FACET JOINT INJECTIONS CHECKLIST Continued:

Excluded: Procedure not routinely funded

FACET JOINT INJECTIONS& MEDIAL BRANCH BLOCK CHECKLIST

The South Central Priorities Committee policies were adopted by both Berkshire East Clinical Commissioning Groups and Berkshire West Clinical Commissioning Groups on the 1st April 2013. The Priorities Committee considered the evidence for the clinical and cost effectiveness of facet joint injections and medial branch blocks for the diagnosis and treatment of chronic low back and neck pain. The Committee concluded that the evidence for cost effectiveness is inadequate and therefore recommends that NHS funding for facet joint injections and medial branch blocks for diagnostic and treatment isa Procedure Not Routinely Funded.

The Policies for can be found at:

Please complete the following questions and return to: Individual Funding Request (IFR) Service via email:

Information about the clinician who is supporting the use of facet injections
Referrer Name:
Referrer Address & Clinic:
PATIENTS DETAILS
NHS No:
Hospital/ Ref No:
Which type of injection are you requesting?
Facet Joint Injection / YES / NO / Medial Branch Block / YES / NO
Diagnostic: / YES / NO / Therapeutic: / YES / NO
FOR ALL PATIENTS – PLEASE PROVIDE THE FOLLOWING: Please complete ALL sections in full
Please provide the patients current:
BMI / kg/m2
Height / cm
Weight / kg
Is the patient a non-smoker? / YES / NO
Has this patient followed the recommended pathway including the local MKS service where available?
Please attach the MSK referral information to the case file if available. / YES / NO
PART 1: Details of historical pain: Please note the Panel will only consider your request for Facet Joint Injections if the patient has had documented pain in the long-term, i.e. one year or over.
Cause of Pain
Type of Pain
Duration of Pain
Recent Average Pain Score(s) over the latest month and dates
Please provide details of which non-drug treatments and conservative measures have been tried and failed to alleviate they symptoms. This should include all conservative management that the patient has been fully compliant with.
Non Drug or Conservative Measures / Yes /No / Details
Completed weight loss program (where applicable)
Exercise
Physiotherapy
Optimised analgesia
Are the patient’s symptoms persistent and do they significantly interfere with activities of daily living? / YES / NO
Please indicate:
Work-related issues / YES / NO
Work-related issues – Off work / missed work / unable to work due to the condition / YES / NO
Domestic activities / YES / NO
Career responsibilities / YES / NO
What type of job does the patient have? Please specify:
Has this patient received any pain treatment privately? / YES / NO
If YES, please indicate which treatments have been treated privately?
What drugs have been tried for this condition?
Drug / Dose / Date Started (approx) / Date Stopped (approx) / Outcome Reason for Stopping/ Continuing –(e.g. state the side effect if it did not work, or reason for continuing)
PART 2: For patients who have already received previous Facet Joint Injections:
Please confirmwhether this patient has received Facet Joint Injections previously? / YES(please provide details) / NO(go to PART 3)
Date of most recent Facet Joint Injection (FJI) / DATE:
Number of previous FJI injections and over what period of time
Anatomical site of previous FJI injections
Details of the extent of the health benefit received from FJI injections, and duration of relief:

Please provide details of the Exceptional Health Need of this patient:

PART 3: Exceptional health need of this patient?
PART 4: If funding is not approved what is the possible alternative treatment?

Clinician’s Signature: Date:

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South, Central and West Commissioning Support Unit – January 217 – v3.4