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Spinal interventions for chronic back pain
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...
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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:r179Linked Research
Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trialsLinked Practice
Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline- Jane C Ballantyne, professor
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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
- Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The author declares no other interests. Further details of the BMJ policy on financial interests is here: https://www.bmj.com/sites/default/f...2016/03/16-current-bmj-education-coi-form.pdf.
