New recommendations urge against spine injections for chronic back pain

Key takeaways:

• An international panel found no high certainty evidence on conventional procedures for spine pain.
• The panel concluded that such procedures are costly, burdensome and do not provide meaningful relief.

Spine injections should not be given to adults with chronic back pain because they provide little or no pain relief vs. sham injections, according to new clinical practice guidelines.

The recommendations, published in BMJ and developed in partnership with the nonprofit MAGIC group, apply to adults with moderate to severe chronic axial or radicular spine pain that is not related to cancer and has lasted for at least 3 months.

Healio previously reported that low back pain remains the leading worldwide cause of years lived with disability, while such pain could impact more than 800 million people by 2050.

According to Jason W. Busse, DC, PhD, a professor at McMaster University in Canada, and colleagues, current procedures for low back pain like nerve blocks, nerve ablation and epidural injections are being increasingly used, but evidence is lacking to support the efficacy of these treatments.

An international panel made up of 10 clinicians, eight methodologists and four people living with chronic back pain conducted an analysis of evidence on procedures using the Grading of Recommendations Assessment, Development and Evaluation approach.

The panel compared the benefits and harms of 13 interventional procedures or combinations of procedures for chronic, noncancer back pain against sham treatments using the data of a systematic review and meta-analysis on randomized trials and observational studies.

Procedures that were assessed included:

• epidural injections of local anesthetic, steroids or a combination;
• injections of local anesthetic, steroids or a combination; and
• radiofrequency ablation with or without local anesthetic plus steroid injections.

No high certainty evidence found

The panel concluded that there was no high certainty evidence for any of the procedures or combinations of procedures, while low and moderate certainty evidence indicate that spine injections would provide no meaningful relief for pain in a specific area of the spine or pain radiating from the spine to the arms or legs compared with sham injections.

The procedures are costly, “burdensome and may result in adverse events,” the experts wrote, adding that almost all informed patients would choose to forgo them due to the little or no benefit received.

The panel noted that there are several remaining questions that future research could attempt to answer, such as if there are systematic differences in treatment effects of interventional procedures based on subtypes of chronic spine pain and what the effects treatments may have on patient outcomes — which were poorly reported in trials — like returning to work, sleep quality, mental functioning and opioid use.

Independent analysis

In an accompanying editorial, Jane C. Ballantyne, MD, FRCA, an anesthesiologist at the University of Washington Medical Center, explained that the guidance raises the question of whether such treatments should still be offered to those with chronic back pain.

“It is never easy to change entrenched culture, and injections have undoubtedly become entrenched as a key component of pain clinic treatments,” she wrote.

One way to change the behavior of patients and physicians when it comes to these treatments “is through financial incentive,” Ballantyne added.

“Yes, there are many pressures on providers to keep doing spine injections, and on payers to keep paying for them, but the more the evidence fails to support the widespread use of these injections, the less inclined health care systems will be to fund them.”

References:

• Ballantyne J. BMJ. 2025;doi:10.1136/bmj.r179.
• Busse J, et al. BMJ. 2025;doi:10.1136/bmj-2024-079970.