An international panel of experts has issued a strong recommendation against the use of spine injections for adults suffering from chronic back pain, citing a lack of significant pain relief compared to placebo treatments. Published in The BMJ, the panel’s guidance specifically targets procedures like epidural steroid injections and nerve blocks for individuals dealing with non-cancerous, non-inflammatory, chronic back pain lasting at least three months.
The recommendation comes as part of The BMJ’s “Rapid Recommendations” initiative, which aims to provide timely, evidence-based advice for healthcare providers to enhance decision-making with patients.
Chronic back pain is a leading global cause of disability, affecting an estimated 20% of adults aged 20-59. It also represents a significant healthcare burden, with low back and neck pain alone accounting for $134.5 billion in healthcare spending in the United States in 2016.
The panel’s review focused on common interventional procedures such as epidural steroid injections, nerve blocks, and radiofrequency ablation—treatments that aim to block pain signals reaching the brain. Despite their widespread use, existing guidelines on these procedures remain inconsistent.
A multidisciplinary panel of clinicians, pain patients, and research methodologists reviewed the most recent evidence using the GRADE approach, which assesses the quality of clinical evidence. Their analysis, comparing 13 interventional procedures and combinations to sham treatments, found that none provided high-certainty evidence of effective pain relief. Low- and moderate-certainty evidence showed no meaningful improvement in both axial pain (localized in the spine) and radicular pain (radiating to the limbs).
Given the lack of substantial benefit, the panel strongly advises against the use of these treatments, which include local anesthetic and steroid injections, as well as radiofrequency ablation. These procedures, they note, are not only costly but also carry a small risk of harm, making them an impractical choice for most patients.
The panel also emphasized the need for further research, especially regarding the potential effects of these interventions on outcomes like opioid use, return to work, and sleep quality. Additional studies could also refine future recommendations, particularly for procedures currently supported by low-quality evidence.
In an editorial accompanying the study, Jane Ballantyne of the University of Washington raised concerns about the continued use of these procedures, despite mounting evidence questioning their efficacy. She acknowledged the challenge of shifting entrenched medical practices but noted that the growing body of evidence against spine injections may eventually lead healthcare systems to reconsider their funding.
“This will not be the final word on spine injections for chronic back pain,” Ballantyne wrote, “but it contributes to the growing realization that chronic pain management must be reconsidered, possibly by reassessing the balance between procedural and non-procedural treatments.”
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