SRP 095 MSK Spinal Injections for Spinal and Radicular Pain

Policy number: SRP 095
Policy name: Spinal Injections for Spinal and Radicular Pain
Status: Therapeutic Non-Specific Spinal Pain – Not Funded
Status: Therapeutic Radicular Pain – Individual Prior Approval
Status: Diagnostic Assessment – Individual Prior Approval
Status: Radiofrequency Denervation – Individual Prior Approval
Effective date: 1 March 2026
Next review date: 1 April 2028

Spinal pain can arise from the cervical, thoracic, lumbar or sacral regions of the spine, and can present with or without radiculopathy. Non-speciﬁc spinal pain can be deﬁned as spinal pain or discomfort which cannot be attributed to recognisable, known speciﬁc pathology (such as cancer, fracture, infection or inflammatory disease process).

Radiculopathy is a condition where a spinal nerve root is compressed or irritated and can occur at different locations along the spine (cervical, thoracic or lumbar). Symptoms vary by location but frequently include pain, weakness, numbness and tingling. Cervical radiculopathy is characterised by sensory or motor symptoms in one or both of the upper extremities with symptoms of occipital headache, neck pain which may radiate to shoulders, arm pain/weakness, and finger numbness/ tingling. Lumbar radiculopathy (also known as sciatica) is characterised by pain that radiates down the leg and may also include weakness, numbness and tingling.

Conservative therapies including physiotherapy should be offered as first line treatment for spinal pain before other interventions are considered. MSE ICB commissions spinal injections on a restricted basis.

This policy does not apply to patients presenting with “red flag symptoms” such as Cauda Equina which requires immediate referral to A+E or sudden/significant deterioration in neurological function which requires urgent investigation and onward referral to spinal specialist.

Treatment of non-specific spinal pain (no radiculopathy)

Not funded

Therapeutic spinal injections of steroid +/- local anaesthetic are not funded for the treatment of non-specific cervical, thoracic, lumbar or sacral pain without radiculopathy.

Therapeutic spinal injections include (but are not limited to):

Facet joint injections
Therapeutic Medial branch blocks/facet joint nerve blocks
Epidural steroid injections for isolated spinal pain or for neurogenic claudication in patients with central spinal canal stenosis
Sacro-iliac injections
Nerve root injections
Intradiscal therapy
Prolotherapy
Trigger Point Injections with any agent, including botulinum toxin.

Any other therapeutic spinal injections not specifically listed above are also classed as low clinical priority and are NOT funded

Treatment of spinal radiculopathy

Status: Individual prior approval

Epidural and nerve root injections for lumbar, thoracic or cervical radicular pain (caudal epidural, lumbar epidural, transforaminal epidural, interlaminar cervical epidural, or nerve root injections) will only be funded in accordance with the criteria specified below.
Nerve root injections should only be performed under imaging.

The patient has radicular pain consistent with the level of spinal involvement
OR
There is evidence of positive neurodynamic testing (e.g. femoral and sciatic nerve testing or positive upper limb tension test)
AND
The patient has moderate to severe and persistent radicular pain despite participation in a comprehensive conservative management programme (e.g. analgesia/medical management, physical therapy, modified activity, etc.).
OR
The pain is acute (<3 months) at the time of referral AND the pain is severe and uncontrollable (rated at 7/10 or more on the visual analogue pain scale).

Under these circumstances, a single procedure will be funded. This can include a combination of approaches such as a caudal and transforaminal injection if directed towards the same symptomatic level.

Repeat injections

A repeat procedure at the same site will be funded where the pain has worsened again such that the criteria above are met, AND co-morbidities exclude surgery or where less invasive treatment is not possible, AND the previous injection has offered at least a 60% improvement in pain sustained for at least 6 months.

A maximum of two procedures will be funded within any 12-month period. The interval between two procedures must be at least 6 months.

Individual prior approval is required for each procedure.

Status: Not funded

Epidural injections are not recommended or funded for neurogenic claudication caused by central spinal canal stenosis.

Diagnostic assessment

Status: Individual prior approval

Medial branch blocks are only commissioned for diagnostic assessment of facet joint pain in accordance with the criteria specified below:

Patient is being assessed for radiofrequency denervation/surgical management of chronic spinal pain e.g. neck pain; low back pain
AND
Patient must have had the pain for more than one year
AND
Other conventional options have failed to resolve the pain (oral analgesics and physiotherapy)

Only procedures at symptomatic level(s) and/or sides will be funded.

Progression to Medial Branch Block Radiofrequency Denervation will only be funded where there is evidence of pain relief of ≥80% at time of the medial branch block injection.

ONE diagnostic procedure per level / side will be funded where the criteria above are met. Repeat diagnostic injections at the same site are not funded.

Individual Prior approval is required for each procedure.

2. Diagnostic injections for sacroiliac joint pain

Status: Individual prior approval

A single diagnostic image guided sacroiliac joint injection of local anaesthetic is commissioned provided that:

Conservative management has failed
AND
Sacroiliac joint pain is elicited using a provocation test, if clinically appropriate.

NOTE: Evidence of the result of the provocation test or evidence of degenerative sacroiliitis must be recorded in the patient’s clinical notes.

If after the sacroiliac joint injection, a further provocation test is negative, then radiofrequency denervation or minimally invasive sacroiliac joint fusion is commissioned in line with NICE IPG578.

ONE diagnostic injection per level / side will be funded where the criteria above are met.

Repeat diagnostic injections at the same site are not funded.

Individual Prior approval is required for each injection.

Status: NOT Funded

Prolotherapy is not funded due to a lack of evidence on clinical and cost effectiveness.
Diagnostic facet joint injections are not funded. The diagnostic injection of choice is medial branch block.

Radiofrequency Denervation (Rhizolysis)

Status: Individual Prior Approval

The procedure called ‘radiofrequency denervation’ involves sealing off some of the nerves to the joints of the spine to stop the nerves transmitting pain signals. It aims to achieve longer-term pain relief and allow rehabilitation in people with spinal pain who experience significant but short-term relief after a diagnostic block by injection of local anaesthetic.

Radiofrequency denervation of the facet or sacroiliac joints for patients with chronic pain in the cervical, thoracic or lumbar spinal regions will only be funded in accordance with the criteria below:

Comprehensive non-surgical treatment including community pain pathway has not been successful.
AND
The main source of pain is thought to come from structures supplied by the medial branch nerve or from the sacro-iliac joint.
AND
Moderate or severe levels of localised back pain (rated as 5 or more on a visual analogue scale, or equivalent) at the time of referral.
AND
Positive response to a diagnostic medial branch block or sacro-iliac joint injection.
AND
The interval to the last radiofrequency denervation (in the same location) must be at least 16 months.

Repeat Procedures

ONE repeated Radiofrequency Denervation after relapse is funded where criteria above are met, AND there is a patient reported outcome measure* demonstrating significant improvement in pain relief and function post initial denervation procedure AND there is interval of at least 16 months from initial denervation procedure.

Individual Prior approval is required for each procedure.

*for example the Musculoskeletal Health Questionnaire (MSK-HQ)

Coccydynia

Status: Individual Prior Approval

Local anaesthetic and steroid injections for coccydynia will only be funded if the patient has moderate to severe symptoms despite comprehensive conservative management with symptoms persisting for more than 2 months.

Under these circumstances, a single injection will be funded.

Repeat injections

A repeat injection will be funded where the pain has worsened again such that the criteria above are met, AND less invasive treatment is not possible, AND the previous injection has offered at least a 70% improvement in pain sustained for at least 6 months.

A maximum of two injections will be funded within any 12-month period. The interval between two injections must be at least 6 months.

Individual prior approval is required for each injection.

Funding for patients not meeting the condition and relevant criteria set out above will not be granted unless there are clinically exceptional circumstances.

Individual funding requests should only be made where the patient demonstrates clinical exceptionality.

Further information on applying for funding in exceptional clinical circumstances can be found by visiting the ICB website.