Excluded: Procedure not routinely funded
Application form: - Facet joint injections and medial branch blocks for chronic neck pain
Name of Referring ClinicianGP Name and Surgery
Patients NHS Number
Is the patient/guardian aware of the proposed treatment and have they consented to you raising this request on their behalf? / Yes ☐No ☐
Has the patient/guardian consented for their personal and clinical information to be provided to the IFR service to enable full consideration of this funding request? / Yes ☐No ☐
Is this a patient/guardian led application? / Yes ☐No ☐
Most Urgent: Decision needed within a week as the patient’s life may be in danger. / ☐ /
Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. / ☐ /
Routine: Decision needed in 4 to 6 weeks. / ☐ /
Thames Valley Priorities Committee has considered the evidence for the clinical and cost effectiveness of therapeutic and diagnostic facet joint injections and medial branch blocks for the treatment of chronic low back and neck pain.
The Committee concluded that the evidence for clinical and cost effectiveness is inadequate and therefore recommends that facet joint injections and medial branch blocks for diagnostic and therapeutic purposes are not normally funded.
Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: or consideration.
The policy statements are available at: :
Clinical Criteria required for consideration of treatment / Please Tick
1.What type of injection is requested?
☐Facet Joint Injection for chronic neck pain – for diagnostic purposes.
☐Facet Joint Injection for chronic neck pain - for therapeutic purposes
☐Medial Branch Block for chronic neck pain – for diagnostic purposes.
☐Medical Branch Block for chronic neck pain - for therapeutic purposes
NB:Please use alternative form for Injections for the management of low back pain and sciatica.
2.Has the patient followed the recommended pathway including the local MSK?
Please attach the MSK referral information to the case file. / YES☐NO☐
3.Details of historical pain: Please note the Panel will only consider your request if the patient has had documented pain in the long-term, i.e. one year or over.
How long has the patient been managing with the symptoms?
Cause of Pain:
Type of Pain:
Duration of Pain:
Recent Average Pain Score(s) over the latest month with dates:
Date / Average Pain Score
Conservative Measures
Please detail which non-drug treatments and conservative measures have been tried
☐Completed weight loss program (where applicable)
☐Exercise
☐Physiotherapy
☐Self-management
Please provide specific details:
Are the patient’s symptoms persistent and do they significantly interfere with activities of daily living?
Please indicate:
☐Work-related issues – Light duties because of the condition
☐Work-related issues – Off work/missed work/ unable to work due to condition
☐Domestic activities
☐Carer activities / YES☐NO☐
4.What drugs have been tried for this condition?
Drug / Dose / Date Started (approx.) / Date Stopped (approx.) / Outcome & Reason for Stopping /Continuing
(e.g. state the side effect, if it did not work or reason for continuing)
5.For patients who have already received previous injections:
Date of the most recent injection:
Number of previous injections:
Anatomical site of previous injection:
Details of the extent of the health benefit received from the injection and over what period of time:
6.Patient’s Body Mass Index
BMI / kg/m2
Height / cm
Weight / kg
7.Is the patient a non-smoker? / YES☐NO☐
8.Exceptional health need of this patient.
Please provide details of the exceptional health need of the patient?
9.If funding is not approved what is the possible alternative treatment?
South, Central and West Commissioning Support Unit June 2017 BU TVPC56