Spinal Injections – Criteria Led Commissioning Statement

Scope

This commissioning policy:

  • Is applicable to non-specific low back pain. This is defined as low back pain not attributable to a recognisable, known specific pathology.
  • Addresses therapeutic use of spinal injections. It does not address diagnostic indications.
  • Does not apply to Radiofrequency Denervation or Medial Branch Blocks.

NICE guidance (NG59) clearly states: Do not offer spinal injections for treating low back pain. This refers to:

1. Epidural Steroid Injections

  • Epidural steroid injections for sciatica and spinal stenosis have an unclear therapeutic effect, but may help reduce pain for a short time in some people.

2. Facet Joint Injections

  • A cervical, thoracic or lumbar facet joint injection involves injecting a small amount of local anaesthetic (numbing agent) and/or steroid medication into one or more facet joints. The therapeutic effect is also unclear but they may help reduce pain for a short time in some people.

3. Selective Nerve Root Block Injections (SNRB),

  • Primarily used to diagnose the specific source of nerve root pain (such as a facet joint medial branch block) and secondarily for temporary therapeutic relief of low back pain and/or leg pain, such as during surgical procedures.

Status

Eligibility Criteria

1) Spinal therapeutic injections in the lumbar spine are not routinely commissioned for patients with chronic (defined as more than 3 months duration) non-specific low back pain with or without sciatica.

2) Spinal therapeutic injections in the lumbar spine should not be routinely commissioned for patients with acute (defined as less than 3 months duration) episodes of back pain.

Exceptions:
  • Following the November 2016 NICE guideline (NG 59) for the management of low back pain and sciatica in the over 16s, CCGs routinely commission a single injection only for acute and severe sciatica of less than 3 months duration for people who would be considered for surgery.
Repeat Spinal Injections

Repeat injections should not be routinely provided as there is a lack of high quality supporting evidence for long term benefit and clinical advice suggests diminishing returns with increased risk of adverse events.

Repeat injections may be commissioned only following a specialist multi-disciplinary pain management team assessment which concludes that: ·

  • Benefits outweigh harm to the patient. ·
  • There is documented evidence from the patient's previous medical history of substantial and sustained benefit; for example if there has been a more than 50% reduction in symptoms for more than 12 weeks with documented evidence of improved health function in physical activity/role and emotional and social role function ·
  • Where it is considered by a pain management clinician that a repeat injection or a single series of injections such as trigger point injections may break the cycle of pain and muscle disuse and support patients to engage with rehabilitation and self-management strategies. ·
  • Pain self-management is more challenging due to coexisting physical or mental illness or frailty.
Referrals
  • On referral to the specialist multidisciplinary pain management service, patients must be informed that the referral is for assessment and development of a pain management plan by the service with focus on multimodal self management approach.
  • For people where there is clear documented evidence of a pre-existing chronic, persistent or long term pain (more than 3 months duration) it should be made clear that the emphasis will be on supporting their confidence and skills to self-manage their condition.
  • Patients should not be under the impression that the decision to provide an injection has already been made or that repeat injections are routinely available.
Note
  • Funding for patients not meeting the above criteria will be considered on an individual basis where their consultant has completed the necessary Individual Funding Request form. Each individual case will be reviewed via the CCGs' Individual Funding Request process (Appendix 4 – NHS North Kirklees CCG Individual Funding Request Application Form and Appendix 6 NHS Wakefield CCG Individual Funding Request Application Form).

Lifestyle Factors - Best Practice

NICE guidance (NG59) clearly states that the decision to refer a person for a surgical opinion should not be influenced by their BMI, smoking status or psychological distress. However, the following should be considered:

  • Obesity - Patients with a BMI >30 should be encouraged by their Clinician to lose weight prior to surgery and signposted to appropriate support to address lifestyle factors that would improve their fitness for surgery and recovery afterwards. There is a clinical balance between risk of surgical complications with obesity and the risk to delaying any surgery.
  • Smoking - In line with 'Healthy Lives, Healthy People; a tobacco control plan for England', local authorities and health professionals are committed to encourage more smokers to quit. Smoking remains the leading cause of preventable morbidity and premature death in England. There is sufficient evidence to suggest that people who smoke have a considerably increased risk of intra- and post-operative complications such as chest infections, lung disorders, wound complications and impaired healing.
  • See Smoking Cessation Care Pathways
Please Note: The life style factors above are not a restriction to the commissioning statements unless otherwise stated

Evidence/Rationale

See References

References

  1. Low back pain and sciatica in over 16s: assessment and management (Nov 2016) https://www.nice.org.uk/guidance/N
  2. Non-specific low back pain and sciatica: management – NICE https://www.nice.org.uk/guidance/ng59/documents/short-version-of-FINAL-guideline
  3. NICE Evidence Search | Spinal injections https://www.evidence.nhs.uk/Search?q=Spinal+injections
  4. NICE Evidence Search | facet joint injections https://www.evidence.nhs.uk/Search?q=facet+joint+injections
  5. NICE Evidence Search | lumbar spine injections https://www.evidence.nhs.uk/search?q=lumbar+spine+injections
  6. NICE Evidence Search | epidural guidelines https://www.evidence.nhs.uk/Search?q=epidural+guidelines
  7. NICE Evidence Search | spinal stenosis treatments https://www.evidence.nhs.uk/Search?q=spinal+stenosis+treatments
  8. NICE Evidence Search | epidural steroid injection - NHS Evidence https://www.evidence.nhs.uk/Search?ps=40&q=epidural+steroid+injection
  9. NICE Evidence Search | epidural steroid injection - NHS Evidence https://www.evidence.nhs.uk/search?q=epidural+steroid+injection
  10. British Pain Society Guidelines for Pain Management Programmes Adults 2013

Assurance & Governance

  • This policy was developed on: 05.2017
  • This policy was approved by: Clinical Strategy Group (NK) and Clinical Cabinet (WK)
  • Date approved: 05.2017
  • Publication Date: 05.2017
  • Last updated: 6.2018
  • Review Date: 06.2019
  • Ref No: PA21 - 05.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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