Spinal injections

Policy context

In 2011, HTA conducted an initial evidence review of spinal injections and the Health Technology Clinical Committee (HTCC) determined therapeutic medial branch nerve block injections, intradiscal injections and facet injections are not a covered benefit. Therapeutic lumbar epidural injections, cervical-thoracic epidural injections, and sacroiliac joint injections are a covered benefit for the treatment of chronic pain following certain conditions.

In 2015, new literature was identified addressing the use of spinal injections, including new safety concerns voiced by the FDA. 

Primary criteria ranking

• Safety = Medium
• Efficacy = High
• Cost = Medium

Documents (all assessments)

Assessment (2016)

• Draft key questions: comment and response
• Final key questions
• Draft evidence report: comment and response
• Final evidence report
• Final evidence report: appendices
• Final findings and decision

Assessment (2011)

• Final key questions
• Draft evidence report: comment and response
• Final evidence report
• Final findings and decision

Background

Back and neck pain are common conditions, with 60 to 80% percent of U.S. adults afflicted at some time during their life. Back pain, and then neck pain, are the most common causes of disability and loss of productivity. Approximately 90% of low back pain is of the nonspecific type, and a similar majority of neck pain is nonspecific. Most patients' symptoms resolve satisfactorily within a relatively short time span (six weeks). In 5 to 10% of patients, pain does not satisfactorily resolve. The symptoms can be disabling and the social and economic impact of chronic pain is enormous. Discovering the cause for nonspecific low back and neck pain symptoms remains challenging. Some psychosocial risk factors for the progression to chronicity have been identified, but the origin and neurophysiologic pain sensations are poorly understood.

Chronic pain treatment may include pharmacological treatment, physical therapy, psychological care and coping skills, exercise, education, antidepressants, cognitive behavioral therapy and supported self-management, spinal manipulations, electrical stimulation, injections, implanted devices, and other surgical treatment. Treatment strategies generally begin with the least invasive and low risk interventions and progress if the treatments are not effective. Treatment often involves a combination of interventions.

Spinal injections are not usually performed until nonsurgical treatments have been given a fair trial and have not provided adequate relief. Intraspinal injections are intended to provide relief by injection of an anti-inflammatory agent (e.g. steroid); and/or anesthetic into the spine or space around the spinal nerves and joints. Intraspinal injections include epidural steroid injections, facet joint injections, medial branch block, sacroiliac joint injections and intradiscal steroid injections.