Experts strongly recommend against spine injections for chronic back pain

Spine injections should not be given to adults with chronic back pain because they provide little or no pain relief compared with sham injections, say a panel of international experts in The BMJ .

Their strong recommendations apply to procedures such as epidural steroid injections and nerve blocks for people living with chronic back pain (lasting at least three months) that is not associated with cancer, infection or inflammatory arthritis.

Their advice is based on the latest evidence and is part of The BMJ’s “Rapid Recommendations” initiative—to produce rapid and trustworthy guidance based on new evidence to help doctors make better decisions with their patients.

Chronic back pain is the leading cause of disability worldwide. It is estimated to affect one in five adults aged 20–59, with higher rates likely among older adults. In 2016, low back and neck pain accounted for the highest health care spending in the US at $134.5 billion.

Procedures such as epidural steroid injections, nerve blocks and radiofrequency ablation (using radio waves to destroy nerves) are widely used to stop pain signals reaching the brain, but current guidelines provide conflicting recommendations for their use.

So an international panel, made up of clinicians, people living with chronic spine pain, and research methodologists, carried out a detailed analysis of the latest evidence using the GRADE approach (a system used to assess the quality of evidence).

This evidence, based on reviews of randomized trials and observational studies, compared the benefits and harms of 13 common interventional procedures, or combinations of procedures, for chronic, non-cancer spine pain against sham procedures.

After careful consideration, the panel concluded that there was no high certainty evidence for any procedure or combination of procedures, and all low and moderate certainty evidence suggests no meaningful relief for either axial pain (in a specific area of the spine) or radicular pain (radiating from the spine to the arms or legs) for spine injections compared with sham procedures.

As such, they strongly recommend against their use.

This includes injections of local anesthetic, steroids, or their combination; epidural injections of local anesthetic, steroids, or their combination; and radiofrequency ablation with or without local anesthetic plus steroid injections.

The panel added that these procedures are costly, a burden on patients, and carry a small risk of harm. As such, they say almost all informed patients would choose to avoid them.

Finally, they acknowledge that further research is warranted and may alter future recommendations, in particular for procedures currently supported by low or very low certainty of effectiveness. Further research is also needed to establish the effects of interventional procedures on important outcomes for patients, such as opioid use, return to work, and sleep quality.

In a linked editorial, Jane Ballantyne at the University of Washington says the question this recommendation raises is whether it is reasonable to continue to offer these procedures to people with chronic back pain.

It is never easy to change entrenched culture, she writes, “but the more the evidence fails to support the widespread use of these injections, the less inclined health care systems will be to fund them.”

“This will not be the last word on spine injections for chronic back pain, but it adds to a growing sense that chronic pain management needs a major rethink that is perhaps best achieved by a better balance of reimbursements between procedural and non-procedural chronic pain treatments,” she concludes.

Spine injections should not be given to adults with chronic back pain because they provide little or no pain relief compared with sham injections, say a panel of international experts in The BMJ .

Their strong recommendations apply to procedures such as epidural steroid injections and nerve blocks for people living with chronic back pain (lasting at least three months) that is not associated with cancer, infection or inflammatory arthritis.

Their advice is based on the latest evidence and is part of The BMJ’s “Rapid Recommendations” initiative—to produce rapid and trustworthy guidance based on new evidence to help doctors make better decisions with their patients.

Chronic back pain is the leading cause of disability worldwide. It is estimated to affect one in five adults aged 20–59, with higher rates likely among older adults. In 2016, low back and neck pain accounted for the highest health care spending in the US at $134.5 billion.

Procedures such as epidural steroid injections, nerve blocks and radiofrequency ablation (using radio waves to destroy nerves) are widely used to stop pain signals reaching the brain, but current guidelines provide conflicting recommendations for their use.

So an international panel, made up of clinicians, people living with chronic spine pain, and research methodologists, carried out a detailed analysis of the latest evidence using the GRADE approach (a system used to assess the quality of evidence).

This evidence, based on reviews of randomized trials and observational studies, compared the benefits and harms of 13 common interventional procedures, or combinations of procedures, for chronic, non-cancer spine pain against sham procedures.

After careful consideration, the panel concluded that there was no high certainty evidence for any procedure or combination of procedures, and all low and moderate certainty evidence suggests no meaningful relief for either axial pain (in a specific area of the spine) or radicular pain (radiating from the spine to the arms or legs) for spine injections compared with sham procedures.

As such, they strongly recommend against their use.

This includes injections of local anesthetic, steroids, or their combination; epidural injections of local anesthetic, steroids, or their combination; and radiofrequency ablation with or without local anesthetic plus steroid injections.

The panel added that these procedures are costly, a burden on patients, and carry a small risk of harm. As such, they say almost all informed patients would choose to avoid them.

Finally, they acknowledge that further research is warranted and may alter future recommendations, in particular for procedures currently supported by low or very low certainty of effectiveness. Further research is also needed to establish the effects of interventional procedures on important outcomes for patients, such as opioid use, return to work, and sleep quality.

In a linked editorial, Jane Ballantyne at the University of Washington says the question this recommendation raises is whether it is reasonable to continue to offer these procedures to people with chronic back pain.

It is never easy to change entrenched culture, she writes, “but the more the evidence fails to support the widespread use of these injections, the less inclined health care systems will be to fund them.”

“This will not be the last word on spine injections for chronic back pain, but it adds to a growing sense that chronic pain management needs a major rethink that is perhaps best achieved by a better balance of reimbursements between procedural and non-procedural chronic pain treatments,” she concludes.