BlueCross BlueShield of Tennessee Medical Policy Manual

Epidural Steroid Injections for Treatment of Back Pain

DESCRIPTION

Epidural steroid injections (ESIs) are a treatment for back pain that has not responded to conservative measures.  Local steroid injections may improve pain by reducing inflammation, thus relieving pressure on nerve roots or other structures that may be the origin of pain. ESIs are performed by inserting a needle into the space between the dura and ligamentum flavum and injecting a steroid preparation.  Several different approaches may be used for entering the epidural space (translaminar, transforaminal, caudal).  The techniques are most accurately performed using fluoroscopy visualization for needle placement. The procedure may be safely performed in the outpatient setting.

POLICY

Policies with similar titles:  Lumbar Facet Steroid Injections for treatment of Low Back Pain

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Limiting the injections to three within a six month period minimizes the risks associated with large doses of steroids.  It is not appropriate to repeat a procedure a third time without improvement from the two prior injections.

Contrast-enhanced fluoroscopy is recommended to guide epidural steroid injections to improve the accuracy of medication delivery.

SOURCES

Agency for Healthcare Research and Quality. (March, 2015). Technology Assessment: Pain management injection therapies for low back pain. Retrieved August 18, 2015 from https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/id98TA.pdf.

American Academy of Neurology. (2007). Assessment: Use of epidural steroid injections to treat radicular lumbosacral pain: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Retrieved April 12, 2016 from   http://www.neurology.org/content/68/10/723.full.pdf+html.

American College of Occupational and Environmental Medicine (ACOEM). (2011). Cervical and thoracic spine disorders. Retrieved April 11, 2016 from the National Guideline Clearinghouse (NGC: 008890).

American College of Occupational and Environmental Medicine (ACOEM). (2011). Low back disorders. Retrieved April 11, 2016 from the National Guideline Clearinghouse (NGC: 009327).

American Society of Anesthesiologists Task Force on Chronic Pain Management and American Society of Regional Anesthesia and Pain Medicine. (2010). 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, 112 (4), 810-833.

Benyamin, R., Manchikanti, L., Parr, A., Diwan, S., Singh, V., & Falco, F. (2012). The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician, 15, E363-E404. (Level 1 evidence)  

BlueCross BlueShield Association. Medical Policy Reference Manual. (11:2015). Epidural steroid injections for back pain (2.01.94). Retrieved April 7, 2016 from BlueWeb. (32 articles and/or guidelines reviewed)

Cahaba Government Benefit Administrators, LLC. (2015, October). LCD for Surgery: Injections of the spinal canal (L34291). Retrieved April 12, 2016 from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34291&ContrId=218&ver=2&ContrVer=1&DocID=L34291&bc=gAAAAAgAAAAAAA%3d%3d&.

Friedly, J. L., Comstock, B.A., Turner, J.A., Heagerty, P.J., Deyo, R. A., et al. (2014). A randomized trial of epidural glucocorticoid injections for spinal stenosis. The New England Journal of Medicine, 371 (1), 11-31. (Level 1 evidence)

Institute for Clinical Systems Improvement. (2012). Adult acute and subacute low back pain. Retrieved February 21, 2014 from https://www.icsi.org/_asset/bjvqrj/LBP.pdf.

Liu, K., Liu, P., Liu, R., Wu, X., & Cai, M. (2015). Steroid for epidural injection in spinal stenosis: a systematic review and meta-analysis. Drug Design, Development and Therapy, 2015 (9), 707-716. (Level 1 evidence)

Manchikanti, L., Abdi, S., Atluri, S., Benyamin, R. M., Boswell, M. V., Buenaventura, R. M., et al. (2013). An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: Guidance and recommendations. Pain Physician, 16 (2 Suppl.), S49-S283.

Manchikanti, L., Buenaventura, R. M., Manchikanti, K. N., Ruan, X., Gupta, S., Smith, H. S., et al. (2012). Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician, 15 (3), E199-E245.

Manchikanti, L., Kaye, A.D., Manchikanti, K., Boswell, M., Pampati, V., & Hirsch, J. (2015). Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review. Anesthesiology and Pain Medicine, 5 (1), e23139. (Level 1 evidence)

North American Spine Society. (2010). Evidence-based clinical guidelines for multidisciplinary spine care: diagnosis and treatment of cervical radiculopathy from degenerative disorders. Retrieved April 12, 2016 from https://www.spine.org/Portals/0/Documents/ResearchClinicalCare/Guidelines/CervicalRadiculopathy.pdf.

North American Spine Society. (2011). Cervical epidural steroid injections: Review & recommendation statement. Retrieved April 11, 2016 from https://www.spine.org/Portals/0/Documents/ResearchClinicalCare/CESIReviewRecStatement.pdf.

North American Spine Society. (2011). Evidence-based clinical guidelines for multidisciplinary spine care: diagnosis and treatment of degenerative lumbar spinal stenosis. Retrieved August 18, 2015 from https://www.spine.org/Portals/0/Documents/ResearchClinicalCare/Guidelines/LumbarStenosis.pdf.

North American Spine Society. (2012). Evidence-based clinical guidelines for multidisciplinary spine care: clinical guidelines for diagnosis and treatment of lumbar disc herniation with radiculopathy. Retrieved August 18, 2015 from https://www.spine.org/Portals/0/Documents/ResearchClinicalCare/Guidelines/LumbarStenosis.pdf.

Winifred S. Hayes, Inc. Medical Technology Directory. (2013, September; last update search July 2015). Epidural steroid injections for cervical radiculopathy. Retrieved April 11, 2016 from www.Hayesinc.com/subscribers. (70 articles and/or guidelines reviewed)

Winifred S. Hayes, Inc. Medical Technology Directory. (2015, January; last update search January 2016). Epidural steroid injections for low back pain and sciatica. Retrieved August 18, 2015 from www.Hayesinc.com/subscribers. (73 articles and/or guidelines reviewed)

Zhai, J., Zhang, L., Li, M., Tian, Y., Zheng, W., Chen, J., et al. (2015). Epidural injection with or without steroid in managing chronic low back and lower extremity pain: a meta-analysis of ten randomized controlled trials. International Journal of Clinical and Experimental Medicine, 15 (8), 8304-8316. Abstract retrieved April 14, 2016 from PubMed database.

ORIGINAL EFFECTIVE DATE:  4/1999

MOST RECENT REVIEW DATE:  8/20/2016

ID_BT

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