Spine injections should not be given to adults with chronic back pain because they provide little or no pain relief compared with sham injections, says a panel of international experts in current edition of 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 ofThe BMJ’s ‘Rapid Recommendations’ initiative – to produce rapid and trustworthy guidance based on new evidence to help doctors make better decisions with their patients.
The panel of experts is led by Jason W Busse from the Michael G. DeGroote National Pain Centre at McMaster University in Hamilton, Ontario. Dr Busse and his colleagues point out that chronic back pain is the leading cause of disability worldwide.
It is estimated to affect one adult in five aged from 20-59, with higher rates likely among older adults. In 2016, low back and neck pain accounted for the highest healthcare spending in the US at $134.5 billion.
Current guidelines offer ‘conflicting recommendations ‘
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.
To shed light on this controversial issue, 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 randomised 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.
[The article] ‘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 ‘[ Jane Ballantyne, in linked editorial]
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 anaesthetic, steroids, or their combination; epidural injections of local anaesthetic, steroids, or their combination; and radiofrequency ablation with or without local anaesthetic 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.
Caveats and conclusions
Finally, Dr Busse and his colleagues acknowledge that further research is warranted and could alter future recommendations, in particular for procedures currently supported by only low or very low certainty evidence 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.
Linked editorial: ‘major rethink’ needed
The article is followed by an editorial by Jane Ballantyne from the Department of Anesthesiology and Pain Medicine at the University of Washington School of Medicine in Seattle, Washington. Dr Ballantyne 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 healthcare 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,’ Dr Ballantyne concludes.
To access the full version of the Rapid Recommendation article – titled Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline doi: 10.1136/bmj-2024-079970 – see: https://www.bmj.com/content/388/bmj-2024-079970
To access the full version of the editorial – titledSpinal interventions for chronic back pain doi: 10.1136/bmj.r179 – see: https://www.bmj.com/content/388/bmj.r179
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