Trust/GP address

Date

IFR team

South, Central & West CSU

Omega House

112 Southampton Road

Eastleigh SO50 5PB

Dear team

Prior Approval–Interventional treatments for back pain

[N.B. Spinal/ epidural injections; facet joint and medial branch blocks; radio-frequency lesioning/ denervation.]

Patient Name/ DoB
NHS Number
Referring GP/ practice
Consultant/ Providing Trust
Date of clinic

See British Pain Society and Royal College of Anaesthetists (Faculty of Pain Medicine) guidelines ‘Standards of good practice for spinal interventional procedures in pain medicine (2015)’

The following procedures are not routinely funded. Prior approval will be considered under the following conditions:

NON-SPECIFIC BACK PAIN

As per NICE guidance, injections of therapeutic substances into the back for non-specific low back pain should not be offered. Therapeutic facet joint injections should only be offered in the context of either special arrangements for clinical governance and clinical audit or research and are not routinely funded. Epidural injections, (either sacral or interlaminar) or nerve root injections are not of value for patients with non-specific low back pain.

SPECIFIC BACK PAIN

Interventional treatments should only be offered in the context of a comprehensive multi-disciplinary programme of care with arrangements for ongoing assessment following a trial of treatment that shows no evidence of response.

Diagnostic facet joint injections and medial branch block or spinal/ epidural injections should be part of a comprehensive MDT led programme.

They are only funded for patients with chronic back pain if performed by a clinician trained in the assessment, diagnosis and management of back pain as part of an MDT.

These should only be funded

As a diagnostic tool to improve the specificity of radio-frequency lesioning where this is being considered

Please detail or confirm a positive response and for how long

OROne injection where all the following criteria are met;

Pain lasting > 12months that has failed to respond to conservative treatment including maximal oral and topical analgesia / ☐
Please demonstrate this (attach referral or clinic letters detailing date of first presentation and evidence of treatments that have failed)
AND the patient has been assessed by a clinician trained in the diagnosis and management of back pain who considers it would enable mobilisation and participation in rehabilitation / ☐
Please attach this assessment here (supportive evidence is required)
AND there is documented use of a standardised Pain and Quality of Life tool before and after the procedure / ☐
Please attach these here (supportive evidence is required)

Repeat injections will only be funded as part of that pain management pathway where there is significant improvement in the Pain and Quality of Life score. No more than TWO injections will be funded within any one year.

Where appropriate it is expected that some procedures will be offered on an outpatient basis and priced accordingly.

CHRONIC BACK PAIN

Radiofrequency denervation/ endothermal ablation should be part of a comprehensive MDT-led plan with ongoing assessment and only following a trial of treatment (medial branch/facet joint block) demonstrating evidence of response.

One diagnostic medial branch/ facet joint block may be funded prior to denervation techniques and this should demonstrate >50% improvement in pain using a validated scoring tool before proceeding with denervation / ☐
Please attach the scoring tool here (supportive evidence is required)
Repeat denervation procedures may only be offered following a previous successful response (as above) with benefits lasting >6 months but with a minimum interval of 12 months.(Therefore those patients experiencing <12 months relief following two procedures will not be offered further denervation treatment). / ☐
Please attach relevant clinic letters demonstrating this (supportive evidence is required)

Please note it is the clinician’s responsibility to obtain patient consent to share this and all supporting materials with the Commissioning Support Unit. All information will be used and stored in accordance with the Data Protection Act.

Yours sincerely

Referring/Treating clinicianGMC Number