Criteria for Cervical or Lumbar Facet Neurotomy
Inclusion Criteria
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CLINICAL FINDINGS |
| CONSERVATIVE CARE |
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SUBJECTIVE/OBJECTIVE |
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DIAGNOSTIC TESTS |
| Failure of 6 months of noninvasive therapy such as physical therapy, medications, or manual therapy (mobilization/manipulation) |
AND |
Non-radicular neck or back pain
AND
Segmental pain or tenderness at the level of the potentially involved facet and not more than 2 joint levels bilaterally or 3 joint levels unilaterally
AND
Neurologically intact for the region involved
OR
If neurologic deficit is present, it should be addressed in the treatment plan.
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AND |
Diagnostic testing as required to rule out any correctable structural lesion to include CT or MRI.
Diagnostic blocks should not involve more than 2 joint levels bilaterally or 3 joint levels unilaterally.
AND
Minimum of at least 2 differential local anesthetic blocks. One block must be of the medial branch of the dorsal ramus innervating the targeted facet joints; the other block may be an intra-articular facet joint block.
AND
Differential blocks may be either 0.5 mL total volume of a short acting local anesthetic (2% to 4% lidocaine); or 0.5 mL total volume of a long acting local anesthetic (0.5% to 0.75% bupivacaine).
AND
Steroid may be used with a local anesthetic for the intra-articular block but total volume of both local and steroid should not exceed 0.5 mL for cervical injection and 0.75 mL for lumbar injection.
AND
Minimum of 80% pain relief following each block while performing activities that previously provoked pain. Documentation of pain relief should be a patient-generated report in real-time, every 15 minutes for the first six hours following the block.
AND
Duration of pain relief should be consistent with the expected duration of the local anesthetic injected (at least 1 hour for short acting and at least 2 hours for long acting local anesthetic).
AND/OR
Placebo controlled blocks may be used to resolve any ambiguity of results of local anesthetic blocks.
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Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging
Exclusion Criteria That Would Require Utilization Review (UR) Physician Review
- Radiculopathy
- Anticipated cervical, thoracic, or lumbar surgery, or surgery for any other condition
- Previous fusion at the targeted level
- Diagnosed with a psychiatric condition likely to interfere with diagnostic accuracy of the workup protocol or with recovery following the anticipated procedure
- Multiple, focal, chronic pain syndromes (i.e., complex regional pain syndrome [CRPS], fibromyalgia, chronic fatigue syndrome)
- Intravenous (IV) sedation during a diagnostic block
Documentation of Pain Relief Following Diagnostic Medial Nerve Branch Block or Facet Joint Block
No pain medication should be taken for four hours prior to each diagnostic medial nerve branch block or facet joint block. No IV sedation should be administered before or during a diagnostic block except in an extreme case of anxiety. Prior to the block, pain should be reproducible with positioning of the patient, to at least a "4" on a 0-10 pain scale.
After each diagnostic block the injured worker must document the level of pain relief obtained using the Neurotomy Workup Pain Relief Report Form found in the original guideline document. The form may be copied as needed. The injured worker is to engage in the activities that previously produced pain and document the level of pain relief obtained every 15 minutes for a minimum of six hours following each block, or until their usual level of pain returns, whichever occurs first. The worker is to return the completed form to the physician at the next scheduled office visit. Place a copy of the Pain Relief Report Form in the medical record, send a copy to the department, and another copy to the department's utilization review vendor if a facet neurotomy is requested.
Reactivation and Maximum Medical Improvement following a Facet Neurotomy
Prior to a facet neurotomy, a formal plan for reactivation must be developed, and agreed upon by the injured worker. If indicated, vocational assessment and/or plan development should be considered prior to the procedure. Progressive reactivation, as appropriate based on the injured worker's condition, may include up to four weeks of outpatient physical therapy or occupational therapy, or work hardening.
A facet neurotomy should be the final procedure performed before an injured worker is expected to be at maximum medical improvement. Payment for repeat facet neurotomy at the same level and the same side will not be authorized. It is important that the injured worker receive a facet neurotomy when it will provide the maximum functional benefit. In almost all cases, that will be when the injured worker is about to return to work or enter vocational rehabilitation. For these reasons, at the conclusion of the post procedure reactivation period, the injured worker should be at maximum medical improvement.
