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Nerve Blocks

Number: 0863



Policy

Aetna considers the following nerve blocks medically necessary:

  • Femoral nerve blocks for acute post-operative pain after knee replacement surgery
  • Intercostal nerve blocks for acute intercostal pain, and for chronic intercostal neuritis as part of a comprehensive pain management program
  • Peripheral nerve blocks (continuous or single-injection) for the treatment of (i) acute pain, and (ii) for chronic pain only as part of an active component of a comprehensive pain management program
  • Peripheral nerve blocks for the treatment of chronic pain post-herniorrhaphy to avoid more aggressive treatments (e.g., surgery)

Aetna considers the following nerve blocks experimental and investigational (not an all-inclusive list) because their effectiveness for these indications has not been established:

  • Cluneal nerve block
  • Ganglion impar block (see CPB 16 - Back Pain: Invasive Procedures)
  • Genicular nerve block
  • Greater occipital nerve blocks for the diagnosis and treatment of neck and upper back pain
  • Intercostal nerve blocks for the sole treatment of chronic intercostal neuritis
  • Obturator nerve block for treatment of chronic pain
  • Paravertebral block for treatment of chronic pain
  • Pedicle screw block/hardware block of spinal instrumentation
  • Peripheral nerve blocks as sole treatment for chronic pain
  • Peripheral nerve blocks for the treatment of headaches including (migraine headaches and treatment-refractory migraine in pregnancy)
  • Repetitive peripheral nerve blocks for chronic non-malignant pain
  • Suprascapular nerve blocks for the treatment of chronic upper extremity pain.

See also CPB 0462 - Migraine and Cluster Headache: Nonsurgical Management, CPB 0722 - Selective Nerve Root Blocks, and CPB 0729 - Diabetic Neuropathy: Selected Treatments.

Background

A nerve block is a form of regional anesthesia.  Peripheral nerve blocks (PNBs) entail the injection of corticosteroids, local anesthetics, neurolytic agents and/or sclerosing agents into or near peripheral nerves or neve ganglion resulting in the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks (somatic and sympathetic nerves).  Peripheral nerve blocks attempt to block pain signals and in theory provide prolonged relief from pain.

Examples of peripheral nerve blocks include, but may not be limited to, cluneal nerve block, ganglion impar block, genicular nerve block or obturator nerve block. The cluneal nerve is a sensory nerve located in the upper portion of the buttocks, consisting of a superior, medial and inferior branch. The genicular nerve is a sensory nerve that surrounds the knee and provides innervation for the joint. An obturator nerve block is an injection of a steroid, an anesthetic or a combination of both, near the obturator nerve, which is primarily a motor nerve arising from the third and fourth lumbar nerves, with distribution to the hip and thigh; this type injection is most commonly used as part of regional anesthesia for knee surgery. 

Peripheral nerve blocks can either be “single-injection” -- refers to one-time injection of local anesthetic to the target nerve for peri-operative analgesia and/or surgical anesthesia, or “continuous” -- refers to the percutaneous insertion of a catheter directly adjacent to the target peripheral nerve(s).  The latter approach is to provide prolonged nerve block by continuous infusion of local anesthetic for longer procedures, as well as post-operative analgesia.  Continuous PNB (cPNB) is primarily used for inpatient procedures, but can also be used in outpatients (Jeng and Rosenblatt, 2012).

Neuropathic pain is a type of pain that can result from injury to nerves, either in the peripheral or central nervous system. Neuropathic pain can occur in any part of the body and is frequently described as a hot, burning sensation. It can result from diseases that affect nerves (such as diabetes) or from trauma, or, because chemotherapy drugs can affect nerves, it can be a consequence of cancer treatment.  Among the many neuropathic pain conditions some that can cause neuropathic pain of the extremities are diabetic neuropathy, reflex sympathetic dystrophy syndrome, phantom limb and post-amputation pain. Chronic pain persists over a longer period of time than acute pain and is resistant to most medical treatments.  A peripheral nerve block may be performed to diagnose and/or treat neuropathic pain.

Aguirre et al (2012) stated that the most common use of cPNBs is in the peri- and post-operative period but different indications have been described like the treatment of chronic pain such as cancer-induced pain, complex regional pain syndrome or phantom limb pain.  The documented benefits strongly depend on the analgesia quality and include decreasing baseline/dynamic pain, reducing additional analgesic requirements, decrease of post-operative joint inflammation and inflammatory markers, sleep disturbances and opioid-related side effects, increase of patient satisfaction and ambulation/functioning improvement, an accelerated resumption of passive joint range-of-motion, reducing time until discharge readiness, decrease in blood loss/blood transfusions, potential reduction of the incidence of post-surgical chronic pain and reduction of costs.  Evidence deriving from randomized controlled trials suggests that in some situations there are also prolonged benefits of regional anesthesia after catheter removal in addition to the immediate post-operative effects.  Unfortunately, there are only few data demonstrating benefits after catheter removal and the evidence of medium- or long-term improvements in health-related quality of life (QOL) measures is still lacking.

In a review on “Evidence-based interventions for chemotherapy-induced peripheral neuropathy”, Visovsky et al (2007) examined the literature on the prevention or treatment of chemotherapy-induced peripheral neuropathy (CIPN), which included pilot studies, clinical trials, systematic reviews of the literature, and case studies.  The Oncology Nursing Society Putting Evidence Into Practice® (PEP) CIPN Team consisted of 2 advanced practice nurses, 2 staff nurses, and a nurse researcher.  The CIPN Team chose not to include animal model-based studies because applicability and generalizability to human populations has not been established.  No meta-analyses addressing the prevention or treatment of CIPN were found in the literature.  The team searched Medline, the National Library of Medicine's database.  Search terms included chemotherapy-induced peripheral neuropathy, peripheral neuropathy, and neuropathy.  Search terms specific to known CIPN interventions also were explored, including human leukemia inhibitory factor, nerve growth factor, neurotrophin-3, exercise and chemotherapy-induced peripheral neuropathy, exercise and neuropathy, diabetes and peripheral neuropathy, vitamin E, tricyclic antidepressants (TCAs), amifostine, calcium/magnesium infusions, carbamazepine, glutathione, alpha lipoic acid, and glutamine.  Other search terms were alternative therapy, complementary therapies, herbal therapies, plants-medicinal, herb(s), herbal(s), acupuncture, electric nerve stimulation, high-frequency external muscle stimulation, transelectrical nerve stimulation, spinal cord stimulation, anodyne therapy, pulsed infrared light therapy, social support, psychosocial support, educational interventions, patient education, patient safety, safety, injury, accidents, safety management, protective devices, and capsaicin.  The authors concluded that CIPN remains a significant problem for patients receiving chemotherapy for cancer.  At present, no interventions for CIPN can be recommended for practice.  No rigorously designed studies, meta-analyses, or systematic reviews support any of the interventions discussed, and risk of harm may out-weigh potential benefits.

The American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine’s practice guidelines on “Chronic pain management” (2010) stated that “Peripheral somatic nerve blocks should not be used for long-term treatment of chronic pain”.

Hartemann et al (2011) stated that the prevalence of painful diabetic neuropathy (PDN) is approximately 20 % in patients with type-2 diabetes and 5 % in those with type-1 diabetes.  Patients should be systematically questioned concerning suggestive symptoms, as they are not usually volunteers.  As PDN is due to small-fiber injury, the 10 g monofilament pressure test as well as the standard electrophysiological procedures may be normal.  Diagnosis is based on clinical findings: type of pain (burning discomfort, electric shock-like sensation, aching coldness in the lower limbs); time of occurrence (mostly at rest and at night); and abnormal sensations (such as tingling or numbness).  The DN4 questionnaire is an easy-to-use validated diagnostic tool.  Three classes of drugs are of equal value in treating PDN: (i) TCAs; (ii) anticonvulsants; and (iii) selective serotonin-reuptake inhibitors (SSRIs).  These compounds may be prescribed as first-line therapy following pain assessment using a visual analog scale (VAS).  If the initial drug at its maximum tolerated dose does not lead to a decrease in pain of at least 30 %, another drug class should be prescribed; if the pain is decreased by 30 % but remains greater than 3/10, a drug from a different class may be given in combination.

The American Academy of Neurology (AAN), American Association of Neuromuscular and Electrodiagnostic Medicine, American Academy of Physical Medicine and Rehabilitation (Bril et al, 2011) developed a scientifically sound and clinically relevant evidence-based guideline for the treatment of PDN.  The basic question that was asked was: "What is the efficacy of a given treatment (pharmacological: anticonvulsants, antidepressants, opioids, others; non-pharmacological: electrical stimulation, magnetic field treatment, low-intensity laser treatment, Reiki massage, others) to reduce pain and improve physical function and QOL in patients with PDN"?  A systematic review of literature from 1960 to August 2008 was performed, and studies were classified according to the AAN classification of evidence scheme for a therapeutic article.  Recommendations were linked to the strength of the evidence.  The results indicated that pregabalin is established as effective and should be offered for relief of PDN (Level A).  Venlafaxine, duloxetine, amitriptyline, gabapentin, valproate, opioids (morphine sulfate, tramadol, and oxycodone controlled-release), and capsaicin are probably effective and should be considered for treatment of PDN (Level B).  Other treatments have less robust evidence, or the evidence is negative.  Effective treatments for PDN are available, but many have side effects that limit their usefulness.  Few studies have sufficient information on their effects on function and QOL.

The South African Expert Panel’s clinical practice guidelines for management of neuropathic pain (Chetty et al, 2012) stated that neuropathic pain (NeuP) is challenging to diagnose and manage, despite ongoing improved understanding of the underlying mechanisms.  Many patients do not respond satisfactorily to existing treatments.  There are no published guidelines for diagnosis or management of NeuP in South Africa.  A multi-disciplinary expert panel critically reviewed available evidence to provide consensus recommendations for diagnosis and management of NeuP in South Africa.  Following accurate diagnosis of NeuP, pregabalin, gabapentin, low-dose TCAs (e.g., amitriptyline) and SSRIs (e.g., duloxetine and venlafaxine) are all recommended as first-line options for the treatment of peripheral NeuP.  If the response is insufficient after 2 to 4 weeks, the recommended next step is to switch to a different class, or combine different classes of agent.  Opioids should be reserved for use later in the treatment pathway, if switching drugs and combination therapy fails.  For central NeuP, pregabalin or amitriptyline are recommended as first-line agents.  Companion treatments (e.g., cognitive behavioral therapy and physical therapy) should be administered as part of a multi-disciplinary approach.  Dorsal root entry zone rhizotomy (DREZ) is not recommended to treat NeuP. 

In an evidence-based guideline on “Neuropathic pain interventional treatments”, Mailis and Taenzer (2012) states that “Based on limited evidence that selective transforaminal nerve root blocks (extraforaminal root injections, periradicular steroid injections, intraforaminal oxygen-ozone injections and epidural perineural autologous conditioned serum injections can provide up to 8 to 12 weeks of relief from lumbar radicular pain, the task force cannot justify a general recommendation, but suggests that these interventions be used with caution depending on the circumstances, with full disclosure to the patient of the limited evidence and potential risks.  Evidence quality: Fair; Certainty: Moderate; Strength of recommendation: Grade C (May recommend depending on circumstances.  At least moderate certainty with small net benefit).

Furthermore, UpToDate reviews on “Treatment of diabetic neuropathy” (Feldman and McCulloch, 2012), “Overview of lower extremity peripheral nerve syndromes” (Rutkove, 2012), and “Epidemiology, clinical manifestations, diagnosis, and treatment of HIV-associated peripheral neuropathy” (Nardin and Freeman, 2012) do not mention the use of PNBs.

Ashkenazi et al (2010) stated that interventional procedures such as PNBs and trigger point injections (TPIs) have long been used in the treatment of various headache disorders.  There are, however, little data on their effectiveness for the treatment of specific headache syndromes.  Moreover, there is no widely accepted agreement among headache specialists as to the optimal technique of injection, type, and doses of the local anesthetics used, and injection regimens.  The role of corticosteroids in this setting is also being debated.  These investigators performed a PubMed search of the literature to find studies on PNBs and TPIs for the treatment of headaches.  They classified the abstracted studies based on the procedure performed and the treated condition.  These researchers found few controlled studies on the effectiveness of PNBs for headaches, and virtually none on the use of TPIs for this indication.  The most widely examined procedure in this setting was greater occipital nerve block, with the majority of studies being small and non-controlled.  The techniques, as well as the type and doses of local anesthetics used for PNBs, varied greatly among studies.  The specific conditions treated also varied, and included both primary (e.g., migraine, cluster headache) and secondary (e.g., cervicogenic, post-traumatic) headache disorders.  Trigeminal (e.g., supraorbital) nerve blocks were used in few studies.  Results were generally positive, but should be taken with reservation given the methodological limitations of the available studies.  The procedures were generally well-tolerated.  The authors concluded that there is a need to perform more rigorous clinical trials to clarify the role of PNBs and TPIs in the management of various headache disorders, and to aim at standardizing the techniques used for the various procedures in this setting.

In summary, there is currently insufficient evidence to support the use of peripheral nerve blocks in the treatment of peripheral neuropathy or other indications.

The Work Loss Data Institute’s guideline on “Neck and upper back (acute & chronic)” (2013) listed greater occipital nerve block (diagnostic and therapeutic) as one of the interventions/procedures that are under study and are not specifically recommended.

In a Cochrane review, Chan et al (2014) evaluated the benefits and risks of femoral nerve block (FNB) used as a post-operative analgesic technique relative to other analgesic techniques among adults undergoing total knee replacement (TKR).  These investigators searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2013, Issue 1, MEDLINE, EMBASE, CINAHL, Web of Science, dissertation abstracts and reference lists of included studies.  The date of the last search was January 31, 2013.  These researchers included randomized controlled trials (RCTs) comparing FNB with no FNB (intravenous patient-controlled analgesia (PCA) opioid, epidural analgesia, local infiltration analgesia, and oral analgesia) in adults after TKR.  They also included RCTs that compared continuous versus single-shot FNB.  Two review authors independently performed study selection and data extraction.  They undertook meta-analysis (random-effects model) and used relative risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) or standardized mean differences (SMDs) for continuous outcomes.  They interpreted SMDs according to rule of thumb where 0.2 or smaller represents a small effect, 0.5 a moderate effect and 0.8 or larger, a large effect.

These investigators included 45 eligible RCTs (2,710 participants) from 47 publications; 20 RCTs had more than 2 allocation groups.  A total of 29 RCTs compared FNB (with or without concurrent treatments including PCA opioid) versus PCA opioid, 10 RCTs compared FNB versus epidural, 5 RCTs compared FNB versus local infiltration analgesia, 1 RCT compared FNB versus oral analgesia and 4 RCTs compared continuous versus single-shot FNB.  Most included RCTs were rated as low or unclear risk of bias for the aspects rated in the risk of bias assessment tool, except for the aspect of blinding.  These researchers rated 14 (31 %) RCTs at high-risk for both participant and assessor blinding and rated 8 (18 %) RCTs at high-risk for one blinding aspect.  Pain at rest and pain on movement were less for FNB (of any type) with or without a concurrent PCA opioid compared with PCA opioid alone during the first 72 hours post-operation.  Pooled results demonstrated a moderate effect of FNB for pain at rest at 24 hours (19 RCTs, 1,066 participants, SMD -0.72, 95 % confidence interval [CI]: -0.93 to -0.51, moderate-quality evidence) and a moderate to large effect for pain on movement at 24 hours (17 RCTs, 1,017 participants, SMD -0.94, 95 % CI: -1.32 to -0.55, moderate-quality evidence).  Pain was also less in each FNB subgroup: single-shot FNB, continuous FNB and continuous FNB + sciatic block, compared with PCA.  Femoral nerve block also was associated with lower opioid consumption (IV morphine equivalent) at 24 hours (20 RCTs, 1,156 participants, MD -14.74 mg, 95 % CI: -18.68 to -10.81 mg, high-quality evidence) and at 48 hours (MD -14.53 mg, 95 % CI: -20.03 to -9.02 mg), lower risk of nausea and/or vomiting (RR 0.47, 95 % CI: 0.33 to 0.68, number needed to treat for an additional harmful outcome (NNTH) 4, high-quality evidence), greater knee flexion (11 RCTs, 596 participants, MD 6.48 degrees, 95 % CI ; 4.27 to 8.69 degrees, moderate-quality evidence) and greater patient satisfaction (four RCTs, 180 participants, SMD 1.06, 95 % CI: 0.74 to 1.38, low-quality evidence) compared with PCA.  The authors could not demonstrate a difference in pain between FNB (any type) and epidural analgesia in the first 72 hours post-operation, including pain at 24 hours at rest (6 RCTs, 328 participants, SMD -0.05, 95 % CI: -0.43 to 0.32, moderate-quality evidence) and on movement (6 RCTs, 317 participants, SMD 0.01, 95 % CI: -0.21 to 0.24, high-quality evidence).  No difference was noted at 24 hours for opioid consumption (5 RCTs, 341 participants, MD -4.35 mg, 95 % CI: -9.95 to 1.26 mg, high-quality evidence) or knee flexion (6 RCTs, 328 participants, MD -1.65, 95 % CI: -5.14 to 1.84, high-quality evidence).  However, FNB demonstrated lower risk of nausea/vomiting (4 RCTs, 183 participants, RR 0.63, 95 % CI: 0.41 to 0.97, NNTH 8, moderate-quality evidence) and higher patient satisfaction (2 RCTs, 120 participants, SMD 0.60, 95 % CI: 0.23 to 0.97, low-quality evidence), compared with epidural analgesia.  Pooled results of 4 studies (216 participants) comparing FNB with local infiltration analgesia detected no difference in analgesic effects between the groups at 24 hours for pain at rest (SMD 0.06, 95 % CI: -0.61 to 0.72, moderate-quality evidence) or pain on movement (SMD 0.38, 95 % CI: -0.10 to 0.86, low-quality evidence).  Only 1 included RCT compared FNB with oral analgesia.  These researchers considered this evidence insufficient to allow judgment of the effects of FNB compared with oral analgesia.  Continuous FNB provided less pain compared with single-shot FNB (4 RCTs, 272 participants) at 24 hours at rest (SMD -0.62, 95 % CI: -1.17 to -0.07, moderate-quality evidence) and on movement (SMD -0.42, 95 % CI: -0.67 to -0.17, high-quality evidence).  Continuous FNB also demonstrated lower opioid consumption compared with single-shot FNB at 24 hours (3 RCTs, 236 participants, MD -13.81 mg, 95 % CI: -23.27 to -4.35 mg, moderate-quality evidence).  Generally, the meta-analyses demonstrated considerable statistical heterogeneity, with type of FNB, allocation concealment and blinding of participants, personnel and outcome assessors reducing heterogeneity in the analyses.  Available evidence was insufficient to allow determination of the comparative safety of the various analgesic techniques.  Few RCTs reported on serious adverse effects such as neurological injury, post-operative falls or thrombotic events.  The authors concluded that following TKR, FNB (with or without concurrent treatments including PCA opioid) provided more effective analgesia than PCA opioid alone, similar analgesia to epidural analgesia and less nausea/vomiting compared with PCA alone or epidural analgesia.  The review also found that continuous FNB provided better analgesia compared with single-shot FNB; RCTs were insufficient to allow definitive conclusions on the comparison between FNB and local infiltration analgesia or oral analgesia.

Bauer et al (2014) noted that pain following TKR is a challenging task for healthcare providers.  Concurrently, fast recovery and early ambulation are needed to regain function and to prevent post-operative complications.  Ideal post-operative analgesia provides sufficient pain relief with minimal opioid consumption and preservation of motor strength.  Regional analgesia techniques are broadly used to answer these expectations.  Femoral nerve blocks are performed frequently but have suggested disadvantages, such as motor weakness.  The use of lumbar epidurals is questioned because of the risk of epidural hematoma.  Relatively new techniques, such as local infiltration analgesia or adductor canal blocks, are increasingly discussed.  The present review discussed new findings and weighted between known benefits and risks of all of these techniques for TKR.  Femoral nerve blocks are the gold standard for TKR.  The standard use of additional sciatic nerve blocks remains controversial.  Lumbar epidurals possess an unfavorable risk/benefit ratio because of increased rate of epidural hematoma in orthopedic patients and should be reserved for lower limb amputation; peripheral regional techniques provide comparable pain control, greater satisfaction and less risk than epidural analgesia.  Although motor weakness might be greater with FNBs compared with no regional analgesia, new data pointed towards a similar risk of falls after TKR, with or without peripheral nerve blocks.  Local infiltration analgesia and adductor canal blockade are promising recent techniques to gain adequate pain control with a minimum of undesired side-effects.  The authors concluded that FNBs are still the gold standard for an effective analgesia approach in knee arthroplasty and should be supplemented (if needed) by oral opioids.  An additional sciatic nerve blockade is still controversial and should be an individual decision.  Moreover, they stated that large-scale studies are needed to reinforce the promising results of newer regional techniques, such as local infiltration analgesia and adductor canal block.

An UpToDate review on “Total knee arthroplasty” (Martin et al, 2014) states that “Increasingly, patients are managed with femoral nerve blocks in order to reduce the complications and the delay in rehabilitation associated with general anesthesia and with indwelling epidural catheters.  Patient-controlled analgesia (PCA) can be useful in the post-arthroplasty setting.  Subsequently, oral opioid analgesics may be used.  Pain control after total knee replacement has improved considerably with increasing use of multimodal pain management strategies.  This typically includes “preemptive” management with acetaminophen, cyclooxygenase-2 (COX-2)-selective nonsteroidal antiinflammatory drugs (NSAIDs), femoral nerve blocks, regional anesthetics, and periarticular injections”.

Law et al (2015) compared paravertebral block (PVB) with general anesthesia/systemic analgesia, neuraxial blocks, and other PNBs. These investigators analyzed 14 RCTs from PubMed, MEDLINE, CENTRAL, EMBASE, and CINAHL up to February 2015, without language restriction, comparing PVB under sedation with general anesthesia/systematic analgesia (135 versus 133 patients), neuraxial blocks (191 versus 186 patients), and other PNBs (119 versus 117 patients). These researchers investigated pain scores, consumption of post-operative analgesia, incidence of post-operative nausea and vomiting (PONV), length of hospital stay, post-anesthesia care unit bypassing rate, time to perform blocks, intra-operative hemodynamics, and incidence of urinary retention. Joint hypothesis testing was adopted for pain and analgesics, PONV, and hemodynamic variables. All analyses were performed with RevMan 5.2.11 (Cochrane Collaboration, Copenhagen). Hartung-Knapp-Sidik-Jonkman method was used for post-hoc testing. Paravertebral block reduced PONV (nausea: RR = 0.22; 95 % CI: 0.05 to 0.93; numbers needed to treat [NNT] = 4.5; I = 15 % and vomiting: RR = 0.15; 95 % CI: 0.03 to 0.76; NNT = 8.3; I = 0 %) compared with general anesthesia/systematic analgesia (quality of evidence [QoE]: high). Compared with neuraxial blocks, PVB resulted in less post-operative nausea (RR = 0.34 [95 % CI: 0.13 to 0.91], NNT = 8.3, I = 0 %) and urinary retention (RR = 0.14 [95 % CI: 0.05 to 0.42], NNT = 7.4, I = 0 %) than neuraxial blocks (QoE: high). More time was needed to perform PVB than neuraxial blocks (standardized mean difference = 1.90 [95 % CI: 0.02 to 3.77], I = 92 %; mean difference = 5.33 minutes; QoE: moderate). However, the available data could not reject the null hypothesis of non-inferiority on all pain scores and analgesic requirements for both PVB versus general anesthesia/systematic analgesia and PVB versus neuraxial blocks (QoE: low), as well as on hemodynamic outcomes for PVB versus neuraxial blocks (QoE: moderate). This systematic review showed that PVB decreased post-operative pain scores and analgesic requirement as compared with ilio-inguinal block and transversus abdominis plane block. The authors concluded that this meta-analysis showed that PVB provides an anesthesia with fewer undesirable effects for inguinal herniorrhaphy. The choice between general anesthesia/systematic analgesia, neuraxial blocks, PVB, and other PNBs should be based on time available to perform the block and a complete coverage over the relevant structures by the blocks.

Treatment of Migraine Headaches:

Levin (2010) stated that nerve blocks and neurostimulation are reasonable therapeutic options in patients with head and neck neuralgias. In addition, these peripheral nerve procedures can also be effective in primary headache disorders, such as migraine and cluster headaches. Nerve blocks for headaches are generally accomplished by using small subcutaneous injections of amide-type local anesthetics (e.g., lidocaine and bupivacaine). Targets include the greater occipital nerve, lesser occipital nerve, auriculo-temporal nerve, supra-trochlear and supraorbital nerves, spheno-palatine ganglion, cervical spinal roots, and facet joints of the upper cervical spine. The author concluded that although definitive studies examining the usefulness of nerve blocks are lacking, reports suggested that this area deserves further attention in the hope of acquiring evidence of effectiveness.

Govindappagari et al (2014) described the use of PNBs in a case series of pregnant women with migraine. A retrospective chart review of all pregnant patients treated with PNBs for migraine over a 5-year period was performed. Injections targeted greater occipital, auriculo-temporal, supraorbital, and supra-trochlear nerves using local anesthetics. Peripheral nerve blocks were performed 27 times in 13 pregnant women either in a single (n = 6) or multiple (n = 7) injection series. Mean patient age was 28 years and gestational age was 23.5 weeks, and all women had migraine, including 38.5 % who had chronic migraine. Peripheral nerve blocks were performed for status migrainosus (51.8 %) or short-term prophylaxis of frequent headache attacks (48.1 %). Before PNBs were performed, oral medications failed for all patients and intravenous medications failed for most. In patients with status migrainosus, average pain reduction was 4.0 (± 2.6 standard deviation [SD]) (p < 0.001) immediately post-procedure and 4.0 (± 4.4 SD) (p = 0.007) 24 hours post-procedure in comparison to pre-procedure pain. For patients receiving PNBs for short-term prophylaxis, immediate mean pain score reduction was 3.0 (± 2.1 SD). No patients had any serious immediate, procedurally related adverse events, and the 2 patients who had no acute pain reduction ultimately developed pre-eclampsia and had post-partum headache resolution. The authors concluded that PNBs for treatment-refractory migraine may be an effective therapeutic option in pregnancy. This was a small (n = 13) retrospective study; these findings need to be validated by well-designed studies.

An UpToDate review on “Headache in pregnant and postpartum women” (Lee et al, 2015) states that “Peripheral nerve blocks may also be effective. In a series of 13 pregnant women with migraine refractory to medication, injection of local anesthetic into one or more peripheral nerves (e.g., occipital, auriculo-temporal, supraorbital, supra-trochlear) resulted in elimination of pain in seven women, pain reduction in two women, and no response in four women. Six patients received a single injection; the other seven patients received two to five sequential nerve blocks. There were no adverse maternal or fetal effects. Given the small number of patients in this study, larger studies should be performed to better define the efficacy of this approach”.

Furthermore, an UpToDate review on “Overview of peripheral nerve blocks” (Jeng and Rosenblatt, 2015) does not mention headache/migraine as an indication of PNBs.

Treatment of Hip Fracture:

Abou-Setta and colleagues (2011) reviewed and synthesized the evidence on pain management interventions in non-pathological hip fracture patients following low-energy trauma. Outcomes include pain management (short- and long-term), mortality, functional status, pain medication use, mental status, health-related quality of life (QOL), quality of sleep, ability to participate in rehabilitation, return to pre-fracture living arrangements, health services utilization, and adverse effects. Comprehensive literature searches were conducted in 25 electronic databases from 1990 to present. Searches of the grey literature, trial registries, and reference lists of previous systematic reviews and included studies were conducted to identify additional studies. Study selection, quality assessment, data extraction, and grading of the evidence were conducted independently and in duplicate. Discrepancies were resolved by consensus or third-party adjudication. Meta-analyses were conducted where data were available and deemed appropriate. In total, 83 studies were included (69 trials, 14 cohort studies). Most participants were females older than 75 with no cognitive impairment. The methodological quality of cohort studies was generally moderate; most trials were at high or unclear risk of bias. Included studies were grouped into 8 intervention categories: (i0 systemic analgesia, (ii) anesthesia, (iii) complementary and alternative medicine, (iv) multi-modal pain management, (v) nerve blocks, (vi) neurostimulation, (vii) rehabilitation, and (viii) traction. Most studies examined peri- and post-operative pain management, albeit from few perspectives such as reported pain, mortality, and adverse effects. Long-term pain was not reported, and other outcomes were reported infrequently. Nerve blockade was effective for relief of acute pain; however, most studies were limited to either assessing acute pain or use of additional analgesia and did not report on how nerve blockades may affect rehabilitation such as ambulation or mobility if the blockade has both sensory and motor effects. Acupressure, relaxation therapy, and transcutaneous electrical neurostimulation may be associated with potentially clinically meaningful reductions in pain, but further evidence is warranted before any firm conclusions are reached. While the strength of evidence is insufficient to make firm conclusions, post-operative physical therapy may improve pain control, and intravenous parecoxib, a systemic analgesic not available in North America, may be a possible alternative to traditional intramuscular injections of opiates and older non-steroidal anti-inflammatory drugs (NSAIDs). Pre-operative traction and spinal anesthesia (with or without additional agents) did not consistently reduce pain or complications in any demonstrable way compared with standard care. Although most studies reported on adverse effects, they were short-term and not adequately powered to identify significant differences. None of the included studies exclusively examined participants from institutional settings or with cognitive impairment, which reduces the generalizability of results to the overall hip fracture patient population. The authors concluded that for most interventions in this review there were sparse data available, which precluded firm conclusions for any single approach or for the optimal overall pain management following hip fracture.

Sahota et al (2014) noted that hip fractures are very painful leading to lengthy hospital stays. Conventional methods of treating pain are limited. Non-steroidal anti-inflammatory drugs are relatively contraindicated and opioids have significant side effects. Regional anesthesia holds promise but results from these techniques are inconsistent. Trials to date have been inconclusive with regard to which blocks to use and for how long; inter-patient variability remains a problem. This is a single center study conducted at Queen's Medical Centre, Nottingham; a large regional trauma center in England. It is a pragmatic, parallel arm, RCT. Sample size will be 150 participants (75 in each group). Randomization will be web-based, using computer generated concealed tables (service provided by Nottingham University Clinical Trials Unit). There is no blinding. Intervention will be a femoral nerve block (0.5 ml/kg 0.25 % levo-bupivacaine) followed by ropivacaine (0.2 % 5 ml/hr) infused via a femoral nerve catheter until 48 hours post-surgery. The control group will receive standard care. Participants will be aged over 70 years, cognitively intact (abbreviated mental score of 7 or more), able to provide informed consent, and admitted directly through the Emergency Department from their place of residence. Primary outcomes will be cumulative ambulation score (from day 1 to 3 post-operatively) and cumulative dynamic pain scores (day 1 to 3 post-operatively). Secondary outcomes will be cumulative dynamic pain score pre-operatively, cumulative side effects, cumulative calorific and protein intake, EUROQOL EQ-5D score, length of stay, and rehabilitation outcome (measured by mobility score). The authors stated that many studies have shown the effectiveness of regional blockade in neck of femur fractures, but the techniques used have varied. This study aims to identify whether early and continuous femoral nerve block can be effective in relieving pain and enhancing mobilization.

Infra-Orbital Nerve Blocks for the Management of Post-Operative Pain Following Cleft Lip Repair:

In a Cochrane review, Feriani and associates (2016) evaluated the effects of infra-orbital nerve block for the management of post-operative pain following cleft lip repair in children. These investigators searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library, Issue 6, 2015), Medline, Embase, and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) from inception to June 17, 2015.  There were no language restrictions.  They searched for ongoing trials in the following platforms: the metaRegister of Controlled Trials; ClinicalTrials.gov (the US National Institutes of Health Ongoing Trials Register), and the World Health Organization International Clinical Trials Registry Platform (on June 17, 2015).  These investigators checked reference lists of the included studies to identify any additional studies.  They contacted specialists in the field and authors of the included trials for unpublished data.  These researchers included RCTs that tested peri-operative infra-orbital nerve block for cleft lip repair in children, compared with other types of analgesia procedure, no intervention, or placebo (sham nerve block).  They considered the type of drug, dosage, and route of administration used in each study.  For the purposes of this review, the term “peri-operative” refers to the 3 phases of surgery: (i) pre-operative, (ii) intra-operative, and (iii) post-operative, and commonly includes ward admission, anesthesia, surgery, and recovery.  Two review authors independently identified, screened, and selected the studies, assessed trial quality, and performed data extraction using the Cochrane Pain, Palliative and Supportive Care Review Group criteria.  In case of disagreements, a 3rd review author (EMKS) was consulted.  The authors assessed the evidence using Grading of Recommendations, Assessment, Development and Evaluation (GRADE).  These researchers included 8 studies involving 353 children in the review.  These studies reported different types of interventions (lignocaine or bupivacaine), observation times, and forms of measuring and describing the outcomes, making it difficult to conduct meta-analyses.  In the comparison of infra-orbital nerve block versus placebo, there was a large effect in mean post-operative pain scores (the first primary outcome) favoring the intervention group (SMD -3.54, 95 % CI: -6.13 to -0.95; very low-quality evidence; 3 studies; 120 children).  Only 1 study reported the duration of analgesia (in hours) (second primary outcome) with a difference favoring the intervention group (MD 8.26 hours, 95 % CI: 5.41 to 11.11; very low-quality evidence) and less supplemental analgesic requirements in the intervention group (RR 0.05, 95 % CI: 0.01 to 0.18; low-quality evidence).  In the comparison of infra-orbital nerve block versus intravenous analgesia, there was a difference favoring the intervention group in mean post-operative pain scores (SMD -1.50, 95 % CI: -2.40 to -0.60; very low-quality evidence; 2 studies; 107 children) and in the time to feeding (MD -9.45 minutes, 95 % CI: -17.37 to -1.53; moderate-quality evidence; 2 studies; 128 children).  No significant adverse events ( AEs; third primary outcome) were associated with the intervention, although 3 studies did not report this outcome; 5 out of 8 studies found no unwanted side effects after the nerve blocks.  Overall, the included studies were at low or unclear risk of bias.  The reasons for down-grading the quality of the evidence using GRADE related to the lack of information about randomization methods and allocation concealment in the studies, very small sample sizes, and heterogeneity of outcome reporting.  The authors concluded that there is low- to very low-quality evidence that infra-orbital nerve block with lignocaine or bupivacaine may reduce post-operative pain more than placebo and intravenous analgesia in children undergoing cleft lip repair.  They stated that further studies with larger samples are needed; and future studies should standardize the observation time and the instruments used to measure outcomes, and stratify children by age group.

Lateral Femoral Cutaneous Nerve Blocks after Total Hip Arthroplasty:

In a prospective, randomized, blinded, placebo-controlled trial, Thybo and colleagues (2016) hypothesized that an lateral femoral cutaneous nerve (LFCN) block would reduce movement-related pain after total hip arthroplasty (THA) in patients with moderate-to-severe pain. A total of 60 patients with VAS score greater than 40 mm during 30-degree active flexion of the hip on either the 1st or 2nd post-operative day after THA were included in this trial.  Group A received an LFCN block with 8 ml of 0.75 % ropivacaine followed after 45 mins by an additional LFCN block with 8 ml of saline.  Group B received an LFCN block with 8 ml of saline followed after 45 mins by an additional LFCN block with 8 ml of 0.75 % ropivacaine.  These researchers found a difference of 17 mm (95 % CI: 4 to 31 mm; p < 0.02) in VAS pain score during 30-degree flexion of the hip 45 mins after the 1st block (primary outcome) in favor of group A.  No other significant difference between groups regarding pain during mobilization and at rest was found.  The overall non-responder rate (less than 15 mm pain reduction) was 42 %.  The authors concluded that LFCN block reduced movement-related pain in patients with moderate-to-severe pain after THA.  Moreover, they state that the substantial non-responder rate (42 %) limited recommendations of this block as part of a standard analgesic treatment regimen.

Liposomal Bupivacaine Peripheral Nerve Blocks for the Management of Post-Operative Pain:

In a Cochrane review, Hamilton and colleagues (2016) evaluated the analgesic effectiveness and adverse effects of liposomal bupivacaine infiltration PNB for the management of patients with post-operative pain. These researchers identified randomized trials of liposomal bupivacaine PNB for the management of post-operative pain.  They searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 1), Ovid Medline (1946 to week 1 of January 2016), Ovid Medline In-Process (January 14, 2016), Embase (1974 to January 13, 2016), ISI Web of Science (1945 to January 14, 2016), and reference lists of retrieved articles.  These investigators sought unpublished studies from Internet sources, and searched clinical trials databases for ongoing trials.  The date of the most recent search was January 15, 2016.  Randomized, double-blind, placebo- or active-controlled clinical trials of a single-dose of liposomal bupivacaine administered as a PNB in adults aged 18 years or over undergoing elective surgery at any surgical site were selected for analysis.  The authors included trials if they had at least 2 comparison groups for liposomal bupivacaine PNB compared with placebo or other types of analgesia.  Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data.  They performed analyses using standard statistical techniques as described in the Cochrane Handbook for Systematic Reviews of Interventions, using Review Manager 5.  They planned to perform a meta-analysis, however there were insufficient data to ensure a clinically meaningful answer; as such they have produced a “Summary of findings” table in a narrative format, and where possible they assessed the evidence using GRADE.  These researchers identified 7 studies that met inclusion criteria for this review; 3 were recorded as completed (or terminated) but no results were published.  Of the remaining 4 studies (299 participants): 2 investigated liposomal bupivacaine transversus abdominis plane (TAP) block, 1 liposomal bupivacaine dorsal penile nerve block, and 1 ankle block.  The study investigating liposomal bupivacaine ankle block was a phase II dose-escalating/de-escalating trial presenting pooled data that these investigators could not use in their analysis.  The studies did not report primary outcome, cumulative pain score between 0 and 72 hours, and secondary outcomes, mean pain score at 12, 24, 48, 72, or 96 hours.  One study reported no difference in mean pain score during the 1st, 2nd, and 3rd post-operative 24-hour periods in participants receiving liposomal bupivacaine TAP block compared to no TAP block.  Two studies, both in people undergoing laparoscopic surgery under TAP block, investigated cumulative post-operative opioid dose, reported opposing findings.  One found a lower cumulative opioid consumption between 0 and 72 hours compared to bupivacaine hydrochloride TAP block and 1 found no difference during the 1st, 2nd, and 3rd post-operative 24-hour periods compared to no TAP block.  No studies reported time to 1st post-operative opioid or percentage not requiring opioids over the initial 72 hours.  No studies reported a health economic analysis or patient-reported outcome measures (outside of pain).  The review authors sought data regarding AEs but none was available, however there were no withdrawals reported to be due to AEs.  Using GRADE, these researchers considered the quality of evidence to be very low with any estimate of effect very uncertain and further research very likely to have an important impact on the confidence in the estimate of effect.  All studies were at high risk of bias due to their small sample size (fewer than 50 participants per arm) leading to uncertainty around effect estimates.  Additionally, inconsistency of results and sparseness of data resulted in further down-grading of the quality of the data.  The authors concluded that a lack of evidence has prevented an assessment of the effectiveness of liposomal bupivacaine administered as a PNB.  At present there is a lack of data to support or refute the use of liposomal bupivacaine administered as a PNB for the management of post-operative pain.  They stated that further research is very likely to have an important impact on the confidence in the estimate of effect and is likely to change the estimate.

Peripheral Nerve Blocks for the Treatment of Facial Pain and Headaches:

Kleen and Levy (2016) stated that PNBs are an increasingly viable therapeutic option for selected groups of headache patients, particularly those with intractable headache or facial pain. Greater occipital nerve block, the most widely used local anesthetic procedure in headache conditions; adverse effects are few and infrequent.  These procedures can result in rapid relief of pain and allodynia, and effects last for several weeks or months.  The authors concluded that the use of nerve block procedures and potentially onabotulinum toxin therapy should be expanded for patients with intractable headache disorders who may benefit, although more studies are needed for clinical safety and effectiveness.

Thoracic Paravertebral Blocks in Abdominal Surgery:

El-Boghdadly and associates (2016) stated that thoracic paravertebral blocks (TPVBs) have an extensive evidence base as part of a multi-modal analgesic strategy for thoracic and breast surgery and have gained popularity with the advent of ultrasound guidance. However, this role is poorly defined in the context of abdominal surgery.  These investigators performed a systematic review of RCTs to clarify the impact of TPVB on peri-operative analgesic outcomes in adult abdominal surgery.  They identified 20 published trials involving a total of 1,044 patients that met inclusion criteria; however there was significant heterogeneity in terms of type of surgery, TPVB technique, comparator groups and study quality.  Pain scores and opioid requirements in the early post-operative period were generally improved when compared with systemic analgesia, but there was insufficient evidence for any definitive conclusions regarding comparison with epidural analgesia or other peripheral block techniques, or the benefit of continuous TPVB techniques.  The reported primary block failure rate was 2.8 % and the incidence of complications was 1.2 % (6/504); there were no instances of pneumothorax.  The authors concluded that TPVB appeared to be a promising analgesic technique for abdominal surgery in terms of safety and effectiveness.  However, they stated that further well-designed and adequately powered studies are needed to confirm its utility, particularly with respect to other regional anesthesia techniques.

Ultrasound-Guided Forearm Peripheral Nerve Blocks for the Treatment of Digit Injuries (e.g., Phalanx Fracture or Interphalangeal Joint Dislocation):

Amini and colleagues (2016) noted that phalanx fractures and interphalangeal joint dislocations commonly present to the emergency department (ED). Although these orthopedic injuries are not complex, the 4-point digital block used for anesthesia during the reduction can be painful.  Additionally, cases requiring prolonged manipulation or consultation for adequate reduction may require repeat blockade.  In a case-series study, these investigators reported the findings of 4 patients who presented after mechanical injuries resulting in phalanx fracture or interphalangeal joint dislocations.  These patients received an ultrasound (US)-guided PNB of the forearm with successful subsequent reduction.  The authors concluded that to their knowledge, the use of US-guided PNBs of the forearm for anesthesia in reduction of upper extremity digit injuries in adult patients in the ED setting has not been described before.  These preliminary findings need to be validated by well-designed studies.

Soberon and associates (2016) stated that limited data exist regarding the role of peri-neural blockade of the distal median, ulnar, and radial nerves as a primary anesthetic in patients undergoing hand surgery. In a prospective, randomized, pilot study, these researchers compared these techniques to brachial plexus blocks as a primary anesthetic in this patient population.  A total of 60 patients scheduled for hand surgery were randomized to receive either an US-guided supra-clavicular, infra-clavicular, or axillary nerve block (brachial plexus blocks) or US-guided median, ulnar, and radial nerve blocks performed at the level of the mid-to- proximal forearm (forearm blocks).  The ability to undergo surgery without analgesic or local anesthetic supplementation was the primary outcome.  Block procedure times, post-anesthesia care unit length of stay (LOS), instances of nausea/vomiting, and need for narcotic administration were also assessed.  The 2 groups were similar in terms of the need for conversion to general anesthesia or analgesic or local anesthetic supplementation, with only 1 patient in the forearm block group and 2 in the brachial plexus block group requiring local anesthetic supplementation or conversion to general anesthesia.  Similar durations in surgical and tourniquet times were also observed.  Both groups reported similarly low numerical rating scale pain scores as well as the need for post-operative analgesic administration (2 patients in the forearm block group and 1 in the brachial plexus block group reported numerical rating scale pain scores greater than 0 and required opioid administration in the post-anesthesia care unit).  Block procedure characteristics were similar between the 2 groups.  The authors concluded that forearm blocks may be used as a primary anesthetic in patients undergoing hand surgery.  They stated that further research is needed to determine the appropriateness of these techniques in patients undergoing surgery in the thumb or proximal to the hand.

CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
Peripheral Nerve Blocks :
CPT codes covered if selection criteria are met:
64400 - 64450 Introduction/Injection of anesthetic agent(nerve block), diagnostic or therapeutic [not covered as sole treatment of chronic pain, for cluneal, ganglion, genicular, and obturator nerve blocks for chronic pain or for repetitive peripheral nerve blocks for chronic non-malignant pain]
ICD-10 codes covered if selection criteria are met:
G89.11 - G89.18 Acute pain
G89.21 - G89.29 Chronic pain
ICD-10 codes not covered for indications listed in the CPB (not all inclusive):
G43.001 - G43.919 Migraines
G44.001 - G44.89 Other headache syndromes
R51 Headache
Femoral Nerve Blocks:
CPT codes covered if selection criteria are met:
64447 Injection of anesthetic agent; femoral nerve, single
ICD-10 codes covered if selection criteria are met (not all-inclusive):
G89.18 Other acute postprocedural pain [following knee replacement surgery]
M25.561 - M25.569 Pain in knee
Z96.651 - Z96.659 Presence of artificial knee joint [acute post-operative pain]
Chronic Pain Post Herniorrhaphy:
CPT codes covered if selection criteria are met:
64425 Injection, anesthetic agent; ilioinguinal, iliohypogastric nerves
ICD-10 codes covered if selection criteria are met (not all inclusive):
K40.00 - K46.9 Hernia [abdominal cavity]
Intercostal Nerve Blocks:
CPT codes covered if selection criteria are met:
64420 - 64421 Intercostal nerve blocks
ICD-10 codes covered if selection criteria are met:
G54.8 Other nerve root and plexus disorders [intercostal neuritis]
Suprascapular Nerve Blocks:
CPT codes not covered for indications listed in the CPB :
64418 Suprascapular nerve block
ICD-10 codes not covered for indications listed in the CPB (not all inclusive):
M79.601 - M79.603
M79.621 - M79.646
Pain in arm, upper arm, forearm, hand and fingers
Greater occipital nerve blocks:
CPT codes not covered for indications listed in the CPB:
64405 Injection, anesthetic agent; greater occipital nerve
ICD-10 codes not covered for indications listed in the CPB (not all inclusive):
M47.21 - M47.24, M47.811 - M47.814 Cervical and thoracic spondylosis with or without myelopathy
M50.00 - M50.03, M51.04 - M51.05 Intervertebral disc disorder with myelopathy, cervical and thoracic region
M50.20 - M50.23, M51.24 Other intervertebral disc displacement, cervical or thoracic region
M50.30 - M50.33, M51.34 - M51.35 Other cervical, thoracic and thoracolumbar intervertebral disc degeneration
M51.44 - M51.45 Schmorl's nodes, thoracic region
M51.84 Other intervertebral disc disorders, thoracic region
M54.2 Cervicalgia
M54.9 Dorsalgia, unspecified
M96.1 Postlaminectomy syndrome, not elsewhere classified [thoracic region]
Paravertebral blocks:
CPT codes not covered for indications listed in the CPB:
64461 - 64463 Paravertebral block (PVB) (paraspinous block), thoracic
ICD-10 codes not covered for indications listed in the CPB (not all inclusive):
G89.21 - G89.29 Chronic pain
Pedicle screw block/hardware block of spinal instrumentation:
CPT codes not covered for indications listed in the CPB:
No specific code


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