Notification

Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management


Notification Issue Date: 10/16/2018

This version of the policy will become effective on 01/14/2019.

The following changes have been made to this policy:

  • For paravertebral facet joint blocks only individuals with synovial cysts may present with pain, which may have a strong radicular component.
  • A major criterion for medical necessity for repeat injections described in this policy bulletin is having at least 50% reduction from prior injection(s), or for epidural injections if the initial therapeutic injection did not result in pain relief, repeat injection may be indicated, provided that the injection is performed at an adjacent level, OR at the same level utilizing a different approach or type of steroid.
  • In addition to other injection types detailed in this policy bulletin, ultrasound guidance for caudal epidural injections is considered experimental/investigational and, therefore, not covered.

Pre-service utilization management is not in place for CPT codes 62320 and 62322, which represent epidural injection procedures, when they are performed for the following three ICD-10-CM diagnoses: G89.11 Acute pain due to trauma, G89.12 Acute post-thoracotomy pain, or G89.18 Other acute post procedural pain. All other ICD-10-CM diagnoses for CPT codes 62320 and 62322 go through pre-service utilization management.


Medical Policy Bulletin


Title:Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management

Policy #:11.15.23g

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

EPIDURAL INJECTIONS
Diagnostic Epidural Injections (also known as diagnostic selective nerve root blocks [DSNRBs] or diagnostic transforaminal injections)

Diagnostic epidural injections using imaging guidance to determine whether pain is somatic, visceral, or functional are considered medically necessary and, therefore, covered for any of the following indications, in accordance with the frequency and maximum number listed below:
  • When there is a question of intercostal neuralgia vs. thoracic facet syndrome
  • When radiologic studies have demonstrated an abnormality related to an adjacent nerve root only
  • When a clinical picture is suggestive, but not typical, for both nerve root and distal nerve or joint disease and multiple sources of pain are in question (e.g., there is a root dysfunction from mid-lumbar disk disease vs. a causalgia-like syndrome from an old, chronic knee injury)
  • When a discrepancy exists between the demonstrated pathology and the complaint or findings (e.g., when the source of pain appears to be due to a classic mono-radiculopathy, yet the neurodiagnostic studies have failed to provide a structural explanation or an L4 disc bulge is seen, radiologically, with an S1 root syndrome)
  • When it needs to be known if the origin of the pain is central or peripheral (e.g., leg pain following spinal cord injury)

Therapeutic Epidural Injections (also known as therapeutic epidural steroid injections [ESIs])

Therapeutic epidural injections using imaging guidance are considered medically necessary and, therefore, covered for any of the following indications, in accordance with the frequency and maximum number chart listed below:
  • When radicular pain is resistant to, or the individual has a contraindication to, other therapeutic measures (such as, non-narcotic analgesic, physical therapy, etc)
  • When surgery is contraindicated
  • When post-decompressive radiculitis or post-surgical scarring exists
  • When there is monoradicular pain, confirmed by diagnostic blockade, in which a surgically correctable lesion cannot be identified
  • When treatment of acute herpes zoster pain or post-herpetic neuralgia is needed
  • When there is persistent pain caused by reflex sympathetic dystrophy, causalgia, or a complex regional pain syndrome I or II, in lieu of a sympathetic blockade

Frequency and Maximum Number of Epidural Injections
  • A maximum of three (3) injection sessions (including diagnostic transforaminal injections) are considered medically necessary and, therefore, covered in each spinal region (cervical or lumbosacral) in a six month period.
  • Up to two (2) transforaminal injections are considered medically necessary and, therefore, covered at a single setting (e.g., single level bilaterally or two levels unilaterally). Injecting one level bilaterally would be considered two (2) injections. Injecting two levels, each unilaterally, would also be considered two (2) injections.
  • For caudal or cervical/lumbar interlaminar injections, only one (1) injection per session is considered medically necessary and, therefore, covered and NOT in conjunction with a transforaminal injection.

Epidural injections up to a maximum of three levels per region unilaterally or up to two levels per region bilaterally may be considered for reimbursement. For the purpose of reimbursement for epidural injections, the spine consists of two general regions. Cervical/thoracic is one region and lumbar/sacral is a separate region. Each individual injection counts toward the maximum number of injections covered. A session, for situations other than caudal or cervical/lumbar interlaminar injections, is defined as all ESIs or spinal procedures performed on a single day.

PARAVERTEBRAL FACET JOINT BLOCKS
Diagnostic (also known as diagnostic medial branch blocks [MBB]) and Therapeutic Blocks (also known as therapeutic intraarticular [IA] facet joint injections)

Paravertebral facet joint blocks using imaging guidance are considered medically necessary and, therefore, covered when all of the following criteria are met, in accordance with the frequency and maximum number listed below:
  • The individual presents with chronic neck, thoracic, or back pain that lacks a strong radicular component (with the exception of synovial cysts), has no associated neurologic deficits, and is often aggravated by hyperextension or rotation of the spine.
  • The pain has been present and documented for greater than 3 months
  • A detailed pain history has been documented that includes prior treatments and responses (e.g., analgesics, physical therapy)

Frequency and Maximum Number of Paravertebral Facet Joint Blocks
  • A maximum of six (6) facet joint procedural sessions per region (cervical/thoracic or lumbar/sacral) are considered medically necessary and, therefore, covered in a 12-month period, regardless of type or indication.

For paravertebral facet joint blocks, up to a maximum of only four (4) joints per session (e.g., two [2] bilateral levels or four [4] unilateral levels), may be considered for reimbursement. For the purpose of reimbursement for paravertebral facet joint blocks, the spine consists of two general regions. Cervical/thoracic is one region and lumbar/sacral is a separate region.

SACROILIAC (SI) INJECTIONS
Diagnostic and Therapeutic Injections

SI joint injections using imaging guidance are considered medically necessary and, therefore, covered, when all of the following criteria are met, in accordance with the frequency and maximum number listed below:
  • Treatment has already addressed and ruled out any non-sacroiliac joint pain generators, as SI joint dysfunction may resolve once these pain generators have been successfully treated. If there is residual sacroiliac joint pain, it may then be appropriate to perform SI joint injections.
  • If the SI joint pain is secondary to another primary source of pain, treatment of the primary source has been performed prior to the initiation of the SI joint injection.
  • Noninvasive treatments (i.e., rest, physical therapy, NSAIDs) have been tried and were unsuccessful, or they were contraindicated.

Frequency and Maximum Number of Sacroiliac Joint Injections

Diagnostic Sacroiliac Injections
  • Dual intraarticular sacroiliac joint injections, defined as injections performed in the same joint on 2 separate occasions (i.e. days) are considered medically necessary and, therefore, covered to confirm the diagnosis due to the unacceptably high false positive rate of single intraarticular sacroiliac joint injections.
    • The second confirmatory injection is considered medically necessary and, therefore, covered only if the first injection produces greater than or equal to 80% relief of the primary (index) pain and the onset and minimum duration of relief is consistent with the agent employed. This confirmatory block confirms the tested sacroiliac joint as the source if the index pain is reduced by greater than or equal to 80% and the onset and minimum duration of relief is consistent with the agent employed.
  • In order to be covered, on the day of the procedure, the patient’s pain must be at least 3/10 severity at rest or during a consistently provocative maneuver, which will allow accurate monitoring of the response to the injection.

Therapeutic Sacroiliac Injections
  • A maximum of three (3) injections in a 12-month period are considered medically necessary and, therefore, covered.
    • A second injection after the first, and a third injection after the second are considered medically necessary and, therefore, covered only if:
      • symptoms recur and the individual demonstrated at least 50% pain relief from the previous injection, and
      • there is documented improvement in individual-specific ADLs for at least 6 weeks after a previous injection, and
      • the injections are administered at intervals of greater than three months.
  • Treatment with therapeutic injections should be accompanied by participation in an ongoing active rehabilitation program, home exercise program, or functional restoration program.

REPEAT INJECTIONS FOR TRANSFORAMINAL EPIDURAL INJECTIONS, PARAVERTEBRAL FACET NERVE BLOCKS, AND SACROILIAC JOINT INJECTIONS
A series of injections may be medically necessary to establish consistency of results, particularly if diagnostic blocks are to be followed by neurolysis. If successful (with a major criterion being at least 50% reduction from prior injection(s), or for epidural injections if the initial therapeutic injection did not result in pain relief, repeat injection may be indicated, provided that the injection is performed at an adjacent level, OR at the same level utilizing a different approach or type of steroid), it is reasonable to repeat this series for a relapse. However, long-term multiple nerve blocks over a period of several weeks or months is not an effective method of chronic pain management.

NOT MEDICALLY NECESSARY

Epidural injections, paravertebral facet nerve blocks, and sacroiliac joint injections are considered not medically necessary and, therefore, not covered when the above criteria and/or the frequency and maximum number requirements are not met.

Epidural injections are considered not medically necessary and, therefore, not covered, for any of the following:
  • The treatment of low back pain associated with myofascial pain syndrome
  • The treatment of a soft-tissue source of pain in which no nerve root pathology exists
  • The treatment of pain performed without imaging guidance

Performing a transforaminal epidural injection (64479, 64480, 64483, 64484) and/or paravertebral facet joint injection (64490, 64491, 64492, 64493, 64494, 64495) on the same day as an interlaminar or caudal (lumbar, sacral) epidural (62311)/intrathecal injection sacroiliac joint injection (27096), lumbar sympathetic block (64520), or other nerve block is considered not medically necessary and, therefore, not covered.

ANESTHESIA

General anesthesia or monitored anesthesia care (MAC) is rarely, if ever, required for these injections. Standard medical practice utilizes local anesthesia or conscious sedation.

Administration of medication and monitoring of the patient are performed by the pain management team; the presence of an anesthesiologist/anesthetist is considered not medically necessary.

EXPERIMENTAL/INVESTIGATIONAL

The use of ultrasound guidance for transforaminal epidural injections, caudal epidural injections, interlaminar injections, or paravertebral injections is considered experimental/investigational and, therefore, not covered.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

UTILIZATION GUIDELINES
  • Diagnostic epidural (selective nerve block) injections are generally performed 1 to 2 weeks apart.
  • Repeat therapeutic blocks within the same region generally do not exceed a frequency of every 2 to 3 months when a previous block produced at least a 50 percent reduction in pain for a sustained period of at least six weeks.
  • Therapeutic transforaminal epidural injections are generally administered into the affected region up to one level bilaterally or two levels unilaterally on the same day.


BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, transforaminal epidural nerve blocks are covered under the medical benefit of the Company's products when the medical necessity criteria listed in the medical policy are met.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

Nerve block injections are not regulated by the US Food and Drug Administration (FDA); pharmaceutical agents used in transforaminal nerve block injections are subject to FDA approval.

BILLING GUIDELINES

Both CPT codes 64479 and 64483 are used for a single injection in the cervical/thoracic or lumbar/sacral areas of the spine, respectively. Each primary code has an associated add-on code, 64480 and 64484 (lumbar/sacral), for use when injections are provided at multiple spinal levels.

EPIDURAL AND/OR PARAVERTEBRAL FACET JOINT NERVE BLOCKS

Due to the inherent risk with epidural injections (specifically with cervical procedures, and the risk of inadvertent arterial injection and L1 and L2 procedures, and the risk of inadvertent injections into the artery of Adamkiewicz), professional providers performing this procedure should have substantial and specific experience with transforaminal epidural injections, and a clear understanding of the individual's risks.

Therapeutic blocks are performed after the diagnosis is established. These blocks typically include the use of anesthetic, corticosteroid substances, or both for long-term control of pain.

Diagnostic blocks for all of these procedures are usually administered in two sessions, one to two weeks apart. During the first session, usually a short-acting anesthetic is used, and during the second session, a long-acting anesthetic may be used. The individual then records his/her response to the pain.

SACROILIAC JOINT INJECTION

Individuals who have gained no symptom relief or functional improvement after two injections of the SI joint should not proceed with additional injections because the likelihood of pain relief after two failed attempts is low.

If the muscles surrounding the sacroiliac joint are injected in lieu of the joint, then a trigger point injection should be recorded, not a sacroiliac joint injection.

Description

Spinal pain is usually classified as acute or chronic. Acute pain in the spinal region usually results from disease, injury, or inflammation, and can develop into chronic pain. Acute and chronic pain syndromes are costly public health issues that pose challenges to the individual experiencing the pain, his or her family, the health care provider, and the health system. Chronic neck and/or back pain can decrease an individual's productivity, limit his or her sense of well being, and lead to physical decline through loss of muscle mass and bone density due to decreased exercise and weight-bearing tolerance. For the purpose of this policy, chronic pain is defined as continuous or intermittent pain that has been unresponsive to conservative measures (e.g., rest, physical therapy, and/or medication) and has persisted for three months or more.

The brain and spinal cord comprise a major portion of the central nervous system. The spinal cord is located within a bony support structure called the vertebral column (spine). The cord extends from the base of the brain to the mid-lumbar region. The cord and brain are encased in a protective covering that consists of the pia mater, the arachnoid membrane, and the dura mater. Nerve roots extend from the spinal cord through spaces between the spinal column to innervate different areas of the body. The space is created by the pads of cartilage called intervertebral discs. These discs allow for flexibility in the spine and also act as shock absorbers to cushion the vertebrae when the body moves.

Pain is addressed in several ways. Initially, non-invasive methods and/or a pain management program may be employed. Pain management programs usually include, but are not limited to, heat or ice compacts, steroidal or non-steroidal analgesics, opioids, resting of the affected area, and some form of exercise. If non-invasive measures fail to give satisfactory relief, invasive methods such as ablation or neurolysis may be employed. The decision to treat chronic pain by invasive procedures is based on assessment of the location, intensity, and pathophysiology of the pain.

EPIDURAL INJECTIONS

The epidural space is formed by the dura and the spiny surface of the spinal column. Cerebrospinal fluid circulates within this space from the brain to the spinal cord in a continuous loop. The spinal cord branches out to form nerve roots, which pass through openings in the spinal column called neuroforamenal openings. Epidural injections for chronic spinal pain involve the administration of steroids into the epidural space. Injections can be performed using an interlaminar, transforaminal, or caudal approach.

An interlaminar approach involves accessing the dorsal epidural space by placing the spinal needle centrally between lamina of adjacent vertebrae. A transforaminal approach (selective nerve root block) involves the placement of the spinal needle in the neuroforamen, ventral to the nerve root. A caudal epidural injection involves the placement of the spinal needle between the sacral cornua and insertion into the sacral canal through the sacral hiatus.

Irrespective of the approach utilized, the block comprises two phases of injections. The first phase is diagnostic, and the second phase is therapeutic. Once the location of the suspected causal nerve root is determined, the needle is introduced into the epidural space via an interlaminar, transforaminal, or caudal approach. Contrast medium and imaging guidance are used to ensure that the tip of the needle is properly placed. This allows for monitoring of the filling pattern within the epidural space. Monitoring of the filling pattern with the contrast ensures that there is no undesirable vascular or intrathecal uptake of the injectate. A small amount of local anesthetic is injected into the site in order to perform a diagnostic, reproducible blockade of a specific nerve root.

Some goals of diagnostic nerve block injections are:
  • To determine source of pain
  • To determine nociceptive pathway
  • To differentiate local from referred pain
  • To differentiate somatic from visceral pain
  • To determine the sympathetic nervous system contribution to the pain
  • To determine whether a painful deformity is caused by spasm or fixed syndromes

The therapeutic aspect of the block is begun only after a successful diagnostic block is achieved. When the placement is confirmed and there is little chance of accidental arterial injection, a therapeutic injection containing an anesthetic, antispasmodic, and/or anti-inflammatory is performed. This injection, if successful, will reduce pain, swelling, inflammation, and irritation of the nerve root(s), which are caused by conditions such as herniated discs and spinal stenosis. The duration of symptom relief following a therapeutic injection varies based upon the pharmacologic agent injected and its expected duration of therapeutic effect from it. In cases of severe radiculopathy, expedited care may be necessary to prevent entrapment syndrome, which may cause slowed conduction velocity, segmental demyelination, and remyelination.

PEER-REVIEWED LITERATURE
In a prospective study, Cyteval et al. (2006) evaluated n=229 patients with lumbar radiculopathy at 2 weeks and 1 year following administration of percutaneous periradicular (transforaminal) steroid infiltration. Patients included in the study were restricted to those chiefly complaining of primary leg pain that did not respond to 4 weeks of conservative treatment, having a history and physical examination consistent with a lumbar radiculopathy pain patter; MR imaging or CT scan results documenting disk herniation; or degenerative disease with nerve root decompression at the level and side of the clinical symptoms. The aim of the study was to determine predictive factors of efficacy or failure of the epidural steroid injection procedure. Epidural steroid injections were performed under fluoroscopic guidance, with periradicular flow confirmed using contrast medium. None of the study participants received repeat injections. Short- and long-term pain relief was observed. Cause of pain, conflict location, and pain intensity were not significant predictors of radicular pain relief. Symptom duration before the procedure was highly correlated with pain relief outcomes, favoring patients with shorter duration of symptoms. Despite the lack of a control group, the authors concluded that periradicular infiltration was a simple, safe, and effective non-surgical procedure that should be performed early in the course of disease to provide radicular pain relief.

Wilson-MacDonald et al. (2005) published data from a randomized, double-blind, controlled trial of methylprednisolone plus local anesthetic for the treatment of nerve root compression. The study was designed to evaluate whether epidural steroid injections would lessen pain at 1 month, and, if efficacious, epidural steroid injections would reduce the need for surgery in the long term among patients who had been offered lumbar decompression surgery. Study participants were randomly allocated to receive either an epidural (n=44) or an intramuscular (n=48) injection of methylprednisolone plus bupivacaine. Injection techniques were similar in both groups; after the needle made contact with the lamina of the vertebra it was withdrawn and redirected for the intramuscular injection or advanced into the epidural space, in order to maintain patient blinding. Patients recorded their pain intensity and relief daily for 35 days using the Oxford pain chart. Patients not receiving benefit from the first injections were given a second epidural steroid injection or were allowed to cross over into the epidural steroid injection arm at the 6-week follow-up point. The authors reported a significant difference in pain relief between groups (P<0.004), favoring the epidural group. The proportion of individuals who had surgery was not significantly different between epidural steroid injection and intramuscular injection treatment groups (41% vs. 31%, respectively, [p=0.45: relative risk 1.3; 95%CI 0.76-2.27]).

Price et al. (2005) evaluated the safety and clinical effectiveness of epidural steroid injections in n=228 individuals diagnosed with either acute or chronic sciatica. Participants were randomized to receive up to 3 epidural steroid or placebo injections and were followed periodically over a 52-week period. Primary outcomes were measured with the Oswestry Disability Questionnaire (ODQ), along with pain relief and psychological and physical function data. At 3 weeks after injection, a greater number of patients in the epidural steroid injection group reported reductions in pain and greater improvements in ODQ compared to the placebo group (P=0.017, NNT=11.4). No significant differences between treatment groups in any outcomes were observed in other follow-up points. The authors concluded that although epidural steroid injections are relatively safe, only transient benefits in symptoms and self-reported function were conferred, with no sustained benefit or need for surgery.

In 2010 and 2011 the Manchikanti et al. workgroup published 1-year results from two randomized, double-blind, clinical trials evaluating the effectiveness of therapeutic local anesthetic caudal epidural injections with or without steroid. Study participants had been diagnosed with chronic lumbar pain of lumbar disc herniation or radiculitis or post-lumbar surgery syndrome. Outcomes related to the numeric rating scale (NRS), the Oswestry Disability Index (ODI), employment status, functional status, and opioid intake were assessed at 3, 6 and 12 months post-treatment. Significant pain relief and disability reduction was defined as a 50 percent or more reduction in scores from baseline. Based on a participant's response to prior injections and improvements in functional and physical status, repeat injections were administered when pain relief decreased below 50 percent. Comparable results were reported in both publications. Combined pain relief and disability reduction was observed across study arms in both RCTs, although the percentage of individuals classified as responders slightly favored the local anesthetic with the steroid group (53/55% versus 59/68%). The average number of injections per year ranged from 3.8 0.9 to 4.30.9 with an average total relief ranging from 28.218.8 to 38.413.2 weeks per year. Based on these results and other secondary outcomes, the Manchikanti et al. workgroup concluded in both trials that caudal epidural injections may be effective in the treatment of chronic low back and lower extremity pain after surgical intervention with post-lumbar surgery syndrome and in managing chronic low back pain without disc herniation or radiculitis. The results from both trials are limited by the lack of placebo or sham controls and the large variation regarding the overall time of relief, which obstruct the ascertainment of generalizable conclusions.

Two-year results from a randomized trial intended to assess the effectiveness of caudal epidural injections with or without steroids in providing long-lasting pain relief for the management of chronic low back pain related to lumbar central stenosis were published in 2012 (Manchikanti et al., 2012a). The study enrolled n=100 individuals, at least 30 years old, with central spinal stenosis with radicular pain of at least 6 months. At the 24-month follow-up point, n=35 and n=36 patients were available for assessment in the local anesthetic only and local anesthetic with steroid groups, respectively. Overall, among those available for assessment at two years, significant pain relief and functional status improvement were observed in 38 percent of the individuals within the local anesthetic only group and in 44 percent of the local anesthetic and steroid group. The authors concluded that caudal epidural injections of local anesthetic with or without steroids provide relief in a modest proportion of patients undergoing the treatment and may be considered an effective treatment for a select patient group.

The Cochrane Collaboration (Staal et al. 2008) published a systematic review intended to assess the effectiveness of injection therapy, stratified by injection site (i.e., facet sites, epidural sites, and local sites) for patients with subacute or chronic low-back pain. The authors, Staal et al., identified 18 total randomized trials, seven of which evaluated the effectiveness of varying epidural injections (i.e., corticosteroids or local anesthetics) versus placebo injections or other treatments (e.g., non-steroidal anti-inflammatory drugs, etc). The authors concluded that, based on the current literature, there is insufficient evidence to support or refute the use of injection therapy, regardless of type and dosage, for patients with subacute and chronic back pain without radicular pain.

Novak and Nemeth (2008) conducted a literature review of the current evidence to suggest guidelines for frequency and timing of epidural steroid injections and to determine what sort of response should occur to repeat an injection. Literature searches resulted in the initial identification of 91 articles, 15 of which meet the pre-determined inclusion/exclusion criteria and were included in the review. The authors concluded that there is limited evidence to suggest guidelines for frequency and timing of epidural steroid injections; additionally, there is little evidence to suggest that repeat epidural steroid injections are beneficial.

Manchikanti et al. (2012) conducted a systematic review to determine the short- (up to 6 months) and long-term (beyond 6 months) effects of transforaminal epidural injections of local anesthetic with or without steroids for disc herniation, spinal stenosis, discogenic pain, and post-surgery syndrome. Literature searches identified 70 studies, 25 of which met the a priori inclusion and exclusion criteria. The authors classified the available evidence as good, fair, or poor based upon a method adapted from the U.S. Preventive Services Task Force evidence grading system. While citing an overall paucity of literature as limiting factor, the authors concluded that the evidence is good for radiculitis secondary to disc herniation with local anesthetics and steroids and fair with local anesthetic only; it is fair for radiculitis secondary to spinal stenosis with local anesthetic and steroids, and limited for post-surgery syndrome using local anesthetic with or without steroids. The authors also noted that among patients with significant nerve root compression, the relief may be similar to placebo effect and surgery may be a more appropriate consideration.

In a double-blind, multi-site, randomized control trial, Friedly et al. (2014) compared epidural injections consisting of a glucocorticoid and lidocaine to injections of lidocaine alone. The study population consisted of 400 patients at least 50 years old with lumbar central spinal stenosis (as evidenced by MRI or CT) and associated leg pain and disability. Patients were randomized to receive glucocorticoids plus lidocaine or lidocaine alone, but were given the option to cross over after initial outcome assessment. All injections were conducted with fluoroscopy and included both transforaminal and interlaminar approaches. Patients could receive one or two injections before primary outcomes were assessed. The primary outcomes, measured at baseline and again at 3 and 6 weeks, were the patient’s self reported score on the Roland-Morris Disability Questionnaire (RMDQ) and the patient’s rating of average leg and back pain in the past week. While both groups experienced reductions in pain and improved function, the authors found no significance between group differences in either primary outcome at 6 weeks (RMDQ: -1.0 points, [CI] -2.1 to 0.1, P=0.07; Leg pain: -0.2 points, [CI] -0.8 to 0.4, P=0.48). There were significant differences at 3 weeks in both outcomes with greater improvement in the glucocorticoid-lidocaine group (RMDQ: -1.8 points; [CI] -2.8 to -0.9, P<0.001; Leg pain: -0.6, [CI] -1.2 to -0.1, P=0.02). The authors concluded that epidural injections of glucocorticoids plus lidocaine offered minimal or no benefit over lidocaine alone at 6 weeks. Study limitations include the lack of a sham injection group and a lack of control on subtypes of spinal stenosis and differences in leg pain between randomized groups.

PROFESSIONAL ORGANIZATIONS AND POSITION STATEMENTS
The American Society of Interventional Pain Physicians (ASIPP) published evidence-based guidelines regarding interventional techniques in the diagnosis and treatment of chronic spinal pain in 2009 (Manchikanti et al.). The authors outlined separate recommendations for the varying epidural administration techniques (i.e., caudal, interlaminar, and transforaminal) and for varying anatomical sites/spinal regions (i.e., cervical, thoracic, and lumbar).

Caudal epidural steroid injections in the management of lumbar pain with disc herniation and radiculitis or discogenic pain without disc herniation or radiculitis were graded as 1A or 1B/strong (1A Benefits clearly outweigh risk and burdens, or vice versa: high-quality evidence; 1B/strong Benefits clearly outweigh risk and burdens, or vice versa: moderate quality of evidence) and 1B or 1C/strong (1C/strong recommendation: benefits clearly outweigh risk and burdens, or vice versa; low-quality or very low-quality evidence) for caudal injections in the management of patients with post-lumbar laminectomy syndrome and spinal stenosis.

ASIPP recommendations regarding the utilization of interlaminar injections in the management of patients with disc herniation and radiculitis was 1C/strong (1C/strong recommendation: benefits clearly outweigh risk and burdens, or vice versa; low-quality or very low-quality evidence) for short-term relief and 2B/weak for long-term relief (2B/weak: benefits closely balanced with risks and burden; moderate-quality evidence).

Transforaminal injections in the management of chronic low-back and lower extremity pain were graded as 1C/strong (1C/strong recommendation: benefits clearly outweigh risk and burdens, or vice versa; low-quality or very low-quality evidence) within the ASIPP guidelines.

The American Society of Anesthesiologists (ASA) (Rosenquist et al. 2010) published clinical practice guidelines regarding the management of chronic pain. The ASA workgroup observed that observational studies on both interlaminar and transforaminal epidural steroid administration with or without local anesthetic reported back pain relief for assessment periods of 2 weeks to 3 months and neck pain relief for assessment periods of 1 week to 12 months (Category B2 evidence: the literature contains noncomparative observational studies with associative [e.g., relative risk and correlation] or descriptive statistics). The data from the randomized trials identified by the ASA workgroup remains equivocal regarding the efficacy of interlaminar or transforaminal epidural steroids with local anesthetics compared with epidural local anesthetics alone for back, leg, or neck pain for assessment periods ranging from 3 weeks to 3 months (Category C2 evidence: there is an insufficient number of studies to conduct meta-analysis and 1) randomized controlled trials have not found significant differences among groups or conditions or 2) randomized controlled trials report inconsistent findings).

Evidence-based clinical practice guidelines published by the American College of Occupational and Environmental Medicine (ACOEM) considered interventions and practices used in the treatment of low back disorders, including various injection therapies and techniques. The guidelines recommend epidural glucocorticosteroid injections as an option for acute or subacute radicular pain syndromes lasting at least 3 weeks, and epidural glucocorticosteroid injections as second-line treatment of acute spinal stenosis flare-ups (I-Consensus based: evidence is insufficient or irreconcilable; the intervention is recommended for appropriate patients and has nominal costs and essentially no potential for harm.). Epidural glucocorticosteroid injections for acute, subacute, or chronic low-back pain in the absence of radicular signs and symptoms are not recommended (C- Moderate evidence; recommendation against routinely providing the intervention).

The American Association of Neurological Surgeons (AANS) (Resnick et al. 2005) published clinical practice guidelines addressing spinal injections and other therapeutic technologies used in the management of chronic low back pain. The authors concluded that there is no meaningful evidence in the medical literature that the use of epidural injections is of any long-term value in the treatment of patients with chronic low-back pain. However, the authors also note that the literature indicates that the use of lumbar epidural injections can provide short-term relief in selected patients with chronic low-back pain.

In 2009 the American Pain Society (APS) published clinical practice guidelines addressing the use of invasive diagnostic tests, interventional therapies, surgery and interdisciplinary rehabilitation for non-radicular low-back pain, and radiculopathy with herniated disc and symptomatic spinal stenosis (Chou et al. 2009). The authors concluded that there is insufficient evidence to adequately evaluate the benefits of epidural steroid injections, along with other technologies, in the treatment of persistent non-radicular low-back pain. The clinical practice guidelines recommend that for patients with persistent radiculopathy due to herniated lumbar disc, clinicians discuss risks and benefits of epidural steroid injection as an option, noting inconsistent evidence showing moderate short-term benefits and lack of long-term benefits.

SUMMARY
Epidural steroid injections (i.e., caudal, interlaminar, and transforaminal) can be utilized diagnostically in the determination of the pathophysiological source of pain, the differentiation of local pain from referred pain, and other scenarios. Therapeutically, epidural injections may reduce swelling and nerve root irritation resulting from disc herniation and radiculopathy, thereby reducing pain and improving functional status in individuals with radicular pain associated with verified nerve root etiology. The duration of symptom relief following a therapeutic injection varies based upon the pharmacologic agent injected and its expected duration of therapeutic effect from it.

The most recent studies comparing the therapeutic effects of therapeutic local anesthetic epidural injections with or without steroids lack placebo controls and are potentially suggestive of long-term pain relief being derived from short-acting anesthetic. This pain relief mechanism has not been established or studied within a clinical research setting. There is an overall paucity of literature evaluating the use of therapeutic epidural injections for the treatment of spinal pain unequivocally establishing epidural injections as an efficacious long-term treatment modality.

Therapeutic epidural injections have been demonstrated as an efficaciously limited treatment option in the treatment of chronic radicular pain in the short and moderate terms (i.e., up to 12 months). These short and moderate term data, from study periods ranging from weeks up to 2 years, have reported improvement in health outcomes related to pain and reductions in the reliance on medication for individuals diagnosed with radicular pain. However, health outcomes data related to long term (i.e., >2 years) improvements in pain, disability status, functional status or the eventual need for additional invasive procedures remains equivocal. Furthermore, the course of sub-acute and chronic back and neck pain is often described as undergoing spontaneous remissions and exacerbations. Therefore, in the treatment of chronic pain it is necessary that effects on pain and disability are consistent for the long-term (i.e., beyond 2 years).

PARAVERTEBRAL FACET JOINT INJECTIONS

A paravertebral facet joint nerve block may be employed for a diagnostic or therapeutic purpose in individuals who have chronic cervical, thoracic, lumbar, or sacral pain in the absence of both a strong radicular component and associated neurologic deficits.

Individuals with lumbar facet pain (commonly referred to as "facet syndrome") typically present with localized tenderness of the back, buttock, and hip; if only back pain is present, it may radiate to the buttocks or the hips, and the pain frequently worsens with extension or side bending. Individuals with cervical facet pain typically present with headache and/or muscle spasms of the neck, and the pain usually worsens with extension or turning of the neck. This presentation of facet syndrome may be seen in disorders such as, but not limited to, degenerative disc disease, post-laminectomy syndrome, and failed back surgery syndrome. Radiculopathy, extremity weakness, and/or numbness are not associated with lumbar or cervical facet pain. Therefore, their presence should suggest an alternate diagnosis.

Paravertebral facet joint nerve block is one method used to confirm suspicion of posterior elemental biomechanical pain of the spine. A diagnostic paravertebral facet joint nerve block assesses the relative contribution of sympathetic and somatosensory nerves in relation to the pain syndrome. A diagnostic nerve block localizes the nerve(s) responsible for the pain or neuromuscular dysfunction, particularly when multiple sources of pain are potentially present. This procedure is performed under fluoroscopic guidance to ensure accurate placement of the needle in the facet joint or on the medial nerve branch of the facet joint (e.g., medial branch block).

After needle placement, a long-acting local anesthetic is injected to temporarily numb the facet joint. The individual is then asked to engage in the activities that had previously precipitated pain, and to evaluate the effect of the procedure at 4 to 8 hours post-injection. A temporary or prolonged absence of spinal pain strongly suggests that the facet joint is the source of the symptoms. A series of injections may be needed to establish consistency of results, particularly if diagnostic nerve blocks are followed by neurolysis.

Paravertebral facet joint nerve blocks with an anesthetic or corticosteroid may be employed for temporary or acute pain management. Once the correct location for the paravertebral facet joint nerve block has been confirmed by fluoroscopic guidance, the agent is injected into the facet joint or on the medial nerve branch of the facet joint (e.g., medial branch block) to attempt pain relief.

Pain relief from therapeutic injection should come from injection of the exact facet or medial branch block, not from injection of local anesthetic into the overlying muscle. There is little scientific evidence to support a long-term plan of multiple therapeutic nerve blocks as an effective method for managing chronic pain. If pain associated with facet syndrome is improved by diagnostic injection, denervation of the affected facet joint nerve should be part of the individual's treatment plan.

PEER-REVIEWED LITERATURE
In 2010 the Manchikanti et al workgroup published three randomized, double-blind clinical trials evaluating the effectiveness of therapeutic local anesthetic medial branch blocks with or without steroids. Included patients had experienced facet joint pain (thoracic, lumbar, cervical), diagnosed through comparative diagnostic anesthetic blocks inducing an 80% reduction in pain. Outcomes related to numeric rating scores (NRS), Owsestry Disability Index (ODI), opioid intake, and return to work status were assessed at intervals of 3, 6, 12, 18, and 24 months. Significant improvement in pain relief was defined as at least a 50% relief of pain and/or functional status improvement.

Manchikanti et al (2010a) enrolled 120 consecutive new patients at an interventional pain management practice. These patients had cervical facet joint pain diagnosed through comparative diagnostic anesthetic blocks inducing an 80% reduction in pain. The randomized double-blinded trial was intended to assess the clinical effectiveness of therapeutic cervical local anesthetic medial branch blocks, with or without steroids. Participants randomized to both the steroid and non-steroid group were further stratified with respect to the administration of Sarapin. Patients were followed at 3-month intervals, with cervical medial branch blocks repeated based upon response to prior injections with improvements in physical and functional status. Blocks were repeated only when reported pain levels decreased to below 50%, with significant pain relief after the previous block. Injections were repeated on average 5.7 times over a period of 2 years. The inclusion of Sarapin did not affect the outcome measurements. At the study end point, 2 years, 85% of patients in the bupivacaine group and 93% of patients in the steroid group were reported to have significant pain relief, defined as 50% improvement in pain relief and/or functional status improvement. Average duration of pain relief was 17-19 weeks across both treatment groups. A 50% improvement in the Neck Disability Index was seen in 70% of patients in the bupivacaine arm and 75% of patients in the bupivacaine and steroid arm. Intake of opioids was unchanged between treatment groups. There was a loss of 38% of data for the 24-month evaluation. Sensitivity analysis using the last follow-up score and best and worst case scenarios were not significantly different.

In a separate publication, Manchikanti et al (2010b) reported 1-year results from a randomized, double-blind trial intended to assess the clinical effectiveness of therapeutic thoracic local anesthetic medial branch blocks, with or without steroids. The trial enrolled 100 consecutive new patients at an interventional pain management practice, diagnosed utilizing comparative anesthetic blocks inducing an 80% reduction in pain. Results from the intent-to-treat analysis at 12 months illustrated a decrease in average pain scores from 7.9 at baseline to 3.2 in the bupivacaine group and from 7.8 to 3.1 in the bupivacaine plus steroid group. A 50% or greater improvement in ODI was observed in 80% and 84% of participants in both the non-steroid and steroid groups, respectively. Across both study groups, 90% of participants showed a significant pain relief at 12 months. The average relief per procedure was 16 weeks for bupivacaine and 14 weeks for bupivacaine plus betamethasone with participants receiving an average of 3.5 treatments per year. No significant change in opioid intake was observed.

Two-year results were reported by Machikanti et al. (2010c) from a randomized, double-blind trial evaluating the efficacy of facet joint nerve blocks in 120 patients with chronic low back pain at an interventional pain management practice. Enrolled patients were randomized to receive cervical medial branch blocks with or without steroids. Participants in both the steroid and non-steroid group were further stratified with respect to the administration of Sarapin. Significant pain relief was observed, at 2-year follow-up in 85% of the patients treated with bupivacaine alone and 90% of the patients treated with bupivacaine and a steroid. Furthermore, a significant improvement in functional status (>40% in ODI) was observed in 87% and 88% of patients in non-steroid and steroid groups, respectively. The average duration of pain relief with each procedure was 19 weeks, with patients requiring approximately 5-6 treatments over the 2-year period. No significant change in opioid intake was observed. Sarapin did not impact the health outcomes reported (NRS and ODI). Data for 20% of the participants at 24 months was not available. NRS sensitivity analysis utilizing the last follow-up score, best case scenario, and worst case scenario were not significantly different.

In 2007, Boswell et al published an update of a previous a systematic review from the same workgroup, published in 2005, with the concurrent goal of assessing the effectiveness of three types of facet joint interventions (facet joint injections, medial branch blocks, and facet joint neurotomy) in managing chronic spinal pain. The primary outcome was pain relief, with other secondary outcomes, including functional improvement, improvement in psychological status, and return to work. In regard to intra-articular facet joint injections and medial branch blocks, short-term pain relief was defined as less than 6 weeks, and long-term relief as 6 weeks or longer. The workgroup described the evidence assessing intra-articular facet joint injections in the treatment of cervical pain as limited. The evidence for short- and long-term lumbar pain treated with intra-articular facet joint injections was deemed to be moderate.

The Cochrane Collaboration conducted a systematic review to determine if injection therapy, stratified by injection site (facet, local, epidural), for low-back pain is more effective than placebo or other treatments for patients with sub-acute or chronic low-back pain. Literature searches identified 18 randomized trials that fulfilled selection criteria, with injection sites varying from epidural and facet joints to local sites. The authors concluded that there is no strong evidence to support the use of any type of injection therapy for sub-acute or chronic low-back pain in patients with or without radicular pain.

The Canadian Agency for Drugs and Technologies in Health (CADTH) published a Health Technology Assessment regarding the clinical and cost effectiveness of facet joint injections as diagnostic and therapeutic tools in March of 2007. The assessment sought to address key questions pertaining to the evidence evaluating the clinical efficacy and safety of numerous technologies used in the treatment of spinal pain, including facet joint injections, as diagnostic and therapeutic tools. The authors concluded that according to the randomized trials identified during the review, facet joint injections with local anesthetics or steroids have not been proven to be superior to placebo in the treatment of chronic low back pain. The CADTH also published a rapid response report on the same topic in January 2011. The 2011 rapid report concluded that there is some evidence of short-term benefit from facet joint injections for relief of low back pain, but evidence for longer-term benefit was unclear.

PROFESSIONAL ORGANIZATIONS AND POSITION STATEMENTS
The American Society of Interventional Pain Physicians (ASIPP) published evidence-based guidelines regarding interventional techniques in the management of chronic spinal pain in 2009 (Manchikanti et al.). The authors concluded that based upon the available evidence, therapeutic intra-articular facet joint injections were not recommended. With regard to therapeutic facet joint nerve blocks (i.e., medial branch blocks), the authors provided a 1B or 1C/strong recommendation (1B /strong recommendation: moderate quality of evidence; benefits clearly outweigh risk and burdens, or vice versa; 1C/strong recommendation: low-quality or very low-quality; evidence benefits clearly outweigh risk and burdens, or vice versa) for the use the use of facet joint nerve blocks to provide both short- and long-term relief in the treatment of chronic cervical, thoracic, or lumbar pain.

The American Society of Anesthesiologists (ASA) (Rosenquist et al 2010) published clinical practice guidelines for the management of chronic pain. The ASA workgroup observed that the randomized controlled trials report equivocal findings (Category C2 evidence: there is an insufficient number of studies to conduct meta-analysis and (1) randomized controlled trials have not found significant differences among groups or conditions or (2) randomized controlled trials report inconsistent findings) regarding the efficacy of facet joint steroid injections compared with facet saline injections for patients with low back pain. Observational data indicated improvements in pain scores over baseline for evaluation periods of 1-6 months (Category B2 evidence: the literature contains noncomparative observational studies with associative [e.g., relative risk and correlation] or descriptive statistics). The authors recommended that intra-articular facet joint injections may be used for symptomatic relief of facet-mediated pain.

Evidence-based clinical practice guidelines published by the American College of Occupational and Environmental Medicine (ACOEM) considered interventions and practices used in the treatment of low back disorders, including various injection therapies and techniques. The guidelines state that therapeutic facet joint injections for acute, sub-acute, chronic low back pain or radicular pain syndrome are not recommended.

Guidelines from the American Association of Neurological Surgeons (AANS) addressing spinal injections and other therapeutic technologies used in the management of chronic low-back pain, state that facet injections are not recommended as long-term treatment for chronic low-back pain (Resnick 2005). The authors further state that no evidence exists to support the effectiveness of facet injections in the treatment of patients with chronic low-back pain.

In 2009 the American Pain Society (APS) published clinical practice guidelines addressing the use of invasive diagnostic tests, interventional therapies, surgery and interdisciplinary rehabilitation for non-radicular low-back pain, radiculopathy with herniated disc and symptomatic spinal stenosis (Chou et al 2009). The authors determined that "there is good or fair evidence from randomized trials that facet joint injection, among other technologies, are not effective" and also that the evidence was insufficient to readily evaluate therapeutic medial branch blocks.

SUMMARY
Diagnostic paravertebral facet joint nerve blocks, involving the injection of local anesthetic into the facet (zygapophysial) joint or on the medial branches innervating a specific facet joint (e.g., medial branch block) are necessary to determine whether the facet joint is the pathophysiological source of the chronic back pain. However, the available evidence (i.e., peer-reviewed literature, clinical practice guidelines, and specialty society position statements) fails to provide unequivocal guidance regarding the diagnostic utility of facet joint nerve blocks, the correct number of positive blocks necessary for diagnosis confirmation, and the degree of pain relief constituting a positive diagnostic block.

Data illustrating short-term benefit derived from therapeutic paravertebral facet joint blocks, or medial branch blocks, have been observed within observational studies and randomized trials. However, these data do not permit conclusions regarding therapeutic paravertebral facet joint injections due to the lack of controlled long-term follow-up, comparison to placebo controls (or adequate sham procedures) or radiofrequency denervation. The most recent studies, comparing the therapeutic effects of therapeutic local anesthetic facet joint blocks with or without steroids, lack placebo controls and are potentially suggestive of long-term pain relief being derived from short-acting anesthetic, thus demonstrating a mechanism that has not been investigated within clinical research settings. These limitations, evident throughout the available literature regarding therapeutic facet joint injections, are additionally highlighted by the lack of a widespread acceptance of them by professional societies and consistent recommendations for their use in clinical practice guidelines. Furthermore, the select professional societies and clinical practice guidelines that do recommend the use of therapeutic facet joint injections dually grade the evidence supporting these recommendations as low to moderate.

In treatment of chronic pain, it is necessary that effects on pain and disability are consistent for the long-term. The course of sub-acute and chronic back pain is often described as undergoing spontaneous remissions and exacerbations. The available literature varies with regard to study follow-up, ranging from weeks up to two years. Data of sufficient size, duration, and methodological quality enabling the results to clinically and statistically demonstrate sustained clinical benefit while simultaneously nullifying potential biases associated with spontaneous remissions and placebo effects are needed to fully evaluate this treatment approach.

The limited methodological quality of the available data does not support a long-term plan of multiple therapeutic nerve blocks as an effective method for managing chronic pain. If pain associated with facet syndrome is improved by a diagnostic injection, permanent denervation of the affected facet joint nerve may become part of the individual's treatment plan.

SACROILIAC JOINT INJECTIONS

The sacroiliac (SI) joint is formed by the joining of the sacrum and the ilium, located at the lower part of the spine. The muscles of the SI joint are shared with the hip. This attachment causes the SI joint to undergo a large amount of unidirectional shearing force, which is repetitive and causes torquing of the joint.

The diagnosis of SI joint pain is difficult, as pain from the SI joint can mimic pain from other structures such as the lumbar disc, lumbar facet, or hip joint, and may seem to be coming from intra- or extra-articular structures. SI injections may be performed diagnostically or therapeutically.

Diagnostic injections are performed using either anesthetic or a contrast media to evaluate the integrity of the articular cartilage and the morphologic features of the joint space and capsule.

Therapeutic injections may employ a corticosteroid and/or an anesthetic. The medication is injected into the SI joint for immediate and potentially lasting pain relief.

PEER REVIEWED LITERATURE
Kim et al (2010) enrolled 48 patients in a randomized, double-blind, controlled trial comparing intra-articular prolotherapy and steroid injections in patients with sacroiliac joint pain. Inclusion criteria were greater than 50% improvement in response to local anesthetic block, lasting 3 months or longer and have failed medical treatment. Injections, intra-articular dextrose (prolotherapy) or steroid, were administered biweekly, with a maximum of three 3 injections, utilizing fluoroscopic guidance until pain relief was 90% or greater. An average of 2.7 injections was required to achieve 90% or greater relief from symptoms in the prolotherapy arm, compared with 1.5 steroid injections. Primary outcomes, pain numerical rating scale (NRS), and Oswestry disability index (ODI) were assessed at baseline, 2-weeks, and monthly, following completion of treatment. The authors observed significant pain and disability improvements from baseline at 2 weeks in both groups with no difference between groups. Pain NRS improved from 6.3 to 1.4 in the prolotherapy group versus 6.7 to 1.9 in the steroid group. At 6 months follow-up, the authors reported that 63.6% of patients in the prolotherapy group remained improved from baseline compared with 27.2% in the steroid group. At 15-month follow-up, the cumulative incidence of sustained pain relief was 58.7% in the prolotherapy group compared with 10.2% in the steroid group.

In 2009, Rupert et al conducted a systematic review that included 13 studies utilizing fluoroscopically guided controlled diagnostic blocks in patients with chronic low back or lower extremity pain lasting longer that 3 months. The review independently assessed literature evaluating the utility of diagnostic and therapeutic injections. Five publications regarding the diagnosis of sacroiliac pain were reviewed and classified as level 2 evidence (well-designed cohort or case-control studies). The authors estimated false-positive rates ranging from 20% to 54% when using single uncontrolled injections. Prevalence rates were between 10% and 38% when a double block paradigm is used in populations with a high likelihood of sacroiliac joint pain. The interpretation of this and other data is limited by the lack of a gold standard diagnosis for sacroiliac joint pain. No evidence supporting or refuting the use of intra-articular sacroiliac injections met the inclusion criteria, mainly due to lack of a valid diagnosis prior to therapeutic interventions. The authors cite a paucity of literature evaluating the role of both diagnostic and therapeutic interventions, as well as widespread methodological flaws as limitations of the current systematic review.

Hansen et al (2012) conducted a systematic review assessing the available literature on therapeutic sacroiliac interventions for the management of chronic low back and lower extremity pain. Primary outcomes assessed were short (up to 6 months of pain relief) and long-term (greater than 6 months of pain relief). Secondary outcomes related to improvements in functional status, psychological status, return to work, and reduction in opioid intake were also assessed. The Hansen workgroup identified four studies, one randomized active-control trial evaluating intra-articular sacroiliac injections, and three observational studies evaluating periarticular sacroiliac injections. The authors concluded that the evidence regarding intra-articular sacroiliac steroid injections and periarticular sacroiliac steroid or botulin toxin for short-term and long-term relief was limited (or poor).

PROFESSIONAL ORGANIZATIONS AND POSITION STATEMENTS
Evidence-based guidelines from the American Society of Interventional Pain Physicians (ASIPP), regarding interventional techniques in the management of chronic spinal pain, were published in 2009 (Manchikanti et al.). The ASIPP guidelines conclude that sacroiliac joint injections appear to be the evaluation method of choice to provide an appropriate diagnosis, due to the inability to make the diagnosis of sacroiliac joint-mediated pain with noninvasive tests. The authors further concluded that the evidence was determined to be insufficient to establish the efficacy of therapeutic intra-articular sacroiliac joint injections.

Evidence-based clinical practice guidelines published by the American College of Occupational and Environmental Medicine (ACOEM) considered interventions and practices used in the treatment of low back disorders, including various injection therapies and techniques. The clinical practice guidelines conclude that sacroiliac joint corticosteroid injections are recommend as an option for patients with a specific known cause of sacroiliitis (Category C: limited evidence that the intervention may improve important health and functional benefits). Sacroiliac joint injections for acute low-back pain, including low-back pain thought to be sacroiliac related, are were not recommended.

The 2009 American Pain Society guidelines addressing the use of invasive diagnostic tests, interventional therapies, surgery and interdisciplinary rehabilitation for non-radicular low-back pain, radiculopathy with herniated disc and symptomatic spinal stenosis (Chou et al 2009) state that there is insufficient evidence to evaluate validity or utility of sacroiliac joint block as a diagnostic procedure for low back pain with or without radiculopathy. The authors also concluded that there is insufficient evidence to adequately evaluate benefits of sacroiliac joint steroid injection for non-radicular low back pain.
References


Abdi S, Datta S, Trescot A, et al. Epidural steroids in the management of chronic spinal pain: A systematic review. Pain Physician. 2007;10:185-212.

Agency for Healthcare Research and Quality (AHRQ). Pain managment injection therapies for low back pain. [AHRQ Web site]. 07/10/2015. Available at: http://www.ahrq.gov/research/findings/ta/index.html. Accessed October 20, 2016.

American Academy of Orthopaedic Surgeons (AAOS). Spinal Injections. [AAOS Web site]. December 2013. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00560. Accessed October 20, 2016.

American College of Occupational and Environmental Medicine (ACOEM). Low back disorders. Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers. 2nd ed. 2007;Elk Grove Village, IL: 366p.

Armon C, Argoff C, Samuels J, et al. Assessment: Use of epidural steroid injections to treat radicular lumbosacral pain. Neurology. 2007;68:723-729.

Benny B, Azari P. The efficacy of lumbosacral transforaminal epidural steroid injections: A comprehensive literature review. J Back Musculoskeletal Rehabil. 2011;24:67-76.

Boquing C, Stitik TP, Foye PM, et al. Epidural Steroid Injections. [Medscape Web site].05/24/2016. Available at: http://emedicine.medscape.com/article/325733-overview. Accessed October 20, 2016.

Boswell M, Trescot A, Sukdeb S, et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007;10:7-111.

Chou R, Atlas SJ, Stanos SP, et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine. 2009;34(10):1078-1093.

Chou R, Loeser J, Owens D, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain. Spine.2009;34(10):1066-1077.

Cohen S, White R,Kurihara C, et al. Epidural steroids, etanercept, or saline in subacute sciatica. Ann Intern Med. 2012;156(8):551-559.

Cyteval C, Fescquet N, Thomas E, et al. Predictive factors of efficacy of periradicular corticosteroid injections for lumbar radiculopathy. Am J Neuroradiol. 2006;27:978-982.

Czermiecki J, Goldstein B. General considerations of pain in the low back, hips, and extremities. In: Loeser J, Butler S, Chapmen CR, et al. Eds. Bonica’s Management of Pain, 3rd ed. Philadelphia PA: Lippincott Williams & Wilkins; 2001: 1475-1507.

Friedly et al., 2014. A randomizied trial of epidural glucocorticoid injections for spinal stenosis. New Engl J Med. 2014;371(1):11-21.

Institute for Clinical Systems Improvement (ICSI). Assessment and management of chronic pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2011 Nov.

Iversen, T, T Solberg , B Romner, et al. Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomized controlled trial. BMJ. 2011;13.

Kim PS. Role of injection therapy: review of indications for trigger point injections, regional blocks, facet joint injections, and intra-articular injections. Curr Opin Rheumatol. 2002;14(1):52-57.

Manchikanti L, Boswell M, Singh V, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2009;12:699-802.

Manchikanti L, Cash K, McManus C, et al. One-year results of a randomized, double-blind, active control trial of fluoroscopic caudal epidural injections with or without steroids in managing chronic discogenic low back pain without disc herniation or radiculitis. Pain Physician.2011;14:25-36.

Manchikanti L, Cash K, McManus C, et al. Results of 2-year follow-up of a randomized, double-blind, controlled trial of fluoroscopic caudal epidural injections in central spinal stenosis. Pain Physician. 2012a;15:371-384.

Manchikanti L, Cash K, Pampati V, and Y Malla. Fluoroscopic cervical epidural injections in chronic axial or disc-related neck pain. J Pain Res. 2012;5:227-236.

Manchikanti L, Buenaventura R, Manchikanti K, et al. Effectiveness of Therapeutic Lumbar Transforaminal Epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012b;15:E199-E245.

Manchikanti L, Singh V, Cash K, et al. Management of pain of post lumbar surgery syndrome: one-year results of a randomized, double-blind, active controlled trial of fluroscopic caudal epidural injections. Pain Physician. 2010;13:509-521.

National Institute of Neurological Disorders and Stroke. Low back pain fact sheet. 11/03/2015. Available at: http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm. Accessed October 20, 2016.

North American Spine Society (NASS). Diagnosis and treatment of cervical radiculopathy from degenerative disorders. Burr Ridge (IL): North American Spine Society (NASS);2010.

North American Spine Society (NASS). Diagnosis and treatment of degenerative lumbar spinal stenosis. Burr Ridge (IL): North American Spine Society (NASS);2011.

Novak S, Nemeth W. The basis for recommending repeating epidural steroid injections for radicular low back pain: A literature review. Arch Phys Med Rehabil. 2008;89:543-552.

Novitas, Solutions Inc. Medicare Services. Local Coverage Determination (LCD).L34892 Transforaminal Epidural, Paravertebral Facet and Sacroiliac Joint Injections Novitas Inc. Medicare Services Web site]. 10/01/2016. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34892&ver=25&Date=10%2f31%2f2016&SearchType=Advanced&DocID=L34892&search_id=&service_date=&bc=KAAAABgAAAAAAA%3d%3d&. Accessed October 20, 2016.

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Quraishi, N. Transforaminal injection of corticosteroids for lumbar radiculopathy: systematic review and meta-analysis. Euro Spine J. 2012;21:214-9.

Resnick, D, T Choudhri, and A Dailey. Guidelines for the performance of fusion procedures for degenerative diseases of the lumbar spine. Part 13: injection therapies, low-back pain, and lumbar fusion. J Neurosurg Spine. 2005;707-715.

Rosenquist, R, H Benzon, R Connis, et al. Practice Guidelines for Chronic Pain Management. Anesthesiology. 2010;112:810-833.

Staal JB, de Bie R, de Vet HCW, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low-back pain. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD001824. DOI: 10.1002/14651858.CD001824.pub3.

Wilson-MacDonald, JW, G Burt, D Griffin, et al. Epidural steroid injection for nerve root compression. J Bone Joint Surg. 2005;87(3):352-355.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY


27096, 62320, 62321, 62322, 62323, 64461, 64462, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 77003, 77012

NOT MEDICALLY NECESSARY

01991, 01992

EXPERIMENTAL/INVESTIGATIONAL

0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0228T, 0229T, 0230T, 0231T



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Report the most appropriate diagnosis code in support of medical necessity as listed in the policy.


HCPCS Level II Code Number(s)



MEDICALLY NECESSARY

G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography


Revenue Code Number(s)

N/A

Coding and Billing Requirements

Note for CPT codes 62320 and 62322:

Pre-service utilization management is not in place for CPT codes 62320 and 62322, which represent epidural injection procedures, when they are performed for the following three ICD-10-CM diagnoses: G89.11 Acute pain due to trauma, G89.12 Acute post-thoracotomy pain, or G89.18 Other acute post procedural pain. All other ICD-10-CM diagnoses for CPT codes 62320 and 62322 go through pre-service utilization management.

Cross References


Policy History

Revisions from 11.15.23g
01/14/2019This version of the policy will become effective on 01/14/2019.

The following changes have been made to this policy:
  • For paravertebral facet joint blocks only individuals with synovial cysts may present with pain, which may have a strong radicular component.
  • A major criterion for medical necessity for repeat injections described in this policy bulletin is having at least 50% reduction from prior injection(s), or for epidural injections if the initial therapeutic injection did not result in pain relief, repeat injection may be indicated, provided that the injection is performed at an adjacent level, OR at the same level utilizing a different approach or type of steroid.
  • In addition to other injection types detailed in this policy bulletin, ultrasound guidance for caudal epidural injections is considered experimental/investigational and, therefore, not covered.

Pre-service utilization management is not in place for CPT codes 62320 and 62322, which represent epidural injection procedures, when they are performed for the following three ICD-10-CM diagnoses: G89.11 Acute pain due to trauma, G89.12 Acute post-thoracotomy pain, or G89.18 Other acute post procedural pain. All other ICD-10-CM diagnoses for CPT codes 62320 and 62322 go through pre-service utilization management.

Revisions from 11.15.23f:
03/01/2018This version of the policy will become effective on 03/01/2018.

Frequencies, when other medical necessity criteria for each clinical scenario are met, for injections are updated among other criteria changes:

EPIDURAL INJECTIONS

Frequency and Maximum Number of Epidural Injections:
  • A maximum of three (3) injections (including diagnostic transforaminal injections) are considered medically necessary and, therefore, covered in each spinal region (cervical or lumbosacral) in a six month period.

PARAVERTEBRAL FACET JOINT BLOCKS

Frequency and Maximum Number of Paravertebral Facet Joint Blocks:
  • A maximum of six (6) facet joint procedural sessions per region (cervical/thoracic or lumbar/sacral) are considered medically necessary and, therefore, covered in a 12-month period, regardless of type or indication.

SACROILIAC (SI) INJECTIONS

Frequency and Maximum Number of Sacroiliac Joint Injections:

Diagnostic Sacroiliac Injections
  • A maximum of two (2) injections in a 12-month period are considered medically necessary and, therefore, covered

Therapeutic Sacroiliac Injections
  • A maximum of three (3) injections in a 12-month period are considered medically necessary and, therefore, covered.


On 02/27/2018 the following clarifications were made to the policy in Notification:

IN THE POLICY SECTION:

Frequency and Maximum Number of Epidural Injections
  • A maximum of three (3) injections sessions (including diagnostic transforaminal injections) are considered medically necessary and, therefore, covered in each spinal region (cervical or lumbosacral) in a six month period.
  • Up to two (2) transforaminal injections are considered medically necessary and, therefore, covered at a single setting (e.g., single level bilaterally or two levels unilaterally). Injecting one level bilaterally would be considered two (2) injections. Injecting two levels, each unilaterally, would also be considered two (2) injections.


PARAVERTEBRAL FACET JOINT BLOCKS

For Pparavertebral facet joint blocks, up to a maximum of only three levels per region unilaterally or up to two levels per region laterally four (4) joints per session (e.g., two [2] bilateral levels or four [4] unilateral levels), may be considered for reimbursement. For the purpose of reimbursement for paravertebral facet joint blocks, the spine consists of two general regions. Cervical/thoracic is one region and lumbar/sacral is a separate region.

NOT MEDICALLY NECESSARY

Epidural injections are considered not medically necessary and, therefore, not covered, for any of the following:
  • The treatment of chronic pain performed without imaging guidance

EXPERIMENTAL/INVESTIGATIONAL

The use of ultrasound guidance for transforaminal epidural injections, interlaminar injections, or paravertebral injections is considered experimental/investigational and, therefore, not covered.


UNDER THE GUIDELINES SECTION:

UTILIZATION GUIDELINES
  • Therapeutic transforaminal epidural injections are generally administered into the affected region up to one two levels bilaterally or two three levels unilaterally on the same day.
  • Individuals may receive up to four therapeutic epidural injections per region, per side, per year. All requests that exceed that amount will be reviewed by the Company, on a case-by-case basis.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/14/2019
Version Issued Date: 01/14/2019
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.