PAIN+ CPN

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).

Physician rater

Despite not being supported by evidence, the interventions in this review are widely practiced. The "wisdom of the crowd" seems to overrule clinical science. Having listened to so many who benefit, I am doubting the science. I would have liked to have a comparison of the positive and negative studies and an analysis to see whether there are any hidden biases we do not appreciate. For instance, are the studies done by those who do the procedures or by those who don't think they work. Despite my disbelief in these procedures, I have allowed my professional caregivers to subject me to facet joint injections and soft tissue injections and they have worked more often than they have failed. Because of this experience I might be classified as biased, but I don't think I am.

Physician rater

Some common sense injected into the topic.

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