Endoscopic Neurectomy for Sacroiliac Joint Pain

Primary Rationale for Non-Certification

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 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 2

Conservative management (including physical therapy, medications, activity modification) is the initial step in treating refractory SIJ pain 2
Diagnostic intraarticular SIJ injections and diagnostic sacral lateral branch blocks are part of the stepwise interventional approach for SIJ pain 2
Radiofrequency ablation of sacral lateral branches is the established therapeutic intervention after diagnostic blocks, with moderate evidence for pain relief from the posterior sacroiliac joint complex 2

The patient's diagnosis of "spondylosis without myelopathy or radiculopathy, lumbar region" does not align with isolated SIJ pain 3, 4, 5
MRI findings of L5-S1 pathology with facet arthropathy and moderate bilateral neural foraminal stenosis, plus L3-4 anterolisthesis with pars defects, indicate multiple potential pain generators 3, 4
Negative medial branch blocks at L4-5 and L5-S1 suggest facet joints are not the primary pain source 2
The presence of L3-4 anterolisthesis with pars defects has not been adequately addressed 3, 4

The American Society of Anesthesiologists recommends a stepwise approach, including conservative management, diagnostic injections, and radiofrequency ablation, before considering more invasive options like neurectomy 2
Proceeding with cooled radiofrequency ablation of bilateral S1, S2, S3 lateral branches is the evidence-based next step given 80-90% relief from diagnostic blocks 2
Only after documented failure of multiple RFA attempts would more invasive options be reconsidered 2

The 2025 BMJ clinical practice guideline does not support endoscopic neurectomy for sacroiliac joint pain, noting that even radiofrequency denervation of the sacroiliac joint requires careful patient selection and has limited evidence 6, 7, 8, 9
The 2025 BMJ 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, highlighting the need for careful consideration of the risk-benefit profile of sacroiliac joint denervation procedures 9