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Injections for nonspecific low back pain without sciatica

Injections for nonspecific low back pain without sciatica

Statutory Guidance

Summary

Spinal injections of local anaesthetic and steroid in people with non-specific low back pain without sciatica.

Recommendation

Spinal injections of local anaesthetic and steroid should not be offered for patients with non-specific low back pain.

For people with non-specific low back pain the following injections should not be offered:

  • Facet joint injections
  • Therapeutic medial branch blocks
  • Intradiscal therapy
  • Prolotherapy
  • Trigger point injections with any agent, including botulinum toxin
  • Epidural steroid injections for chronic low back pain or for neurogenic claudication in patients with central spinal canal stenosis
  • Any other spinal injections not specifically covered above

Radiofrequency denervation can be offered according to NICE guideline (NG59) if all non-surgical and alternative treatments have been tried and there is moderate to severe chronic pain that has improved in response to diagnostic medial branch block.

Epidurals (local anaesthetic and steroid) should be considered in patients who have acute and severe lumbar radiculopathy at time of referral.

Alternative and less invasive options have been shown to work e.g. exercise programmes, behavioural therapy, and attending a specialised pain clinic. Alternative options are suggested in line with the National Back Pain Pathway.

For further information,

NICE Guidance [NG 59] Low back pain and sciatica in over 16s: assessment and management

Rationale for recommendation

NICE guidelines recommend that spinal injections should not be offered for non- specific low back pain.

Radiofrequency denervation (to destroy the nerves that supply the painful facet joint in the spine) can be considered in some cases as per NICE guidance.

Exclusion criteria for the NICE (NG59) include:

Conditions of a non-mechanical nature, including;

  • Inflammatory causes of back pain (for example, ankylosing spondylitis or diseases of the viscera)
  • Serious spinal pathology (for example, neoplasms, infections or osteoporotic collapse)
  • Neurological disorders (including cauda equina syndrome or mononeuritis)
  • Adolescent scoliosis.

Not covered were conditions with a select and uniform pathology of a mechanical nature (e.g. spondylolisthesis, scoliosis, vertebral fracture or congenital disease) Other agreed exclusions by the GDG are: Pregnancy-related back pain, Sacroiliac joint dysfunction, Adjacent-segment disease, Failed back surgery syndrome, Spondylolisthesis and Osteoarthritis.

NICE recommends the following approach for non-surgical invasive treatments for low back pain and sciatica in over 16s.

Spinal injections

1.3.1 Do not offer spinal injections for managing nonspecific low back pain

Radiofrequency denervation

1.3.2 Consider referral for assessment for radiofrequency denervation for people with non-specific low back pain when non-surgical treatment has not worked for them and the main source of pain is thought to come from structures supplied by the medial branch nerve and they have moderate or severe levels of localised back pain (rated as 5 or more on a visual analogue scale, or equivalent) at the time of referral.

1.3.3 Only perform radiofrequency denervation in people with non-specific low back pain after a positive response to a diagnostic medial branch.

1.3.4 Do not offer imaging for people with non-specific low back pain with specific facet join pain as a prerequisite for radiofrequency denervation.

Patient information

Information for Patients

A recent review of which treatments work for back pain has shown that injections are not very effective. One example is the injection of pain-killer into the facet joints. Although many of these have been used in the past, and sometimes with good, short-term relief, they do not work often enough or long enough to make them a good treatment. The risks of the procedure, such as infection, although rare, make them a poor choice.

The NHS finds that the evidence points to other treatment methods as a better option for many people.

What can you do about the condition

Episodes of back pain are very common and normally improve within a few weeks or months. Although the pain can be very limiting and distressing, in most cases the pain isn’t caused by anything serious and will usually get better over time. If the problem persists, your GP may refer you to a specific care pathway which will include physiotherapy, group exercise classes and manual therapy along with self-management strategies.

It’s important you and your doctor make a shared decision about what’s best for you if the pain is becoming a problem. When deciding what’s best you should both consider the benefits, risks, alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

The routine use of spinal injections for low back pain is not recommended by the National Institute for Health and Care Excellence (NICE) which assesses the effectiveness of all tests, treatment and procedures.

What are the RISKS?

The procedure itself can cause discomfort. Complications include bruising, infection of the spine and nerve damage.

What are the ALTERNATIVES?

There are many alternatives and you should discuss what might be best for you with your doctor.

Options can include exercise and weight loss, physiotherapy, pain-relief medication, and psychological support such as cognitive behavioural therapy (CBT) which can help you live a better life with the pain. If the clinician treating you feels you need further assessment they should refer you to a specialist who will consider other treatments. This includes other forms of injections which can help some people.

What if you do NOTHING?

Doing nothing is not likely to be harmful and back pain usually improves after a few weeks. If the problem persists and is difficult to cope with, you should talk to your doctor about which treatment is best for you.

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2019

NHS UK - BAck pain

2022

Make the most of your appointment using BRAN

2020

Coding

Code script

WHEN LEFT(der.Spell_Dominant_Procedure,4) in ('A521','A522','A528','A529','A577','A735','V544')
AND LEFT(der.spell_primary_diagnosis,4) in ('M545’) 
AND APCS.Admission_Method not like ('2%')
THEN 'D_low_back_pain_inj'

Code Definitions

Procedure codes (OPCS)

Main
A521 Therapeutic lumbar epidural injection
A522 Therapeutic sacral epidural injection
A528 Other specified therapeutic epidural injection
A529 Unspecified therapeutic epidural injection
A577 Injection of therapeutic substance around spinal nerve root
A735 Injection of therapeutic substance around peripheral nerve
V544 Injection around spinal facet of spine

Potential
W903 Injection of therapeutic substance into joint (shouldn’t be used but may be as workaround with Z66 Vertebra or Z67 Intervertebral joint)
V528 Other specified other operations on intervertebral disc(plus Y388 Other specified injection of therapeutic substance into organ NOC or Y389 Unspecified injection of therapeutic substance into organ NOC)
V484 Denervation of spinal facet joint of thoracic vertebra NEC
V486 Denervation of spinal facet joint of lumbar vertebra NEC
V488 Other specified denervation of spinal facet joint of vertebra
V489 Unspecified denervation of spinal facet joint of vertebra

Diagnosis codes (ICD)

Includes
M545 Low back pain
Potential
M546 Pain in thoracic spine
M548 Other dorsalgia
M549 Dorsalgia, unspecified

Exclusions
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and 
apcs.der_diagnosis_all not like '%D0%' and 
apcs.der_diagnosis_all not like '%D3[789]%' and
apcs.der_diagnosis_all not like '%D4[012345678]%’

This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
for adults.

–Private Appointment Exclusion
AND apcs.Administrative_Category<>’02’

References

  1. NICE guidance (2016) Low back pain and sciatica in over 16s: assessment and management [NG59].
  2. United Kingdom Spine Societies Board: Improving Spinal Care Project : https://www.ukssb.com/improving-spinal-care-project
  3. Benyamin RM, Manchikanti L, Parr AT, Diwan S, Singh V, Falco FJ, et al. The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician. 2012 Jul- Aug;15(4):E363-404.
  4. Choi HJ, Hahn S, Kim CH, Jang BH, Park S, Lee SM, et al. Epidural steroid injection therapy for low back pain: a meta-analysis. Int J Technol Assess Health 2013 Jul;29(3):244-53.
  5. Cohen SP, Bicket MC, Jamison D, Wilkinson I, Rathmell JP. Epidural steroids: a comprehensive, evidence-based review. Reg Anesth Pain Med. 2013 May- Jun;38(3):175-200.
  6. Faculty of Pain Management (2015) Core Standards in Pain Management Services in the UK.

How up to date is this Information?

Last revised December 2023

Changes

December 2023 - Coding updated. August 2022 - Coding updated

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