SRP 095 Spinal Injections for Low Back Pain and Radicular Leg Pain

Policy number: SRP 095
Policy name: Spinal Injections for Low Back Pain and Radicular Leg Pain

Status: Therapeutic Low Back Pain – Not funded
Status: Therapeutic Radicular Pain – Individual Prior Approval 
Status: Diagnostic Assessment – Individual Prior Approval
Status: Radiofrequency Denervation – Individual Prior Approval 

Effective date: 30 April 2024  
Next review date: 30 April 2026 

Mid and South Essex ICB commission Spinal Injections on a restricted basis. 

Not Funded 

Therapeutic spinal injections of local anaesthetic and steroid are not funded for the treatment of non-specific low back pain without sciatica. 

Spinal injections include: 

  • Facet joint injections 
  • Therapeutic Medial branch blocks 
  • Intradiscal therapy 
  • Prolotherapy 
  • Trigger Point Injections with any agent, including botulinum toxin. 
  • Any other spinal injections not specifically covered above. 

Medial branch blocks for diagnostic purposes prior to radiofrequency denervation will be funded only once for one particular level or side (see below). 

Epidural, Sacro-iliac and Nerve Root injections 

Not Funded 

Epidural, sacro-iliac and nerve root injections are not funded for the treatment of non-specific low back pain without sciatica.   

Epidural steroid injections for neurogenic claudication in patients with central spinal canal stenosis are not funded. 

Individual Prior Approval 

Epidural, sacro-iliac and nerve root injections for radicular leg pain (caudal epidural, lumbar epidural, transforaminal 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 leg pain (below the knee for lower lumbar herniation, into the anterior thigh for upper lumbar herniation) consistent with the level of spinal involvement 

OR 

  • There is evidence of nerve-root irritation with a positive nerve-root tension sign (straight leg raise-positive between 30° and 70° or positive femoral tension sign) 

AND 

  • Moderate to severe and persistent radicular leg pain despite participation in comprehensive back pain programme (e.g. analgesia, physical therapy, modified activity, etc.). 

Under these circumstances, a total of up to two injections will be funded per episode.  The interval between two injections must be at least 6 months.  Individual prior approval is required for each injection. 

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

Diagnostic Assessment

Individual Prior Approval 

Medial branch blocks are only commissioned for diagnostic assessment when one procedure will be funded for one particular level or side in each patient being assessed for radiofrequency denervation/surgical management of chronic spinal pain e.g. neck pain; low back pain; leg pain.  Patients must have had the pain for more than one year and other conventional options have failed to resolve the pain (oral analgesics and physiotherapy)  

Progression to Medial Branch Block Radiofrequency Denervation will only be commissioned (funded) where there is evidence of pain relief of ≥80% at time of the medial branch block injection and the pain starts to recur within 72hours.   

Radiofrequency Denervation (rhizolysis) 

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 for chronic non-specific low back pain 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. 

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. 

AND 

  • The interval to the last radiofrequency denervation (in the same location) must be at least 12 months. 

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.   

Find out more information on applying for funding in exceptional clinical circumstances 

Reference:  

Low back pain and sciatica in over 16s: assessment and management 

NICE guideline [NG59] Published: 30 November 2016 Last updated: 11 December 2020 

Do not offer spinal injections for managing low back pain. 

Do not offer ultrasound for managing low back pain with or without sciatica. 

Do not offer PENS for managing low back pain with or without sciatica. 

Do not offer TENS for managing low back pain with or without sciatica. 

Do not offer interferential therapy for managing low back pain with or without sciatica. 

Do not offer traction for managing low back pain with or without sciatica. 

Do not offer belts or corsets for managing low back pain with or without sciatica. 

Do not offer foot orthotics for managing low back pain with or without sciatica. 

Do not offer rocker sole shoes for managing low back pain with or without sciatica 

Do not offer disc replacement in people with low back pain. 

Do not offer spinal fusion for people with low back pain unless as part of a randomised controlled trial. 

Do not offer gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines for managing sciatica as there is no overall evidence of benefit and there is evidence of harm.  

Do not offer opioids for managing chronic sciatica. 

Do not offer paracetamol alone for managing low back pain.

Do not routinely offer opioids for managing acute low back pain 

Do not offer opioids for managing chronic low back pain.  

Do not offer selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors or tricyclic antidepressants for managing low back pain.  

Do not offer gabapentinoids or antiepileptics for managing low back pain 

National Back Pain and Radicular Pain Pathway https://docs.wixstatic.com/ugd/dd7c8a_caf17c305a5f4321a6fca249dea75ebe.pdf