Clinical UM Guideline


Subject:Pain Management: Epidural Steroid Injections
Guideline #:  CG-SURG-39Current Effective Date:  04/07/2015
Status:RevisedLast Review Date:  02/05/2015

Description

This document addresses epidural steroid injections (ESIs) with or without anesthetic agents. ESIs are a technique used to treat radicular pain, such as sciatica. This document does not address epidural anesthesia (administered to manage pain during childbirth and surgical procedures), facet joint injections or sacroiliac joint injections.

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

Clinical Indications

MedicallyNecessary:

 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:

  1. The individual has radicular pain; and
  2. The pain is interfering with functional activities; and
  3. The pain has not responded to 6 weeks of appropriate conservative therapy*; and
  4. There is no evident systemic infection or local infection at the injection site, bleeding tendency, or unstable medical condition; and
  5. ESI can be repeated up to 4 times per cervical or lumbar spinal region per 12 months with at least 1 week between injections, so long as the prior injection in that spinal region produced at least partial symptomatic relief.

*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, and for all other indications including, but not limited to:

  1. ESI at a thoracic spinal level
  2. ESI is used for treatment of non-radicular spinal pain, myofascial pain syndrome, spinal stenosis, or post herpetic neuralgia
  3. Repeat ESI performed in the absence of documented improvement in pain or function upon reassessment
  4. Repeat ESI performed more frequently than once weekly
  5. More than 4 ESI injections at the same spinal region in 1 year.
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 10/01/2015]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses
  
Discussion/General Information

Acute pain caused by spinal injury, surgery, or illness is usually self-limited and disappears when the underlying cause has been treated or has healed. Conversely, chronic pain can persist despite the fact that the cause (e.g., injury, disease) has resolved. The intensity of chronic pain can vary from mild to severely disabling pain that may have a significant, negative impact on one's quality of life. Management of chronic pain presents a major challenge to healthcare providers because of its complex natural history and unclear etiology. Furthermore, clinical decision making for diagnosing and treating chronic pain is difficult due to the subjective nature of pain. The results of clinical studies of ESIs vary with respect to design and the degree and duration of pain relief, further complicating the standardization of treatment modalities.

Injections for Cervical and Lumbar Radiculopathy

One type of injection used for the treatment of cervical and lumbar radicular pain (such as sciatica) is ESI. ESI uses corticosteroids, either alone or in combination with anesthetic agents to target the epidural space that is localized to the area of affected nerve roots. According to the American Academy of Orthopaedic Surgeons (AAOS, 2009) "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)."  The American Society of Anesthesiologists (ASA; 1997) has stated that the goals of pain management are to:

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. The authors conclude, "… there is no strong evidence for or against the use of any type of injection therapy for individuals with subacute or chronic low-back pain."

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 ESI; however, the decision to use ESI should take into account the short-term nature of symptom relief and inconsistent results of epidural steroid trials. A systematic review conducted by Pinto and colleagues (2012), similarly concluded that the clinical utility of ESIs in lower back pain management lies in their ability to relieve radicular pain in the short-term (< 2 weeks ≥ 3 months), demonstrated from results of 23 randomized placebo-controlled clinical trials.

Datta and colleagues (2013) sought to better define the role of injection therapy for diagnostic purposes and conducted a systematic review of their use in the diagnosis of lower back and lower extremity pain. They concluded that the evidence is limited and additional research and consensus is warranted to further clarify the role of epidural injections as a diagnostic tool.

Injections for Thoracic Radiculopathy

A preliminary report by Manchikanti and colleagues (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 participants in the anesthetic-alone group reported at least 50% pain reduction while 85% 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.

A randomized, double-blind, controlled trial was conducted by Manchikanti and colleagues (2014), evaluating the efficacy of thoracic ESI. A total of 110 participants were enrolled in 1 of 2 groups; Group 1 received only a local anesthetic and Group 2 received a local anesthetic and steroid. Primary outcomes of the study included Numeric Rating Scale (NRS), Oswestry Disability Index (ODI) 2.0, employment status and opioid use. Significant improvement was defined as 50% or greater decrease in NRS and ODI scores. Follow-up occurred at 3, 6, 12, 18 and 24 months. Both the "successful" and "unsuccessful" treatments in Groups 1 and 2 showed significant improvement from baseline at 3 months up through study end at 2 years. However, the lack of a control arm or between group comparisons precludes a definitive determination of causality.

Currently, there are ongoing trials evaluating the use of ESIs for the thoracic region.

Injections for Spinal Stenosis

Currently, there is limited evidence to support the use of ESIs 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 lower back pain and lower extremity pain secondary to spinal stenosis. The authors reported:

…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.

The lumbar ESIs for spinal stenosis (LESS) study (Friedly and colleagues study protocol, 2012) is an ongoing randomized, double-blind trial evaluating the effectiveness of ESIs in improving pain and function among older adults with lumbar spinal stenosis. Estimated trial completion is 2015. Although this trial is on-going, preliminary data have been published from the first 400 participants that were enrolled. The authors' preliminary conclusions at 6-week follow-up from this large, randomized, double-blind trial stated, "In the treatment of lumbar spinal stenosis, epidural injection of glucocorticoids plus lidocaine offered minimal or no short-term benefit as compared with epidural injection of lidocaine alone" (Friedly, 2014). A limitation of the study was the lack of a control arm.

The North American Spine Society (NASS) in its Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis 2011 states: "Interlaminar epidural steroid injections are suggested to provide short-term (two weeks to six months) symptom relief in patients with neurogenic claudication or radiculopathy. There is, however, conflicting evidence concerning long-term (21.5-24 months) efficacy." Although the grade of this recommendation was given a B (denotes a "suggested" recommendation), the level of evidence presented to support it consisted largely of levels of evidence, III and IV, which by definition are non-randomized, case-series, retrospective, or possess a methodological flaw. The only study with a level of evidence II was published by Fukusaki in 1998 and included 53 participants. Significant differences in pain improvement were seen in the anesthetic and steroid groups over the saline group at one month follow-up. However, there was no significant difference between the anesthetic and steroid group; therefore, ESI did not provide an additional, demonstrable clinical benefit in pain management. Furthermore, at 3 months no significant difference remained between all 3 study arms.

NASS's recommendations for future research (2011) include:

  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 recent Cochrane review assessing the evidence for non-surgical treatment approaches for spinal stenosis concluded, "Moderate and high-quality evidence for nonoperative treatment is lacking and thus prohibits recommendations for guiding clinical practice. Given the expected exponential rise in the prevalence of lumbar spinal stenosis with neurogenic claudication, large high-quality trials are urgently needed" (Ammendolia, 2013).

Currently, there is insufficient evidence supporting the use of ESI for the treatment of spinal stenosis.

Injections for Herpetic Neuralgia

van Wijck and colleagues (2006) reported results of the PINE study of epidural steroids and local anaesthetics to prevent postherpetic neuralgia. In a RCT, 598 participants with acute herpes zoster either received standard therapy (oral antivirals and analgesics) or standard therapy and one additional ESI. After 1, 3 and 6 month evaluations, they found that an epidural injection had a modest effect in reducing zoster associated pain after only 1 month and that this treatment is not effective for prevention of long-term post-herpetic 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, 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: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). 2009; 34(10):1078-1093.
  2. Datta S, Manchikanti L, Falco FJ, et al. Diagnostic utility of selective nerve root blocks in the diagnosis of lumbosacral radicular pain: systematic review and update of current evidence. Pain Physician. 2013 (2 Suppl): SE97-124.
  3. 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.
  4. Friedly JL, Comstock BA, Turner JA, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014; 371(1):11-21.
  5. Fukusaki M, Kobayashi I, Hara T, Sumikawa K. Symptoms of spinal stenosis do not improve after epidural steroid injection. Clin J Pain. 1998; 14(2):148-151.
  6. 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(6):E357-369.
  7. 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(5):371-384.
  8. Pinto RZ, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med. 2012; 157(12):865-877.
  9. 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.
  10. 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://americanpainsociety.org/uploads/education/guidelines/evaluation-management-lowback-pain.pdf. Accessed on November 21, 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. American Society of Anesthesiologists. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010; 112(4):810-33.
  5. Ammendolia C, Stuber KJ, Rok E, et al. Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication. Cochrane Database Syst Rev. 2013;(8):CD010712.
  6. 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 November 21, 2014.
  7. 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 November 21, 2014.
  8. North American Spine Society (NASS). Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and treatment of degenerative lumbar spinal stenosis. NASS. 2011. Available at:  https://www.spine.org/Pages/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx. Accessed on December 2, 2014.
  9. 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 November 21, 2014.
  10. Resnick D, Choudhri T, Dailey A, 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.
  11. 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.
  12. University of Washington. Lumbar Epidural Steroid Injections for Spinal Stenosis Multicenter Randomized, Controlled Trial (LESS Trial). NLM identifier: NCT01238536. Last updated on July 09, 2014. Available at: http://www.clinicaltrial.gov/ct2/show/NCT01238536?term=NCT01238536&rank=1. Accessed on November 21, 2014.
Websites for Additional Information
  1. American Academy of Orthopaedic Surgeons. Spinal injections. Last updated on December 2013. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00560. Accessed on November 21, 2014.
  2. MedlinePlus. Back pain. Last updated on October 17, 2014. Available at: http://www.nlm.nih.gov/medlineplus/backpain.html. Accessed on November 21, 2014.
  3. MedlinePlus. Epidural injections for back pain. Last updated on November 7, 2014. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/007485.htm. Accessed on November 25, 2014.
  4. Medscape. Epidural steroid injections. July 29, 2013. Available at: http://emedicine.medscape.com/article/325733-overview. Accessed on November 21, 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

Revised02/05/2015Medical Policy & Technology Assessment Committee (MPTAC) review. Revised Title. Clarified Not Medically Necessary statement. Updated Description, Discussion/General Information and Reference sections.
Reviewed02/13/2014MPTAC review. Updated Coding, Description and Websites sections.
New

11/14/2013

 

MPTAC review. Initial document development.