Guideline Number: NIA_CG_301 Last Revised Date: October 2014 Responsible Department: Implementation Date: October 2014 Clinical Operations

Transcription

1 Natinal Imaging Assciates, Inc. Clinical guidelines PARAVERTEBRAL FACET JOINT INJECTIONS OR BLOCKS CPT Cdes: Cervical Thracic Regin: ( , ), 0213T (+0214T, +0215T) Lumbar Sacral Regin: (+64494, ), 0216T (+0217T, +0218T) Original Date: Octber 2012 Page 1 f 5 Last Review Date: Octber 2014 Guideline Number: NIA_CG_301 Last Revised Date: Octber 2014 Respnsible Department: Implementatin Date: Octber 2014 Clinical Operatins INTRODUCTION Facet jints (als called zygapphysial jints r z-jints), psterir t the vertebral bdies in the spinal clumn and cnnecting the vertebral bdies t each ther, are lcated at the junctin f the inferir articular prcess f a mre cephalad vertebra and the superir articular prcess f a mre caudal vertebra. These jints prvide stability and enable mvement, allwing the spine t bend, twist, and extend in different directins. They als restrict hyperextensin and hyperflexin. Facet jints are clinically imprtant spinal pain generatrs in patients with chrnic spinal pain. In patients with chrnic lw back pain, facet jints have been implicated as a cause f the pain in 15% t 45% f patients. Facet jints are cnsidered as the cause f chrnic spinal pain in 48% f patients with thracic pain and 54% t 67% f patients with chrnic neck pain. Facet jints may refer pain t adjacent structures, making the underlying diagnsis difficult as referred pain may assume a pseudradicular pattern. Lumbar facet jints may refer pain t the back, buttcks, and lwer extremities while cervical facet jints may refer pain t the head, neck and shulders. Imaging findings are f little value in determining the surce and lcatin f facet jint syndrme, a term riginally used by Ghrmley and referring t back pain caused by pathlgy at the facet jints. Imaging studies may detect changes in facet jint architecture, but crrelatin between radilgic findings and symptms is unreliable. Althugh clinical signs are als unsuitable fr diagnsing facet jint-mediated pain, they may be f value in selecting patients fr cntrlled lcal anesthetic blcks f either the medial branches r the facet jint itself. This is an established tl in diagnsing facet jint syndrme. The mst cmmn surce f chrnic pain is the spine and abut tw-thirds f the U.S. ppulatin suffers frm spinal pain smetime during their life span. Facet jint interventins are used in the treatment f pain in certain patients with a cnfirmed diagnsis f facet jint pain. Interventins include intraarticular injectins and medial branch nerve blcks in the lumbar, cervical and thracic spine. Prir t perfrming this prcedure, shared decisin-making between patient and physician must ccur, and patient 1 Paravertebral Facet Jint Injectins_Blcks Prprietary

2 must understand the prcedure and its ptential risks and results. Facet jint injectins r medial branch nerve blcks require guidance imaging. INDICATIONS FOR FACET JOINT INJECTIONS OR MEDIAL BRANCH NERVE BLOCKS: T cnfirm disabling nn-radicular lw back (lumbsacral) r neck (cervical) pain, suggestive f facet jint rigin as dcumented in the medical recrd based upn all f the fllwing: histry, cnsisting f mainly axial r nn-radicular pain, and physical examinatin, with psitive prvcative signs f facet disease (pain exacerbated by extensin and rtatin, r assciated with lumbar rigidity). Lack f evidence, either fr discgenic r sacriliac jint pain; AND Lack f disc herniatin r evidence f radiculitis; AND Intermittent r cntinuus pain with average pain levels f 6 n a scale f 0 t 10 r functinal disability; AND Duratin f pain f at least 2 mnths; AND Failure t respnd t cnservative nn-perative therapy management. All prcedures must be perfrmed using guidance (Flur, CT, r Ultrasund). FREQUENCY OF FACET BLOCK: There must be a minimum f 14 days between injectins. There must be a psitive respnse f 50% pain relief and imprved ability t perfrm previusly painful mvements. Maximum f 3 prcedures per regin every 6 mnths. If the prcedures are applied fr different regins (cervical and thracic regins are cnsidered as ne regin and lumbar and sacral are cnsidered as ne regin), they may be perfrmed at intervals f n sner than 2 weeks fr mst types f prcedures. Maximum f 3 levels injected n same date f service. Radifrequency Neurlysis prcedures shuld be cnsidered in patients with psitive facet blcks (with at least 50% pain relief and ability t perfrm prir painful mvements withut any significant pain). CONTRAINDICATIONS FOR FACET JOINT INJECTIONS: Histry f allergy t cntrast administratin, lcal anesthetics, sterids, r ther drugs ptentially utilized; Hypvlemia; Infectin ver puncture site; Bleeding disrders r cagulpathy; Histry f allergy t medicatins t be administered; Inability t btain percutaneus access t the target facet jint; Prgressive neurlgical disrder which may be masked by the prcedure; Pregnancy; Spinal infectin; OR Acute Fracture 2 Paravertebral Facet Jint Injectins_Blcks Prprietary

3 ADDITIONAL INFORMATION: *Cnservative Therapy: (spine) shuld include a multimdality apprach cnsisting f a cmbinatin f active and inactive cmpnents. Inactive cmpnents, such as rest, ice, heat, mdified activities, medical devices, acupuncture and/r stimulatrs, medicatins, injectins (epidural, facet, bursal and/r jint, nt including trigger pint), and diathermy can be utilized. Active mdalities may cnsist f physical therapy, a physician supervised hme exercise prgram**, and/r chirpractic care. **Hme Exercise Prgram - (HEP) the fllwing tw elements are required t meet guidelines fr cmpletin f cnservative therapy: Infrmatin prvided n exercise prescriptin/plan AND Fllw up with member with dcumentatin prvided regarding cmpletin f HEP, (after 4 6 week perid) r inability t cmplete HEP due t physical reasn- i.e. increased pain, inability t physically perfrm exercises. (Patient incnvenience r nncmpliance withut explanatin des nt cnstitute inability t cmplete HEP). Terminlgy: Facet Injectins; Facet Jint Blcks; Paravertebral Facet Injectins; Paravertebral Facet Jint Injectins; Paravertebral Facet Jint Nerve Injectins; Zygapphyseal injectins; Lumbar Facet Blckade; Medial Branch blcks 3 Paravertebral Facet Jint Injectins_Blcks Prprietary

4 REFERENCES Atluri, S., Datta, S., Falc, F.J.E., (2008). Systematic review f diagnstic utility and therapeutic effectiveness f thracic facet jint interventins. Pain Physician, 11(5), ISSN Binder, D.S. & Nampiaparampil, D.E. (2009). The prvcative lumbar facet jint. Curr Rev Musculskelet Med, 2(1), di: /s y. Bgduk, N. (2005). A narrative review f intraarticular crticsterid injectins fr lw back pain. Pain Med, 6(4), Retrieved frm Datta, S., Lee, M., Falc, F.J.E., Bryce, D.A. & Hayek, S.M.(2009). Systematic assessment f diagnstic accuracy and therapeutic utility f lumbar facet jint interventins. Pain Physician, 12(2), Retrieved frm Falc, F.J.E., Erhart, S., Warg, B.W., Atluri, S., Datta, S. & Hayek, S.M. (2009). Systematic review f diagnstic utility and therapeutic effectiveness f cervical facet jint interventins. Pain Physician, 12(2), Manchikanti, L., Abdi, S., Atluri, S., Benyamin, R.M., Bswell, M.V., Buenaventura, R.M., Bryce, D.A.,... Hirsch, J.A.(2013). An update f cmprehensive evidence-based guidelines fr interventinal techniques f chrnic spinal pain: Part II: Guidance and recmmendatins. Pain Physician, 16(2 suppl), S49-S283. ISSN Manchikanti, L., Bswell, M.V., Singh, V., Benyamin, R.M., Fellws, B., Abdi, S. Buenaventura, R.M.,... ASIPP-IPM. (2009). Cmprehensive evidence-based guidelines fr interventinal techniques in the management f chrnic spinal pain. Pain Physician, 12(4), ISSN Manchikanti, L., Singh, V., Falc, F.J.E., Cash, K.A. & Pampati, V. (2010). Evaluatin f lumbar facet jint nerve blcks in managing chrnic lw back pain: A randmized, duble-blind, cntrlled trial with a 2-year fllw-up. Internatinal Jurnal Medical Science, 7(3), Retrieved frm Manchikanti, L., Bswell, M.V., Singh, V., Pampati, V., Damrn, K.S. & Beyer. C.D. (2004). Prevalence f facet jint pain in chrnic spinal pain f cervical, thracic, and lumbar regins. BMC Musculskeletal Disrders, 5, 15. Retrieved frm Manchikanti, L., Pampati, V., Singh, V., Bswell, M.V., Smith, H.S. & Hirsch, J.A. (2010). Explsive grwth f facet jint interventins in the medicare ppulatin in the United States: a cmparative evaluatin f 1997, 2002, and 2006 data. BMC Health Serv Research, 10, 84. di: / Paravertebral Facet Jint Injectins_Blcks Prprietary

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