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Evidence case study: to review the clinical efficacy of injection therapy for treating low back pain

What was the aim of the evidence review?

Treating back pain is very costly. Bristol Clinical Commissioning Group (CCG) wanted to look at efficacy of injection therapy in light of the high cost. Other pathways are being considered in a wider related piece of work.

Who completed the evidence review?

Dr Nick Snelling, GP Clinical Evidence Fellow (funded by the West of England Academic Health Science Network and Bristol Clinical Commissioning Group).

What did they do?

Nick looked at the most up to date review in the Cochrane database and did a search using British Medical Association library search services across Embase, Medline and Cochrane.

How long did it take?

The review took 30 hours over about two months, working four hours per week. This is the equivalent of one GP session per week.

What did they find?

The evidence Nick found for both treatments was of low to moderate quality. For spinal stenosis and localised low back pain, the evidence suggests epidural injections are not clinically effective. For facet joint injections, the evidence suggests insufficient clinical effectiveness.

Who was the evidence shared with and why?

The evidence was shared with Bristol Clinical Commissioning Group’s Planned Care Lead, to consider whether to make any changes to the service.

It was also shared with the integrated pain management health integration team to assess views of implementation in practice. This is a multi-disciplinary team of clinicians across Bristol, North Somerset and South Gloucestershire.

How were the findings used in local decision-making?

The evidence review was submitted to the commissioning policy review group in Bristol Clinical Commissioning Group, which makes clinical recommendations on individual funding request policies. The group was aware that the National Institute for Health and Care Excellence (NICE) was reviewing its lower back pain guidance but the update was not expected for several months.

The locally produced evidence review provided confidence to the group in making policy change, at a time when the policy was under review. Engagement with clinical leads to implement this change took three to four months, the usual length of time for any new policy.

What has changed as a result?

Facet joint injections can now only be requested by exception via the ‘interventions not normally funded’ process.

The anticipated savings are based on the majority of the £100,000 spend per annum for facet join injections that will no longer routinely be administered, across three clinical commissioning groups (Bristol, North Somerset and South Gloucestershire).

This change in policy has impacted patient satisfaction for some patients who were getting short-term relief with regular facet joint injections. Some will be managed by exception, others may be managed more comprehensibly in the future.