British Medical Journal (The BMJ)Commonly Used Interventional Procedures for Non-cancer Chronic Spine Pain: A Clinical Practice Guideline

This 2025 BMJ clinical practice guideline provides strong recommendations against commonly used interventional procedures for chronic non-cancer spine pain, based on systematic review evidence showing minimal benefit compared to sham procedures, while identifying potential harms and procedural burdens for patients.

Key Clinical Considerations

• Strong recommendations against interventional procedures for chronic axial spine pain, including joint radiofrequency ablation, epidural injections, joint-targeted injections, and intramuscular injections.
• Strong recommendations against dorsal root ganglion radiofrequency and epidural injections for chronic radicular spine pain.
• Moderate certainty evidence showed epidural and joint-targeted injections produced little to no pain relief compared to sham procedures for both axial and radicular chronic pain.
• Even with low certainty evidence, the panel concluded that risk of harm (8.6% risk of prolonged pain/stiffness, 1.4% risk of dural puncture) outweighed benefits.
• The guideline specifically excludes acute spine pain (<3 months) and spine pain associated with cancer or inflammatory arthropathy.

Clinical Practice Impact

• Patient Communication: Explain that despite their widespread use, current evidence doesn’t support interventional procedures for chronic spine pain, as they provide minimal pain relief beyond placebo while carrying risks and substantial cost burden. Consider discussing evidence-supported alternatives like exercise therapy.
• Practice Integration: Re-evaluate referral patterns for interventional spine procedures, particularly in patients with >3 months of symptoms. Note that the panel concluded that “all or almost all informed patients would choose to avoid interventional procedures” given the current evidence.
• Risk Management: Document discussions about evidence limitations, particularly in jurisdictions where interventional procedures remain common despite this guideline. The significant cost ($1,000 – $5,000 per procedure) without demonstrated benefit raises ethical considerations.
• Action Items: Review current chronic spine pain management protocols and consider de-implementing routine referrals for interventional procedures outside research settings.

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