Intended for healthcare professionals

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

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

BMJ 2025; 388 doi: https://doi.org/10.1136/bmj-2024-079971 (Published 19 February 2025) Cite this as: BMJ 2025;388:e079971

Linked Practice

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

Linked Editorial

Spinal interventions for chronic back pain
  1. Xiaoqin Wang, methodologist12,
  2. Grace Martin, MD anesthesia resident3,
  3. Behnam Sadeghirad, assistant professor134,
  4. Yaping Chang, assistant professor4,
  5. Ivan D Florez, professor567,
  6. Rachel J Couban, medical librarian13,
  7. Fatemeh Mehrabi, doctoral student89,
  8. Holly N Crandon, MBiotech candidate1,
  9. Meisam Abdar Esfahani, MSc candidate3,
  10. Laxsanaa Sivananthan, MD candidate10,
  11. Neil Sengupta, MD candidate11,
  12. Elena Kum, PhD candidate412,
  13. Preksha Rathod, MD candidate3,
  14. Liang Yao, assistant professor113,
  15. Rami Z Morsi, neurology resident14,
  16. Stéphane Genevay, rheumatologist, professor15,
  17. Norman Buckley, anesthesiologist, professor emeritus1312,
  18. Gordon H Guyatt, general internist, distinguished professor4,
  19. Y Raja Rampersaud, orthopedic surgeon, professor1617,
  20. Christopher J Standaert, physiatrist, associate professor18,
  21. Thomas Agoritsas, general internist, associate professor41920,
  22. Jason W Busse, professor134
  1. 1Michael G DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
  2. 2University of Ottawa Heart Institute, Ottawa, Ontario, Canada
  3. 3Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
  4. 4Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
  5. 5Department of Pediatrics, Universidad de Antioquia, Medellin, Colombia
  6. 6School of Rehabilitation Science, McMaster University, Hamilton, Canada.
  7. 7Pediatric Intensive Care Unit, Clínica Las Americas, Medellin, Colombia.
  8. 8HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
  9. 9Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
  10. 10Graduate Entry Medical School, University of Limerick, Limerick, Ireland
  11. 11Department of Medicine, Division of Emergency Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
  12. 12Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
  13. 13Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore
  14. 14Department of Neurology, University of Chicago, Chicago, Illinois, USA
  15. 15Department of Rheumatology, Geneva University Hospitals, Geneva, Switzerland.
  16. 16Schroeder Arthritis Institute, Krembil Research Institute, Division of Orthopaedics, University Health Network, Toronto, Ontario, Canada
  17. 17Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  18. 18Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
  19. 19Division General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
  20. 20The MAGIC Evidence Ecosystem Foundation, Oslo, Norway.
  1. Correspondence to: L Yao yaoliangebm2016{at}gmail.com
  • Accepted 11 October 2024

Abstract

Objective To address the comparative effectiveness of common interventional procedures for chronic non-cancer (axial or radicular) spine pain.

Design Systematic review and network meta-analysis (NMA) of randomised controlled trials (RCTs).

Data sources Medline, Embase, CINAHL, CENTRAL, and Web of Science from inception to 24 January 2023.

Study selection RCTs that enrolled patients with chronic non-cancer spine pain, randomised to receive a commonly used interventional procedure versus sham procedure, usual care, or another interventional procedure.

Data extraction and synthesis Pairs of reviewers independently identified eligible studies, extracted data, and assessed risk of bias. We conducted frequentist network meta-analyses to summarise the evidence and used the GRADE approach to rate the certainty of evidence.

Results Of 132 eligible studies, 81 trials with 7977 patients that explored 13 interventional procedures or combinations of procedures were included in meta-analyses. All subsequent effects refer to comparisons with sham procedures. For chronic axial spine pain, the following probably provide little to no difference in pain relief (moderate certainty evidence): epidural injection of local anaesthetic (weighted mean difference (WMD) 0.28 cm on a 10 cm visual analogue scale (95% CI −1.18 to 1.75)), epidural injection of local anaesthetic and steroids (WMD 0.20 (−1.11 to 1.51)), and joint-targeted steroid injection (WMD 0.83 (−0.26 to 1.93)). Intramuscular injection of local anaesthetic (WMD −0.53 (−1.97 to 0.92)), epidural steroid injection (WMD 0.39 (−0.94 to 1.71)), joint-targeted injection of local anaesthetic (WMD 0.63 (−0.57 to 1.83)), and joint-targeted injection of local anaesthetic with steroids (WMD 0.22 (−0.42 to 0.87)) may provide little to no difference in pain relief (low certainty evidence); intramuscular injection of local anaesthetic with steroids may increase pain (WMD 1.82 (−0.29 to 3.93)) (low certainty evidence). Evidence for joint radiofrequency ablation proved of very low certainty.

For chronic radicular spine pain, epidural injection of local anaesthetic and steroids (WMD −0.49 (−1.54 to 0.55)) and radiofrequency of dorsal root ganglion (WMD 0.15 (−0.98 to 1.28)) probably provide little to no difference in pain relief (moderate certainty evidence). Epidural injection of local anaesthetic (WMD −0.26 (−1.37 to 0.84)) and epidural injection of steroids (WMD −0.56 (−1.30 to 0.17)) may result in little to no difference in pain relief (low certainty evidence).

Conclusion Our NMA of randomised trials provides low to moderate certainty evidence that, compared with sham procedures, commonly performed interventional procedures for axial or radicular chronic non-cancer spine pain may provide little to no pain relief.

Registration PROSPERO (CRD42020170667)

Footnotes

  • Contributors: XW, BS, JWB, DNB, GHG, YRR, CJS, and TA made substantial contributions to conception and design of the review. RJC conducted all literature searches of electronic databases. GM, YC, IDF, RJC, FM, HNC, MAE, LS, NS, EK, PR, LY, and RZM screened studies and extracted data. XW carried out the statistical analysis. XW, BS and JWB interpreted the data. XW, BS, and JWB drafted the manuscript. All authors critically revised the manuscript for important intellectual content and gave final approval for the article. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting criteria have been omitted.

  • Funding: This study was funded by the Chronic Pain Centre of Excellence for Canadian Veterans. Xiaoqin Wang is supported through a post-doctoral fellowship funded by the Institute for Pain Research and Care. Jason Busse is supported, in part, by a Canadian Institutes of Health Research Canada Research Chair in the Prevention and Management of Chronic Pain. The funding organisations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form and declare: no financial support from any industry for the submitted work.

  • Transparency: All authors affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

  • Dissemination to participants and related patient and public communities: Our results were used to develop MAGICapp decision aids (available at www.magicapp.org/) to facilitate conversations between healthcare providers and patients. The MAGICapp decision aids were co-created with people living with chronic pain. We also plan to use social media, the websites of our organisations and those of pain-related associations and societies to disseminate our findings.

Data availability statement

Details of the characteristics of the included studies were shared in the supplementary materials. The study specific data included in meta-analyses can be obtained from the first author at wangx431@mcmaster.ca

View Full Text
Back to top