The Wrong Way to Treat Chronic Spine Pain

The latest “Rapid Recommendation” from the BMJ (formerly the British Medical Journal) addresses “commonly used interventional procedures for non-cancer chronic spine pain.”¹ The recommendation, which applies to adults with chronic spine pain not caused by cancer or inflammatory arthropathy, and is based on a clinical practice guideline developed by an international expert panel, “strongly recommend[s] against” the following interventions:

For chronic axial spine pain:

• 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
• Intramuscular injection of local anaesthetic with or without steroids

For chronic radicular spine pain:

• Dorsal root ganglion radiofrequency with or without epidural injection of local anaesthetic or local anaesthetic plus steroids
• Epidural injection of local anaesthetic, steroids, or their combination

Perhaps the most important aspect of the BMJ recommendation is this statement: “All or nearly all well-informed people would likely not want such interventions. Such interventions should therefore not be offered outside of a clinical trial.”

Comprised of “four people living with chronic spine pain, 10 clinicians with experience managing chronic spine pain, and eight methodologists,” the international expert panel, based its clinical guideline on a “systematic review and network meta-analysis of randomised trials and a systematic review of observational studies, summarising the current body of evidence.”

An accompanying article in the BMJ discusses several issues brought to light by the guideline; most notably that of cost. Assuming an estimated 9 million epidural injections a year with an average cost of approximately $1,000 each means such injections burden the U.S. health system by $9 billion annually. The article also pointed out that, like corticosteroids, opioids and NSAIDs, spinal injections may be effective for acute and subacute pain, but are often ineffective, if not problematic, for the treatment of chronic pain.²

References

1. Busse JW, et al, Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline. BMJ, 2025;388:e079970. Read Here
2. Ballentine JC. Spinal interventions for chronic back pain. BMJ, 2025;388:r179. Read Here