Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline

PainSci » bibliography » Busse et al 2025
updated Apr 25, 2025

Tags: treatment, injections, denervation, neck, back pain, bad news, scientific medicine, controversy, medicine, neurology, head/neck, spine, pain problems, debunkery

Four pages on PainSci cite Busse 2025: 1. The Complete Guide to Low Back Pain 2. The Complete Guide to Neck Pain & Cricks 3. Do Nerve Blocks Work for Neck Pain and Low Back Pain? 4. Block and burn for backs and necks bombs a big test, doctors bluster

PainSci commentary on Busse 2025: ?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

This clinical guideline paper is based on Wang, a major new review of interventional pain medicine (IPM) — the “block and burn” approach to chronic spinal pain (numbing or destroying nerves, with various injections, and heat). It’s summarized by a good infographic.

It concludes that “well-informed people would likely not want” these treatments, provoking thirty-four medical societies to call for its retraction. The evidence isn’t complete or perfect, but there is significant evidence of absence, and a conspicuous lack of positive results. Their outrage is loud, but not evidence-based, mostly the usual “in my experience” stuff. There could still be a reasonable argument for using these procedures judiciously and with consent — but there is no excuse for trying to silence inconvenient science! If IPM is can be helpful for some patients, that needs to be demonstrated with good trials, not the haughty harrumphing of doctors with obvious conflict of interests.

~ Paul Ingraham

original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

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).

original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

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