Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline, 2025, Busse et al.

Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline
Jason W Busse; Stéphane Genevay; Arnav Agarwal; Christopher J Standaert; Kevin Carneiro; Jason Friedrich; Manuela Ferreira; Hilde Verbeke; Jens Ivar Brox; Hong Xiao; Jasmeer Singh Virdee; Janet Gunderson; Gary Foster; Conrad Heegsma; Caroline F Samer; Matteo Coen; Gordon H Guyatt; Xiaoqin Wang; Behnam Sadeghirad; Faheem Malam; Dena Zeraatkar; Per O Vandvik; Ting Zhou; Feng Xie; Reed A C Siemieniuk; Thomas Agoritsas

CLINICAL QUESTION
What is the comparative effectiveness and safety of commonly used interventional procedures (such as spinal injections and ablation procedures) for chronic axial and radicular spine pain that is not associated with cancer or inflammatory arthropathy?

CURRENT PRACTICE
Chronic spine pain is a common, potentially disabling complaint, for which clinicians often administer interventional procedures. However, clinical practice guidelines provide inconsistent recommendations for their use.

RECOMMENDATIONS
For people living with chronic axial spine pain (≥3 months), the guideline panel issued strong recommendations against: joint radiofrequency ablation with or without joint targeted injection of local anaesthetic plus steroid; epidural injection of local anaesthetic, steroids, or their combination; joint-targeted injection of local anaesthetic, steroids, or their combination; and intramuscular injection of local anaesthetic with or without steroids. For people living with chronic radicular spine pain (≥3 months), the guideline panel issued strong recommendations against: dorsal root ganglion radiofrequency with or without epidural injection of local anaesthetic or local anaesthetic plus steroids; and epidural injection of local anaesthetic, steroids, or their combination.

HOW THIS GUIDELINE WAS CREATED
An international guideline development panel including four people living with chronic spine pain, 10 clinicians with experience managing chronic spine pain, and eight methodologists, produced these recommendations in adherence with standards for trustworthy guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation provided methodological support. The guideline panel applied an individual patient perspective when
formulating recommendations.

THE EVIDENCE
These recommendations are informed by a linked systematic review and network meta-analysis of randomised trials and a systematic review of observational studies, summarising the current body of evidence for benefits and harms of common interventional procedures for axial and radicular, chronic, non-cancer spine pain. Specifically, injection of local anaesthetic, steroids, or their combination into the cervical or lumbar facet joint or sacroiliac joint; epidural injections of local anaesthetic, steroids, or their combination; radiofrequency of dorsal root ganglion; radiofrequency denervation of cervical or lumbar facet joints or the sacroiliac joint; and paravertebral intramuscular injections of local anaesthetic, steroids, or their combination.

UNDERSTANDING THE RECOMMENDATIONS
These recommendations apply to people living with chronic spine pain (≥3 months duration) that is not associated with cancer or inflammatory arthropathy and do not apply to the management of acute spine pain. Further research is warranted and may alter recommendations in the future: in particular, whether there are differences in treatment effects based on subtypes of chronic spine pain, establishing the effectiveness of interventional procedures currently supported by low or very low certainty evidence, and effects on poorly reported patient-important outcomes (such as opioid use, return to work, and sleep quality).


Link | PDF (BMJ) [Open Access]

 

Editorial at Spinal interventions for chronic back pain (2025, BMJ) [Paywall]

Systematic review —

Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials (2025)
Xiaoqin Wang; Grace Martin; Behnam Sadeghirad; Yaping Chang; Ivan D Florez; Rachel J Couban; Fatemeh Mehrabi; Holly N Crandon; Meisam Abdar Esfahani; Laxsanaa Sivananthan; Neil Sengupta; Elena Kum; Preksha Rathod; Liang Yao; Rami Z Morsi; Stéphane Genevay; Norman Buckley; Gordon H Guyatt; Y Raja Rampersaud; Christopher J Standaert; Thomas Agoritsas; Jason W Busse

OBJECTIVE
To address the comparative effectiveness of common interventional procedures for chronic non-cancer (axial or radicular) spine pain.

DESIGN
Systematic review and network meta-analysis (NMA) of randomised controlled trials (RCTs).

DATA SOURCES
Medline, Embase, CINAHL, CENTRAL, and Web of Science from inception to 24 January 2023.

STUDY SELECTION
RCTs that enrolled patients with chronic non-cancer spine pain, randomised to receive a commonly used interventional procedure versus sham procedure, usual care, or another interventional procedure.

DATA EXTRACTION AND SYNTHESIS
Pairs of reviewers independently identified eligible studies, extracted data, and assessed risk of bias. We conducted frequentist network meta-analyses to summarise the evidence and used the GRADE approach to rate the certainty of evidence.

RESULTS
Of 132 eligible studies, 81 trials with 7977 patients that explored 13 interventional procedures or combinations of procedures were included in meta-analyses. All subsequent effects refer to comparisons with sham procedures. For chronic axial spine pain, the following probably provide little to no difference in pain relief (moderate certainty evidence): epidural injection of local anaesthetic (weighted mean difference (WMD) 0.28 cm on a 10 cm visual analogue scale (95% CI −1.18 to 1.75)), epidural injection of local anaesthetic and steroids (WMD 0.20 (−1.11 to 1.51)), and joint-targeted steroid injection (WMD 0.83 (−0.26 to 1.93)). Intramuscular injection of local anaesthetic (WMD −0.53 (−1.97 to 0.92)), epidural steroid injection (WMD 0.39 (−0.94 to 1.71)), joint-targeted injection of local anaesthetic (WMD 0.63 (−0.57 to 1.83)), and joint-targeted injection of local anaesthetic with steroids (WMD 0.22 (−0.42 to 0.87)) may provide little to no difference in pain relief (low certainty evidence); intramuscular injection of local anaesthetic with steroids may increase pain (WMD 1.82 (−0.29 to 3.93)) (low certainty evidence). Evidence for joint radiofrequency ablation proved of very low certainty.
For chronic radicular spine pain, epidural injection of local anaesthetic and steroids (WMD −0.49 (−1.54 to 0.55)) and radiofrequency of dorsal root ganglion (WMD 0.15 (−0.98 to 1.28)) probably provide little to no difference in pain relief (moderate certainty evidence). Epidural injection of local anaesthetic (WMD −0.26 (−1.37 to 0.84)) and epidural injection of steroids (WMD −0.56 (−1.30 to 0.17)) may result in little to no difference in pain relief (low certainty evidence).

CONCLUSION
Our NMA of randomised trials provides low to moderate certainty evidence that, compared with sham procedures, commonly performed interventional procedures for axial or radicular chronic non-cancer spine pain may provide little to no pain relief.

REGISTRATION
PROSPERO (CRD42020170667)


Link | PDF (BMJ) [Open Access]

 

Busse and Zeraatkar were also authors of Interventions for the management of post-COVID-19 condition long COVID: protocol for a living systematic review and network meta-analysis (2025, BMJ Open)

 

I am strongly of the view that a huge chunk of back pain (and probably some other chronic symptoms) can be managed, and sometimes eliminated, by better mattresses, chairs, and footwear. In particular customised ones.

All the engineering & materials tech exists to do it, but it hasn't made it into the market yet. Besides the cost, which would come down with widespread use, it is not clear to me why it has not yet happened.