Policy for Managing Back Pain – Spinal /Facet Joint and Epidural Injections
A significant number of people suffer from lower back pain, and this places a considerable demand on NHS services. The management of low back pain represents one of the greatest challenges to the health service. East Lancashire and Blackburn with Darwen CCG are focussed on commissioning the most effective, evidence-based health care possible. Using the latest evidence we have developed a policy for the management of low back pain, particularly considering spinal, facet and epidural injections.
Careful and gentle exercise and keeping mobile with advice from physiotherapists or similarly trained professionals can be the best course of action for the majority of people. In East Lancashire and Blackburn with Darwen, the CCGs have gone through a process of redesign to integrate MSK, Pain Management and Rheumatology Services to streamline the delivery of services which should facilitate the appointment of patients with the most suitable first point of contact. One of the key areas for this service is the self-referral based spinal drop in clinics in each of the boroughs. This allows patients rapid access to physiotherapy services for back and neck pain closer to a patients home. These are set up so that patients can turn up and be assessed, offered self-care and monitored. Serious problems are ruled out at and patients are reassured. Self-care through physiotherapy exercises and management of posture are mainly successful for the majority of patients.
In the past the CCGs (BwD and East Lancashire) has commissioned (paid for) pain-relief injections for people with unspecific back pain. However, following a review of the evidence, including NICE (National Institute for Clinical Excellence) guidance it is clear that this type of treatment is not considered to be clinically or medically effective as a long term Treatment.
NICE clinical guidelines recommend how healthcare professionals should care for people with specific conditions. They can cover any aspect of a condition and may include recommendations about providing information and advice, prevention, diagnosis, treatment
and longer-term management.
The first consideration is whether a treatment that has been used routinely over time is medically effective for patients in the light of new and up to date evidence. Our knowledge about what works and is effective is improving and changing all the time. If new information, or the latest evidence tells us that a treatment is not medically effective the NHS should not fund the treatment. Furthermore, if this treatment is expensive it can inadvertently take NHS funds away from other more medically effective treatments. The NHS has a limited pot of money and it is important that we spend this money or treatments that work for all patients. To invest in treatments that are not medically effective is not a good use of services, or of NHS funds.
As a result of this review, BwD CCG and East Lancashire CCG will not be routinely funding the following type of injections for non-specific lower back pain unless all of the criteria within the “Policy for Managing Back Pain – Spinal/Facet Joint and Epidural Injections” are met. In addition, no more than two injections should be given within a 12 month period unless there is exceptional clinical need. In this case an individual funding request (IFR) process must be followed. This means that if the patients’ GP considers that back pain injections for non specific back pain are worth considering – the CCGs will review this.
The following injections will not be routinely funded unless all the criteria within the Policy is met:
1) Epidural injections, either sacral or interlaminar and nerve root injections
2) Facet joint injections for lower back pain
3) Medial branch blocks for chronic cervical, thoracic or lumbar back pain
4) Percutaneous Intradiscal radio-frequency thermo-coagulation (PIRFT), Intra-discal electrothermal therapy (IDET) and Radiofrequency facet joint denervation
5) Spinal Cord Stimulation for Chronic Pain.