General Guideline Principles for Injections:
Therapeutic Spinal for workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Injections: Therapeutic Spinal.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Introduction of Injections: Therapeutic Spinal of Therapeutic Procedures

After attempting early conservative treatments such as acupuncture, physiotherapy, occupational therapy, medicine, manual therapy, and exercise, a therapeutic spinal injection may be performed.

  • Only once pathology has been proven through imaging examinations and diagnostic injections should therapeutic injections be administered.


  • Because injections are intrusive procedures that have the potential to result in serious consequences, clinical guidelines and contraindications should be strictly followed.


  • The goal of progesterone injections is to provide a series therapy by offering momentary pain and inflammation alleviation.


  • All patients would continue with functionally oriented rehabilitation while engaging in appropriate exercise.


  • Patients will frequently need to repeat the sessions that were originally scheduled for active treatment, which they should have had before getting injections.


  • By alone, injections are unlikely to offer long-term relief. Instead, active rehabilitation with reduced work improves active the range of motion, muscle, and stability to promote long-term relief.


  • If an injection doesn’t work the first time, don’t get another one.


    • Enhanced functionality


    • A 50% pain decline on the Visual Analog Scale, which is one of the acknowledged pain measures used to quantify temporary and long-term pain alleviation.


  • Decrease in the dosage of prescription analgesics. Depending on the assessment and response of the patient, medical care should be prolonged or modified.

Special Considerations

  • Multi-planar fluoroscopy is necessary during procedures for all thoracic, lumbar, and sacroiliac injections (apart from the rigger point). This is done to record procedure and needle placement.


  • A doctor with experience in the technique must administer every injection (excluding trigger point). A physician or a nurse healthcare professional assistant skilled in the procedure can administer trigger point injections.


  • To record where the needle was placed, permanent photos are necessary.


  • The specialist disciplines of the doctors giving injections can range, for example, from anesthesiology to radiology to surgery or physiatry.


  • The physician should have finished fellowship training with interventional training in a relevant medical specialty (e.g., neurosurgery, orthopedic surgery, physiatry, pain control, etc.). Additionally, radiation safety awareness is required of the practitioner.


General complications of spinal injections may include:

  • transient neurapraxia


  • local pain


  • nerve injury


  • infection


  • headache


  • vasovagal effects


  • There could potentially be a spinal meningeal abscess, epidural hematoma, long-term neurologic harm, Dural perforation and CSF loss, and/or other complications.


  • Although they are uncommon, more severe side effects might cause mortality, quadriplegia, spinal cord injury, and persistent ataxia.


  • The hypothalamic-pituitary-adrenal axis may be suppressed by steroid injections in a dose-dependent manner for one to three months.


  • When receiving steroid injections, glucose levels may briefly increase, especially in diabetics.


Absolute contraindications to therapeutic injections include:

  • bleeding diatheses


  • hematological conditions


  • possible pregnancy

Associated indications why diagnostic injections should not be used include:

  • allergy to contrast


  • poorly controlled Diabetes Mellitus


  • hypertension

Before injection, it’s common practice to restrict the use of coagulation-affected medications such as aspirin, NSAIDs, anti-platelets, and anticoagulants. In light of the patient’s unique underlying medical history, decisions on anticoagulation should be determined in consultation with the injector, the prescribing doctor, and any other necessary specialists

Lumbar Transforaminal/Interlaminar/Caudal Epidural Injections (ESI)

By reducing pain and inflammation and improving range of motion, ESI helps patients advance in more active regimens. As with other therapies, it’s crucial to make sure patients have reasonable expectations for how the process will turn out.

Participants for ESI should be advised that while a post-intervention blood glucose rise may be noticeable, the increase is often momentary. Lumbar ESI must be surveyed shows guided to ensure accurate needle placement.

To record the placement of the needle, permanent pictures are necessary. One can confirm the passage of medications into the epidural space using contrast spirograms. It is advised to do one epiroprim for each session of ESI when clinically necessary.

  1. Lumbar Transforaminal/Interlaminar/Caudal Epidural Injections (ESI)

    Lumbar Transforaminal/Interlaminar/Caudal Epidural Injections (ESI) is recommended for people who have lumbar radicular pain syndrome symptoms.


  2. Lumbar Transforaminal/Interlaminar/Caudal Epidural Injections (ESI)

    Lumbar Transforaminal/Interlaminar/Caudal Epidural Injections (ESI) is not recommended ESI is ineffective for no radicular pain syndromes or lumbar axial pain.



    • Anesthetics and/or steroids are among the medications for ESI.


    • For acute radicular pain disorders, ESI is an alternative.


    • Radicular pain syndromes lasting at least three weeks may be treated with ESI.


    • Having had NSAID treatment and showing no signs of trending approaching impromptu resolution


    • ESI is a second-line therapeutic option for severe flare-ups of vertebral stenosis.


    • ESI is a treatment option for spinal stenosis symptoms of at least one to two months, using NSAIDs and other treatments in the past. exercise that progresses.

      Not Recommended as first- or second-line treatment in individuals with back pain symptoms that predominate over leg pain

      Not Recommended as treatment for any non-acute axial back pain without a radicular component.


    • ESI is not advised for back pain, whether it is non-acute or acute. substantial radicular symptoms are absent.

      Maximum Frequency:


    • Depending on the patient’s reaction (better function and pain reduction), three doses (per spinal zone) may be administered over the course of 12 months to levels maximum per treatment session.


    • Instead of arranging a “Series of Three,” it is advised that each injection be planned independently and its effects be assessed based on the patient’s response (increased function and pain reduction).


    • Repeat shots are not advised if the initial injection does not result in a response with transitory and sustained pain alleviation (for at least two weeks) supported by recognized pain scales (i.e., a 50% reduction in pain as assessed by instruments like the VAS) and an improvement in function.


    • Measurable advancement in physical health should accompany a successful outcome (functional improvement).


  3. Intradiscal Steroids

    Intradiscal Steroids is not recommended Rehabilitation of acute or non-acute back pain. There is insufficient research to support the effectiveness of disjoining steroid injections in treating acute back pain. Furthermore, there is little solid proof that these injections alter the course of acute back pain.


  4. Chemonucleolysis (Chymopapain and Collagenase)

    Chemonucleolysis (Chymopapain and Collagenase) is not recommended Despite being a successful treatment, the technique is not offered in the United States because of substantial side effects.


  5. Tender and Trigger Point Injections

    Localized hyperirritable, palpable nodules called myofascial trigger spots are found in extraordinarily sensitive bands of tense skeletal muscle fibers. These nodules cause both local agony and pain that is referred to in distant regions when they are compressed.


    • Trigger point Shots are not the same as acupuncture; the only methods of treating trigger points are dry needling or local anesthetic injections into myofascial trigger points.


    • Please consult the Medical Treatment Guideline’s section on acupuncture for more information. Lower and middle back injury:


    • No proof administering drugs intravenously enhances the outcomes of trigger point shots. • As with other treatments, it’s crucial to make sure that individuals have realistic expectations concerning treatment outcomes. Needling may only account for the portion of the treatment response.


      1. Tender and Trigger Point Injections

        Tender and Trigger Point Injections are recommended could be a secondary option for no acute pain


      2. Tender and Trigger Point Injections

        Tender and Trigger Point Injections are not recommended as they could be the treatment for acute pain.


        • The main goal of trigger point shots should be to promote functional advancement.


        • Trigger point shots can help with active therapy and flexibility of the troubled areas while easing myofascial pain.


        • It is not advised to utilize therapeutic injections when not enrolled in an active therapy program or when trying to keep a job.


        • Two weeks following each injection, patients should be reevaluated for: enhancement of performance


        • Depending on the evaluation and reaction of the patient, surgical treatment should be kept or modified. A three-month period should pass after functional improvement.


        • A successful outcome (functional improvement) should involve a return to baseline functionality or job responsibilities as well as a discernible improvement in physical exercise goals.


        • It is not advised to employ ultrasonography or other imaging tests for trigger point injections.



        • No more than four shots per session, and no more than four sessions in a calendar year,


        • if the first series of injections yield unsatisfactory results. is sensible. If no subjective nor objective data are presented, Further shots are not advised at that moment due to the improvements.


        • Resolution, intolerance, or other indications for discontinuation


        • finishing two rounds of injections without having a significant impact on The condition.


        • If there has been any evidence of improvement following the initial set of The second series of injections might be appropriate.


        • It is advised to wait at least three to four weeks between appointments. a few of these shots.


        • If at that point there are no subjective or objective improvements At this point, more injections are not advised.


        • Recurrent injections ought to be connected to subjective and objectively better


  6. Lumbar Diagnostic and Therapeutic Medial Nerve Branch Blocks or Intra-articular Facet (Zygapophyseal) Joint Injections



    • Medial branch block injections or intra-articular facet joint injections are recommended for:


    • Patients whose exam results suggest that their pain has a large facet component (i.e., quasi axial pain made worse by extension-facet loading) and/or


    • Confirmed facet disease (facet arthropathy/hypertrophy at the targeted level(s) and imaging testing)


    • Who has completed a documented regimen of conservative management by Medium and Low Back Injury Medical Therapeutic Strategies, including but not restricted to.


      These shots must guide patients.

      A monitoring and/or therapeutic component may be included in intra-articular facet joint injections or lumbar lateral nerve branch blocks.


    • A corticosteroid serves as the therapeutic component and an anesthetic serves as the diagnostic component.


    • The diagnostic component (anesthetic only) may be administered singly or as part of a single diagnostic/therapeutic injection with a steroid.


    • To diagnose discomfort that is thought to originate from the facet joint, a medial nerve segment block is recommended.


    • The basis for the presumed diagnosis should be supported by a physical exam and a history.


    • A favourable reaction to a therapeutic dose (steroid) does not always indicate that radiofrequency ablation is necessary.

      Acute back pain

      When there is persistent axial back pain following an injury that has not improved with conservative therapy, intra-articular facet joint injections or medial division block injections (which block medial nerve innervation) may be helpful. Medial branch block injections may help identify pain triggers, treat pain, and help patients move forwards in a rehab center when they have acute back pain.

      These injections combine an anesthetic and a steroid to treat acute pain. The addition of steroids extends the benefits. Reduced pain and increased function with the capacity to engage in an effective rehabilitation program (something the patient was unable to accomplish before the injection) are the main objectives of the sustained therapeutic benefit. Diagnostic intra-articular intraarticular injections or diagnostic posterior branch block injections.

      Positive Therapy Response (either interpersonal and inter facet joint injection or medial branch block injection):


    • After each therapeutic injection, patients should be reevaluated for a documented 50% reduction in pain, as determined by recognized pain measures, and for evidence of strength gains for at least 4-6 weeks.


    • Measurable progress to physical activity goals, including a return to previous functions or work activities, should be part of a successful outcome (functional improvement).


    • Before, shortly after, and at certain intervals following the procedure, pain should be assessed using approved pain scales.


    • Repeat steroid injections are not advised if the first remedial injection does not result in improved performance for at least four to six weeks and persistent pain alleviation supported by recognized pain scales (i.e., 50% verified pain reduction as evaluated by recognized pain tools).

      Frequency: Depending on the patient’s documented response (i.e., better functional gain and pain reduction), up to three joint levels (four medial department nerves) per session may be injected into each appropriate joint twice within 12 months. Two sessions maximum per year.

      Non-acute back pain

      For a small subset of patients with quasi-back pain, diagnostic medical branch blockage injections are advised to identify whether particular procedures targeting the facet joint (by blocking medial nerve stimulation to the aspect joint) should be carried out.

      A positive reaction to diagnose injections (anesthetic solo or anesthetic with steroid) rather than a therapeutic injection is what determines whether radiofrequency ablation should be performed (with steroid only). To allow for the possibility of prolonged pain alleviation, the anesthetic agent and steroid should be combined when providing a diagnostic injection.

      A reduction in pain of at least 50%, as determined by recognized pain scales, and an improvement in mechanism for the duration of the local anesthetic constitute a positive response to the clinical component of a medial nerve branch block. This initial temporary improvement may last for one to four hours. When non-acute pain is present, the main objective of a clinical medial nerve branch block is to assess whether further therapy is necessary (i.e., radiofrequency ablation).


    • Whether or not steroids are utilized, a second medial channel block injection should be given to a patient who responds favorably to a diagnostic one to verify the diagnosis.


    • To validate the degree of involvement, a second comparative medial stream block injection should be administered on a different day.


    • The patient should be assessed to see whether they require more definitive treatment, such as radiofrequency ablation if there is a decent reaction to the repeat diagnostic medium branch block injection.


    • The diagnosis must be reevaluated if the initial injection does not produce a positive response.


    • Repeat diagnostic shots are not advised if the first shot does not produce a good reaction.

      Frequency: Depending on the patient’s documented response (i.e., better functional gain and pain reduction), up to three joint levels (four medial division nerves) per session may be injected into each appropriate joint twice within 12 months.12 months per year.


  7. Facet Joint Hyaluronic Acid Injections

    Facet Joint Hyaluronic Acid Injections is not recommended


  8. Sacroiliac Joint Injections


    • Sacroiliac Joint Injections is recommended  Patients with a particular aetiology of sacroiliitis, such as a work-related escalation of conclusively diagnosed rheumatologic inflammatory arthritis affecting the sacroiliac joints, are advised to consider sacroiliac joint corticosteroid injections as a potential therapy option.


    • Sacroiliac Joint Injections is recommended. Sacroiliac joint injections are recommended for the treatment of sacroiliac joint sprain/dysfunction.

      Sacroiliac sprain may present with local tenderness corresponding to the anatomical sacroiliac joint. Such presentation is an extra-axial finding, without radiation, and may be the result of inflammation or trauma. The pain may be acute or non-acute.

      Frequency/Duration: If the results after the first injection are not satisfactory, fluoroscopic guidance must be used for the second injection. Subsequent injections are not recommended unless significant improvement is noted after the initial injections.


  9. Prolotherapy Injections

    Prolotherapy Injection is not recommended for acute or non-acute back pain, or for any radicular pain syndrome.


  10. Platelet Rich Plasma (PRP)

    Platelet Rich Plasma (PRP) is not recommend.

What our office can do if you have workers compensation Injections: Therapeutic Spinal lnjuries

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.


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Dr. Nakul Karkare

I am fellowship trained in joint replacement surgery, metabolic bone disorders, sports medicine and trauma. I specialize in total hip and knee replacements, and I have personally written most of the content on this page.

You can see my full CV at my profile page.