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Cervical-spine-injury-medical-treatment-guidelines
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<h1>Cervical spine injury medical treatment guidelines.</h1>
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<table><tr><td>Colorado Division of Workers' Compensation. Cervical spine injury medical treatment guidelines. Denver (CO): Colorado Division of Workers' Compensation; 2014 Feb 3. 96 p. </td></tr></table> <p><a href="/web/20180713033424/https://www.guideline.gov/Home/Disclaimer?id=49019&contentType=fulltextlink&redirect=https%253a%252f%252fwww.colorado.gov%252fpacific%252fsites%252fdefault%252ffiles%252fMTG_Ex8_CSI.pdf">View the original guideline documentation</a> <img alt="External Web Site Policy" src="/web/20180713033424im_/https://www.guideline.gov/UI/images/icon_externallink.gif"/></p>
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<p><div class="content_para"><p>This is the current release of the guideline.</p>
<p>This guideline meets NGC's 2013 (revised) inclusion criteria.</p></div></p>
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<h5 class="field-label">HCPCS</h5>
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<a href="/web/20180713033424/https://www.guideline.gov/search?f_HCPCS_CUI=C0500223&fLockTerm=Prolotherapy">Prolotherapy</a>
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<a href="/web/20180713033424/https://www.guideline.gov/search?f_ICD9CM_CUI=C0012002&fLockTerm=Diathermy">Diathermy</a>
(93.34), <a href="/web/20180713033424/https://www.guideline.gov/search?f_ICD9CM_CUI=C0282615&fLockTerm=Division+of+intraspinal+nerve+root">Division of intraspinal nerve root</a>
(03.1), <a href="/web/20180713033424/https://www.guideline.gov/search?f_ICD9CM_CUI=C0206078&fLockTerm=Excision+of+intervertebral+disc">Excision of intervertebral disc</a>
(80.51), <a href="/web/20180713033424/https://www.guideline.gov/search?f_ICD9CM_CUI=C0022024&fLockTerm=Iontophoresis">Iontophoresis</a>
(99.27), <a href="/web/20180713033424/https://www.guideline.gov/search?f_ICD9CM_CUI=C0037935&fLockTerm=Spinal+fusion%2c+not+otherwise+specified">Spinal fusion, not otherwise specified</a>
(81.00), <a href="/web/20180713033424/https://www.guideline.gov/search?f_ICD9CM_CUI=C0034996&fLockTerm=Vocational+rehabilitation">Vocational rehabilitation</a>
(93.85) </div>
<!-- /.field-content -->
</div>
<!-- /.field -->
<div class="field">
<h5 class="field-label">MSH</h5>
<div class="field-content">
<a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0000970&fLockTerm=Acetaminophen">Acetaminophen</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0001288&fLockTerm=Activities+of+Daily+Living">Activities of Daily Living</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0394664&fLockTerm=Acupuncture+Therapy">Acupuncture Therapy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0002772&fLockTerm=Analgesics%2c+Opioid">Analgesics, Opioid</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0005491&fLockTerm=Biofeedback%2c+Psychology">Biofeedback, Psychology</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0527443&fLockTerm=Bone+Morphogenetic+Protein+2">Bone Morphogenetic Protein 2</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0006055&fLockTerm=Botulinum+Toxins">Botulinum Toxins</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0162563&fLockTerm=Catheter+Ablation">Catheter Ablation</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0009244&fLockTerm=Cognitive+Therapy">Cognitive Therapy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0009452&fLockTerm=Communication">Communication</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0010412&fLockTerm=Cryotherapy">Cryotherapy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0376530&fLockTerm=Decompression%2c+Surgical">Decompression, Surgical</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0011307&fLockTerm=Denervation">Denervation</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0012002&fLockTerm=Diathermy">Diathermy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0206078&fLockTerm=Diskectomy">Diskectomy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0206080&fLockTerm=Diskectomy%2c+Percutaneous">Diskectomy, Percutaneous</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0013787&fLockTerm=Electric+Stimulation+Therapy">Electric Stimulation Therapy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0717758&fLockTerm=Etanercept">Etanercept</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0452240&fLockTerm=Exercise+Therapy">Exercise Therapy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0196248&fLockTerm=Foraminotomy">Foraminotomy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0020548&fLockTerm=Hyperthermia%2c+Induced">Hyperthermia, Induced</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0020592&fLockTerm=Hypnotics+and+Sedatives">Hypnotics and Sedatives</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0020944&fLockTerm=Immobilization">Immobilization</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0020852&fLockTerm=Immunoglobulin+G">Immunoglobulin G</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0021486&fLockTerm=Injections%2c+Epidural">Injections, Epidural</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0021818&fLockTerm=Intervertebral+Disc+Displacement">Intervertebral Disc Displacement</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0022024&fLockTerm=Iontophoresis">Iontophoresis</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0022983&fLockTerm=Laminectomy">Laminectomy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0024725&fLockTerm=Manipulation%2c+Orthopedic">Manipulation, Orthopedic</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0079637&fLockTerm=Monitoring%2c+Intraoperative">Monitoring, Intraoperative</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0026833&fLockTerm=Muscle+Relaxants%2c+Central">Muscle Relaxants, Central</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0521168&fLockTerm=Occupational+Injuries">Occupational Injuries</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0524852&fLockTerm=Orthopedic+Procedures">Orthopedic Procedures</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0029365&fLockTerm=Orthotic+Devices">Orthotic Devices</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0030679&fLockTerm=Patient+Care+Team">Patient Care Team</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0030688&fLockTerm=Patient+Education+as+Topic">Patient Education as Topic</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0949766&fLockTerm=Physical+Therapy+Modalities">Physical Therapy Modalities</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0500223&fLockTerm=Prolotherapy">Prolotherapy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0033978&fLockTerm=Psychotropic+Drugs">Psychotropic Drugs</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0077503&fLockTerm=Receptors%2c+Tumor+Necrosis+Factor">Receptors, Tumor Necrosis Factor</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0034991&fLockTerm=Rehabilitation">Rehabilitation</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0034996&fLockTerm=Rehabilitation%2c+Vocational">Rehabilitation, Vocational</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0425105&fLockTerm=Return+to+Work">Return to Work</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0282615&fLockTerm=Rhizotomy">Rhizotomy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0037935&fLockTerm=Spinal+Fusion">Spinal Fusion</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0037937&fLockTerm=Spinal+Injuries">Spinal Injuries</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0038317&fLockTerm=Steroids">Steroids</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C2144940&fLockTerm=Total+Disc+Replacement">Total Disc Replacement</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0040597&fLockTerm=Traction">Traction</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0040610&fLockTerm=Tramadol">Tramadol</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0040654&fLockTerm=Transcutaneous+Electric+Nerve+Stimulation">Transcutaneous Electric Nerve Stimulation</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0041620&fLockTerm=Ultrasonic+Therapy">Ultrasonic Therapy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MSH_CUI=C0043233&fLockTerm=Workers%27+Compensation">Workers' Compensation</a>
</div>
<!-- /.field-content -->
</div>
<!-- /.field -->
<div class="field">
<h5 class="field-label">MTH</h5>
<div class="field-content">
<a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0000970&fLockTerm=Acetaminophen">Acetaminophen</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0001288&fLockTerm=Activities+of+Daily+Living+(activity)">Activities of Daily Living (activity)</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0394664&fLockTerm=Acupuncture+procedure">Acupuncture procedure</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0002772&fLockTerm=Analgesics%2c+Opioid">Analgesics, Opioid</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0005491&fLockTerm=Biofeedback">Biofeedback</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0678663&fLockTerm=Biological+feedback">Biological feedback</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0527443&fLockTerm=bone+morphogenetic+protein+2">bone morphogenetic protein 2</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0006055&fLockTerm=Botulinum+Toxins">Botulinum Toxins</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0162563&fLockTerm=Cardiac+ablation">Cardiac ablation</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0186010&fLockTerm=Cervical+arthrodesis">Cervical arthrodesis</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0175751&fLockTerm=Cervical+collar+(device)">Cervical collar (device)</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C2026796&fLockTerm=cervical+laminoplasty">cervical laminoplasty</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0009244&fLockTerm=Cognitive+Therapy">Cognitive Therapy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0010412&fLockTerm=Cold+Therapy">Cold Therapy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0009452&fLockTerm=Communication">Communication</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0332459&fLockTerm=Compressed+structure">Compressed structure</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0011307&fLockTerm=Denervation">Denervation</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0012002&fLockTerm=Diathermy">Diathermy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0242362&fLockTerm=Disk%2c+Herniated">Disk, Herniated</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0013787&fLockTerm=Electric+Stimulation+Therapy">Electric Stimulation Therapy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0717758&fLockTerm=Etanercept">Etanercept</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0181278&fLockTerm=Halo+brace">Halo brace</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0020592&fLockTerm=Hypnotics+and+Sedatives">Hypnotics and Sedatives</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0020944&fLockTerm=Immobilization">Immobilization</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0020852&fLockTerm=Immunoglobulin+G">Immunoglobulin G</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0020548&fLockTerm=Induced+Hyperthermia">Induced Hyperthermia</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0021818&fLockTerm=Intervertebral+Disk+Displacement">Intervertebral Disk Displacement</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0022024&fLockTerm=Iontophoresis">Iontophoresis</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0476648&fLockTerm=Limitation+of+activities+due+to+disability">Limitation of activities due to disability</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0498269&fLockTerm=Manipulation+under+anesthesia">Manipulation under anesthesia</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C3536731&fLockTerm=Massage+Therapy">Massage Therapy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0029365&fLockTerm=Orthotic+Devices">Orthotic Devices</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0030688&fLockTerm=Patient+education+(procedure)">Patient education (procedure)</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0206080&fLockTerm=Percutaneous+discectomy">Percutaneous discectomy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0021486&fLockTerm=Peridural+Injection">Peridural Injection</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0949766&fLockTerm=Physical+therapy">Physical therapy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0452240&fLockTerm=Physical+therapy+exercises">Physical therapy exercises</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C1445578&fLockTerm=recombinant+human+bone+morphogenetic+protein-2">recombinant human bone morphogenetic protein-2</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0034991&fLockTerm=Rehabilitation+therapy">Rehabilitation therapy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0282615&fLockTerm=Rhizotomy+procedure">Rhizotomy procedure</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0037935&fLockTerm=Spinal+fusion+(procedure)">Spinal fusion (procedure)</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0037937&fLockTerm=Spinal+Injuries">Spinal Injuries</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0038317&fLockTerm=Steroids">Steroids</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0150611&fLockTerm=Therapeutic+heat+application">Therapeutic heat application</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0040610&fLockTerm=Tramadol">Tramadol</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0040654&fLockTerm=Transcutaneous+Electric+Nerve+Stimulation">Transcutaneous Electric Nerve Stimulation</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0077503&fLockTerm=Tumor+Necrosis+Factor+Receptor">Tumor Necrosis Factor Receptor</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0041620&fLockTerm=Ultrasonic+Therapy">Ultrasonic Therapy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0372857&fLockTerm=Vertebral+corpectomy+(vertebral+body+resection)%2c+partial+or+complete%2c+anterior+approach+with+decompression+of+spinal+cord+and%2for+nerve+root(s)%3b+cervical%2c+each+additional+segment">Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0034996&fLockTerm=Vocational+rehabilitation">Vocational rehabilitation</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0878538&fLockTerm=Work+conditioning">Work conditioning</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_MTH_CUI=C0043233&fLockTerm=Worker+Compensation">Worker Compensation</a>
</div>
<!-- /.field-content -->
</div>
<!-- /.field -->
<div class="field">
<h5 class="field-label">PDQ</h5>
<div class="field-content">
<a href="/web/20180713033424/https://www.guideline.gov/search?f_PDQ_CUI=C0000970&fLockTerm=acetaminophen">acetaminophen</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_PDQ_CUI=C0394664&fLockTerm=acupuncture">acupuncture</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_PDQ_CUI=C0717758&fLockTerm=etanercept">etanercept</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_PDQ_CUI=C3536731&fLockTerm=massage+therapy">massage therapy</a>
, <a href="/web/20180713033424/https://www.guideline.gov/search?f_PDQ_CUI=C0949766&fLockTerm=physiotherapy">physiotherapy</a>
</div>
<!-- /.field-content -->
</div>
<!-- /.field -->
<div class="field">
<h5 class="field-label">SNOMEDCT_US</h5>
<div class="field-content">
<a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0000970&fLockTerm=Acetaminophen">Acetaminophen</a>
(387517004), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0000970&fLockTerm=Acetaminophen">Acetaminophen</a>
(90332006), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0001288&fLockTerm=Activity+of+daily+living">Activity of daily living</a>
(129025006), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0394664&fLockTerm=Acupuncture">Acupuncture</a>
(44868003), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0181956&fLockTerm=Acupuncture+needle">Acupuncture needle</a>
(60161006), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0582444&fLockTerm=Assisting+with+functional+activity">Assisting with functional activity</a>
(304559009), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0678663&fLockTerm=Biofeedback">Biofeedback</a>
(61334006), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0005491&fLockTerm=Biofeedback+procedure">Biofeedback procedure</a>
(28150003), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0179310&fLockTerm=Biofeedback+system">Biofeedback system</a>
(466651006), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0026833&fLockTerm=Centrally+acting+muscle+relaxant">Centrally acting muscle relaxant</a>
(116524002), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0026833&fLockTerm=Centrally+acting+muscle+relaxant">Centrally acting muscle relaxant</a>
(372583009), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0186010&fLockTerm=Cervical+arthrodesis">Cervical arthrodesis</a>
(81099000), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0175751&fLockTerm=Cervical+collar">Cervical collar</a>
(63562005), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0457369&fLockTerm=Cervical+epidural+steroid+injection">Cervical epidural steroid injection</a>
(278214001), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C2919897&fLockTerm=Cervical+laminectomy">Cervical laminectomy</a>
(445429009), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0206078&fLockTerm=Chondrectomy+of+spine">Chondrectomy of spine</a>
(3418002), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0006055&fLockTerm=Clostridium+botulinum+toxin+agent">Clostridium botulinum toxin agent</a>
(11894001), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0006055&fLockTerm=Clostridium+botulinum+toxin+agent">Clostridium botulinum toxin agent</a>
(418236003), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0006055&fLockTerm=Clostridium+botulinum+toxin+agent">Clostridium botulinum toxin agent</a>
(419254007), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0009244&fLockTerm=Cognitive+therapy">Cognitive therapy</a>
(183383008), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0009244&fLockTerm=Cognitive+therapy">Cognitive therapy</a>
(228553007), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0009244&fLockTerm=Cognitive+therapy">Cognitive therapy</a>
(228557008), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0009244&fLockTerm=Cognitive+therapy">Cognitive therapy</a>
(304891004), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0010412&fLockTerm=Cold+therapy">Cold therapy</a>
(182660006), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0010412&fLockTerm=Cold+therapy">Cold therapy</a>
(257786008), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0010412&fLockTerm=Cold+therapy">Cold therapy</a>
(26782000), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0009452&fLockTerm=Communication">Communication</a>
(263536004), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0332459&fLockTerm=Compression">Compression</a>
(71173004), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0578804&fLockTerm=Decompression+of+cervical+spine">Decompression of cervical spine</a>
(302130002), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0011307&fLockTerm=Denervation+-+action">Denervation - action</a>
(286792001), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0012002&fLockTerm=Diathermy">Diathermy</a>
(21825005), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0012002&fLockTerm=Diathermy">Diathermy</a>
(428381003), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C1445578&fLockTerm=Dibotermin+alfa">Dibotermin alfa</a>
(408090006), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C1445578&fLockTerm=Dibotermin+alfa">Dibotermin alfa</a>
(421944000), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0394648&fLockTerm=Dry+needle+acupuncture">Dry needle acupuncture</a>
(231082000), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C3164092&fLockTerm=Endoscopic+division+of+epidural+adhesions">Endoscopic division of epidural adhesions</a>
(448333002), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0196394&fLockTerm=Epidural+steroid+injection">Epidural steroid injection</a>
(303611006), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0196394&fLockTerm=Epidural+steroid+injection">Epidural steroid injection</a>
(91520000), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0717758&fLockTerm=Etanercept">Etanercept</a>
(118259007), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0717758&fLockTerm=Etanercept">Etanercept</a>
(387045004), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0408598&fLockTerm=Excision+of+cervical+intervertebral+disc">Excision of cervical intervertebral disc</a>
(239541009), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0196248&fLockTerm=Foraminotomy">Foraminotomy</a>
(62409009), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0262414&fLockTerm=Fracture+of+cervical+spine">Fracture of cervical spine</a>
(125606003), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0181278&fLockTerm=Halo+brace">Halo brace</a>
(183187001), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0150611&fLockTerm=Heat+therapy">Heat therapy</a>
(266694003), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0020591&fLockTerm=Hypnotics">Hypnotics</a>
(321088006), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0020591&fLockTerm=Hypnotics">Hypnotics</a>
(372585002), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0020944&fLockTerm=Immobilization+-+action">Immobilization - action</a>
(257884004), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0020852&fLockTerm=Immunoglobulin+G">Immunoglobulin G</a>
(29246005), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0196558&fLockTerm=Incision+of+nerve">Incision of nerve</a>
(11972005), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0282615&fLockTerm=Incision+of+spinal+nerve+root">Incision of spinal nerve root</a>
(19214009), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0282615&fLockTerm=Incision+of+spinal+nerve+root">Incision of spinal nerve root</a>
(287212005), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0394849&fLockTerm=Injection+of+facet+joint">Injection of facet joint</a>
(231276005), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0185340&fLockTerm=Injection+of+trigger+points">Injection of trigger points</a>
(39074004), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0432666&fLockTerm=Injury+of+cervical+spine">Injury of cervical spine</a>
(262522002), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0242362&fLockTerm=Intervertebral+disc+prolapse">Intervertebral disc prolapse</a>
(73589001), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0022024&fLockTerm=Iontophoresis+-+action">Iontophoresis - action</a>
(129442009), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0022024&fLockTerm=Iontophoresis+-+action">Iontophoresis - action</a>
(91480001), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0022983&fLockTerm=Laminectomy">Laminectomy</a>
(387731002), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0198539&fLockTerm=Laparoscopic+lysis+of+adhesions">Laparoscopic lysis of adhesions</a>
(9540004), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0498269&fLockTerm=Manipulation+under+anesthesia">Manipulation under anesthesia</a>
(274470005), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C3536731&fLockTerm=Massage+physiotherapy">Massage physiotherapy</a>
(387854002), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0419108&fLockTerm=Neuromuscular+re-education">Neuromuscular re-education</a>
(183289005), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0521168&fLockTerm=Occupational+injury">Occupational injury</a>
(371128008), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0029365&fLockTerm=Orthotic+device">Orthotic device</a>
(224898003), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0030688&fLockTerm=Patient+education">Patient education</a>
(311401005), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0206080&fLockTerm=Percutaneous+discectomy">Percutaneous discectomy</a>
(178668000), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0949766&fLockTerm=Physical+therapy+procedure">Physical therapy procedure</a>
(91251008), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0408605&fLockTerm=Primary+foraminotomy+of+cervical+spine">Primary foraminotomy of cervical spine</a>
(178524009), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C2711202&fLockTerm=Primary+reconstruction+of+lamina+of+cervical+spine">Primary reconstruction of lamina of cervical spine</a>
(441706006), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0500223&fLockTerm=Prolotherapy">Prolotherapy</a>
(417047001), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C1960202&fLockTerm=Prosthetic+replacement+of+cervical+intervertebral+disc">Prosthetic replacement of cervical intervertebral disc</a>
(427424009), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0033978&fLockTerm=Psychotherapeutic+agent">Psychotherapeutic agent</a>
(418183005), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0033978&fLockTerm=Psychotherapeutic+agent">Psychotherapeutic agent</a>
(419937006), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0033978&fLockTerm=Psychotherapeutic+agent">Psychotherapeutic agent</a>
(46063005), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0394961&fLockTerm=Radiofrequency+denervation+of+spinal+facet+joint+of+cervical+vertebra">Radiofrequency denervation of spinal facet joint of cervical vertebra</a>
(178815009), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0034991&fLockTerm=Rehabilitation+therapy">Rehabilitation therapy</a>
(52052004), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0425105&fLockTerm=Returned+to+work">Returned to work</a>
(266962006), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0204027&fLockTerm=Short+wave+diathermy">Short wave diathermy</a>
(59705002), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0686940&fLockTerm=Soft+tissue+mobilization">Soft tissue mobilization</a>
(105379007), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0037935&fLockTerm=Spinal+arthrodesis">Spinal arthrodesis</a>
(55705006), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0037937&fLockTerm=Spinal+injury">Spinal injury</a>
(262521009), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0038317&fLockTerm=Steroid">Steroid</a>
(116566001), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0376530&fLockTerm=Surgical+decompression+-+action">Surgical decompression - action</a>
(410756002), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0376530&fLockTerm=Surgical+decompression+-+action">Surgical decompression - action</a>
(410803008), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0013787&fLockTerm=Therapeutic+electrical+stimulation">Therapeutic electrical stimulation</a>
(169430000), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0013787&fLockTerm=Therapeutic+electrical+stimulation">Therapeutic electrical stimulation</a>
(57942008), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0452240&fLockTerm=Therapeutic+exercise">Therapeutic exercise</a>
(226029000), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0452240&fLockTerm=Therapeutic+exercise">Therapeutic exercise</a>
(229065009), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0452240&fLockTerm=Therapeutic+exercise">Therapeutic exercise</a>
(51998003), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0041620&fLockTerm=Therapeutic+ultrasound">Therapeutic ultrasound</a>
(89002000), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0020548&fLockTerm=Thermotherapy">Thermotherapy</a>
(261570006), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0040597&fLockTerm=Traction">Traction</a>
(129411004), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0040597&fLockTerm=Traction">Traction</a>
(66391000), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0180980&fLockTerm=Traction+frame">Traction frame</a>
(465682002), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0040610&fLockTerm=Tramadol">Tramadol</a>
(108507005), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0040610&fLockTerm=Tramadol">Tramadol</a>
(386858008), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0040654&fLockTerm=Transcutaneous+electrical+nerve+stimulation">Transcutaneous electrical nerve stimulation</a>
(229559001), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0040654&fLockTerm=Transcutaneous+electrical+nerve+stimulation">Transcutaneous electrical nerve stimulation</a>
(432061000124105), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0272806&fLockTerm=Traumatic+dislocation+of+joint+of+cervical+vertebra">Traumatic dislocation of joint of cervical vertebra</a>
(44264009), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0034996&fLockTerm=Vocational+rehabilitation">Vocational rehabilitation</a>
(70082004), <a href="/web/20180713033424/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0556565&fLockTerm=Work+simulation">Work simulation</a>
(228645006) </div>
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(12-730), <a href="/web/20180713033424/https://www.guideline.gov/search?f_UMD_CUI=C0029365&fLockTerm=Orthoses">Orthoses</a>
(12-837), <a href="/web/20180713033424/https://www.guideline.gov/search?f_UMD_CUI=C0810627&fLockTerm=Stimulators%2c+Electrical%2c+Neuromuscular">Stimulators, Electrical, Neuromuscular</a>
(13-775), <a href="/web/20180713033424/https://www.guideline.gov/search?f_UMD_CUI=C0184203&fLockTerm=Ultrasound+Therapy+Systems%2c+Physical+Therapy">Ultrasound Therapy Systems, Physical Therapy</a>
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<textarea id="citation">National Guideline Clearinghouse (NGC). Guideline summary: Cervical spine injury medical treatment guidelines. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2014 Feb 03. [cited 2018 Jul 13]. Available: https://www.guideline.gov</textarea>
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<h2 id="394" class="accordion-title section-394 is-active" role="tab" aria-expanded="true"><a href="#">Regulatory Alert</a></h2>
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<h3><a href="#">FDA Warning/Regulatory Alert</a></h3>
<p><div class="content_para"><p><strong>Note from the National Guideline Clearinghouse</strong>: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.</p>
<ul style="list-style-type: disc;">
<li><a href="https://web.archive.org/web/20180713033424/http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm518710.htm" target="_blank" title="FDA Web site">August 31, 2016 – Opioid pain and cough medicines combined with benzodiazepines</a> <img alt="External Web Site Policy" src="/web/20180713033424im_/https://www.guideline.gov/UI/images/icon_externallink.gif"/>: A U.S. Food and Drug Administration (FDA) review has found that the growing combined used of opioid medicines with benzodiazepines or other drugs that depress the central nervous system (CNS) has resulted in serious side effects, including slowed or difficult breathing and deaths. FDA is adding Boxed Warnings to the drug labeling of prescription opioid pain and prescription opioid cough medicines and benzodiazepines. </li>
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<h2 id="420" class="accordion-title section-420 is-active" role="tab" aria-expanded="true"><a href="#">Recommendations</a></h2>
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<h3><a href="#">Major Recommendations</a></h3>
<p><div class="content_para"><p><strong>Note from the National Guideline Clearinghouse (NGC)</strong>: This summary includes the treatment recommendations of the guideline. See the original guideline document for additional information on initial evaluation, diagnostic, and maintenance procedures for patients with cervical spine injuries and for further descriptions of the therapies discussed below.</p>
<p><strong><span style="text-decoration: underline;">Therapeutic Procedures—Non-operative</span></strong></p>
<p>Before initiation of any therapeutic procedure, the authorized treating provider, employer, and insurer must consider these 4 important issues in the care of the injured worker.</p>
<p><em>First</em>, patients undergoing therapeutic procedure(s) should be released or returned to modified or restricted duty during their rehabilitation at the earliest appropriate time. Refer to Section F.11, "Return-to-Work," in the original guideline document, for detailed information.</p>
<p><em>Second</em>, cessation and/or review of treatment modalities should be undertaken when no further significant subjective or objective improvement in the patient's condition is noted. If patients are not responding within the recommended duration periods, alternative treatment interventions, further diagnostic studies, or consultations should be pursued.</p>
<p><em>Third</em>, providers should provide and document patient education. Before diagnostic tests or referrals for invasive treatment take place, the patient should be able to clearly articulate the goals of the intervention, the general side effects and associated risks, and the patient's agreement with the expected treatment plan.</p>
<p><em>Last</em>, formal psychological or psychosocial evaluation should be performed on patients not making expected progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate with objective signs and tests.</p>
<p>Home therapy is an important component of therapy and may include active and passive therapeutic procedures as well as other modalities to assist in alleviating pain, swelling, and abnormal muscle tone.</p>
<p>The following procedures are listed in alphabetical order.</p>
<p><strong>Acupuncture</strong></p>
<p>There is good evidence that acupuncture, true or sham, is superior to usual care for the reduction of disability and pain in patients with chronic nonspecific low back pain, and that true and sham acupuncture are likely to be equally effective.</p>
<p>There is good evidence that both acupuncture and sham acupuncture are superior to usual care without acupuncture for moderate short-term and mild long-term alleviation of low back pain, neck pain, and the pain of joint osteoarthritis. In these studies 5 to 15 treatments were provided. Comparisons of acupuncture and sham acupuncture have been inconsistent, and the advantage of true over sham acupuncture has been small in relation to the advantage of sham over no acupuncture.</p>
<p>Acupuncture is recommended for chronic pain patients who are trying to increase function and/or decrease medication usage and have an expressed interest in this modality. It also may be beneficial for individuals experiencing acute or subacute neck pain who cannot tolerate non-steroidal anti-inflammatory drugs (NSAIDs). Acupuncture is not the same procedure as dry needling for coding purposes; however, some acupuncturists may use acupuncture treatment for myofascial trigger points. Dry needling is performed specifically on myofascial trigger points.</p>
<p>Credentialed practitioners with experience in evaluation and treatment of chronic pain patients must perform acupuncture evaluations.</p>
<p><em>Acupuncture</em></p>
<p>This is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points). Needles may be inserted, manipulated, and retained for a period of time. Acupuncture has a variety of possible physiologic actions, but their relevance to the clinical response is speculative.</p>
<p>Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain.</p>
<p><em>Acupuncture with Electrical Stimulation</em></p>
<p>This procedure is the use of electrical current (micro-amperage or mille-amperage) on the needles at the acupuncture site. It is used to increase effectiveness of the needles by continuous stimulation of the acupoint. Physiological effects (depending on location and settings) can include endorphin release for pain relief, reduction of inflammation, increased blood circulation, analgesia through interruption of pain stimulus, and muscle relaxation.</p>
<p>It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.</p>
<p>There is some evidence that a combination of electrical acustimulation to the wrist combined with neck stretching and strengthening exercises for 30 minutes 2 times per week for a period of about 4 weeks demonstrates more improvement in chronic neck pain and patient self-confidence in performing functional activities than neck exercises alone for up to 1 month.</p>
<p><em>Other Acupuncture Modalities</em></p>
<p>Acupuncture treatment is based on individual patient needs and therefore treatment may include a combination of procedures to enhance treatment effect. Other procedures may include the use of heat, soft tissue manipulation/massage, and exercise. Refer to "Therapy–Active" and "Therapy–Passive" below.</p>
<p><em>Total Time Frames for Acupuncture and Acupuncture with Electrical Stimulation</em></p>
<p>Time frames are not meant to be applied to each of the above sections separately. The time frames are to be applied to all acupuncture treatments regardless of the type or combination of therapies being provided. Refer to the original guideline document for time to produce effect, frequency, and optimum and maximum duration of treatments.</p>
<p><strong>Biofeedback</strong></p>
<p>Biofeedback is a form of behavioral medicine that helps patients learn self-awareness and self-regulation skills for the purpose of gaining greater control of their physiology, such as muscle activity, brain waves, and measures of autonomic nervous system activity. Stress-related psycho-physiological reactions may arise as a reaction to organic pain and in some cases may cause pain. Electronic instrumentation is used to monitor the targeted physiology and then displayed or fed back to the patient visually, auditorily, or tactilely with coaching by a biofeedback specialist. There is good evidence that biofeedback or relaxation therapy is equal in effect to cognitional behavioral therapy for chronic low back pain.</p>
<p>Indications for biofeedback include cases of musculoskeletal injury, in which muscle dysfunction or other physiological indicators of excessive or prolonged stress response affects and/or delays recovery. Other applications include training to improve self-management of pain, anxiety, panic, anger or emotional distress, opioid withdrawal, insomnia/sleep disturbance, and other central and autonomic nervous system imbalances. Biofeedback is often utilized for relaxation training. Mental health professionals may also utilize it as a component of psychotherapy, where biofeedback and other behavioral techniques are integrated with psychotherapeutic interventions. Biofeedback is often used in conjunction with physical therapy or medical treatment.</p>
<p>Please refer to the original guideline document for recognized types of biofeedback.</p>
<p>Psychologists or psychiatrists, who provide psycho-physiological therapy which integrates biofeedback with psychotherapy, should be either Biofeedback Certification International Alliance (BCIA) certified or practicing within the scope of their training. All non-licensed health care providers of biofeedback for chronic pain patients must be BCIA certified and shall have their biofeedback treatment plan approved by the authorized treating psychologist or psychiatrist. Biofeedback treatment must be done in conjunction with the patient's psychosocial intervention. Biofeedback may also be provided by health care providers who follow a set treatment and educational protocol. Such treatment may utilize standardized material or relaxation tapes.</p>
<p>Refer to the original guideline document for time to produce effect, frequency, and optimum and maximum duration of treatments.</p>
<p><strong>Injections–Spinal Therapeutic</strong></p>
<p><em>Description</em></p>
<p>Therapeutic spinal injections have not been proven to change the long-term course of patients with spinal pain. They have a very limited role in treatment and should be used in only a small subset of patients where the criteria below have been clearly met.</p>
<p>Cervical epidural injections carry additional risks of injury including death, spinal cord injury, and stroke when compared to lumbar injections. Given the lack of proof for significant long-term benefit and the risks, steroid injections are less commonly used in the cervical spine. Many of the neurologic and vascular complications are related to particulate steroid solutions. For cervical spinal injections, dexamethasone or another non-particulate substance should be used. Diagnostic injections may be useful if more specific diagnosis is needed prior to other invasive procedures.</p>
<p>In the lumbar spine, a high quality meta-analysis provides good evidence against the use of lumbar facet or epidural injections for relief of non-radicular low back pain. Thus, epidural injections should not be performed for non-radicular pain. Similarly epidural injections are <strong>not recommended</strong> for non-radicular cervical pain. There is insufficient evidence to support the use of therapeutic cervical facet injections. Facet injections have very limited therapeutic or diagnostic use. Refer to "Zygapophyseal (Facet) Injections" below.</p>
<p>Therapeutic injections should only be used after diagnostic injections and imaging studies have established pathology which has not clinically improved after active engagement (6–8 weeks) of physical therapy and in patients who otherwise qualify for more invasive procedures and may need injections because they do not wish to proceed to surgery.</p>
<p>The purpose of spinal injections is to facilitate active therapy by providing short-term relief through reduction of pain and inflammation. All patients must commit to continuing appropriate exercise with functionally directed rehabilitation, usually beginning within 7 days, at the injectionist's discretion. Active treatment, which patients should have had prior to injections, will frequently require a repeat of the sessions previously ordered (refer to "Therapy–Active" below). Injections, by themselves, are not likely to provide long-term relief. Rather, active rehabilitation with modified work achieves long-term relief by increasing active range of motion (ROM), strength, and stability.</p>
<p><em>Special Requirements for Spinal Therapeutic Injections</em></p>
<p>Since multi-planar fluoroscopy during procedures is required to document technique and needle placement, an experienced physician should perform the procedure. Injection of contrast dye to assure correct needle placement is required to verify the flow of medication. Permanent images are required to verify needle placement. Unnecessary fluoroscopy procedures should be avoided due to the radiation exposure contributing to cancer risk.</p>
<p><em>Complications</em></p>
<p>Cervical spinal injections have resulted in death, paralysis and infarctions, mainly in the brainstem, cerebellum and posterior cerebral artery. The arterial anatomy in the intervertebral foramina can vary widely which increases the likelihood of arterial spasm or embolism from particulate steroids and can result in severe morbidity. Other general complications of spinal injections may include transient neurapraxia, local pain, nerve injury, infection, headache, and vasovagal effects. Epidural hematoma, permanent neurologic damage, spinal cord injury, dural perforation and cerebrospinal fluid (CSF) leakage; and/or spinal meningeal abscess or meningitis may also occur. There are reports of direct spinal cord injury due to needle trauma. Permanent paresis, anaphylaxis, and arachnoiditis have been rarely reported with the use of epidural steroids.</p>
<p><em>Contraindications</em></p>
<p>Absolute contraindications to diagnostic injections include: (a) bacterial infection – systemic or localized to region of injection, (b) bleeding diatheses, (c) hematological conditions, (d) pain of 3 points or less on a 10-point Visual Analog Scale (VAS) measurement, (e) possible pregnancy, and (f) poorly controlled diabetes mellitus for steroid injections.</p>
<p>Relative contraindications to diagnostic injections may include: allergy to contrast, somatization disorders, poorly controlled congestive heart failure (CHF) for steroid injections, risk factors for osteoporosis, uncontrolled hypertension, and inadequate space for interlaminar, due to spinal stenosis. The use of interlaminar injections requires evaluation by MRI to assure there is adequate space. They should not to be performed if there is significant spinal stenosis.</p>
<p>Drugs affecting coagulation frequently require restriction from use.</p>
<p>The following are in alphabetical order:</p>
<p><span style="text-decoration: underline;">Epidural Steroid Injection (ESI)</span> (may include transforaminal or interlaminar injections)</p>
<p>Description</p>
<p>Epidural steroid injections are injections of corticosteroid into the epidural space. Purported to reduce pain and inflammation in the acute or sub-acute phases of injury, restoring range of motion and, thereby, facilitating progress in more active treatment programs. Use non-particulate steroids to avoid complications.</p>
<p>Therapeutic spinal injections have not been proven to change the long-term course of patients with spinal pain. They have a very limited role in treatment and should be used in only a small subset of patients where the criteria below have been clearly met. Cervical epidural injections carry additional risks of injury including death, spinal cord injury, and stroke when compared to lumbar injections. Given the lack of proof for significant long-term benefit and the risks, steroid injections are less commonly used in the cervical spine. ESI uses two approaches: transforaminal and interlaminar (midline). The transforaminal approach is the preferred method for unilateral, single-level pathology and for post-surgical patients.</p>
<p>A high quality meta-analysis provides good evidence against the use of lumbar facet or epidural injections for relief of non-radicular low back pain. Thus, epidural injections should not be performed for lumbar non-radicular pain. Similarly, epidural injections are <strong>not recommended</strong> for non-radicular cervical pain.</p>
<p>Needle Placement</p>
<p>Multi-planar fluoroscopic imaging is required for all epidural steroid injections. Injection of contrast dye to assure correct needle placement is required to verify the flow of medication. Permanent images are required to verify needle placement. Digital subtraction angiography may be used as appropriate.</p>
<p>Indications</p>
<p>Evidence does not support long-term benefits and patients can suffer long-term morbidity from injections; although these complications are rare. Therefore, injections are allowed for only a small subset of patients with radicular findings. They may be used for patients who are having significant pain that is interfering with daily functions and the active therapy necessary for recovery despite medical pain management and active therapy. Injections should be preceded by an MRI. Interlaminar injections should not be done above level C6-C7, nor at the level of any stenosis as demonstrated on pre-procedure imaging review due to the higher likelihood of neural damage.</p>
<p>See the original guideline document for sets of patients that may have therapeutic epidural injections, when diagnostic epidural injections are positive. Also see the original guideline document for time to produce effect, frequency, optimum duration, and maximum duration of injections.</p>
<p><span style="text-decoration: underline;">Intradiscal Steroid Therapy</span></p>
<p>There is some evidence that intradiscal steroid injection is unlikely to relieve pain or provide functional benefit in patients with non-radicular back pain therefore they are <strong>not recommended</strong>.</p>
<p>Intradiscal injections of other substances such as bone marrow, stem cells, are <strong>not recommended</strong> at this time due to lack of evidence and possible complications.</p>
<p><span style="text-decoration: underline;">Transforaminal Injection with Etanercept</span></p>
<p>Description</p>
<p>Transforaminal injection with a tumor necrosis factor alpha inhibitor is thought to decrease the inflammatory agents which may be associated with the pathophysiology of lumbar radicular pain from a herniated disc.</p>
<p>It is <strong>not recommended</strong> due to the results of a study which showed no advantage over steroids or saline injections.</p>
<p><span style="text-decoration: underline;">Zygapophyseal (Facet) Injection</span></p>
<p>Description</p>
<p>This in an accepted intra-articular or pericapsular injection of local anesthetic and corticosteroid with very limited uses. There is no justification for a combined facet and medial branch block.</p>
<p>Needle Placement</p>
<p>Multi-planar fluoroscopic imaging is required for all steroid injections. Injection of contrast dye to assure correct needle placement is required to verify the flow of medication. Permanent images are required to verify needle placement.</p>
<p>Indications</p>
<p>Patients with pain 1) suspected to be facet in origin based on exam findings <strong>and</strong> 2) affecting activity; OR patients who have refused a rhizotomy and appear clinically to have facet pain; OR patients who have facet findings with a thoracic component. Refer to the original guideline document for additional information on indications as well as time to product effect, frequency, and optimum and maximum duration of injections.</p>
<p><strong>Injections–Other (Including Radiofrequency [RF])</strong></p>
<p>The following are in alphabetical order:</p>
<p><em>Botulinum Toxin Injections</em></p>
<p>Description</p>
<p>Used to temporarily weaken or paralyze muscles. These injections may reduce muscle pain in conditions associated with spasticity or dystonia.</p>
<p>Botulinum injections are no longer generally recommended for cervicogenic or other headaches based on good evidence of lack of effect. There is good evidence that botulinum toxin is not more effective than placebo for reducing the frequency of episodic migraines. It may be considered in a very small subset of patients with chronic migraines 12 to 15 days/month who have failed all other conservative treatment, including trials of at least 3 drug classes, and who have committed to any life style changes related to headache triggers.</p>
<p>Indications</p>
<p>For conditions which produce chronic spasticity or dystonia. There should be evidence of limited range-of-motion prior to the injection. <strong>Not recommended</strong> for cervicogenic headaches. Refer to the NGC summary of the Colorado Division of Workers' Compensation <a href="/web/20180713033424/https://www.guideline.gov/content.aspx?id=43752" title="Guideline #9598">Traumatic brain injury medical treatment guidelines</a> for indications regarding headache.</p>
<p>There is insufficient evidence to support its use for longer-term pain relief of other myofascial trigger points and it is likely to cause muscle weakness or atrophy if used repeatedly. Examples of such consequences include subacromial impingement, as the stabilizers of the shoulder are weakened by repeated injections of trigger points in the upper trapezii. Therefore, it is <strong>not recommended </strong>for use for other myofascial trigger points.</p>
<p>Complications</p>
<p>There is good evidence that cervical botulinum toxin A injections cause transient dysphagia and neck weakness. Allergic reaction to medications, dry mouth and vocal hoarseness may also occur. Rare systemic effects include flu-like syndrome, and weakening of distant muscle. There is an increased risk of systemic effects in patients with motor neuropathy or disorders of the neuromuscular junction.</p>
<p>Refer to the original guideline document for time to produce effect, frequency, and optimum and maximum duration of treatments.</p>
<p><em>Epiduroscopy and Epidural Lysis of Adhesions</em></p>
<p>This is an investigational treatment of cervical pain. It involves the introduction of a fiberoptic endoscope into the epidural space via the sacral hiatus. With cephalad advancement of the endoscope under direct visualization, the epidural space is irrigated with saline. Adhesiolysis may be done mechanically with a fiberoptic endoscope. The saline irrigation is performed with or without epiduroscopy and is intended to distend the epidural space in order to obtain an adequate visual field. It is designed to produce lysis of adhesions, which are conjectured to produce symptoms due to traction on painful nerve roots. Saline irrigation is associated with risks of elevated pressures which may impede blood flow and venous return, possibly causing ischemia of the cauda equina and retinal hemorrhage. Other complications associated with instrumented lysis include catheter shearing, need for catheter surgical removal, infection (including meningitis), hematoma, and possible severe hemodynamic instability during application. Although epidural adhesions have been postulated to cause chronic cervical pain, studies have failed to find a significant correlation between the level of fibrosis and pain or difficulty functioning. Studies of epidural lysis demonstrate no transient pain relief from the procedure. Given the low likelihood of a positive response, the additional costs and time requirement, and the possible complications from the procedure, epiduroscopy, or mechanical lysis, is <strong>not recommended</strong>.</p>
<p>Epiduroscopy-directed steroid injections are also <strong>not recommended</strong> because there is no evidence to support an advantage in using an epiduroscope with steroid injections.</p>
<p><em>Prolotherapy</em></p>
<p>Also known as sclerotherapy, prolotherapy consists of a series of injections of hypertonic dextrose, with or without glycerine and phenol, into the ligamentous structures of the neck. Its proponents claim that the inflammatory response to the injections will recruit cytokine growth factors involved in the proliferation of connective tissue, stabilizing the ligaments of the neck when these structures have been damaged by mechanical insults.</p>
<p>There is good evidence that prolotherapy alone is not an effective treatment for chronic low back pain. Similarly, the use of prolotherapy for cervical pain is generally <strong>not recommended</strong>.</p>
<p><em>RF Ablation–Dorsal Nerve Root Ablation</em></p>
<p>Due to the combination of adverse side effects, time-limited effectiveness, and mixed study results, this treatment is <strong>not recommended</strong>.</p>
<p><em>RF Denervation–Medial Branch Neurotomy/Facet Rhizotomy</em></p>
<p>Description</p>
<p>A procedure designed to denervate the facet joint by ablating the corresponding sensory medial branches. Continuous percutaneous RF is the method generally used. Pulsed RF should not be used as it may result in incomplete denervation. Cooled RF is generally <strong>not recommended</strong> due to current lack of evidence.</p>
<p>There is some evidence that RF neurotomy relieves pain and restores function in patients whose neck pain arises from the facet joint but benefits beyond one year are not yet established. Generally, pain relief lasts 7 to 9 months and repeat RF neurotomy can be successful and last longer. RF neurotomy is the procedure of choice over alcohol, phenol, or cryoablation. Precise positioning of the probe using fluoroscopic guidance is required because the maximum effective diameter of the device is a 5 x 8 millimeter oval. Permanent images should be recorded to verify placement of the device.</p>
<p>Needle Placement</p>
<p>Multi-planar fluoroscopic imaging is required for all injections. Injection of contrast dye to assure correct needle placement is required to verify the flow of medication. Permanent images are required to verify needle placement.</p>
<p>Indications</p>
<p>Those patients with proven, significant, facetogenic pain. This procedure is <strong>not recommended</strong> for patients with multiple pain generators or involvement of more than 3 levels of medial branch nerves. Individuals should have met all of the following indications:</p>
<ul style="list-style-type: disc;">
<li>Physical exam findings consistent with facet origin pain, <strong>and</strong> </li>
<li>Positive response to controlled medial branch blocks, <strong>and</strong> </li>
<li>At least 3 months of pain, unresponsive to 6-8 weeks of conservative therapies, including manual therapy, <strong>and</strong> </li>
<li>A psychosocial screening (e.g., thorough psychosocial history, screening questionnaire) with treatment as appropriate has been undergone. </li>
</ul>
<p>All patients should continue appropriate exercise with functionally directed rehabilitation. Active treatment, which patients will have had prior to the procedure, will frequently require a repeat of the sessions previously ordered (refer to Section F.13, "Therapy–Active," in the original guideline document).</p>
<p>It is obligatory that sufficient data be accumulated by the examiner performing this procedure such that the value of the medial branch block is evident to other reviewers. This entails documentation of patient response regarding the degree and type of response to specific symptoms. As recommended by the International Spine Intervention Society (ISIS) guidelines, the examiner should identify three or four measurable physical functions, which are currently impaired and can be objectively reassessed 30 minutes or more after the injection. A successful block requires documentation of positive functional changes by trained medical personnel experienced in measuring range of motion or assessing activity performance. The evaluator should be acquainted with the patient, in order to determine pre and post values, and preferably unaffiliated with the injectionist's office. Qualified evaluators include nurses, physician assistants, medical assistants, therapists, or non-injectionist physicians. To be successful the results should occur within the expected time frame and there should be pain relief of approximately 80% demonstrated by pre and post VAS scores. Examples of functional changes include reaching and lifting. Additionally, a prospective patient completed pain diary must be recorded as part of the medical record that documents response hourly for a minimum requirement of the first 8 hours post injection or until the block has clearly worn off and preferably for the week following an injection. The diary results should be compared to the expected duration of the local anesthetic phase of the procedure. Responses must be identified as to specific body part (e.g., neck, arm pain). The practitioner must identify the local anesthetic used and the expected duration of response for diagnostic purposes.</p>
<p>In almost all cases, this will mean a reduction of pain to 1 or 2 on the 10-point VAS correlated with functional improvement. The patient should also identify activities of daily living (ADLs) (which may include measurements of ROM) that are impeded by their pain and can be observed to document objective functional improvement in the clinical setting. Ideally, these activities should be assessed throughout the observation period for function. The observer should not be the physician who performed the procedure. It is suggested that this be recorded on a form similar to ISIS recommendations.</p>
<p>A separate comparative block on a different date should be performed to confirm the level of involvement prior to the rhizotomy. A comparative block uses anesthetics with varying lengths of activity. Medial Branch blocks are probably not helpful to determine the likelihood of success for spinal fusion.</p>
<p>The success rate of RF neurotomy is likely to decrease with lower percentages of pain relief from a medial branch block.</p>
<p>Informed decision making should also be documented for injections and all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. The purpose of spinal injections is to facilitate active therapy by providing short-term relief through reduction of pain. Patients should be encouraged to express their personal goals, outcome expectations and desires from treatment as well as any personal habits or traits that may be impacted by procedures or their possible side effects. All patients must commit to continuing appropriate exercise with functionally directed rehabilitation usually beginning within 7 days, at the injectionist's discretion. Since most patients with these conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment. All injections must be accompanied by active therapy.</p>
<p>Complications</p>
<p>Bleeding, infection, or neural injury. The clinician must be aware of the risk of developing a localized neuritis, or rarely, a deafferentation centralized pain syndrome as a complication of this and other neuroablative procedures. Spinal musculature atrophy is likely to occur especially with repeat procedures as a rhizotomy denervates the multifidas muscle in patients. For this reason, repeated rhizotomies and multiple level rhizotomies can be harmful by decreasing supportive spinal musculature. This is especially problematic for younger patients who may engage in athletic activities or workers with strenuous job requirements as the atrophy could result in increased injuries or pain, although this has not been documented.</p>
<p>Post-procedure Therapy: Active Therapy</p>
<p>Implementation of a gentle aerobic reconditioning program (e.g., walking, neck range of motion exercise) and neck education within the first post-procedure week, barring complications. Instruction and participation in a long-term home-based program of ROM, core strengthening, postural or neuromuscular re-education, endurance, and stability exercises should be accomplished over a period of 4 to 10 visits post-procedure. Patients who are unwilling to engage in this therapy should not receive this procedure.</p>
<p>Requirements for repeat RF medial branch neurotomy (or additional-level RF neurotomies): In some cases pain may recur. Successful RF Neurotomy usually provides from 6 to 18 months of relief. Due to denervation of spinal musculature repeated rhizotomies should be limited. Before a repeat RF Neurotomy is done, a confirmatory medial branch injection should be performed if the patient's pain pattern presents differently than the initial evaluation. In occasional patients, additional levels of RF neurotomy may be necessary. The same indications and limitations apply.</p>
<p><em>Transdiscal Biacuplasty</em></p>
<p>Description</p>
<p>Cooled RF procedure intended to coagulate fissures in the disc and surrounding nerves which could be pain generators. It is <strong>not recommended</strong> due to lack of published data demonstrating effectiveness.</p>
<p><em>Trigger Point Injections and Dry Needling Treatment</em></p>
<p>Description</p>
<p>Trigger point injections are a generally accepted treatment. Trigger point treatment can consist of dry needling or injection of local anesthetic, with or without corticosteroid, into highly localized, extremely sensitive bands of skeletal muscle fibers that produce local and referred pain when activated. Medication is injected in a four-quadrant manner in the area of maximum tenderness. Injection efficacy can be enhanced if injections are immediately followed by myofascial therapeutic interventions, such as vapo-coolant spray and stretch, ischemic pressure massage (myotherapy), specific soft tissue mobilization and physical modalities. There is conflicting evidence regarding the benefit of trigger point injections. A truly blinded study comparing dry needle treatment of trigger points is not feasible. There is no evidence that injection of medications improves the results of trigger-point injections. Needling alone may account for some of the therapeutic response. Needling must be performed by practitioners with the appropriate credentials in accordance with state and other applicable regulations.</p>
<p>There is no indication for conscious sedation for patients receiving trigger point injections. The patient must be alert to help identify the site of the injection.</p>
<p>Indications</p>
<p>Trigger point injections may be used to relieve myofascial pain and facilitate active therapy and stretching of the affected areas. They are to be used as an adjunctive treatment in combination with other treatment modalities such as active therapy programs. Trigger point injections should be utilized primarily for the purpose of facilitating functional progress. Patients should continue in an aggressive aerobic and stretching therapeutic exercise program as tolerated throughout the time period they are undergoing intensive myofascial interventions. Myofascial pain is often associated with other underlying structural problems and any abnormalities need to be ruled out prior to injection.</p>
<p>Trigger point injections are indicated in those patients where well circumscribed trigger points have been consistently observed, demonstrating a local twitch response, characteristic radiation of pain pattern and local autonomic reaction, such as persistent hyperemia following palpation. Generally, these injections are not necessary unless consistently observed trigger points are not responding to specific, noninvasive, myofascial interventions within approximately a 6-week time frame. However, trigger point injections may be occasionally effective when utilized in the patient with immediate, acute onset of neck pain.</p>
<p>Complications</p>
<p>Potential but rare complications of trigger point injections include infection, pneumothorax, anaphylaxis, penetration of viscera, neurapraxia, and neuropathy. If corticosteroids are injected in addition to local anesthetic, there is a risk of local myopathy. Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be immediately repositioned.</p>
<p>Refer to the original guideline document for time to produce effect, frequency, and optimum and maximum duration of treatments.</p>
<p><strong>Interdisciplinary Rehabilitation Programs</strong></p>
<p>This is the gold standard of treatment for individuals with chronic pain who have not responded to less intensive modes of treatment. There is good evidence that interdisciplinary programs which include screening for psychological issues, identification of fear-avoidance beliefs and treatment barriers, and establishment of individual functional and work goals, will improve function and decrease disability. These programs should assess the impact of pain and suffering on the patient's medical, physical, psychological, social, and/or vocational functioning. In general, interdisciplinary programs evaluate and treat multiple and sometimes irreversible conditions, including but not limited to painful musculoskeletal, neurological, and other chronic pain conditions and psychological issues, drug dependence, abuse or addiction high levels of stress and anxiety, failed surgery; and pre-existing or latent psychopathology. The number of professions involved on the team in a chronic pain program may vary due to the complexity of the needs of the person served. The Division recommends consideration of referral to an interdisciplinary program within 6 months post-injury in patients with delayed recovery unless successful surgical interventions or other medical and/or psychological treatment complications intervene.</p>
<p>Chronic pain patients need to be treated as outpatients within a continuum of treatment intensity. Outpatient chronic pain programs are available with services provided by a coordinated interdisciplinary team within the same facility (formal) or as coordinated among practices by the authorized treating physician (informal). Formal programs are able to provide coordinated, high intensity level of services and are recommended for most chronic pain patients who have received multiple therapies during acute management.</p>
<p>Patients with addiction problems or high dose opioid or other drugs of abuse use may require inpatient and/or outpatient chemical dependency treatment programs before or in conjunction with other interdisciplinary rehabilitation. Guidelines from the American Society of Addiction Medicine are available and may be consulted relating to the intensity of services required for different classes of patients in order to achieve successful treatment.</p>
<p>Informal interdisciplinary pain programs may be considered for patients who are currently employed, those who cannot attend all day programs, those with language barriers, or those living in areas not offering formal programs. Before treatment has been initiated, the patient, physician, and insurer should agree on treatment approach, methods, and goals. Generally the type of outpatient program needed will depend on the degree of impact the pain has had on the patient's medical, physical, psychological, social and/or vocational functioning.</p>
<p>When referring a patient for formal outpatient interdisciplinary pain rehabilitation, an occupational rehabilitation or an opioid treatment program, the Division recommends the program meets the criteria of the Commission on Accreditation of Rehabilitation Facilities (CARF).</p>
<p>Inpatient pain rehabilitation programs are rarely needed but may be necessary for patients with any of the following conditions: (a) high risk for medical instability; (b) moderate-to-severe impairment of physical/functional status; (c) moderate-to-severe pain behaviors; (d) moderate impairment of cognitive and/or emotional status; (e) dependence on medications from which he or she needs to be withdrawn; and (f) the need for 24-hour supervised nursing.</p>
<p>The following passive therapies and modalities are listed in alphabetical order. Please see the original guideline document for additional information, including indications for each therapy.</p>
<p>Whether formal or informal programs, they should be comprised of the following dimensions:</p>
<ul style="list-style-type: disc;">
<li>Communication </li>
<li>Documentation </li>
<li>Treatment modalities </li>
<li>Therapeutic exercise programs </li>
<li>Return-to-work </li>
<li>Patient education </li>
<li>Psychosocial evaluation and treatment </li>
<li>Vocational assistance </li>
</ul>
<p>Interdisciplinary programs are characterized by a variety of disciplines that participate in the assessment, planning, and/or implementation of the treatment program. These programs are for patients with greater levels of perceived disability, dysfunction, de-conditioning and psychological involvement. Programs should have sufficient personnel to work with the individual in the following areas: behavior, functional, medical, cognitive, pain management, psychological, social and vocational.</p>
<p>Refer to the original guideline document for more information regarding formal and informal interdisciplinary rehabilitation programs.</p>
<p><strong>Medications</strong></p>
<p>Use in the treatment of cervical spine injuries is appropriate for controlling acute and chronic pain and inflammation. Use of medications will vary widely due to the spectrum of injuries, from simple strains to post-surgical healing. A thorough medication history, including use of alternative and over-the-counter medications, should be performed at the time of the initial visit and updated periodically. Treatment for pain control is initially accomplished with acetaminophen and/or NSAIDs. The patient should be educated regarding the interaction of prescription and over-the-counter medications as well as the contents of over-the-counter herbal products. The medication lists in the original guideline document do not provide complete information on side effects or drug interactions. Providers should seek information from other sources for details.</p>
<p>Refer to the original guideline document for additional information about each of the medications listed below, including optimal and maximum duration of treatment.</p>
<ul style="list-style-type: disc;">
<li>Acetaminophen </li>
<li>Intravenous steroids </li>
<li>Muscle relaxants </li>
<li>NSAIDs (chronic use of NSAIDS <strong>not generally recommended</strong>) </li>
<li>Opioids (use beyond 30 days after non-traumatic injuries, or 6 weeks post-surgery after the original injury or post operatively is <strong>not recommended</strong>) </li>
<li>Oral steroids (<strong>not generally recommended</strong>) </li>
<li>Psychotropic/anti-anxiety/hypnotic agents (due to the habit-forming potential of the benzodiazepines and other drugs found in this class, they are <strong>not generally recommended</strong>) </li>
<li>Tramadol (<strong>not generally recommended</strong> for those with prior opioid addiction) </li>
</ul>
<p><strong>Orthotics</strong></p>
<p>Primary principles and objectives of the application of cervical orthosis include: (a) control of the position through the use of control forces; (b) application of corrective forces to abnormal curvatures; (c) aid in spinal stability when soft tissues or osteoligamentous structures cannot sufficiently perform their role as spinal stabilizers; and (d) restrict spinal segment movement after acute trauma or surgical procedure. In cases of traumatic cervical injury, the most important objective is the protection of the spinal cord and nerve root. Refer to the original guideline document for additional information on cervical orthoses, including:</p>
<ul style="list-style-type: disc;">
<li>Cervical collars </li>
<li>Poster appliances (<strong>not recommended</strong> in sprain or strain injuries) </li>
<li>Cervicothoracic orthosis (<strong>not recommended</strong> in sprain or strain injuries) </li>
<li>Halo devices </li>
<li>Other orthosis devices and equipment </li>
</ul>
<p><strong>Education/Informed Decision Making</strong></p>
<p>Education/informed decision making of the patient and family, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of low back/neck pain and disability. Unfortunately, practitioners often think of education and informed decision making last, after medications, manual therapy, and surgery.</p>
<p>Informed decision making is the hallmark of a successful treatment plan. In most cases the continuum of treatment from the least invasive to the most invasive (e.g., surgery) should be discussed. The intention is to find the treatment along this continuum which most completely addresses the condition. Patients should identify their personal functional goals of treatment at the first visit. It is recommended that specific individual goals are articulated at the beginning of treatment as this is likely to lead to increased patient satisfaction above that achieved from improvement in pain or other physical function. There is some evidence that a 2-day course focusing on the biopsychosocial model with an emphasis on the goals of returning to usual activities and fitness is as effective in reducing disability as 6 sessions of manual therapy sessions provided by physiotherapists and more limited patient education. Progress toward the individual functional goals identified should be addressed at follow up-visits and throughout treatment by other members of the health care team as well as the authorized physicians.</p>
<p>Documentation of this process should occur whenever diagnostic tests or referrals from the authorized treating physician are contemplated. The informed decision making process asks the patient to set their personal functional goals of treatment, describe their current health status and any concerns they have regarding adhering to the diagnostic or treatment plan proposed. The provider should clearly describe the following:</p>
<ul style="list-style-type: disc;">
<li>The expected functional outcomes from the proposed treatment, or expected results and plan of action if diagnostic tests are involved </li>
<li>Any side effects and risks to the patient </li>
<li>Required post treatment rehabilitation time and impact on work, if any </li>
<li>Alternative therapies or diagnostic testing </li>
</ul>
<p>Before diagnostic tests or referrals for invasive treatment take place the patient should be able to clearly articulate the goals of the intervention, the general side effects and risks associated with it and their decision regarding compliance with the suggested plan. One study indicated that information provided only by video might not be sufficient education.</p>
<p>Practitioners must develop and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers, and the community as a whole. An education-based paradigm should always start with providing reassuring information to the patient and informed decision making. More in-depth education currently exists within a treatment regimen employing functional restoration, prevention, and cognitive behavioral techniques. Patient education and informed decision making should facilitate self-management of symptoms and prevention.</p>
<p><strong>Personality/Psychological/Psychosocial Intervention</strong></p>
<p>Psychosocial treatment is a well-established therapeutic and diagnostic intervention with selected use in acute pain problems, and more widespread use in sub-acute and chronic pain populations. Psychosocial treatment is recommended as an important component in the total management of a patient with chronic pain and should be implemented as soon as the problem is identified.</p>
<p>If a diagnosis consistent with the standards of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) has been determined, the patient should be evaluated for the potential need for psychiatric medications. Use of any medication to treat a diagnosed condition may be ordered by the authorized treating physician or by the consulting psychiatrist. Visits for management of psychiatric medications are medical in nature and are not a component of psychosocial treatment. Therefore, separate visits for medication management may be necessary, depending on the patient and medications selected.</p>
<p>Psychosocial interventions include psychotherapeutic treatments for mental health conditions, as well as behavioral medicine treatments. These interventions may similarly be beneficial for patients without psychiatric conditions, but who may need to make major life changes in order to cope with pain or adjust to disability. Examples of these treatments include cognitive behavioral therapy (CBT), relaxation training, mindfulness training, and sleep hygiene training.</p>
<p>The screening or diagnostic workup should clarify and distinguish between pre-existing, aggravated, and/or purely causative psychological conditions. Therapeutic and diagnostic modalities include, but are not limited to, individual counseling, and group therapy. Treatment can occur within an individualized model, a multi-disciplinary model, or within a structured pain management program.</p>
<p>A psychologist with a PhD, PsyD, EdD credentials, or a psychiatric MD/DO may perform psychosocial treatments. Other licensed mental health providers or licensed health care providers with training in CBT, or certified as CBT therapists working in consultation with a PhD, PsyD, EdD, or psychiatric MD/DO; and with experience in treating chronic pain disorders in injured workers may also perform treatment.</p>
<p>CBT refers to a group of psychological therapies that are sometimes referred to by more specific names, such as rational emotive behavior therapy, rational behavior therapy, rational living therapy, cognitive therapy, and dialectic behavior therapy. Variations of CBT methods can be used to treat a variety of conditions, including chronic pain, depression, anxiety, phobias and post-traumatic stress disorder (PTSD). For patients with multiple diagnoses, more than one type of CBT might be needed. The CBT used in research studies is often "manualized CBT", meaning that the treatment follows a specific protocol in a manual. In clinical settings, CBT may involve the use of standardized materials, but is also commonly adapted by a psychologist or psychiatrist to the patient's unique circumstances. If the CBT is being performed by a non-mental health professional, a manual approach would be strongly recommended. CBT must be distinguished from neuropsychological therapies used to teach compensatory strategies to brain injured patients, which are also called "cognitive therapy."</p>
<p>It should be noted that most clinical trials on CBT exclude subjects who have significant psychiatric diagnoses. Consequently, the selection of patients for CBT should include the following considerations. CBT is instructive and structured, using an educational model with homework to teach inductive rational thinking. Because of this educational model, a certain level of literacy is assumed for most CBT protocols. Patients who lack the cognitive and educational abilities required by a CBT protocol are unlikely to be successful. Further, given the highly structured nature of CBT, it is more effective when a patient's circumstances are relatively stable. For example, if a patient is about to be evicted, is actively suicidal, or coming to sessions intoxicated, these matters will generally preempt CBT treatment for pain, and require other types of psychotherapeutic response. Conversely, literate patients whose circumstances are relatively stable, but catastrophize or cope poorly with pain or disability are often good candidates for CBT for pain. Similarly, literate patients whose circumstances are relatively stable, but who exhibit unfounded medical phobias are often good candidates for CBT for anxiety.</p>
<p>There is good evidence that psychological interventions, especially CBT, are superior to no psychological intervention for chronic low back pain, and that self-regulatory interventions such as biofeedback and relaxation training may be equally effective. There is good evidence that 6 sessions of 1.5 hour group therapy focused on CBT skills improved function and alleviated pain in uncomplicated subacute and chronic low back pain patients. There is some evidence that CBT provided in seven 2-hour small group sessions can reduce the severity of insomnia in chronic pain patients. A Cochrane meta-analysis grouped very heterogeneous behavioral interventions and concluded that there was good evidence that CBT may reduce pain and disability but the effect size was uncertain. In total, the evidence clearly supports cognitive behavioral therapy and it should be offered to all chronic pain patents who do not have other serious issues, as discussed above.</p>
<p>CBT is often combined with active therapy in an interdisciplinary program formal or informal. It must be coordinated with a psychologist or psychiatrist. CBT can be done in a small group or individually and the usual number of treatments varies between 8 and 16 sessions. There is some evidence that cognitive behavioral intervention with or without physical therapy reduces neck related disability in the long term, sick leave and health care utilization. The therapy consisted of six 2-hour sessions given weekly.</p>
<p>Before CBT is done, the patient must have a full psychological evaluation. The CBT program must be done under the supervision of a PhD, PsyD, EdD, or psychiatric MD/DO.</p>
<p>Psychological DSM Axis I disorders are common in chronic pain. One study demonstrated that the majority of patients who had failed other therapy and participated in an active therapy also suffered from major depression. However, in a program which included CBT and other psychological counseling the success rate for return to work was similar for those with and without a DSM IV diagnosis. This study further strengthens the argument for having some psychological intervention included in all chronic pain treatment plans.</p>
<p>For all psychological/psychiatric interventions, an assessment and treatment plan with measurable behavioral goals, time frames, and specific interventions planned, <strong>must</strong> be provided to the treating physician prior to initiating treatment. A status report must be provided to the authorized treating physician every 2 weeks during initial more frequent treatment and monthly thereafter. The report should provide documentation of progress towards functional recovery and discussion of the psychosocial issues affecting the patient's ability to participate in treatment. The report should also address pertinent issues such as pre-existing, aggravated, and/or causative, as well as realistic functional prognosis.</p>
<p>Refer to the original guideline document for time to produce effect, frequency, and optimum and maximum duration of psychological/psychiatric therapies.</p>
<p><strong>Restriction of Activities</strong></p>
<p>Continuation of normal daily activities is the recommendation for chronic pain patients since immobility will negatively affect rehabilitation. Prolonged immobility results in a wide range of deleterious effects, such as a reduction in aerobic capacity and conditioning, loss of muscle strength and flexibility, increased segmental stiffness, promotion of bone demineralization, impaired disc nutrition, and the facilitation of the illness role.</p>
<p>Immobility may range from bed rest to the continued use of orthoses, such as cervical collars. While these interventions may occasionally have been ordered in the acute phase, the provider should be aware of their impact on the patient's ability to adequately comply with and successfully complete rehabilitation. With cervical pain it is generally recommended that returning to stretching and range of motion early is likely to be beneficial. Significant restriction of range of motion may render the worker unsafe for driving.</p>
<p>Patients should be educated regarding the detrimental effects of immobility versus the efficacious use of limited rest periods. Adequate rest allows the patient to comply with active treatment and benefit from the rehabilitation program. In addition, complete work cessation should be avoided, if possible, since it often further aggravates the pain presentation and promotes disability. Modified return-to-work is almost always more efficacious and rarely contraindicated in the vast majority of injured workers with neck pain.</p>
<p><strong>Return-to-Work</strong></p>
<p>Return-to-work and/or work-related activities whenever possible is one of the major components in chronic pain management and rehabilitation. There is some evidence that an integrated care program including workplace interventions and graded activity teaching that pain need not limit activity, is effective in returning patients with chronic low back pain to work, even with minimal reduction of pain. The effect may be similar for uncomplicated neck pain. Return-to-work is a subject that should be addressed by each workers' compensation provider at the first meeting with the injured employee, and be updated at each additional visit. A return-to-work format should be part of a company's health plan, knowing that return-to-work can decrease anxiety, reduce the possibility of depression, and reconnect the worker with society.</p>
<p>Because a prolonged period of time off work will decrease the likelihood of return to work, the first weeks of treatment are crucial in preventing and/or reversing chronicity and disability mindset. In complex cases, experienced nurse case managers may be required to assist in return-to-work. Other services, including psychological evaluation and/or treatment, jobsite analysis, and vocational assistance may be employed.</p>
<p>The following should be considered when attempting to return an injured worker with chronic pain to work.</p>
<ul style="list-style-type: disc;">
<li>Job history interview </li>
<li>Coordination of care </li>
<li>Communication </li>
<li>Establishment of return-to-work status </li>
<li>Establishment of activity level restrictions </li>
<li>Rehabilitation and return-to-work </li>
<li>Vocational assistance </li>
</ul>
<p>Refer to the original guideline document for additional information.</p>
<p><em>Recommendations to Employers and Employees of Small Businesses</em></p>
<p>Employees of small businesses who are diagnosed with chronic pain may not be able to perform any jobs for which openings exist. Temporary employees may fill those slots while the employee functionally improves. Some small businesses hire other workers and if the injured employee returns to the job, the supervisor/owner may have an extra employee. To avoid this, it is suggested that case managers be accessed through their payer or third party administrator. Case managers may assist with resolution of these problems, as well as assist in finding modified job tasks, or find jobs with reduced hours, etc., depending upon company philosophy and employee needs.</p>
<p><em>Recommendations to Employers and Employees of Mid-sized and Large Businesses</em></p>
<p>Employers are encouraged by the Division to identify modified work within the company that may be available to injured workers with chronic pain who are returning to work with temporary or permanent restrictions. To assist with temporary or permanent placement of the injured worker, it is suggested that a program be implemented that allows the case manager to access descriptions of all jobs within the organization.</p>
<p><strong>Therapy–Active</strong></p>
<p>The following active therapies are widely used and accepted methods of care for a variety of work-related injuries. They are based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, ROM, and can alleviate discomfort. Active therapy requires an internal effort by the individual to complete a specific exercise or task. This form of therapy requires supervision from a therapist or medical provider, such as verbal, visual, and/or tactile instruction(s). At times, the provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is predominately executed by the patient.</p>
<p>Education and counseling should include 1) understanding of the strength inherent in the human spine, spinal neutral postures, and stabilization musculature (e.g., multifidas muscles), 2) how neuroscience explains pain perception, 3) the favorable prognosis of neck pain, 4) use of active pain coping strategies that decrease fear and catastrophizing, 5) early resumption of normal activities while still experiencing pain, and 6) the importance of increasing activity levels. Patients should be instructed to continue active therapies at home as an extension of the treatment process in order to maintain improvement levels. Follow-up visits to reinforce and monitor progress and proper technique are recommended. Home exercise can include exercise with or without mechanical assistance or resistance and functional activities with assistive devices. The patient's baseline and progress should be measured using validated tools such as the Neck Disability Index and the Patient–Specific Functional Scale for patient with neck pain.</p>
<p>Therapists should notify the authorized treating physician when 1) clinical findings suggest serious medical or psychological pathology, 2) reported activity limitations are not consistent with the diagnosis, or 3) symptoms are not improving subjectively or objectively after 4 weeks or resolving with interventions focused on normalizing body function. Various means can be used to measure the functional success of treatment; however; it appears that an increase of 5 kg lifting or 7 points on the pain disability index may be useful.</p>
<p>On occasion, specific diagnoses and post-surgical conditions may warrant durations of treatment beyond those listed as "maximum." Factors such as exacerbation of symptoms, re-injury, interrupted continuity of care and co-morbidities may also extend durations of care. Specific goals with objectively measured functional improvement during treatment must be cited to justify extended durations of care. It is recommended that, if no functional gain is observed after the number of treatments under "time to produce effect" have been completed, then alternative treatment interventions, further diagnostic studies, or further consultations should be pursued.</p>
<p>The following active therapies are listed in alphabetical order. Refer to the original guideline document for a description of the following active therapies including time to product effect, frequency, and optimum and maximum duration of treatment:</p>
<ul style="list-style-type: disc;">
<li>Activities of daily living (ADLs) </li>
<li>Functional activities </li>
<li>Functional electrical stimulation </li>
<li>Neuromuscular re-education </li>
<li>Therapeutic exercise </li>
<li>Work conditioning </li>
<li>Work simulation </li>
</ul>
<p><strong>Therapy–Passive</strong></p>
<p>Most of the following passive therapies and modalities are generally accepted methods of care for a variety of work-related injuries. Passive therapy includes those treatment modalities that do not require energy expenditure on the part of the patient. They are principally effective during the early phases of treatment and are directed at controlling symptoms such as pain, inflammation, and swelling and to improve the rate of healing soft tissue injuries. They should be used adjunctively with active therapies such as postural stabilization and exercise programs to help control swelling, pain, and inflammation during the active rehabilitation process. Please refer to Section F.12, "Therapy–Active," in the original guideline document. Passive therapies may be used intermittently as a therapist deems appropriate or regularly if there are specific goals with objectively measured functional improvements during treatment.</p>
<p>The following passive therapies and modalities are listed in alphabetical order. Refer to the original guideline document for a description of the following passive therapies including time to product effect, frequency, and optimum and maximum duration of treatment:</p>
<ul style="list-style-type: disc;">
<li>Electrical stimulation (unattended) </li>
<li>Iontophoresis (<strong>not recommended</strong>) </li>
<li>Manipulation </li>
<li>Manipulation under general anesthesia (MUA) (<strong>not recommended</strong>) </li>
<li>Manipulation under joint anesthesia (MUJA) (<strong>not recommended</strong>) </li>
<li>Massage – manual or mechanical </li>
<li>Mobilization (joint) </li>
<li>Mobilization (soft tissue) </li>
<li>Short-wave diathermy </li>
<li>Superficial heat and cold therapy (excluding infrared therapy) </li>
<li>Traction – manual </li>
<li>Traction – mechanical </li>
<li>Transcutaneous electrical nerve stimulation (TENS) </li>
<li>Ultrasound (including phonophoresis) </li>
</ul>
<p><strong>Vocational Rehabilitation</strong></p>
<p>This is a generally accepted intervention, but Colorado limits its use as a result of Senate Bill 87-79. Initiation of vocational rehabilitation requires adequate evaluation of patients for quantification of highest functional level, motivation, and achievement of maximum medical improvement (MMI). Vocational rehabilitation may be as simple as returning to the original job or as complicated as being retrained for a new occupation.</p>
<p>It may also be beneficial for full vocational rehabilitation to be started before MMI if it is evident that the injured worker will be unable to return to his/her previous occupation. A positive goal and direction may aid the patient in decreasing stress and depression and promoting optimum rehabilitation.</p>
<p><strong><span style="text-decoration: underline;">Therapeutic Procedures—Operative</span></strong></p>
<p>In order to justify operative interventions, clinical findings, clinical course, and diagnostic tests must <strong>all</strong> be consistent resulting in a reasonable likelihood of at least a measurable and meaningful functional and symptomatic improvement. A comprehensive assimilation of these factors must lead to a specific diagnosis with positive identification of pathologic conditions and in most cases a specific site of nerve root compression, spinal cord compression, or spinal instability. It is imperative to rule out non-physiologic modifiers of pain presentation or non-operative conditions mimicking radiculopathy or instability (e.g., psychological conditions, peripheral neuropathy, myofascial pain, rheumatologic, or other pain syndromes, etc.) prior to consideration of elective surgical intervention.</p>
<p>Operative treatment is indicated when the natural history of surgically treated lesions is better than the natural history for non-operatively treated lesions. All patients being considered for surgical intervention should first undergo a comprehensive neuro-musculoskeletal examination to identify mechanical pain generators that may respond to non-surgical techniques or may be refractory to surgical intervention. Patients who demonstrate centralization on directional preference testing may not need surgery when treated with directional preference neuromuscular educations. Refer to Section F.12.f., "Therapeutic Exercise," in the original guideline document.</p>
<p>While sufficient time allowances for non-operative treatment are required to determine the natural cause and response to non-operative treatment of cervical pain disorders, an accurate diagnosis and timely decision making for operative intervention are critical. Thorough neurologic exams should be performed periodically to assure timely treatment; to avoid de-conditioning and increased disability; and to treat emergent pathology or neurologically compromising conditions which may require early surgery.</p>
<p>Brief psychological screening tools, or more frequently full evaluations, are done to predict surgical success. Psychological screening is indicated for all patients with continuing pain who are considering surgical interventions as indicated under the specific surgical procedure. Lower patient satisfaction after repeat surgical procedures and other treatment are related to pre-existing depression.</p>
<p>In general, if the program of non-operative treatment fails, operative treatment is indicated when symptoms and findings suggest a surgically amenable problem and:</p>
<ul style="list-style-type: disc;">
<li>Improvement of the symptoms has plateaued and the residual symptoms of pain and functional disability are unacceptable at the end of 6 to 12 weeks of active therapy and manual treatment. (Mere passage of time with poorly guided treatment is not considered an active treatment program.) In cases of myelopathy and some cases of severe nerve root compression, earlier intervention is indicated or </li>
<li>Frequent recurrences of symptoms cause serious functional limitations, even if a non-operative active treatment program provides significant improvement of symptoms, and restoration of function on each recurrence; and </li>
<li>The patient and treating physician have identified functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work activities. The patient should agree to comply with the pre- and post-operative treatment plan including home exercise. The provider should be especially careful to make sure the patient understands the amount of post-operative treatment required and the length of partial- and full-disability expected post-operatively. The patient should have committed to the recommended post-operative treatment plan and fully completed the recommended active, manual and pre-operative treatment plans. </li>
</ul>
<p>There are some clinical scenarios which necessitate surgical interventions. Surgical workup and implementation of decompression of patients with herniated nucleus pulposus and radiculopathy should occur within 6 to 12 weeks, at the latest, after injury within the above stated contingencies. Small herniations and most protrusions are often not pain generators, however small foraminal disc herniations are likely to compress the nerve root and may require surgical removal.</p>
<p>In order to qualify for surgery for nerve root compression, the patient should exhibit the following signs of radiculopathy before invasive procedures are considered:</p>
<ul style="list-style-type: disc;">
<li>Pain in the arms greater than in the neck which interferes with function, return to work and/or active therapy; <strong>and</strong> </li>
<li>Physical exam findings of abnormal reflexes, motor weakness or radicular sensation deficits; <strong>and</strong> </li>
<li>Findings on the MRI which indicate impingement of nerves or the spinal cord corresponding to reproducible physical exam findings. </li>
</ul>
<p>Treatment of myelopathy may occur earlier. Surgical procedures should be directed toward neurological findings which correlate with MRI imaging. For the unusual patients with refractory cervical pain in whom fusion is being considered, it is strongly recommended that a decisive commitment to surgical or non-surgical interventions occur within five months following injury.</p>
<p>Re-operation is indicated only when the functional outcome following the re-operation is expected to be better, within a reasonable degree of certainty, than the outcome of other non-invasive or less invasive treatment procedures. "Functional outcomes" refer to the patient's ability to improve functional tolerances such as, standing, walking, strength, endurance, functional cervical range of motion, and/or vocational status. While timely surgical decision-making is critical to avoid de-conditioning and increased disability, a time limited trial of reconditioning should be tried prior to re-operation. Re-operation has a high rate of complications and failure and may lead to disproportionately increased disability.</p>
<p>Every post-operative patient should be involved in an active treatment program after clearance by the surgeon (refer to Section F.12., "Therapy—Active," in the original guideline document). Interdisciplinary interventions should be strongly considered post-operatively in any patient not making functional progress within expected time frames (refer to Section F.5., "Interdisciplinary Rehabilitation Programs," in the original guideline document).</p>
<p>Informed decision making should be documented for all invasive procedures. This must include a thorough discussion of the pros and cons of the procedure and the possible complications as well as the natural history of the identified diagnosis. Since most patients with the most common conditions will improve significantly over time, without invasive interventions, patients must be able to make well-informed decisions regarding their treatment.</p>
<p>Return to work restrictions should be specific according to the recommendations in Section F.11., "Return to Work," in the original guideline document. Most surgical patients can return to a limited level of duty between 3 to 6 weeks. Full activity is generally achieved between 3 months to 1 year, depending on the procedure, the type of duties performed, and healing of the individual. Patient should be informed of expected time off work.</p>
<p><strong>Acute Fractures and Dislocations</strong></p>
<p>Decisions regarding the need for surgery in acute traumatic injury will depend on the specific injury type and possibility of long-term neurologic damage. Acute disc herniations may occur in the presence of traumatic injury. Refer to the original guideline document for a description and other information concerning the following interventions, including complications, surgical indication, operative treatment and post-operative treatment:</p>
<ul style="list-style-type: disc;">
<li>Halo immobilization </li>
<li>Anterior or posterior decompression with fusion </li>
<li>Recombinant human bone morphogenetic protein (rhBMP-2) </li>
</ul>
<p><strong>Disc Herniation and Other Cervical Conditions</strong></p>
<p>Operative treatment is indicated only when the natural history of an operatively treatable problem is better than the natural history of the problem without operative treatment. All patients being considered for surgical intervention should undergo a comprehensive neuromuscular examination to identify pain generators that may respond to nonsurgical techniques or may be refractory to surgical intervention. Timely decision making for operative intervention is critical to avoid deconditioning, and increased disability of the cervical spine.</p>
<p><em>General Recommendations</em></p>
<p>There is insufficient evidence due to weak quality of studies to determine whether recovery from cervical radiculopathy in patients without clinical signs of spinal cord compression at one year is similar for one-level discectomy and fusion; physical therapy; or rigid cervical collar use. Some non-surgical patients will recover over time. For patients with whiplash injury (Quebec Classification Grade Levels I or II), there is no evidence of any beneficial effect of operative treatment. Refer to D.1.e., "Soft Tissue Injury Evaluation," in the original guideline document for a discussion on Quebec Classification Levels.</p>
<p>If cervical fusion with discectomy is being considered, it is recommended that the injured worker refrain from smoking for at least six weeks prior to surgery and during the time of healing. Because smokers have a higher risk of non-union and higher post-operative costs, it is recommended that insurers cover a smoking cessation program peri-operatively.</p>
<p><em>General Indications for Surgery</em></p>
<p>Operative intervention should be considered and a consultation obtained when improvement of radicular symptoms has plateaued and the residual symptoms of pain and functional disability are unacceptable at the end of six weeks of treatment. In cases of multiple trauma or complex injuries, the procedure may be delayed due to lack of early recognition or the need to treat other conditions first. Choice of operative approach and hardware instrumentation is based on anatomy, the patient's pathology, and the surgeon's experience and preference.</p>
<p><em>Specific Indications for Surgery</em></p>
<p>Refer to the original guideline document for specific indications for surgery.</p>
<p><em>Surgical Procedures</em></p>
<p>Refer to the original guideline document for a description of the following surgical procedures for disc herniation and other cervical conditions, as well as complications, surgical indication, and operative and post-operative treatment:</p>
<ul style="list-style-type: disc;">
<li>Anterior cervical discectomy with or without fusion </li>
<li>Anterior cervical corpectomy </li>
<li>Posterior cervical laminectomy, foraminotomy, discectomy with or without fusion </li>
<li>Posterior cervical laminoplasty </li>
<li>Percutaneous discectomy </li>
</ul>
<p><strong>Total Artificial Cervical Disc Replacement (TDR)</strong></p>
<p>Involves the insertion of a prosthetic device into the cervical intervertebral space with the goal of maintaining physiologic motion at the treated cervical segment. The use of artificial discs in motion-preserving technology is based on the surgeons preference and training. One advantage of disc replacement over fusion is the generally shorter recovery time.</p>
<p>Refer to the original guideline document for a description of the procedure, complications, surgical indications, contraindications, and post-operative treatment.</p>
<p><strong>Percutaneous RF Disc Decompression</strong></p>
<p>Percutaneous RF disc decompression of the cervical spine is an investigational procedure that introduces a 19-gauge cannula under local anesthesia and fluoroscopic guidance into the nucleus pulposus of a contained herniated disc, using RF energy to dissolve and remove disc material. Pressure inside the disc is lowered as a result. The only trial was limited to a population not likely to apply to the workers' compensation population. It is <strong>not recommended</strong>.</p>
<p><strong>Epiduroscopy and Epidural Lysis of Adhesions</strong></p>
<p>Refer to Section F.4b, "Epiduroscopy and Epidural Lysis of Adhesions," in the original guideline document.</p>
<p><strong>Intraoperative Monitoring</strong></p>
<p>A common intraoperative electrodiagnostic technique that may include somatosensory evoked potentials (SSEP), motor evoked potentials (MEP), or pedicle screw monitoring. The monitoring procedure may be used to evaluate spinal cord integrity and screw placement during the operative procedure.</p></div></p>
<h3><a href="#">Clinical Algorithm(s)</a></h3>
<p><div class="content_para"><p>None provided</p></div></p>
</div>
<h2 id="396" class="accordion-title section-396 is-active" role="tab" aria-expanded="true"><a href="#">Scope</a></h2>
<div class="accordion-panel is-active" role="tabpanel">
<h3><a href="#">Disease/Condition(s)</a></h3>
<p><div class="content_para"><p>Cervical spine injury</p></div></p>
<h3><a href="#">Guideline Category</a></h3>
<p>Counseling</p>
<p>Management</p>
<p>Rehabilitation</p>
<p>Treatment</p>
<h3><a href="#">Clinical Specialty</a></h3>
<p>Chiropractic</p>
<p>Emergency Medicine</p>
<p>Family Practice</p>
<p>Internal Medicine</p>
<p>Neurological Surgery</p>
<p>Physical Medicine and Rehabilitation</p>
<p>Psychiatry</p>
<p>Psychology</p>
<p>Radiology</p>
<p>Surgery</p>
<h3><a href="#">Intended Users</a></h3>
<p>Advanced Practice Nurses</p>
<p>Chiropractors</p>
<p>Health Care Providers</p>
<p>Health Plans</p>
<p>Hospitals</p>
<p>Managed Care Organizations</p>
<p>Nurses</p>
<p>Occupational Therapists</p>
<p>Patients</p>
<p>Pharmacists</p>
<p>Physical Therapists</p>
<p>Physician Assistants</p>
<p>Physicians</p>
<p>Psychologists/Non-physician Behavioral Health Clinicians</p>
<p>Public Health Departments</p>
<p>Social Workers</p>
<p>Utilization Management</p>
<h3><a href="#">Guideline Objective(s)</a></h3>
<p><div class="content_para"><p>To provide advisory and educational guidelines for the treatment of cervical spine injury that are enforceable under the Colorado Workers' Compensation Rules of Procedure</p></div></p>
<h3><a href="#">Target Population</a></h3>
<p><div class="content_para"><p>Individuals who qualify as injured workers with cervical spine injuries under the Colorado Workers' Compensation Act</p></div></p>
<h3><a href="#">Interventions and Practices Considered</a></h3>
<p><div class="content_para"><p><strong>Non-operative Therapeutic Procedures*</strong></p>
<ol style="list-style-type: decimal;" start="1">
<li>Acupuncture </li>
<li>Biofeedback </li>
<li>Therapeutic injections
<ul style="list-style-type: disc;">
<li>Epidural steroid injections (ESI) </li>
<li>Intradiscal steroid therapy </li>
<li>Transforaminal injection with etanercept </li>
<li>Zygapophyseal (facet) injections </li>
<li>Botulinum toxin injections </li>
<li>Epiduroscopy and epidural lysis of adhesions </li>
<li>Prolotherapy </li>
<li>Radiofrequency (RF) ablation - dorsal nerve root ablation </li>
<li>RF denervation - medial branch neurotomy/facet rhizotomy </li>
<li>Transdiscal biacuplasty </li>
<li>Trigger point injections and dry needling treatment </li>
</ul>
</li>
<li>Interdisciplinary rehabilitation programs (formal and informal) </li>
<li>Medications
<ul style="list-style-type: disc;">
<li>Acetaminophen </li>
<li>Intravenous steroids </li>