (Frtin s pint, i.e. at the insertin f the lng drsal ligament inferir t the psterir superir iliac spine r PSIS) in the absence f tenderness f similar severity elsewhere (e.g., greater trchanter, lumbar spine, cccyx) and that ther bvius surces fr their pain d nt exist Psitive respnse t a cluster f three prvcative tests (e.g., thigh thrust test, cmpressin test, Gaenslen s test, distractin test, Patrick s sign, psterir prvcatin test). Absence f generalized pain behavir (e.g., smatfrm disrder) r generalized pain disrders (e.g., fibrmyalgia) Diagnstic imaging studies that include ALL f the fllwing: Imaging (plain radigraphs and a CT r MRI) f the SI jint that excludes the presence f destructive lesins (e.g., tumr, infectin), fracture, traumatic SIJ instability, r inflammatry arthrpathy that wuld nt be prperly addressed by percutaneus SIJ fusin Imaging f the pelvis (AP plain radigraph) t rule ut cncmitant hip pathlgy Imaging f the lumbar spine (CT r MRI) t rule ut neural cmpressin r ther degenerative cnditin that can be causing lw back r buttck pain At least 75 percent reductin f pain fr the expected duratin f tw anesthetics (n separate visits each with a different duratin f actin), and the ability t perfrm previusly painful maneuvers, fllwing an image-guided, cntrast-enhanced intra-articular SIJ injectin. A trial f at least ne therapeutic intra-articular SIJ injectin (i.e., crticsterid injectin) Radifrequency ablatin used fr sacriliac jint pain is cnsidered investigatinal whether perfrmed using traditinal, cled, r pulsed radifrequency. Page 5 f 9

6 Medicare Advantage Plicy Guidelines Diagnstic and therapeutic injectins f the SI jint wuld nt likely be perfrmed unless cnservative therapy and nninvasive treatments (i.e., rest, physical therapy, NSAIDs, etc.) have failed. Arthrpathy (jint disease) is diagnsed thrugh a duble-cmparative lcal anesthetic blckade f the jint by the intra-articular injectin f a small vlume f lcal anesthetics f different duratins f actins. A psitive respnse shuld demnstrate initial pain relief greater than r equal t (>/=) % and the ability t perfrm previusly painful maneuvers. Sterids may be injected in additin t the lcal anesthetic. SI jint arthrgraphy and/r therapeutic injectin f an anesthetic/sterid are nly apprpriate when imaging cnfirmatin f intra-articular needle psitining with applicable radilgical and/r flurscpic prcedures have been perfrmed. Backgrund Sacriliac Jint Pain Similar t ther structures in the spine, it is assumed that the SIJ may be a surce f lw back pain. In fact, befre 1928, the SIJ was thught t be the mst cmmn cause f sciatica. In 1928, the rle f the intervertebral disc was elucidated, and frm that pint frward, the SIJ received less research attentin. Diagnsis Research int SIJ pain has been plagued by lack f a criterin standard t measure its prevalence and against which varius clinical examinatins can be validated. Fr example, SIJ pain is typically withut any cnsistent, demnstrable radigraphic r labratry features and mst cmmnly exists in the setting f mrphlgically nrmal jints. Clinical tests fr SIJ pain may include varius mvement tests, palpatin t detect tenderness, and pain descriptins by the patient. Further cnfunding study f the SIJ is that multiple structures, (e.g., psterir facet jints, lumbar discs) may refer pain t the area surrunding the SIJ. Because f incnsistent infrmatin btained frm histry and physical examinatin, sme have prpsed the use f image-guided anesthetic injectin int the SIJ fr the diagnsis f SIJ pain. Treatments being investigated fr SIJ pain include prltherapy (see the Prltherapy Prtcl), crticsterid injectin, radifrequency ablatin, stabilizatin, and arthrdesis. Sme prcedures have been referred t as SIJ fusin but may be mre apprpriately called fixatin (this is because there is little t n bridging bne n radigraphs). Devices fr SIJ fixatin/fusin that prmte bne ingrwth t fixate the implants include a triangular implant (ifuse Implant System) and cylindrical threaded devices (Rialt, SImmetry, Silex, SambaScrew, SI-LOK). Sme devices als have a slt in the middle where autlgus r allgeneic bne can be inserted. This added bne is intended t prmte fusin f the SIJ. Regulatry Status A number f radifrequency generatrs and prbes have been cleared fr marketing by the U.S. Fd and Drug Administratin (FDA) thrugh the 510(k) prcess. In 2005, the SInergy (Halyard; frmerly Kimberly-Clark), a water-cled single-use prbe, was cleared by the FDA, listing the Baylis Pain Management Prbe as a predicate device. The intended use is in cnjunctin with a radifrequency generatr t create radifrequency lesins in nervus tissue. FDA prduct cde: GXD. A number f percutaneus r minimally invasive fixatin/fusin devices have been cleared fr marketing by the FDA thrugh the 510(k) prcess. They include the ifuse Implant System (SI Bne), the Rialt SI Jint Fusin System (Medtrnic), SIJ-Fuse (Spine Frntier), the SImmetry Sacriliac Jint Fusin System (Zyga Technlgies), Page 6 f 9

7 Silex Sacriliac Jint Fusin System (XTANT Medical), SambaScrew (Orthfix), and the SI-LOK Sacriliac Jint Fixatin System (Glbus Medical). FDA prduct cde: OUR. Related Prtcls Facet Jint Denervatin Percutaneus Vertebrplasty and Sacrplasty Prltherapy Services that are the subject f a clinical trial d nt meet ur Technlgy Assessment Prtcl criteria and are cnsidered investigatinal. Fr explanatin f experimental and investigatinal, please refer t the Technlgy Assessment Prtcl. It is expected that nly apprpriate and medically necessary services will be rendered. We reserve the right t cnduct prepayment and pstpayment reviews t assess the medical apprpriateness f the abve-referenced prcedures. Sme f this prtcl may nt pertain t the patients yu prvide care t, as it may relate t prducts that are nt available in yur gegraphic area. References We are nt respnsible fr the cntinuing viability f web site addresses that may be listed in any references belw. 1. Dreyfuss P, Michaelsen M, Pauza K, et al. The value f medical histry and physical examinatin in diagnsing sacriliac jint pain. Spine (Phila Pa 1976). Nv ; 21(22): PMID Chu R, Atlas SJ, Stans SP, et al. Nnsurgical interventinal therapies fr lw back pain: a review f the evidence fr an American Pain Sciety clinical practice guideline. Spine (Phila Pa 1976). May 1, 2009; 34(10): PMID Chu R, Leser JD, Owens DK, et al. Interventinal therapies, surgery, and interdisciplinary rehabilitatin fr lw back pain: an evidence-based clinical practice guideline frm the American Pain Sciety. Spine (Phila Pa 1976). May 1, 2009; 34(10): PMID Manchikanti L, Datta S, Derby R, et al. A critical review f the American Pain Sciety clinical practice guidelines fr interventinal techniques: part 1. Diagnstic interventins. Pain Physician. May-Jun 2010; 13(3):E PMID Manchikanti L, Datta S, Gupta S, et al. A critical review f the American Pain Sciety clinical practice guidelines fr interventinal techniques: part 2. Therapeutic interventins. Pain Physician. Jul-Aug 2010; 13(4):E PMID Rupert MP, Lee M, Manchikanti L, et al. Evaluatin f sacriliac jint interventins: a systematic appraisal f the literature. Pain Physician. Mar-Apr 2009; 12(2): PMID Manchikanti L, Abdi S, Atluri S, et al. An update f cmprehensive evidence-based guidelines fr interventinal techniques in chrnic spinal pain. Part II: guidance and recmmendatins. Pain Physician. Apr 2013; 16(2 Suppl):S PMID Hansen H, Manchikanti L, Simpuls TT, et al. A systematic evaluatin f the therapeutic effectiveness f sacriliac jint interventins. Pain Physician. May-Jun 2012; 15(3):E PMID Kennedy DJ, Engel A, Kreiner DS, et al. Flurscpically guided diagnstic and therapeutic intra-articular sacriliac jint injectins: a systematic review. Pain Med. Aug 2015; 16(8): PMID Page 7 f 9

8 10. Visser LH, Wudenberg NP, de Bnt J, et al. Treatment f the sacriliac jint in patients with leg pain: a randmized-cntrlled trial. Eur Spine J. Oct 2013; 22(10): PMID Kim WM, Lee HG, Jeng CW, et al. A randmized cntrlled trial f intra-articular prltherapy versus sterid injectin fr sacriliac jint pain. J Altern Cmplement Med. Dec 2010; 16(12): PMID Aydin SM, Gharib CG, Mehnert M, et al. The rle f radifrequency ablatin fr sacriliac jint pain: a meta-analysis. PM R. Sep 2010; 2(9): PMID Chen SP, Hurley RW, Buckenmaier CC, 3rd, et al. Randmized placeb-cntrlled study evaluating lateral branch radifrequency denervatin fr sacriliac jint pain. Anesthesilgy. Aug 2008; 109(2): PMID Patel N, Grss A, Brwn L, et al. A randmized, placeb-cntrlled study t assess the efficacy f lateral branch neurtmy fr chrnic sacriliac jint pain. Pain Med. Mar 2012; 13(3): PMID Patel N. Twelve-mnth fllw-up f a randmized trial assessing cled radifrequency denervatin as a treatment fr sacriliac regin pain. Pain Pract. Feb 2016; 16(2): PMID Zheng Y, Gu M, Shi D, et al. Tmgraphy-guided palisade sacriliac jint radifrequency neurtmy versus celecxib fr ankylsing spndylitis: a pen-label, randmized, and cntrlled trial. Rheumatl Int. Sep 2014; 34(9): PMID van Tilburg CW, Schuurmans FA, Strnks DL, et al. Randmized sham-cntrlled duble-blind multicenter clinical trial t ascertain the effect f percutaneus radifrequency treatment fr sacriliac jint pain: threemnth results. Clin J Pain. Nv 2016; 32(11): PMID Juch JNS, Maas ET, Ostel R, et al. Effect f radifrequency denervatin n pain intensity amng patients with chrnic lw back pain: The Mint Randmized Clinical Trials. JAMA. Jul ; 318(1): PMID Whang P, Cher D, Plly D, et al. Sacriliac jint fusin using triangular titanium implants vs. nn-surgical management: six-mnth utcmes frm a prspective randmized cntrlled trial. Int J Spine Surg. Mar 2015; 9:6. PMID Plly DW, Cher DJ, Wine KD, et al. Randmized cntrlled trial f minimally invasive sacriliac jint fusin using triangular titanium implants vs. nnsurgical management fr sacriliac jint dysfunctin: 12-mnth utcmes. Neursurgery. Nv 2015; 77(5): PMID Plly DW, Swffrd J, Whang PG, et al. Tw-year utcmes frm a randmized cntrlled trial f minimally invasive sacriliac jint fusin vs. nn-surgical management fr sacriliac jint dysfunctin. Int J Spine Surg. Sep 2016; 10:28. PMID Sturessn B, Kls D, Pflugmacher R, et al. Six-mnth utcmes frm a randmized cntrlled trial f minimally invasive SI jint fusin with triangular titanium implants vs. cnservative management. Eur Spine J. Mar 2017; 26(3): PMID Dengler JD, Kls D, Pflugmacher R, et al. 1-Year results f a randmized cntrlled trial f cnservative management vs. minimally invasive surgical treatment fr sacriliac jint pain. Pain Physician. Sep 2017; 20(6): PMID Dengler J, Sturessn B, Kls D, et al. Referred leg pain riginating frm the sacriliac jint: 6-mnth utcmes frm the prspective randmized cntrlled imia trial. Acta Neurchir (Wien). Nv 2016; 158(11): PMID Duhn BS, Cher DJ, Wine KD, et al. Triangular titanium implants fr minimally invasive sacriliac jint fusin: a prspective study. Glbal Spine J. May 2016; 6(3): PMID Duhn BS, Bitan F, Lckstadt H, et al. Triangular titanium implants fr minimally invasive sacriliac jint fusin: 2-year fllw-up frm a prspective multicenter trial. Int J Spine Surg. May 2016; 10:13. PMID Rudlf L. Sacriliac jint arthrdesis-mis technique with titanium implants: reprt f the first 50 patients and utcmes. Open Orthp J. 2012; 6: PMID Page 8 f 9

9 28. Sachs D, Kvalsky D, Redmnd A, et al. Durable intermediate-t lng-term utcmes after minimally invasive transiliac sacriliac jint fusin using triangular titanium implants. Med Devices (Auckl). Jul 2016; 9: PMID Rudlf L, Capbianc R. Five-year clinical and radigraphic utcmes after minimally invasive sacriliac jint fusin using triangular implants. Open Orthp J. 2014; 8: PMID Sachs D, Capbianc R, Cher D, et al. One-year utcmes after minimally invasive sacriliac jint fusin with a series f triangular implants: a multicenter, patient-level analysis. Med Devices (Auckl). Sep 2014; 7: PMID Vanaclcha V, Herrera JM, Saiz-Sapena N, et al. Minimally invasive sacriliac jint fusin, radifrequency denervatin, and cnservative management fr sacriliac jint pain: 6-year cmparative case series. Neursurgery. Apr PMID Spain K, Hlt T. Surgical revisin after sacriliac jint fixatin r fusin. Int J Spine Surg. Apr 2017; 11:5. PMID Cher DJ, Reckling WC, Capbianc RA. Implant survivrship analysis after minimally invasive sacriliac jint fusin using the ifuse Implant System ((R)). Med Devices (Auckl). Dec 2015; 8: PMID Schell K, Buser Z, Jaki A, et al. Pstperative cmplicatins in patients underging minimally invasive sacriliac fusin. Spine J. Nv 2016; 16(11): PMID Rappprt LH, Luna IY, Jshua G. Minimally Invasive sacriliac jint fusin using a nvel hydrxyapatitecated screw: preliminary 1-year clinical and radigraphic results f a 2-year prspective study. Wrld Neursurg. May 2017; 101: PMID Nrth American Spine Sciety (NASS). NASS cverage plicy recmmendatins: Percutaneus sacriliac jint fusin. 2015; AF031E}. Accessed June 21, American Sciety f Anesthesilgists Task Frce n Chrnic Pain Management, American Sciety f Reginal Anesthesia and Pain Medicine. Practice guidelines fr chrnic pain management: an updated reprt by the American Sciety f Anesthesilgists Task Frce n Chrnic Pain Management and the American Sciety f Reginal Anesthesia and Pain Medicine. Anesthesilgy. Apr 2010; 112(4): PMID Lri MP, Rashbaum R. ISASS plicy statement - minimally invasive sacriliac jint fusin. Int J Spine Surg. Feb 2014; 8. PMID Lri MP. ISASS plicy statement -- Minimally invasive sacrilliac jint fusin (July 2016). 2016; /. Accessed Jun 21, Natinal Institute fr Health and Care Excellence. Minimally invasive sacriliac jint fusin surgery fr chrnic sacriliac pain [IPG578]. 2017; Accessed June 21, DePalma MJ, Ketchum JM, Saull TR. Etilgy f chrnic lw back pain in patients having undergne lumbar fusin. Pain Medicine. 12(5):732-9, Vanelderen P, Szadek K, Chen SP et al. Sacriliac jint pain. Pain Practice. 10(5):470-8, Szadek KM, van der Wurff P, van Tulder MW et al. Diagnstic validity f criteria fr sacriliac jint pain: a systematic review. Jurnal f Pain. 10(4):354-68, Fley BS, Buschbacher RM Sacriliac jint pain: anatmy, bimechanics, diagnsis, and treatment. American Jurnal f Physical Medicine & Rehabilitatin. 85(12): , Chen SP. Sacriliac jint pain: a cmprehensive review f anatmy, diagnsis, and treatment. Anesthesia & Analgesia. 101(5): , 2005 Nv. 46. Laslett M, Aprill CN, McDnald B, Yung SB. Diagnsis f sacriliac jint pain: validity f individual prvcatin tests and cmpsites f tests. Manual Therapy. 10(3):207-18, Page 9 f 9