Practice Guideline: Do Not Use Injections or Radiofrequency to Treat Chronic Cervical Spine or Low Back Pain

What interventions should be avoided in patients with chronic cervical spine or low back pain?

The guidelines strongly recommend against the use of corticosteroid or local anesthetic injection or radiofrequency ablation to treat chronic low back or cervical spine pain not due to cancer based on a lack of evidence of benefit greater than placebo. (Level of Evidence = 1a)

The guidelines are based on a systematic review and network meta-analysis of randomized trials and a systematic review of observational studies of interventional procedures for chronic axial and radicular noncancer spine (cervical and lower back) pain. The development group included patients, clinicians, and methodologists. No members had financial conflicts of interest.

For localized chronic low back or cervical pain, the group recommends against epidural or joint injection of a corticosteroid or local anesthetic; joint radiofrequency ablation; or intramuscular injection of a local anesthetic, with or without a corticosteroid. For radicular cervical or low back pain, they recommend against using dorsal root ganglion radiofrequency or epidural injection of a corticosteroid or local anesthetic. The group considered recommending treatments with moderate-to high-certainty evidence of harms or burden if there was moderate- or high-certainty evidence of important benefit. However, they were unable to find evidence of benefit compared with placebo or sham procedures for any of the evaluated interventions, and their recommendations are considered strong (high confidence that the intervention will produce more harm than benefit).

This is concerning because “did not work better than placebo” is not the same as “did not work,” and there is often a profound response to placebo treatments—whether placebo or a real treatment is the cause for pain reduction, better is better. The meta-analysis did not report on response rates in the comparator groups so it is difficult to know.

Study design: Practice guideline

Funding source: Foundation

Setting: Various (guideline)

Reference: Busse JW, Genevay S, Agarwal A, et al. Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline. BMJ. 2025;388:e079970.

Editor’s Note: Dr. Shaughnessy is an assistant medical editor for AFP.