BMJ & Jane Ballentyne Say Spine Interventions Suck

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drusso

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Editorials

Spinal interventions for chronic back pain​

BMJ 2025; 388 doi: Spinal interventions for chronic back pain (Published 19 February 2025)Cite this as: BMJ 2025;388:r179

Linked Research​

Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials

Linked Practice​

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


  1. Jane C Ballantyne, professor
  2. Author affiliations
  3. [email protected]
Do negative findings demand action?

Despite the common use of spine injections in pain clinics around the world, it has been hard to come up with evidence that strongly supports this practice when applied to chronic back pain (persisting for >3 months). Existing guidelines range from recommending use to recommending avoidance.12345 A new addition to the BMJ Rapid Recommendations series,67 produced by an international team of experts, methodologists, and patients carefully selected to have no conflicts of interest, 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 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.7 The question this recommendation raises is whether it is reasonable to continue to offer these procedures to people with chronic back pain. Chronic back pain is highly prevalent,8 a great deal of money is spent on the injections,910 and a lot of patient hopes and expectations are vested in this type of treatment.11 It is estimated, for example, assuming 9 million epidural injections a year12 at an average cost of $1000, epidural injections alone would cost the United States $9 billion annually.

One might ask how the situation arose whereby we spend so much of our healthcare capital on a treatment for a common condition that compromises the lives of so many people but seemingly does not work. This is where a look at the history helps. Pain medicine was founded in the mid-20th century by anaesthetists, who dominated its early years and continue to be key players in pain clinics and pain training programmes. They had discovered effective ways to treat acute pain and believed they could apply anaesthetic principles to the treatment of chronic pain. But it never really panned out.13 Through corticosteroids, opioids, NSAIDs, and now injections, we learn that treatments that may be highly effective for acute, subacute, or acute-on-chronic pain are often ineffective or problematic when used to treat chronic pain. Today, the dominance of procedural treatments in pain clinics is perpetuated because trainees, including non-anaesthetists, want to acquire procedural skills and gravitate to the anaesthesia-run programmes that teach them.131415 For whatever reason, reimbursement is often far more favourable for procedural than non-procedural treatments. On the patient side, there is a persistent demand for procedures. After all, what patient struggling with debilitating pain does not want to try an injection that has low risk, even if they know it has little chance of helping? And what patient does not actually improve, at least temporarily, because their pain is acknowledged, and because the white coat and hospital setting are a comfort in themselves?16 On the provider side, pain practitioners are motivated by the gratification of acquiring skills that are in demand, that often produce high patient satisfaction at least in the short term, and that are well reimbursed.

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? These are all questions that future research must answer. But in the meantime, does the strong recommendation against the use of spine injections made in the linked Rapid Recommendation demand action? It is never easy to change entrenched culture, and injections have undoubtedly become entrenched as a key component of pain clinic treatments. One way to change physician and patient behaviour is through financial incentive. 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 healthcare systems will be to fund them. 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 that is perhaps best achieved by a better balance of reimbursements between procedural and non-procedural chronic pain treatments.

Footnotes​


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Editorials

Spinal interventions for chronic back pain​

BMJ 2025; 388 doi: Spinal interventions for chronic back pain (Published 19 February 2025)Cite this as: BMJ 2025;388:r179

Linked Research

Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials

Linked Practice

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


  1. Jane C Ballantyne, professor
  2. Author affiliations
  3. [email protected]
Do negative findings demand action?

Despite the common use of spine injections in pain clinics around the world, it has been hard to come up with evidence that strongly supports this practice when applied to chronic back pain (persisting for >3 months). Existing guidelines range from recommending use to recommending avoidance.12345 A new addition to the BMJ Rapid Recommendations series,67 produced by an international team of experts, methodologists, and patients carefully selected to have no conflicts of interest, 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 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.7 The question this recommendation raises is whether it is reasonable to continue to offer these procedures to people with chronic back pain. Chronic back pain is highly prevalent,8 a great deal of money is spent on the injections,910 and a lot of patient hopes and expectations are vested in this type of treatment.11 It is estimated, for example, assuming 9 million epidural injections a year12 at an average cost of $1000, epidural injections alone would cost the United States $9 billion annually.

One might ask how the situation arose whereby we spend so much of our healthcare capital on a treatment for a common condition that compromises the lives of so many people but seemingly does not work. This is where a look at the history helps. Pain medicine was founded in the mid-20th century by anaesthetists, who dominated its early years and continue to be key players in pain clinics and pain training programmes. They had discovered effective ways to treat acute pain and believed they could apply anaesthetic principles to the treatment of chronic pain. But it never really panned out.13 Through corticosteroids, opioids, NSAIDs, and now injections, we learn that treatments that may be highly effective for acute, subacute, or acute-on-chronic pain are often ineffective or problematic when used to treat chronic pain. Today, the dominance of procedural treatments in pain clinics is perpetuated because trainees, including non-anaesthetists, want to acquire procedural skills and gravitate to the anaesthesia-run programmes that teach them.131415 For whatever reason, reimbursement is often far more favourable for procedural than non-procedural treatments. On the patient side, there is a persistent demand for procedures. After all, what patient struggling with debilitating pain does not want to try an injection that has low risk, even if they know it has little chance of helping? And what patient does not actually improve, at least temporarily, because their pain is acknowledged, and because the white coat and hospital setting are a comfort in themselves?16 On the provider side, pain practitioners are motivated by the gratification of acquiring skills that are in demand, that often produce high patient satisfaction at least in the short term, and that are well reimbursed.

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? These are all questions that future research must answer. But in the meantime, does the strong recommendation against the use of spine injections made in the linked Rapid Recommendation demand action? It is never easy to change entrenched culture, and injections have undoubtedly become entrenched as a key component of pain clinic treatments. One way to change physician and patient behaviour is through financial incentive. 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 healthcare systems will be to fund them. 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 that is perhaps best achieved by a better balance of reimbursements between procedural and non-procedural chronic pain treatments.

Footnotes​

SIS has task force already working on rebutting this nonsense.
 
Three articles demand action:

The series of 3 articles:
  • Busse et al - a clinical practice guideline (CPG) strongly recommending against all procedures
  • Wang et al - Rapid Recommendations (based on the CPG) strongly recommending against all procedures
  • Ballantyne - an editorial calling for action to change financial incentives to discourage the use of these procedures
 
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For whatever reason, reimbursement is often far more favourable for procedural than non-procedural treatments
Well, the former can paralyze or kill someone. The latter can’t.
 
Well, the former can paralyze or kill someone. The latter can’t.

The joke is on these guys. Thanks to AI, the thinking part will be almost worthless soon. The only work will be for the doers. So good luck treating radiculopathy with guided imagery. I'll still be getting paid to stick the needle in.
 
since I’m feeling spicy I always chuckled when someone says “cognitive” and “procedural ” specialities.

ah yes when I read the MRI, pick up subtle clues sitting across from the patient , assess goals, walk through legitimate r/b/a, gain trust, plan out the angle, take a step back during the procedure to troubleshoot a bit and plan out the trajectory in real time I’m certainly not using a “cognitive” approach.
 
I'm sorry, what?

Epidural injections cost an average of $1000? No way. Total take where I worked was $150 for a lumbar or thoracic epidural and $180 for a cervical epidural. Then I had to pay the clinic overhead on my total billing. Where did they get these numbers?
 
I wonder how the University of Washington pain department feels about this article from their (former?) fellowship director
Doesn't suprise me honestly. When I interviewed at U of W for their pain fellowship years ago, one of the older attendings (also from the UK I believe) asked me during the interview what worked for pain. Then proceeded to tell me nothing does. And that there was more evidence that opiates did compared to procedures. Obviously they were dead last in my rank (strongly considered not ranking at all).
 
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I'm sorry, what?

Epidural injections cost an average of $1000? No way. Total take where I worked was $150 for a lumbar or thoracic epidural and $180 for a cervical epidural. Then I had to pay the clinic overhead on my total billing. Where did they get these numbers?

A doc on Physician Community wrote recently that his insurance PAID the hospital $3800 for his epidural. No anesthesia present. This was just for the procedure.

A patient in my office today said her bill for an x-ray was $700. She said her out of pocket on an MRI was cheaper ($500). On the surface this makes little sense, but she's a reliable historian.
 
A doc on Physician Community wrote recently that his insurance PAID the hospital $3800 for his epidural. No anesthesia present. This was just for the procedure.

A patient in my office today said her bill for an x-ray was $700. She said her out of pocket on an MRI was cheaper ($500). On the surface this makes little sense, but she's a reliable historian.
Aw man, don’t come in here and tell us stuff like that. You’ll just raise poor DRusso’s blood pressure.
 
they are biased because the ones that can't be helped/psych comorbidity we always say "sorry I can't help you but Mayo clinic (whatever brandname tertiary) may be able to. this probably leads to therapeutic nihilism. I remember in fellowship thinking jeez the procedures are cool but not working as well. Then I hit private practice, most patients do well with simple epidurals.
 
I wonder how the University of Washington pain department feels about this article from their (former?) fellowship director
When I was applying to fellowships, the word on the street was that the UW fellowship was not very interventional. I didn't interview there, and I don't know anyone who did fellowship there, so I can't really say if that is true or not.
 
I'm sorry, what?

Epidural injections cost an average of $1000? No way. Total take where I worked was $150 for a lumbar or thoracic epidural and $180 for a cervical epidural. Then I had to pay the clinic overhead on my total billing. Where did they get these numbers?
I routinely hear from my patients that they got a bill for $2-3k for the epidural. I get paid $140 and the hospital gets several thousand for the damn facility fee. It’s a complete racket
 
A doc on Physician Community wrote recently that his insurance PAID the hospital $3800 for his epidural. No anesthesia present. This was just for the procedure.

A patient in my office today said her bill for an x-ray was $700. She said her out of pocket on an MRI was cheaper ($500). On the surface this makes little sense, but she's a reliable historian.
 
I personally paid 3k (deductible not met) for a cesi at an asc without anesthesia 10 years ago.
 
When I was applying to fellowships, the word on the street was that the UW fellowship was not very interventional. I didn't interview there, and I don't know anyone who did fellowship there, so I can't really say if that is true or not.
I heard Virginia Mason’s program was the more interventional of the two.
 
I agree it's a racket but Medicare pays about $800 for a HOPD interlaminar LESI in my area. Whatever insurance is paying 2-3k for an ILESI, I would like to move there. Unless it's multilevel TFESIs you guys are talking about...

On this particular topic (SOS), DOGE could help us. The risk of course if they look at "literature" like above...
 
So brave of an academic doc to call for reduced financial reimbursement for the rest of us. If UW truly believes that procedural intervention is worthless, perhaps they should close down their pain fellowship. It certainly doesn’t take a year of special training to prescribe PT, gabapentin and Norco.
 
Well given the societal impact of norco and other opioids, maybe it does require a year to go over all the ramifications; include the study of addiction medicine in that year...
 
So brave of an academic doc to call for reduced financial reimbursement for the rest of us. If UW truly believes that procedural intervention is worthless, perhaps they should close down their pain fellowship. It certainly doesn’t take a year of special training to prescribe PT, gabapentin and Norco.
With all the unfilled pain fellowship positions, they may be headed in that direction.
 
So brave of an academic doc to call for reduced financial reimbursement for the rest of us. If UW truly believes that procedural intervention is worthless, perhaps they should close down their pain fellowship. It certainly doesn’t take a year of special training to prescribe PT, gabapentin and Norco.
jokes on you. UW pain clinic doesn't even prescribe opioids lol. Their fellows don't get taught opioid management, nor is the program very procedural.
 
Did you all check uptodate? They also don't recommend most pain procedures, but there are conflicting recommendations in other articles. Article is "Subacute and chronic low back pain." Written by an internist... who else better to weigh in on spine procedures?
 
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