The guidelines established by the New York State Workers Compensation Board are designed to assist healthcare professionals in administering therapeutic spinal injections. These directives aim to support physicians and healthcare practitioners in determining the appropriateness of therapeutic injections into the spinal region as part of a comprehensive treatment plan.
Healthcare professionals specializing in therapeutic spinal injections can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the use of such injections for their patients.
It is crucial to emphasize that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding therapeutic spinal injections should involve collaboration between the patient and their healthcare provider.
Injections: Therapeutic Spinal
Therapeutic spinal injections may come into play once initial conservative treatments like physical and occupational therapy, medication, manual therapy, and exercise have been attempted. It’s crucial to consider these injections only after imaging studies and diagnostic injections have identified the underlying issues. Given that injections are invasive and carry the risk of severe complications, adherence to clinical indications and contraindications is paramount.
The primary goal of spinal injections is to support active therapy by offering short-term relief through pain and inflammation reduction. It’s essential for all patients to maintain suitable exercise routines alongside targeted rehabilitation. Active treatment, a prerequisite before opting for injections, often necessitates repeating the sessions previously recommended.
Administering injections alone is unlikely to offer long-term relief. Instead, sustained relief is typically achieved through active rehabilitation coupled with modified work, enhancing active range of motion, strength, and stability.
If the initial injection fails to deliver:
- Improvement in function,
- Temporary and sustained pain relief, measured by recognized pain scales (such as a 50% reduction on the Visual Analog Scale), and/or
- A decrease in the use of prescribed analgesic medication,
it’s not advisable to repeat the injection. Medical management should be continued or adjusted based on ongoing patient assessment and response.
Special consideration should be given to all thoracic, lumbar, and sacroiliac injections (excluding trigger point injections) as they require multi-planar fluoroscopy during procedures to accurately document technique and needle placement.
All injections, excluding trigger point injections, should be carried out by a physician with relevant experience in the procedure. Trigger point injections, on the other hand, may be administered by a physician or a Nurse Practitioner/Physician Assistant with expertise in the procedure.
To document needle placement accurately, permanent images are necessary.
Physicians performing injections may come from various subspecialty disciplines, such as anesthesiology, radiology, surgery, or physiatry, among others.
The practitioner should ideally have completed fellowship training in a suitable medical specialty (neurosurgery, orthopedic surgery, physiatry, pain management, etc.) with a focus on interventional training. Additionally, the practitioner must possess knowledge in radiation safety.
Complications
Complications associated with spinal injections can encompass several general issues such as transient neurapraxia, local pain, nerve injury, infection, headaches, and vasovagal effects. More severe complications, albeit rare, may involve epidural hematoma, permanent neurologic damage, dural perforation, CSF leakage, and spinal meningeal abscess. In extremely rare instances, serious complications like spinal cord damage, quadriplegia, permanent ataxia, and even death may occur.
Steroid injections, in particular, carry additional considerations. There might be a dose-dependent suppression of the hypothalamic-pituitary-adrenal axis lasting between one and three months. Furthermore, steroid injections can lead to a transient rise in glucose levels, particularly in individuals with diabetes.
Contraindications
Contraindications to therapeutic injections can be broadly categorized into absolute and relative contraindications:
Absolute contraindications encompass situations where therapeutic injections should not be pursued, and these include:
– Bacterial infection, either systemic or localized to the region of injection
– Bleeding diatheses
– Hematological conditions
– Possible pregnancy
On the other hand, relative contraindications to diagnostic injections may involve factors such as:
– Allergy to contrast
– Poorly controlled Diabetes Mellitus
– Hypertension
Certain drugs that influence coagulation, like aspirin, NSAIDs, anti-platelets, or anticoagulants, are typically restricted before injections. Decisions regarding anticoagulation are typically reached through collaboration between the provider conducting the injection, the prescribing physician, and other specialists as needed, all within the context of the patient’s specific underlying medical history.
Lumbar Transforaminal/Interlaminar/Caudal Epidural Injections (ESI)
The primary goal of Epidural Steroid Injections (ESI) is to alleviate pain and inflammation, ultimately restoring range of motion and enabling progress in more active rehabilitation programs. Like any treatment, it’s crucial to ensure that patients maintain realistic expectations regarding the outcomes of the intervention.
For diabetic individuals eligible for ESI, counseling should include the acknowledgment that a temporary increase in blood glucose may occur post-intervention.
When performing Lumbar ESI, it’s imperative to use fluoroscopic guidance to confirm accurate needle placement. Permanent images are essential for documenting this placement. Contrast epidurograms are beneficial for verifying the proper flow of medication into the epidural space, with one epidurogram per series of ESI recommended based on clinical indications.
ESI is recommended for patients experiencing symptoms of lumbar radicular pain syndromes, indicating its usefulness in such cases.
ESI is not recommended for treating lumbar axial pain or nonradicular pain syndromes. Specific indications for ESI include the use of anesthetics and/or steroids. It is considered as an option for acute radicular pain syndromes and for radicular pain syndromes that persist for at least three weeks after treatment with NSAIDs, without showing signs of spontaneous resolution.
ESI is also an option for second-line treatment during acute flare-ups of spinal stenosis and for symptoms of spinal stenosis lasting one to two months, following prior treatment that involved NSAIDs and progressive exercise. However, it is not recommended for acute or non-acute back pain in the absence of significant radicular symptoms. Additionally, using ESI as the first- or second-line treatment in individuals whose back pain symptoms outweigh leg pain is not advised. Furthermore, ESI is not recommended as a treatment for any non-acute axial back pain lacking a radicular component.
It’s essential to note that the specified time frames for considering ESIs may vary based on individual patient-specific clinical considerations.
Regarding the frequency of injections, several considerations apply:
– A maximum of three injections (per spinal region) can be administered within a 12-month period. The decision for additional injections is contingent upon the patient’s response, specifically improvement in function and pain reduction.
– During each treatment session, no more than two levels should be addressed.
– It’s advisable to schedule each injection separately, allowing for the evaluation of individual effects. This evaluation should be based on the patient’s response, emphasizing improved function and pain reduction, rather than adopting a “Series of Three” approach.
– If the initial injection fails to yield a response, characterized by temporary and sustained pain relief lasting at least two weeks, supported by recognized pain scales (e.g., 50% pain reduction using tools like VAS) and an improvement in function, repeating injections is not recommended.
To deem an injection successful, a positive result, indicated by functional improvement, should involve measurable enhancements in physical activity goals, potentially leading to a return to baseline function or regular work duties. After each injection, patients should undergo reassessment, focusing on:
– Improvement in function.
– Temporary and sustained pain relief, measured by recognized pain scales (such as achieving a 50% reduction on the Visual Analog Scale).
– A decrease in the use of prescribed analgesic medication.
Medical management should be consistently evaluated and either continued or adjusted based on the ongoing assessment of the patient’s response. Discontinuation of injections is warranted in the event of symptom resolution, a decrease in symptoms to a tolerable level, or the absence of a favorable response.
Intradiscal Steroids
Not recommended for the treatment of acute or non-acute back pain. There is a lack of quality evidence supporting the efficacy of intradiscal steroid injections for acute back pain, and there’s no indication that these injections improve the natural course of acute back pain.
Chemonucleolysis (Chymopapain and Collagenase):
Not recommended as the procedure, although previously successful, is not available in the U.S. due to serious adverse effects.
Tender and Trigger Point Injections:
Myofascial trigger points are localized, hyperirritable palpable nodules within sensitive bands of taut skeletal muscle fibers. These nodules cause pain on compression and can lead to local pain as well as referred pain in distant structures.
– Trigger point treatment involves dry needling or the injection of a local anesthetic into myofascial trigger points.
– It’s important to note that trigger point injection is not equivalent to acupuncture, and for details on acupuncture, one should refer to the relevant section in each Medical Treatment Guideline.
Indications:
– Trigger point injections should primarily be employed to support functional progress.
– These injections can be used to alleviate myofascial pain and aid in active therapy and stretching of the affected areas.
– It is not advisable to use therapeutic injections in isolation without active participation in a therapy program or while maintaining employment.
Patient Reassessment:
– Patients should undergo reassessment two weeks after each injection, focusing on:
– Improvement in function.
– Temporary and sustained pain relief, with a target of achieving at least a 50% reduction on the Visual Analog Scale.
– Reduction in the use of prescribed analgesic medication.
– Medical management should be consistently evaluated and either continued or adjusted based on the patient’s assessment and response.
Functional Improvement:
– Sustained functional improvement should last for a duration of three months.
– A positive outcome, signified by functional improvement, should involve measurable enhancements in physical activity goals, potentially leading to a return to baseline function or regular work duties.
Imaging Use:
– The use of ultrasound or other imaging studies for trigger point injections is not recommended.
Frequency:
– Limit to no more than four injections per session, with a maximum of four sessions within a 12-month period.
– If the initial set of injections doesn’t yield satisfactory results, a second set may be considered. However, if there is no documented improvement, further injections are not advised.
– Reasons for discontinuation include resolution of the condition, intolerance, or completion of two sets of injections without significant impact on the condition.
– If only partial improvement is demonstrated after the first set, considering a second set may be reasonable, with a recommended interval of three to four weeks between injections.
– Continued injections should be contingent upon both subjective and objective improvement.
Lumbar Diagnostic and Therapeutic Medial Nerve Branch Blocks or Intra-articular Facet (Zygapophyseal) Joint Injections
Indications:
– Medial branch block injections or intra-articular facet joint injections are recommended for:
– Patients experiencing pain suspected to be primarily facet-related, supported by examination findings (e.g., non-radicular axial pain worsened by extension-facet loading), and/or
– Those with documented evidence (e.g., imaging study) of facet disease (facet arthropathy/hypertrophy at the targeted level(s)) who have completed a documented course of conservative management per the New York Mid and Low Back Injury Medical Treatment Guidelines.
Description:
– These injections must be guided by fluoroscopy.
– Lumbar medial nerve branch blocks or intra-articular facet joint injections may include both a diagnostic and/or a therapeutic component.
– The diagnostic component involves an anesthetic, and the therapeutic component includes a corticosteroid.
– The diagnostic component (anesthetic only) can be used alone or combined with a steroid in a single diagnostic/therapeutic injection.
– A medial nerve branch block is indicated for diagnosing pain suspected to originate from the facet joint, with the rationale documented in the history and physical examination.
– A positive response to a therapeutic injection (steroid) does not definitively indicate the necessity for radiofrequency ablation.
Recommended – for specific patients as clinically justified.
Indications:
Acute Back Pain:
– Intra-articular facet joint injections (into the intra-articular facet joint space) or medial branch block injections (blocking medial nerve innervation) may be considered for acute back pain when there persists axial back pain after an injury that hasn’t responded to conservative management.
– In patients experiencing acute back pain, medial branch block injections can help identify pain sources, provide therapeutic pain relief, and contribute to progress in a rehabilitation program.
– For acute pain, these injections involve a combination of an anesthetic and a steroid, where the steroid is added for extended therapeutic benefit. The objective is to reduce pain, enhance function, and enable participation in an active rehabilitation program that was challenging before the injection.
– Diagnostic medial branch block injections (anesthetic only, without steroids) or diagnostic intra-articular facet joint injections (anesthetic only, without steroids) are not recommended for acute back pain.
Positive Therapeutic Response (either Medial Branch Block Injection or Intra-articular Facet Joint Injection):
– After each therapeutic injection, patients should undergo reassessment, aiming for a documented 50% improvement in pain, as measured by accepted pain scales, and evidence of functional enhancement lasting at least 4-6 weeks.
– A positive outcome (functional improvement) should manifest as measurable progress in physical activity goals, indicating advancement towards a return to baseline function or work activities.
– Pain assessment should occur pre-procedure, immediately post-procedure, and at designated intervals following the procedure, with the goal of achieving sustained relief.
– If the initial therapeutic injection fails to provide lasting pain relief substantiated by accepted pain scales (i.e., 50% documented pain reduction measured by accepted pain tools) and functional improvement for a minimum of 4-to-6 weeks, the recommendation is against repeating steroid injections.
– Time to observe the effect can extend up to 72 hours.
– In terms of frequency, two injections for each relevant joint are permissible within a 12-month period, not exceeding three joint levels (four medial branch nerves) per session. This allowance depends on the patient’s documented response, particularly improved functional gain and pain reduction. The maximum frequency is two sessions per year.
