Spinal Injection

Individual Funding Request Referrals

The Clinical Commissioning Group (CCG) does not routinely commission Facet Joint Injections (FJI), epidurals, nerve root ablation or rhizolysis for spinal pain.

There are three exceptions:

1.  Therapeutic epidurals are commissioned as part of the acute / sub acute back pain pathway which is suitable for patients with back pain up to 12 weeks duration

2.  Diagnostic / FJI nerve blocks will be commissioned as part of the pre-surgical assessment of patients being considered for surgery for multi level disease to aid localisation of surgery in the management of spinal pain with nerve root involvement

3.  Spinal injections are required to treat cancer related spinal pain

The CCG commissions spinal injections for patients with chronic spinal pain (>12 weeks) only in clinically exceptional circumstances. A patient may be considered to be clinically exceptional to the general policy if both the following apply:

·  He/she is different to the general population of patients who would normally be refused the healthcare intervention, and

·  There are good grounds to believe that the patient is likely to gain significantly more benefit from the intervention than might be expected for the average patient with that particular condition.

Only evidence of clinical need will be considered. Factors such as gender, ethnicity, age, lifestyle or other social factors such as employment or parenthood will not be considered. The fact that the treatment might be efficacious for the patient is not, in itself, grounds for exceptionality.

In order to help review your patient’s case, please tick the appropriate boxes and return the form with relevant clinical letters (including outcomes of multidisciplinary assessments) to:

Address: The Individual Funding Request Panel

North of England Commissioning Support

Unit 3

Alpha Court

Monks Cross North

York

YO32 9WN

Email:

THIS FORM CAN BE COMPLETED ELECTRONICALLY

Spinal pain location

Patients Name:
Address:
DOB:
NHS Number:

Cervical

Thoracic

Lumbar / sacral

Nature, site, dermatome and quality of pain

(Please tick if appropriate) Reduced muscle power

Absent reflexes

Muscle wasting

Spinal injection requested

Pharmacological treatment history

Current analgesia (please specify drug and dosage)

Past analgesia (please specify drug and dosage)

Other relevant medication (please specify drug and dosage)

Limiting side effects (please specify)

Other non pharmacological treatments tried

Yes / No / Date / Outcome
Acupuncture
Chronic pain management programme
Physiotherapy
Psychology / CBT
Spinal manipulation
Spinal cord nerve stimulator
Surgical opinion
(please enclose letter)
Other (please specify)

History of Spinal injections

Yes No

Facet joint injection

Duration of treatment
Percentage improvement in pain
Dates of procedure or average frequency of injections (per year)
Ave Duration of response (months)
Impact on activities of daily living

Yes No

Epidural injection

Duration of treatment
Percentage improvement in pain
Dates of procedure or average frequency of injections (per year)
Ave Duration of response (months)
Impact on activities of daily living

Yes No

Nerve root ablation

Or

Yes No

Radio-frequency lesioning

Duration of treatment
Percentage improvement in pain
Dates of procedure or average frequency of injections (per year)
Ave Duration of response (months)
Impact on activities of daily living

Exceptionality

1. Are there clinical reasons why the patient is unable to engage with a pain management / structured spinal rehabilitation programme?

Yes No

If yes please specify:

2. Is there a history of significant neurological co-morbidity that affects gait / balance or muscle tone?

Yes No

If yes please specify:

3. Does the patient suffer from extreme frailty – whose medical condition is likely to worsen with regular travel such as, might be required to attend physiotherapy or a pain management group?

Yes No

If yes please specify:

Please describe any relevant clinical factors that you believe should be taken into account, which would support individual funding approval on the grounds of exceptionality: (please note, social demographic or occupational factors cannot normally be taken into account when determining clinical exceptionality):

Requesting Clinician Name and Job Title