New Guidelines on Spinal Injections and Ablation Procedures

A new medical guideline published in The BMJ looks at injections and ablation procedures used to treat long-term back and neck pain. The experts who created this guideline found that these treatments don’t provide much benefit and come with significant risks. They strongly recommend avoiding these procedures.

What Did the Experts Find?

A group of doctors, researchers, and patient representatives looked at the most commonly used procedures for chronic spine pain. They studied the latest research to see which treatments actually help people feel better and which ones may not be worth the risks.

Recommendations

For people living with chronic localized spine pain the guideline panel issued strong recommendations against:

Joint radiofrequency ablation with or without joint targeted injection of local anesthetic plus steroid.
Epidural injection of local anesthetic, steroids, or their combination.
Joint-targeted injection of local anesthetic, steroids, or their combination.
Intramuscular injection of local anesthetic with or without steroids.

For people living with chronic radicular spine pain such as sciatica, the guideline panel issued strong recommendations against:

Dorsal root ganglion radiofrequency with or without epidural injection of local anesthetic local anesthetic plus steroids; and
Epidural injection of local anesthetic, steroids, or their combination.

Risks of Spinal Injections and Ablation Procedures

Infection: Introducing instruments into the spine can lead to infections, such as epidural abscess or meningitis.
Bleeding: Procedures may cause bleeding or hematomas, especially in patients with coagulation disorders or those on anticoagulant therapy.
Nerve Injury: Misplacement of needles or catheters can result in nerve damage, leading to numbness, tingling, or even paralysis.
Dural Puncture: Accidental puncture of the dura mater can cause cerebrospinal fluid leaks, leading to headaches and other complications.
Allergic Reactions: Patients may experience adverse reactions to injected substances, including local anesthetics or steroids.
Arachnoiditis: a rare inflammatory condition that affects the arachnoid membrane, one of the three layers of tissue (meninges) that cover and protect the brain and spinal cord. Symptoms include:
- Chronic, severe pain in the back, legs, or arms
- Numbness, tingling, or burning sensations
- Muscle weakness
- Difficulty walking or standing
- Bladder and bowel problems
- Sexual dysfunction

Frequency of Use and Cost

These procedures are very common in the United States. Over 10 million epidural spinal injections alone are performed every year at a cost of approximately $750 to $1500 a year. If we calculate the cost at an average of $1000, that’s over $10 billion a year for a procedure that doesn’t work and can cause significant harm.

History of Spinal Injections

Spinal injections for pain relief date back over a century. The first recorded epidural injection was performed in 1901 by Jean Sicard and Fernand Cathelin, both French physicians. They independently experimented with injecting cocaine into the epidural space to treat sciatic pain. The technique evolved over the decades, and by the 1950s and 1960s, corticosteroids were introduced as a primary agent in epidural injections for managing back pain.

Widespread Adoption of Spinal Injections Before RCT Evidence

Despite their increasing popularity, randomized controlled trials (RCTs) were scarce before spinal injections became widely used. By the 1980s and 1990s, these procedures had become a standard part of pain management, even in the absence of strong clinical trial evidence proving long-term efficacy.

Several early observational studies and case reports supported the use of epidural steroid injections, leading to rapid clinical adoption. However, the first well-designed RCTs evaluating epidural steroid injections for chronic back pain appeared only in the late 1990s and early 2000s. Many of these studies found limited or no long-term benefits compared to placebo.

Despite this, patients are still undergoing these useless and sometimes harmful procedures, which are highly profitable for healthcare providers. At the same time, pain patients are frequently told that natural treatments are unproven, even though there are numerous studies showing they are safe and effective.

Better Alternatives for Back and Neck Pain Relief

There are many other ways to manage chronic spine pain, and they may work better for you in the long run. Some options include:

Physical therapy – Strengthening and stretching exercises can improve mobility and reduce pain.

Regular exercise – Activities like walking, swimming, stretching or yoga can help keep your spine healthy.

Massage Therapy: This approach involves manipulating soft tissues to alleviate pain and improve function. Studies have shown that massage therapy can be effective for chronic back pain, with benefits lasting at least six months.

Acupuncture: By inserting fine needles into specific body points, acupuncture aims to balance energy flow and relieve pain. Research indicates that acupuncture affects neurochemical levels, including endorphins and cortisol, contributing to its pain-relieving effects,

Relaxation Training and Other Mind/Body Approaches: Techniques such as meditation, guided imagery, Pain Reprocessing Therapy, and energy psychology help reduce muscle tension and stress, which can contribute to pain. These methods promote a state of calmness, decreasing pain.

Biofeedback: This technique teaches individuals to control physiological functions, such as muscle tension, to manage pain. It's used to help prevent or treat conditions, including migraine headaches and chronic pain.

Red Light Therapy: Also known as low-level laser therapy, this treatment uses specific wavelengths of light to reduce pain and inflammation. Research has found evidence that light therapy is an effective therapy for relieving low back pain

Marijuana (Cannabis): Some studies suggest that medicinal cannabis may be effective in treating back pain with an acceptable side effect profile.

Chiropractic Therapy: Corrects alignment problems to ease pain and support the body's natural ability to heal.

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The Bottom Line

It’s time for the U.S. healthcare system to pay attention to the actual evidence, stop paying for useless, dangerous procedures and start covering safe, effective pain care.

If you’re struggling with chronic spine pain, don’t lose hope. While some conventional treatments may not be as effective as once thought, there are many other ways to find relief. Find a healthcare provider who will create a plan that prioritizes your safety and well-being while giving you the best chance at managing your pain.

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