Non-surgical spinal procedures

Evidence

Systematic reviews indicate that epidural injections can provide only short-term improvements in pain relief and disability in patients suffering with sciatica (6). 
A multi-centre randomised double blind study comparing gabapentin and epidural steroid injections, found that although epidural injections led to modest improvement in pain and function, the outcomes were similar to that of gabapentin (7).
NICE suggest considering epidural injections of local anaesthetic and steroid in people with acute and severe sciatica (2). It also advises not to use epidural injections for neurogenic claudication in people who have central spinal canal stenosis.

Funding decision

Vitality will fund claims for one initial epidural nerve root block injection in members with lumbosacral radicular pain if they are unfit for surgical intervention or unable to tolerate neuropathic pain medications, as per the National Back and Radicular Pain Pathway (3). 
In addition, we will fund one further repeat injection assuming the initial injection resulted in six months of pain relief and functional improvement (4). However, we will not fund any further epidural injections.  
Also, we will not fund claims for epidural injections for neurogenic claudication with central spinal stenosis.

Other information

The GIRFT report has recommended the mandatory recording of patient reported outcomes for those having radicular pain injections at six months on the British Spine Registry (3).

Evidence

Systematic reviews indicate that there is no sufficient evidence to support the use of facet joint injections over conservative management in patients with lower back pain (1). 
NICE guidelines recommend against offering spinal injections to manage lower back pain (2). 
The GIRFT report (3) also suggests that clinicians should adhere to and implement the National Back Pain and Radicular Pain Pathway (4) that does not support facet injection use either.

Funding decision

As per the recommendations above, Vitality will not fund any claims for facet joint injections. 

Other information

As an alternative, the GIRFT report has recommended that facet joint injections should be replaced with diagnostic medial branch block (3).

Evidence

The recent GIRFT report has commissioned medial branch block use but stated it should not be repeated (3).   
The National Back Pain and Radicular Pain Pathway also supports the use of medial branch block in patients with chronic lower back pain (4). Patients must present with the facet joint suspected to be the source of pain and have had failed to respond to conservative management. 

Funding decision

Vitality will initially fund one episode of treatment in members with mechanical axial back pain which includes one medial branch block per area of the spine (i.e., cervical, thoracic, lumbar, sacral) followed by one radiofrequency denervation (assuming there has been a positive response to the medial branch block). A member can have up to two episodes of treatment per area of the spine. Vitality will not fund further medial branch blocks beyond these two episodes.

Other information

A positive response to a diagnostic medial branch block will inform the decision to undergo radiofrequency denervation (2).   

Evidence

Systematic reviews found low to moderate overall quality of evidence and indicate facet joint radiofrequency denervation is more effective than placebo (5). Some studies suggest it is more effective than a steroid injection in pain control.
NICE recommends radiofrequency denervation for people with chronic low back pain if (2):

• Non-surgical intervention was found to be ineffective
• The source of pain is thought to originate from structures supplied by the medial branch nerve
• Moderate to severe back pain is localised at the point of referral.

Funding decision

Vitality will fund claims for radiofrequency denervation for members who have a positive response to a medial branch block and fulfil the above NICE recommendations regarding the severity of pain and an unsuccessful period of conservative management.
We will only fund a repeat procedure if there is evidence demonstrating a significant previous improvement in pain and function, at 12 months after the initial procedure. 

Other information

We will not fund imaging as a prerequisite for radiofrequency denervation in members with facet joint focussed lower back pain which is in line with the National Lower Back Pain Pathway (4).

Facet joint injections, Medial branch block & Radiofrequency denervation
1. Vekaria, R., Ellard, D. R., Henschke, N., Underwood, M., & Sandhu, H. (2016). Intra-articular facet joint injections for low back pain: a systematic review. European Spine Journal, 25(4), 1266-1281.
2. National Institute for Health and Care Excellence (2016). Low Back Pain and sciatica in over 16s: assessment and management. NICE Interventional procedures guidance. Retrieved from: nice.org.uk/guidance/ng59
3. Hutton, M. (2019) Spinal Services: GIRFT Programme National Speciality Report. Online access: https://gettingitrightfirsttime.co.uk/wp-content/uploads/2019/01/Spinal-Services-Report-Mar19-L1.pdf
4. Greenough, C. (2017) National Low Back Pain and Radicular Pain Pathway, Third Edition 3.0, page 5 Retrieved from: ukssb.com/improving-spinal-care-project
5. Poetscher, A. W., Gentil, A. F., Lenza, M., & Ferretti, M. (2014). Radiofrequency denervation for facet joint low back pain: a systematic review. Spine, 39(14), E842-E849.

Epidural nerve root injections
6. Pinto, R. Z., Maher, C. G., Ferreira, M. L., Hancock, M., Oliveira, V. C., McLachlan, A. J.,& Ferreira, P. H. (2012). Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Annals of internal medicine, 157(12), 865-877.
7. Cohen, S. P., Hanling, S., Bicket, M. C., White, R. L., Veizi, E., Kurihara, C.& Gordin, V. (2015). Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study. bmj, 350, h1748

Non-surgical spinal procedures guidelines published 25/22/2020