Interventions for Noncancer Chronic Spine Pain: Rapid Recommendations From BMJ

Chronic spine pain is defined as back pain lasting 3 months or longer with pain on at least one-half of days in the past 6 months. Chronic low back pain has been estimated to affect 4% of adults ages 24 to 39 years and 20% of adults ages 20 to 59 years. Chronic low back and neck pain are the first and third leading causes of disability worldwide, respectively.

Interventional procedures, including epidural injections, paravertebral intramuscular injections, nerve blocks, and nerve ablation procedures, are used to manage chronic pain, including that involving the back or neck. Interventional procedures have been increasingly used over the past 30 years despite uncertain supporting evidence. These BMJ guidelines are based on a systematic review of the effectiveness of interventional procedures for chronic spine pain.

A patient panel survey suggested that most people living with chronic spine pain would choose an interventional procedure if there were a moderate to high certainty they would benefit, even with moderate- to high-certainty evidence of harm. It found that nearly all patients living with chronic spine pain would reject a procedure with uncertain effectiveness due to risk of harm or procedure burden.

For chronic axial spine pain, interventions such as epidural injections, joint-targeted injections, intramuscular injections, and joint radiofrequency ablation do not appear to improve pain compared with sham procedures.

For epidural injections with local anesthetic, steroids, or both, there is moderate-certainty evidence that they result in little to no difference in pain relief in patients with chronic axial pain compared with sham injection. Very low-certainty evidence suggests that epidural steroid injections may improve function in these patients to a greater degree than placebo injection.

There is moderate-certainty evidence that facet joint steroid injections have little to no effect on pain or function compared with sham procedures.

Low-certainty evidence suggests that paravertebral intramuscular injections have little to no effect on pain or physical function. Intramuscular injections of local anesthetic and steroids may increase pain severity compared with sham procedures, whereas intramuscular injections of local anesthetic alone may slightly improve physical function.

For chronic axial spine pain, radiofrequency nerve ablation does not seem to produce additional benefit compared with placebo for pain improvement based on very low-certainty evidence. Four trials in which the clinicians administering the interventions were not blinded demonstrated a nearly 2-point decrease in pain compared with sham treatment. Seven trials with blinded clinicians showed no significant effect on pain. Low-certainty evidence suggests little to no improvement in function with radiofrequency ablation in all studies.