Clinical UM Guideline


Subject:Pain Management: Epidural Injections for Pain Relief
Guideline #:  CG-SURG-39Current Effective Date:  04/15/2014
Status:ReviewedLast Review Date:  02/13/2014

Description

Epidural steroid injection (ESI), steroids is a technique used to treat radicular pain. This document addresses ESIs with or without anesthetic agents. 

Note: Please see the following related documents for additional information:

Clinical Indications

Medically Necessary: 

ESI of the cervical or lumbar spine with or without added anesthetic agents may be medically necessary when all of the following criteria are met:

*Note: Conservative therapy consists of an appropriate combination of medication (e.g., NSAIDs, analgesics), physical therapy, spinal manipulation therapy, or other interventions based on the individual's specific presentation, physical findings and imaging results.

Not Medically Necessary:

ESIs are considered not medically necessary when the criteria specified above are not met, or when any of the following apply:

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 
62310Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic [when specified as epidural steroid injection]
62311Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) [when specified as epidural steroid injection]
64479Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level
64480Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level
64483Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level
64484Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level
0228TInjection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level
0229TInjection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level
0230TInjection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level
0231TInjection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
 All diagnoses
  
Discussion/General Information

Acute pain from injury, surgery or illness is usually self-limited and disappears when the underlying cause has been treated or has healed. Chronic pain can persist despite the fact that the cause (e.g., injury, disease) has resolved. The intensity will vary from mild to severe disabling pain that may significantly reduce quality of life.

One type of injection used for the treatment of cervical and lumbar radicular pain is ESI using anesthetic agents or steroids alone or in combination. An epidural steroid injection targets the epidural space that is localized to the area of affected nerve roots. According to the American Academy of Orthopaedic Surgeons (AAOS) "most spinal injections are performed as one part of a more comprehensive treatment program. Simultaneous treatment nearly always includes an exercise program to improve or maintain spinal mobility (stretching exercises) and stability (strengthening exercises) (2009)."
The ASA (1997) has stated that the goals of pain management are to:

Pain management presents a major challenge to healthcare providers because of its complex natural history and unclear etiology. Clinical decision making for diagnosing and treating chronic pain is difficult due to the subjective nature of pain. The results of clinical studies of epidural steroid injections vary with respect to the degree and duration of pain relief and it is difficult to standardize treatment models.

In a 2008 update of the Cochrane Database Systematic Review, Staal and associates stated that the effectiveness of injection therapy for low-back pain is still debatable. Heterogeneity of target tissue, pharmacological agent and dosage generally found in randomized controlled trials (RCTs) points to the need for clinically valid comparisons in a literature synthesis. However, it cannot be ruled out that specific subgroups of individuals may respond to a specific type of injection therapy.

Chou and colleagues (2009) evaluated clinical data for the American Pain Society Clinical Practice Guideline: Nonsurgical Interventional Therapies for Low Back Pain. They found that evidence from randomized, placebo controlled trials showing benefits of most interventional injection therapies for back pain is limited. For radiculopathy, there is fair evidence of benefits associated with epidural steroid injections however; the decision to use epidural steroid injection should take into account the short-term nature of symptom relief and inconsistent results of epidural steroid trials. More well-designed randomized trials are needed to guide appropriate use of injection therapy for back pain.

The North American Spine Society (NASS) in its Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis 2007 states:

Non fluoroscopically-guided interlaminar epidural steroid injections can result in short term (two to three weeks) symptom relief in patients with neurogenic claudication or radiculopathy. There is, however, conflicting evidence concerning long-term efficacy.

NASS's recommendations (2007) were:

  1. A large double-masked, randomized, controlled clinical trial with at least one-year follow-up in patients with unilateral leg pain from lumbar spinal stenosis treated by fluoroscopically-guided contrast-enhanced transforaminal epidural steroid injections in which the control group receives saline placebo injections.
  2. A large double-masked, randomized, controlled clinical trial with at least two-year follow-up in patients with neurogenic claudication from lumbar spinal stenosis treated by fluoroscopically-guided interlaminar or caudal epidural steroid injections in which the control group receives saline placebo injections.

A preliminary report by Manchikanti et al. (2010) evaluated the safety and effectiveness of thoracic epidural injections in 40 participants who underwent treatment for relief of chronic mid and upper back pain secondary to radiculitis or disc herniation with local anesthetic alone or local anesthetic with steroids. At 12 months, 80% of the patients in the anesthetic alone group reported at least 50% pain reduction while 85% of patients receiving local anesthetic plus steroid reported at least 50% pain reduction (p value not reported). This pilot study was small and lacked a sham control group to measure treatment effect. Currently there are ongoing trials evaluating the use of ESIs for the thoracic region.

Currently, there is limited evidence to support the use of epidural steroids in the treatment of spinal stenosis. Guidelines from the American Pain Society (2009) concluded that there is "insufficient evidence to adequately evaluate the benefits and harms of epidural steroid injections for spinal stenosis."

Manchikanti and colleagues (2012) reported results from a double-blind sham controlled study of 100 participants who underwent lumbar epidural injections of local anesthetic with steroids (Group I; n=50) or without steroids (Group II; n=50) for chronic function-limiting low back pain and lower extremity pain secondary to spinal stenosis The authors reported " the significant pain relief and functional status improvement were seen in 50% in group I and 57% in group II at the end of 2 years in a subset (" the successful group") of participants. However, overall significant pain relief and functional status improvement (greater than or equal to 50%) was demonstrated in 38% of group I and 44% in group II at the end of 2 years." Limitations of the study included its small size and a modest treatment effect in a minority of participants. Further study is needed.

The lumbar epidural steroid injections for spinal stenosis (LESS) study (Friedly et al. 2012 study protocol) is an ongoing randomized, double-blind trial evaluating the effectiveness of ESIs in improving pain and function among adults with lumbar spinal stenosis. Estimated trial completion is 2015. Currently, there is insufficient evidence supporting the use of ESI for the treatment of spinal stenosis.

van Wijck et al. (2006) reported results of the The PINE study of epidural steroids and local anaesthetics to prevent postherpetic neuralgia. In a randomized controlled trial, 598 participants with acute herpes zoster either received standard therapy (oral antivirals and analgesics) or standard therapy and one additional epidural steroid injection. After one, three and six month evaluations, they found that an epidural injection had a modest effect in reducing zoster associated pain after only one month and that this treatment is not effective for prevention of long term postherpetic neuralgia.

Definitions

Non-radicular back pain: Pain which does not radiate along a dermatome (sensory distribution of a single root). Appropriate imaging does not reveal signs of spinal nerve root compression and there is no evidence of spinal nerve root compression seen on clinical exam.

Radicular back pain: Pain which radiates along a dermatome (sensory distribution of a single root) into an upper or lower extremity. Evidence of spinal nerve root compression may be seen on clinical exam and supported by appropriate imaging (generally Magnetic Resonance Imaging [MRI]) studies.

Radiculopathy: Radiculopathy is characterized by pain which radiates from the spine to extend outward to cause symptoms away from the source of the spinal nerve root irritation.

Straight Leg Raise Test: In the supine position and the leg is elevated, with the knee held in extension by the clinician, up to 70 degrees; a positive test reproduces radicular pain along the path of a nerve root in the 30- to 70-degree range of elevation.

References

Peer Reviewed Publications:

  1. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain. Spine. 2009; 34(10):1078-1093.
  2. Friedly JL, Bresnahan BW, Comstock B, et al. Study protocol- lumbar epidural steroid injections for spinal stenosis (LESS): a double-blind randomized controlled trial of epidural steroid injections for lumbar spinal stenosis among older adults. BMC Musculoskeletal Disorders. 2012; 13:48.
  3. Manchikanti L, Cash KA, McManus CD, et al. A preliminary report of a randomized double-blind, active controlled trial of fluoroscopy thoracic interlaminar epidural injections in managing chronic thoracic pain. Pain Physician. 2010; 13:357-369.
  4. Manchikanti L, Cash KA, McManus CD, 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 2012; 15:371-384.
  5. van Wijck AJ, Opstelten W, Moons KG, et al. The PINE study of epidural steroids and local anaesthetics to prevent postherpetic neuralgia: a randomized controlled trial. Lancet. 2006; 367(9506):219-224.
  6. Young IA, Hyman GS, Packia-Raj LN, Cole AJ. The use of lumbar epidural/transforaminal steroids for managing spinal disease. J Am Acad Orthop Surg. 2007; 15(4):228-238.

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. American Pain Society (APS) and American Academy of Pain Medicine (ASPM). Clinical guideline for the evaluation and management of low back pain: Evidence review. 2009. Available at: http://www.americanpainsociety.org/uploads/pdfs/LBPEvidRev.pdf. Accessed on February 13, 2014.
  2. American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: An evidence-based clinical practice guideline from the American Pain Society. Spine. 2009; 34(10):1066-1077.
  3. American Society of Anesthesiologists (ASA). Task Force on Pain Management: General practice guidelines for chronic pain management. Anesthesiology 1997; 86(4):995-1004.
  4. Institute for Clinical Systems Improvement (ISCI). Health care guideline: Adult acute and subacute low back pain. 2011. Available at: https://www.icsi.org/_asset/bjvqrj/LBP.pdf. Accessed on February 13, 2014.
  5. National Institute for Health and Clinical Excellence (NICE). Low back pain: Early management of persistent non-specific low back pain. 2009. Available at: http://www.nice.org.uk/nicemedia/pdf/CG88NICEGuideline.pdf. Accessed on February 13, 2014.
  6. North American Spine Society (NASS). Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and treatment of degenerative lumbar spinal stenosis. NASS. 2007; 1-262.
  7. Pain Management Center of Paducah. Treatment of chronic thoracic and neck and upper extremity pain. NLM identifier: NCT01071369. Last updated on June 20, 2013. Available at: http://www.clinicaltrial.gov/ct2/show/NCT01071369?term=thoracic+epidural+steroid+injection&rank=1. Accessed on February 13, 2014.
  8. Resnick D, Choudhri T, Dailey A, Khoo L, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low-back pain and lumbar fusion. J Neurosurg: Spine 2005; 2(636):707–715.
  9. Staal JB, de Bie R, de Vet HC, et al. Update of: Cochrane Database Syst Rev. 2000; (2):CD001824. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev. 2008; (3):CD001824.
  10. University of Washington. Lumbar Epidural Steroid Injections for Spinal Stenosis Multicenter Randomized, Controlled Trial (LESS Trial). NLM identifier: NCT01238536. Last updated on December 18, 2013. Available at: http://www.clinicaltrial.gov/ct2/show/NCT01238536?term=NCT01238536&rank=1. Accessed on February 13, 2014.
Websites for Additional Information
  1. American Academy of Orthopaedic Surgeons. Spinal injections. November 2009. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00560. Accessed on September 13, 2014.
  2. MedlinePlus. Back pain. August 17, 2013. Available at: http://www.nlm.nih.gov/medlineplus/backpain.html. Accessed on February 13, 2014.
  3. Medscape. Epidural steroid injections. June 29, 2013. Available at: http://emedicine.medscape.com/article/325733-overview. Accessed on February 13, 2014.
Index

Anti-inflammatory
Epidural injection
Steroid injection

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

Reviewed02/13/2014Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Coding, Description and Websites.
New

11/14/2013

 

MPTAC review. Initial document development.