19 Del. Admin. Code § 1342-B-5.0

Current through Register Vol. 27, No. 12, June 1, 2024

Section 1342-B-5.0 - Initial Evaluation and Diagnostic Procedures

The Department recommends the following diagnostic procedures be considered, at least initially, the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Standard procedures that should be utilized when initially diagnosing a work-related chronic pain complaint are listed below.

5.1 HISTORY AND PHYSICAL EXAMINATION (HX & PE)

5.1.1 Medical History: As in other fields of medicine, a thorough patient history is an important part of the evaluation of chronic pain. In taking such a history, factors influencing a patient's current status can be made clear and taken into account when planning diagnostic evaluation and treatment. One efficient manner in which to obtain historical information is by using a questionnaire. The questionnaire may be sent to the patient prior to the initial visit or administered at the time of the office visit.

5.1.2 Pain History: Characterization of the patient's pain and of the patient's response to pain is one of the key elements in treatment.

5.1.3 Medical Management History

5.1.4 Substance Use/Abuse

5.1.5 Other Factors Affecting Treatment Outcome

5.1.6 Physical Examination

5.2 DIAGNOSTIC STUDIES Imaging of the spine and/or extremities is a generally accepted, well-established, and widely used diagnostic procedure when specific indications, based on history and physical examination, are present.

5.2.1 Radiographic Imaging, MRI, CT, bone scan, radiography, and other special imaging studies may provide useful information for many musculoskeletal disorders causing chronic pain.

5.2.2 Electrodiagnostic studies may be useful in the evaluation of patients with suspected myopathic or neuropathic disease and may include Nerve Conduction Studies (NCS), Standard Needle Electromyography, or Somatosensory Evoked Potential (SSEP). The evaluation of electrical studies is difficult and should be relegated to specialists who are well trained in the use of this diagnostic procedure.

5.2.3 Special Testing Procedures may be considered when attempting to confirm the current diagnosis or reveal alternative diagnosis. In doing so, other special tests may be performed at the discretion of the physician.

5.3 LABORATORY TESTING is generally accepted well-established and widely used procedures and can provide useful diagnostic and monitoring information. They may be used when there is suspicion of systemic illness, infection, neoplasia, or underlying rheumatologic disorder, connective tissue disorder, or based on history and/or physical examination. Tests include, but are not limited to:

5.3.1 Complete Blood Count (CBC) with differential can detect infection, blood dyscrasias, and medication side effects;

5.3.2 Erythrocyte sedimentation rate, rheumatoid factor, antinuclear antigen (ANA), human leukocyte antigen (HLA), and C-reactive protein can be used to detect evidence of a rheumatologic, infection, or connective tissue disorder;

5.3.3 Thyroid, glucose and other tests to detect endocrine disorders;

5.3.4 Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease;

5.3.5 Urinalysis to detect bacteria (usually with culture and sensitivity), calcium, phosphorus, hydroxyproline, or hematuria;

5.3.6 Liver and kidney function may be performed for baseline testing and monitoring of medications; and

5.3.7 Toxicology Screen and/or Blood Alcohol Level if suspected drug or alcohol abuse.

5.4 INJECTIONS-DIAGNOSTIC

5.4.1 Spinal Diagnostic Injections:

Description - generally accepted, well-established procedures. These injections may be useful for localizing the source of pain, and may have added therapeutic value when combined with injection of therapeutic medication(s). Selection of patients, choice of procedure, and localization of the level for injection should be determined by clinical information indicating strong suspicion for pathologic condition(s) and the source of pain symptoms.

The interpretation of the test results are primarily based on functional change, symptom report, and pain response (via a recognized pain scale before and at an appropriate time after the injection). The diagnostic significance of the test result should be evaluated in conjunction with clinical information and the results of other diagnostic procedures. Injections with local anesthetics of differing duration may be used to support a diagnosis. In some cases, injections at multiple levels may be required to accurately diagnose conditions. Regarding diagnostic injections, it is obligatory that sufficient data be accumulated by the examiner performing this procedure such that the diagnostic value of the procedure is evident to other reviewers. A log must be recorded as part of the medical record which documents response, if any, on an hourly basis for, at a minimum, the expected duration of the local anesthetic phase of the procedure. Responses should be identified as to specific body part (e.g., low back, neck, leg, or arm pain).

Special Requirements for Diagnostic Injections - Since multi-planar, fluoroscopy during procedures is required to document technique and needle placement, an experienced physician should perform the procedure. Permanent images are required to verify needle placement for all spinal procedures. The subspecialty disciplines of the physicians performing injections may be varied, including, but not limited to: anesthesiology, radiology, surgery, or physiatry. The practitioner who performs spinal injections should document hands-on training through workshops of the type offered by organizations such as the International Spine Intervention Society (ISIS) and/or completed fellowship training with interventional training. Practitioners performing spinal injections for low back and cervical pain must also be knowledgeable in radiation safety.

Specific Diagnostic Injections - In general, relief should last for at least the duration of the local anesthetic used and/or should significantly relieve pain and result in functional improvement. The following injections are used primarily for diagnosis:

5.4.1.1 Medial Branch Blocks:

Medial Branch Blocks are primarily diagnostic injections, used to determine whether a patient is a candidate for radiofrequency medial branch neurotomy (also known as facet rhizotomy). To be a positive diagnostic block, the patient should report a reduction of pain of 50% or greater relief from baseline for the length of time appropriate for the local anesthetic used. It is suggested that this be reported on a form.

A separate block on a different date should be performed to confirm the level of involvement. Frequency and Maximum Duration: May be repeated once for comparative blocks. Limited to 4 levels.

5.4.1.2 Transforaminal Injections are useful in identifying spinal pathology. When performed for diagnosis, small amounts of local anesthetic up to a total volume of 1.0 cc should be used to determine the level of nerve root irritation. A positive diagnostic block should result in a 50% reduction in nerve-root generated pain appropriate for the anesthetic used as measured by accepted pain scales (such as a VAS).

Frequency and Maximum Duration: Once per suspected level. Limited to three levels, may be repeated for confirmation.

5.4.1.3 Zygapophyseal (facet) blocks: Facet blocks are generally.

They may be used diagnostically to direct functional rehabilitation programs. A positive diagnostic block should result in a positive diagnostic functional benefit and/or a 50% reduction in pain appropriate for the anesthetic used as measured by accepted pain scales (such as a Visual Analog Scale). They then may be repeated per the therapeutic guidelines

Frequency and Maximum Duration: Once per suspected level, limited to three levels, may be repeated for confirmation.

5.4.1.4 Atlanto-Axial and Atlanto-Occipital Injections: are generally accepted for diagnosis and treatment but do not lend themselves to denervation techniques owing to variable neuroanatomy.

Frequency and Maximum Duration: Once per side

5.4.1.5 Sacroiliac Joint Injection:

Description - a generally accepted injection of local anesthetic in an intra-articular fashion into the sacroiliac joint under fluoroscopic guidance.

Indications - Primarily diagnostic to rule out sacroiliac joint dysfunction versus other pain generators. Intra-articular injection can be of value in diagnosing the pain generator. There should be at least 50% pain relief.

Frequency and Maximum Duration: 1 may be repeated for confirmation.

19 Del. Admin. Code § 1342-B-5.0