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The following results are compiled from all voting question responses received via the Survey Monkey form that was sent to the twelve (12) panelists and jurisdictional CAC members.
Question 1: Do you agree that the clinical literature supports the following definition of radicular back pain? Radicular pain = Radicular pain is nerve root pain radiating from the affected spinal segment in a distribution concordant with the known distribution of the nerve root.
Answered: 32 Skipped: 0
Answer Choices |
Responses |
Yes |
100.00% |
32 |
No |
0.00% |
0 |
Total |
|
32 |
Question 2: What is your level of confidence that the evidence supports the benefit of epidural steroid injection outweigh risk for radicular pain?
Answered: 32 Skipped: 0
Answer Choices |
Responses |
Extremely confident |
71.88% |
23 |
Very confident |
18.75% |
6 |
Somewhat confident |
3.13% |
1 |
Not so confident |
6.25% |
2 |
Not at all confident |
0.00% |
0 |
Total |
|
32 |
Question 3: Do you agree the evidence supports that “radicular pain” must be concordant with a radiologist’s interpretation of an advanced diagnostic imaging study (MRI or CT) of the spine demonstrating compression of the involved named spinal nerve root(s)?
Answered: 32 Skipped: 0
Answer Choices |
Responses |
Extremely confident |
0.00% |
0 |
Very confident |
0.00% |
0 |
Somewhat confident |
46.88% |
15 |
Not so confident |
40.63% |
13 |
Not at all confident |
12.50% |
4 |
Total |
|
32 |
Question 4: Rate your confidence in the evidence provided to support the use of epidural steroid injections for the following conditions? If you are confident (≥3.0), Please cite references.
Answered: 32 Skipped: 0
Condition |
Extremely Confident |
Very Confident |
Somewhat Confident |
Not So Confident |
Not at All Confident |
Total |
Weighted Average |
Axial spine pain or discogenic pain |
16.67% (5) |
36.67% (11) |
23.33% (7) |
20.00% (6) |
3.33% (1) |
30 |
3.43 |
Lumbar central spinal stenosis |
23.33% (7) |
53.33% (16) |
13.33% (4) |
10.00% (3) |
0.00% (0) |
30 |
3.90 |
Foraminal stenosis |
37.50% (12) |
28.13% (9) |
25.00% (8) |
6.25% (2) |
3.13% (1) |
32 |
3.91 |
Subarticular stenosis |
21.43% (6) |
39.29% (11) |
14.29% (4) |
10.71% (3) |
14.29% (4) |
28 |
3.43 |
Nonspecific low back pain |
0.00% (0) |
0.00% (0) |
0.00% (0) |
23.33% (7) |
76.67% (23) |
30 |
1.23 |
Post-Laminectomy pain syndrome |
6.25% (2) |
59.38% (19) |
18.75% (6) |
6.25% (2) |
9.38% (3) |
32 |
3.47 |
Non-organic back pain |
0.00% (0) |
0.00% (0) |
0.00% (0) |
6.67% (2) |
93.33% (28) |
30 |
1.07 |
Widespread diffuse pain |
0.00% (0) |
0.00% (0) |
3.23% (1) |
3.23% (1) |
93.55% (29) |
31 |
1.10 |
Complex regional pain syndrome |
0.00% (0) |
0.00% (0) |
37.93% (11) |
27.59% (8) |
34.48% (10) |
29 |
2.03 |
Post herpetic neuralgia |
3.45% (1) |
6.90% (2) |
41.38% (12) |
31.03% (9) |
17.24% (5) |
29 |
2.48 |
Acute herpes zoster |
6.90% (2) |
17.24% (5) |
34.48% (10) |
24.14% (7) |
17.24% (5) |
29 |
2.72 |
Traumatic neuropathy of the spinal nerve roots |
0.00% (0) |
6.90% (2) |
20.69% (6) |
44.83% (13) |
27.59% (8) |
29 |
2.07 |
Intractable and severe pain secondary to neuropathy from other causes (e.g., diabetic or metabolic) |
0.00% (0) |
0.00% (0) |
10.00% (3) |
60.00% (18) |
30.00% (9) |
30 |
1.80 |
Severe, intractable pain in patients with advanced stages of cancer with estimated life expectancy of 4 months or less. |
3.33% (1) |
6.67% (2) |
26.67% (8) |
43.33% (13) |
20.00% (6) |
30 |
2.30 |
Cervicogenic headaches |
6.90% (2) |
6.90% (2) |
41.38% (12) |
34.48% (10) |
10.34% (3) |
29 |
2.66 |
Cervicobrachialgia |
34.48% (10) |
34.48% (10) |
10.34% (3) |
3.45% (1) |
17.24% (5) |
29 |
3.66 |
Facet synovial cysts |
17.24% (5) |
10.34% (3) |
20.69% (6) |
20.69% (6) |
31.03% (9) |
29 |
2.62 |
Epidural lipomatosis |
0.00% (0) |
6.90% (2) |
24.14% (7) |
58.62% (17) |
10.34% (3) |
29 |
2.28 |
Question 5: What level of confidence do you have that the evidence supports a period of conservative management prior to treatment with an epidural injection?
Answered: 31 Skipped: 1
Answer Choices |
Responses |
Extremely confident |
22.58% |
7 |
Very confident |
12.90% |
4 |
Somewhat confident |
41.94% |
13 |
Not so confident |
19.35% |
6 |
Not at all confident |
3.23% |
1 |
Total |
|
31 |
Question 6: What level of confidence do you have that the evidence supports there should be documented pain relief failure of at least two (2) classes of medications prior to patients receiving an epidural procedure. Note: Medication classes would consist of: NSAIDs, opiates, non-opioid analgesics, anti-epileptic medications used for treatment of chronic pain, antidepressant medications used for treatment of chronic pain, ASA or ASA derivatives, muscle relaxants, steroids, or documented contraindication to each of these drug classes.
Answered: 31 Skipped: 1
Answer Choices |
Responses |
Extremely confident |
12.90% |
4 |
Very confident |
6.45% |
2 |
Somewhat confident |
9.68% |
3 |
Not so confident |
48.39% |
15 |
Not at all confident |
22.58% |
7 |
Total |
|
31 |
Question 7: What level of confidence do you have that the evidence supports the following are considered contraindications to epidural injections?
Answered: 31 Skipped: 1
Condition |
Extremely Confident |
Very Confident |
Somewhat Confident |
Not So Confident |
Not at All Confident |
Total |
Medically controlled Coagulopathy |
32.26% (10) |
16.13% (5) |
19.35% (6) |
16.13% (5) |
16.13% (5) |
31 |
Concurrent systemic infection |
70.97% (22) |
16.13% (5) |
9.68% (3) |
3.23% (1) |
0.00% (0) |
31 |
Infectious spondylitis |
74.19% (23) |
12.90% (4) |
6.45% (2) |
3.23% (1) |
3.23% (1) |
31 |
Acute spinal cord compression |
58.06% (18) |
9.68% (3) |
12.90% (4) |
6.45% (2) |
12.90% (4) |
31 |
Acute myelopathy or cauda equina syndrome |
58.06% (18) |
19.35% (6) |
6.45% (2) |
9.68% (3) |
6.45% (2) |
31 |
Inability to obtain informed consent from patient, healthcare surrogate or legal guardian |
70.97% (22) |
16.13% (5) |
3.23% (1) |
3.23% (1) |
6.45% (2) |
31 |
Infection at the skin puncture site |
70.97% (22) |
16.13% (5) |
3.23% (1) |
9.68% (3) |
0.00% (0) |
31 |
Major risk factor for cancer or strong clinical suspicion for cancer with no established etiology |
16.13% (5) |
16.13% (5) |
12.90% (4) |
38.71% (12) |
16.13% (5) |
31 |
Potential presence of a CNS process resulting in the presenting symptoms, e.g., transverse myelitis, central demyelination/rapidly progressing neurological deficits |
16.13% (5) |
35.48% (11) |
16.13% (5) |
19.35% (6) |
12.90% (4) |
31 |
Question 8: What is your level of confidence that the evidence supports the benefit of epidural steroid injection outweigh risk for cervical radicular pain?
Answered: 31 Skipped: 1
Answer Choices |
Responses |
Extremely confident |
58.06% |
18 |
Very confident |
25.81% |
8 |
Somewhat confident |
6.45% |
2 |
Not so confident |
6.45% |
2 |
Not at all confident |
3.23% |
1 |
Total |
|
31 |
Question 9: What is your level of confidence that the evidence supports the benefit of epidural steroid injection outweigh risk for thoracic radicular pain?
Answered: 31 Skipped: 1
Answer Choices |
Responses |
Extremely confident |
19.35% |
6 |
Very confident |
48.39% |
15 |
Somewhat confident |
12.90% |
4 |
Not so confident |
16.13% |
5 |
Not at all confident |
3.23% |
1 |
Total |
|
31 |
Question 10: What level of confidence do you have that the evidence supports epidural injections should only performed be with an anesthetic, corticosteroid, and/or a contrast agent (i.e., do you agree other substances are experimental)?
Answered: 31 Skipped: 1
Answer Choices |
Responses |
Extremely confident |
38.71% |
12 |
Very confident |
29.03% |
9 |
Somewhat confident |
16.13% |
5 |
Not so confident |
9.68% |
3 |
Not at all confident |
6.45% |
2 |
Total |
|
31 |
Question 11: What level of confidence do you have that the evidence supports the following routes of administration.
Answered: 31 Skipped: 1
Administration Route |
Extremely Confident |
Very Confident |
Somewhat Confident |
Not That Confident |
Not at All Confident |
Total |
transforaminal (TFESI) |
70.97% (22) |
19.35% (6) |
3.23% (1) |
6.45% (2) |
0.00% (0) |
31 |
interlaminar (IESI) |
61.29% (19) |
25.81 (8) |
6.45% (2) |
6.45% (2) |
0.00% (0) |
31 |
caudal (CESI) |
54.84% (17) |
19.35% (6) |
16.13% (5) |
9.68% (3) |
0.00% (0) |
31 |
Question 12: What is your confidence that the clinical literature supports that the epidural steroid injection provide at least 50% pain relief? What scales do you recommend for measuring pain relief?
Answered: 31 Skipped: 1
Answer Choices |
Responses |
Extremely confident |
35.48% |
11 |
Very confident |
32.26% |
10 |
Somewhat confident |
12.90% |
4 |
Not so confident |
16.13% |
5 |
Not at all confident |
3.23% |
1 |
Total |
|
31 |
Question 13: What is your confidence level that there is evidence to support improvement in function as a measurement of epidural steroid injection success?
Answered: 31 Skipped: 1
Answer Choices |
Responses |
Extremely confident |
35.48% |
11 |
Very confident |
35.48% |
11 |
Somewhat confident |
19.35% |
6 |
Not so confident |
9.68% |
3 |
Not at all confident |
0.00% |
0 |
Total |
|
31 |
Question 14: What is your level of confidence that the evidence demonstrates epidural steroid injection provided relief for a minimum of six weeks after the injection?
Answered: 31 Skipped: 1
Answer Choices |
Responses |
Extremely confident |
29.03% |
9 |
Very confident |
41.94% |
13 |
Somewhat confident |
12.90% |
4 |
Not so confident |
6.45% |
2 |
Not at all confident |
9.68% |
3 |
Total |
|
31 |
Question 15: Is there evidence supporting repeat epidural treatments if the initial epidural treatment did not result in substantial pain relief?
Answered: 31 Skipped: 1
Answer Choices |
Responses |
Extremely confident |
32.26% |
10 |
Very confident |
22.58% |
7 |
Somewhat confident |
19.35% |
6 |
Not so confident |
16.13% |
5 |
Not at all confident |
9.68% |
3 |
Total |
|
31 |
Question 16: Is there evidence to support treatment at a different nerve level even in the same spinal region may be effective?
Answered: 31 Skipped: 1
Answer Choices |
Responses |
Extremely confident |
12.90% |
4 |
Very confident |
41.94% |
13 |
Somewhat confident |
25.81% |
8 |
Not so confident |
16.13% |
5 |
Not at all confident |
3.23% |
1 |
Total |
|
31 |
Question 17: Is there literature to support an optimal interval between repeat epidural steroid injections, provided that previous injections resulted in at least 50% relief or functional improvement for at least six weeks?
Answered: 29 Skipped: 3
Answer Choices |
Responses |
Yes |
41.38% |
12 |
No |
58.62% |
17 |
Total |
|
29 |
Question 18: Does the literature provide input on a safe or harmful number of epidurals injections per year? Yes or no, please provide references. If there is no evidence, is there societal input and what do you consider a safe number in 12 months and why? Please include input on the potential effects of the repeat steroid administration.
Answered: 28 Skipped: 4
Note: this was an open-ended question; no scored response.
Question 19: Does the literature provide input on the safety of multiple levels of epidural steroid injections in the same session? Yes or no, please provide references. If there is no evidence, what do you consider a safe number per session, and why?
Answered: 28 Skipped: 4
Note: this was an open-ended question; no scored response.
Question 20: Does the literature provide input on safe duration of time between the administrations of separate epidurals in the same spinal region?
Answered: 27 Skipped: 5
Note: this was an open-ended question; no scored response.
Question 21: Does the clinical literature provide evidence that epidural steroid injections can be administered safely at the same time as other interventional procedures (such as facet, nerve blocks)?
Answered: 29 Skipped: 3
Answer Choices |
Responses |
Yes |
58.62% |
17 |
No |
41.38% |
12 |
Total |
|
29 |
Question 22: What is your level of confidence in the evidence to support repeat epidural injections for long-term (> 6 months) management of chronic back pain? Score 1-5. If you are confident (score ≥3), there is support for what patients are considered good candidates for long-term treatments, and based on what literature?
Answered: 31 Skipped: 1
Answer Choices |
Responses |
Extremely confident |
45.16% |
14 |
Very confident |
29.03% |
9 |
Somewhat confident |
9.68% |
3 |
Not so confident |
9.68% |
3 |
Not at all confident |
6.45% |
2 |
Total |
|
31 |
Question 23: What is your level of confidence epidural injections should not be performed with moderate sedation or general anesthesia?
Answered: 30 Skipped: 2
Answer Choices |
Responses |
Extremely confident |
40.00% |
12 |
Very confident |
16.67% |
5 |
Somewhat confident |
13.33% |
4 |
Not so confident |
16.67% |
5 |
Not at all confident |
13.33% |
4 |
Total |
|
30 |
Question 24: What is your level of confidence that the evidence supports a maximal steroid dose for corticosteroid limits for the injectants and what limits are supported?
Answered: 31 Skipped: 1
Answer Choices |
Responses |
Extremely confident |
45.16% |
14 |
Very confident |
25.81% |
8 |
Somewhat confident |
12.90% |
4 |
Not so confident |
12.90% |
4 |
Not at all confident |
3.23% |
1 |
Total |
|
31 |
Question 25: What is your level of confidence that the evidence supports the continuation of anticoagulation for epidural injections?
Answered: 30 Skipped: 2
Answer Choices |
Responses |
Extremely confident |
6.67% |
2 |
Very confident |
6.67% |
2 |
Somewhat confident |
13.33% |
4 |
Not so confident |
43.33% |
13 |
Not at all confident |
30.00% |
9 |
Total |
|
30 |
Question 26: What is your level of confidence that the evidence supports that epidural adhesiolysis is effective and safe?
Answered: 30 Skipped: 2
Answer Choices |
Responses |
Extremely confident |
23.33% |
7 |
Very confident |
20.00% |
6 |
Somewhat confident |
23.33% |
7 |
Not so confident |
20.00% |
6 |
Not at all confident |
13.33% |
4 |
Total |
|
30 |
Question 27: Is there evidence to support epidural steroid injections reduce the need for surgical intervention?
Answered: 31 Skipped: 1
Answer Choices |
Responses |
Extremely confident |
16.13% |
5 |
Very confident |
29.03% |
9 |
Somewhat confident |
45.16% |
14 |
Not so confident |
9.68% |
3 |
Not at all confident |
0.00% |
0 |
Total |
|
31 |
Question 28: Is there evidence to support epidural steroid injections reduce the need for opioids?
Answered: 31 Skipped: 1
Answer Choices |
Responses |
Extremely confident |
12.90% |
4 |
Very confident |
32.26% |
10 |
Somewhat confident |
45.16% |
14 |
Not so confident |
6.45% |
2 |
Not at all confident |
3.23% |
1 |
Total |
|
31 |
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