Imma Perfetto
Cosmos science journalist
Spine injections offer little, or no pain relief for certain kinds of chronic back pain compared to sham injections, a panel of international experts has found.
They strongly recommend against the use of the procedures, such as epidural steroid injections and nerve blocks, for people living with chronic back pain that lasts least 3 months and is not associated with cancer, infection or inflammatory arthritis.
The clinical practice guideline is part of respected British Medical Journal, (The BMJ) Rapid Recommendations initiative, which aims to critically evaluate the latest evidence and create new treatment advice for doctors to provide up-to-date care.
“The question this recommendation raises is whether it is reasonable to continue to offer these procedures to people with chronic back pain,” Professor Jane Ballantyne, an anaesthesiologist at the University of Washington Medical Center in the US, wrote in a linked editorial.
Chronic back pain is estimated to effect 20% of people aged 20-59 years old and is the leading cause of disability worldwide.
Procedures such as steroid injections, nerve blocks, and nerve ablation are increasingly being used to manage the problem.
According to Ballantyne, the new report: “…attempts to correct some of the shortcomings of previous confusing and conflicting evidence synthesis and evidence-based guidelines.
“Most notably, a clear distinction is made between acute and chronic back pain, and the effort involves not just one type of spine pain, but a range of common spine pain conditions and the most common interventions used to treat them.”
The international panel of 10 clinicians, 4 patients living with chronic spine pain, and 8 research methodologists assessed the quality of existing evidence.
It reviewed randomised controlled trials and observational studies to compare the benefits and harms of 13 common interventional procedures with sham ones.
Ultimately, they concluded that here was no high certainty evidence of benefit for any of the interventions.
“The research and guideline recommendations are worthy of attention, especially the conclusion that spine injections result in little or no pain relief for either axial or radicular back pain, leading the guideline to strongly recommend against their use,” writes Ballantyne.
For people living with chronic axial spine pain (localised to the midline) they strongly recommend against the use of:
- 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 those living with chronic radicular spine pain (radiates down a limb), they strongly recommend against the use of:
- dorsal root ganglion radiofrequency ablation with or without epidural injection of local anaesthetic or local anaesthetic plus steroids; and
- epidural injection of local anaesthetic, steroids, or their combination.
As the procedures are costly, are a burden on patients who must travel to a healthcare provider to receive them, and carry a small risk of harm, the panel concluded that almost all informed patients would choose to avoid them.
But, according to Ballantyne, there are still questions to be answered by future research.
“Would the conclusions of the linked meta-analysis have looked different if series of injections rather than single injections had been studied, or if the injections had only been provided in the context of comprehensive rehabilitation, or if the injections were confined to acute exacerbations of chronic back pain?” she asks.
“This Rapid Recommendation cluster 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…”
