Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline
BMJ 2025; 388 doi: https://doi.org/10.1136/bmj-2024-079970 (Published 19 February 2025) Cite this as: BMJ 2025;388:e079970Linked Research
Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials
Linked Editorial
Spinal interventions for chronic back pain
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Dear Editor:
On behalf of 34 societies* representing physicians across the world who treat patients with chronic pain, we write respectfully to request that The BMJ Editorial Board consider retracting the clinical practice guideline authored by Busse et al. [1]. We have serious concerns about the methodology, insufficient clinical context, and implications for patient care.
Methodological Concerns
The guideline aggregates disparate groups of patients, conditions, spinal regions, and procedures. The procedures have distinct technical requirements, effectiveness profiles, and indications. It is based on a systematic review/network meta-analysis (NMA) that includes studies of abandoned procedures and non-standard techniques from which the guideline draws erroneous conclusions about the appropriate use and coverage of commonly used and well-accepted techniques [2].
The disappointing truth is that there are not enough high-quality RCTs in interventional spine care to perform a well-powered meta-analysis in this area. As a result, we rely on carefully reasoned and balanced systematic reviews that incorporate the breadth of the available literature [3]. We are confident that the authors will support our call for increased research funding on interventional spine care to provide clarity and improve clinical decision-making.
Insufficient Clinical Context
The guideline does not adequately consider the role of patient preference and informed decision-making in treatment selection. Two recently published clinical guidelines emphasize patient autonomy and shared decision-making in choosing interventional spine treatments [4,5]. Many patients, when provided with appropriate information, opt for interventional procedures due to their potential to provide meaningful pain relief and functional improvement.
Moreover, interventional procedures are rarely standalone treatments; they are part of a multimodal approach that may include physical therapy, cognitive behavioral therapy, and other conservative treatments. Some procedures are only indicated when attempts at other conservative treatments have failed to yield sufficient improvements in pain and function. The guideline’s broad discouragement of these procedures overlooks their role within comprehensive care strategies.
Implications for Patient Care
The methodological shortcomings of the guideline have direct consequences for healthcare policy and insurance coverage. Mischaracterizing interventional procedures as broadly ineffective may lead to unnecessary restrictions on patient access. Denying coverage for these treatments based on flawed interpretations of evidence could push patients toward more invasive surgical interventions or long-term opioid therapy, both of which carry greater risks and costs.
In appropriately selected patients, interventional spine procedures can offer substantial relief, improve function, allow for return to work, and may delay or obviate the need for more invasive surgical interventions or long-term reliance on opioids. Thus, they remain an essential treatment option for patients.
Conclusion
Interventional spine procedures are not universally effective and careful patient selection is essential. We agree with Busse et al. that patients suffering from chronic spine pain deserve to be properly informed and receive personalized care where they choose their path to safe and effective pain relief. When performed with technical precision [6,7] and integrated into a broader, individualized treatment plan, these procedures have been shown to provide significant benefits [3]. We also stress the importance of selecting, analyzing, and aggregating appropriate studies when developing clinical guidelines [8-10]. We call upon researchers, clinicians, and policymakers to recognize the complexity of chronic spine pain and to support expanded research and ongoing access to interventional procedures underpinned by rigorous clinical standards.
* Access the full response, which includes the list of 34 signatories, at https://cdn.ymaws.com/www.ipsismed.org/resource/resmgr/advocacy/25/Multi....
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References:
1. Busse J W, Genevay S, Agarwal A, et al. Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline. BMJ 2025;388:e079970. doi:10.1136/bmj-2024-079970
2. Wang X, Martin G, Sadeghirad B, et al. Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials. BMJ 2025;388:e079971. doi:10.1136/bmj-2024-079971
3. IPSIS Systematic Reviews. https://www.ipsismed.org/page/SystematicReviews [Accessed 3/18/2025]
4. Cohen SP, Bhaskar A, Bhatia A, et al. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Reg Anesth Pain Med 2020 Jun;45(6):424-467. doi: 10.1136/rapm-2019-101243. Epub 2020 Apr 3. PMID: 32245841; PMCID: PMC7362874
5. Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Reg Anesth Pain Med 2022 Jan;47(1):3-59. doi: 10.1136/rapm-2021-103031. Epub 2021 Nov 11. PMID: 34764220; PMCID: PMC8639967
6. Practice Guidelines for Spinal Diagnostic and Treatment Procedures, 2nd edition. Bogduk N, ed.San Francisco: International Spine Intervention Society; 2013.
7. Maus TP, Cohen I, McCormick ZL, Schneider BJ, Smith CC, Stojanovic MP, Waring PH (Eds). Technical Manual and Atlas of Interventional Pain and Spine Procedures. International Pain and Spine Intervention Society; 2024.
8. Multisociety letter to the agency for healthcare research and quality: serious methodological flaws plague technology assessment on pain management injection therapies for low back pain. Pain Med 2016 Jan;17(1):10-5. doi: 10.1111/pme.12934. PMID: 26400156
9. Vorobeychik Y, Stojanovic MP, McCormick ZL. Radiofrequency denervation for chronic low back pain. JAMA 2017 Dec 12;318(22):2254-2255. doi: 10.1001/jama.2017.16386. PMID: 29234800
10. McCormick ZL, Vorobeychik Y, Gill JS, et al. Guidelines for composing and assessing a paper on the treatment of pain: a practical application of evidence-based medicine principles to the Mint randomized clinical trials. Pain Med 2018 Nov 1;19(11):2127-2137. doi: 10.1093/pm/pny046. PMID: 29579232
Competing interests: No competing interests
Dear Editor,
The recently published BMJ guidelines implies that the value of spine interventions is nothing more than a placebo and hence recommends strongly against most spinal interventions (1). The basis of these recommendations primarily comes from a network meta-analysis (NMA) by the same author group, which reports minimal or small improvements in pain. As a research work, the NMA has its strengths and limitations, but it does highlight the lack of level 1 evidence in this field (2). However, do the recommendations take into account other evidence and nuances and challenges involved in the management of patients with chronic low back pain (CLBP)?
The prevalence of LBP continues to increase globally (3). Although episodes of LBP can be self-limiting, many patients have recurrent or chronic LBP over time, significantly affecting function and quality of life. It is this cohort of patients that are predominantly seen in tertiary pain clinics. CLBP increases with age (4,5) and can be of substantial intensity (6). Although it becomes convenient for us to label the majority as non-specific (no specific structural cause) (7), it conveys nothing in the way of biological explanation, other than ruling out the need for surgery. At the patient level it suggests a generic, non-personalized and reductive approach to ignore the potential contribution from a structural cause such as facet arthropathy or discogenic radicular pain. When it comes to CLBP, the increased use is not restricted to spinal injections alone, but is also observed for anti-depressants, gabapentinoids, opioids, muscle relaxants, chiropractic visits, physiotherapy visits, and spine surgeries (4); reviews and meta-analytical evidence indicates lack of efficacy for all of these therapies as well (8). The reduction of pain even with multidisciplinary rehabilitation programs range from 0.21 to 0.60 units (less than clinically meaningful to patients) (9).
To a large extent, most guidelines and pathways do not appreciate the disconnect that exists between treatments of proven efficacy for LBP in the short period, and effective treatment response for CLBP in the clinical context. Options suggested mostly include strategies that are generally safer, incorporating psycho-behavioural strategies and exercises. These fail to consider that a substantial proportion of these patients can be non-responders, these strategies may not directly impact pain severity, cannot be continued beyond a certain period (such as anti-inflammatories), and that effects could only be temporary. Even guidelines from recognized organizations have been found to have differential approach and lack of consistency (7,10).
Formulation of guidelines cannot consider interventional options in isolation but within the broader framework of CLBP management. At our clinic, we offer a multidisciplinary care, including spinal interventions. Each patient attends a pre-consult education-orientation session that informs about chronic pain and its bio-psycho-social management. All patients are seen along with a psychologist and a kinesiologist with decisions being made together regarding pharmacological, non-pharmacological and interventional options. Financial conflicts may play a role in some intervention clinics but to put that blame on all physicians practicing interventions does not explain the simultaneous increase in literally every medication or strategy over these years and their failure of effectiveness as demonstrated by studies and worsening indices of CLBP prevalence, intensity and suffering.
The guidelines panel needed to be more circumspect in their recommendations. An objective methodology may not preclude a subjective judgment, inconsistency in valuing relative benefits and harms of alternative treatments, and potential anchoring bias when people with appropriate expertise are not involved. A more constructive approach would have been to recommend a higher threshold and longer duration of pain reduction commensurate with the invasiveness and resource utilization of an intervention, along with tools to better identify responders, so that performance of these procedures is tied to better outcomes.
REFERENCES
1. Busse JW, Genevay S, Agarwal A, et al. Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline. BMJ (Clinical research ed). Feb 19 2025;388:e079970. doi:10.1136/bmj-2024-079970
2. Wang X, Martin G, Sadeghirad B, et al. Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials. BMJ (Clinical research ed). Feb 19 2025;388:e079971. doi:10.1136/bmj-2024-079971
3. Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. Jun 2023;5(6):e316-e329. doi:10.1016/s2665-9913(23)00098-x
4. Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med. Feb 9 2009;169(3):251-8. doi:10.1001/archinternmed.2008.543
5. Wong CK, Mak RY, Kwok TS, et al. Prevalence, Incidence, and Factors Associated With Non-Specific Chronic Low Back Pain in Community-Dwelling Older Adults Aged 60 Years and Older: A Systematic Review and Meta-Analysis. J Pain. Apr 2022;23(4):509-534. doi:10.1016/j.jpain.2021.07.012
6. Wallwork SB, Braithwaite FA, O'Keeffe M, et al. The clinical course of acute, subacute and persistent low back pain: a systematic review and meta-analysis. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. Jan 21 2024;196(2):E29-e46. doi:10.1503/cmaj.230542
7. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. Feb 18 2017;389(10070):736-747. doi:10.1016/s0140-6736(16)30970-9
8. Ferreira GE, McLachlan AJ, Lin CC, et al. Efficacy and safety of antidepressants for the treatment of back pain and osteoarthritis: systematic review and meta-analysis. BMJ (Clinical research ed). Jan 20 2021;372:m4825. doi:10.1136/bmj.m4825
9. Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev. Sep 2 2014;2014(9):Cd000963. doi:10.1002/14651858.CD000963.pub3
10. Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. Jun 9 2018;391(10137):2368-2383. doi:10.1016/s0140-6736(18)30489-6
Competing interests: I am a chronic pain physician working at McMaster University. I am also a clinician researcher involved in acute and chronic pain research. I am associated with Canadian Pain Society (Interventional SIG Chair) and American Society of Regional Anesthesia and Pain Medicine (regulatory and standards committee).
Dear Editor,
We appreciate the interest in our work. The guideline panel was composed of methodologists, patient partners, and clinicians with a collective experience administering thousands of interventional procedures for chronic spine pain. The panel was free of important financial and intellectual conflicts of interest, independently confirmed by the BMJ, which was critical to ensure objective appraisal of the evidence. We note that none of the Rapid Responses authors declared any conflicts of interest, although several perform interventional procedures and receive financial benefits from doing so.
We followed GRADE guidance when formulating recommendations. This includes making strong recommendations when there is low certainty of lack of benefit and moderate to high certainty of greater risk of important harm or burden. (1) Our team members include a co-founder of the GRADE Working Group.
As per Radley et al., we agree that responder analyses are more interpretable, and we complemented pooled mean differences for pain relief with the risk difference for achieving the minimally important difference. We acknowledged the possibility that future research may find interventional procedures effective for subtypes of patients, (2) although secondary analyses of randomized trial data have failed to support this hypothesis (e.g., refs 3,4). The editorial accompanying our guideline asks if results may have differed if injections were provided in the context of comprehensive rehabilitation. (5) We echo Radley et al.’s call for more evidence. Comparison to sham procedures is required to identify the incremental contribution of specific effects, intentionally removing placebo effects that may be associated with the intervention.
Robinson et al. question our pooling decisions, which were guided by subgroup analyses that found no difference in treatment effects based on location, or approach, of administration. (see Supplementary Table 24 in our network meta-analysis) (6) No intervention categorized as sham in our review included delivery of active treatment. The Rapid Responses section of our network meta-analysis, where they raised similar issues, provides additional details regarding their concerns. We disagree that denying patients ineffective interventions results in therapeutic nihilism. Moreover, freeing up the substantial resources dedicated to interventional procedures could address the under-resourcing of biopsychosocial approaches that have been shown effective.(7)
Kalia et al. question why we included unblinded trials in our network meta-analysis. We did find a credible subgroup analysis based on provider blinding status for pair-wise meta-analysis of radiofrequency ablation vs. sham procedures. Seven trials that did blind providers showed a pooled effect on pain relief of -0.23 cm on a 10 cm VAS (95%CI -0.60 to 0.14) vs. 4 unblinded trials that showed a pooled effect of -1.74 cm (95%CI -2.73 to -0.76). (Supplement Table 24) However, there was insufficient power to detect this association in our network meta-regression. (Supplement Table 32) As such, we retained unblinded trials in our network but rated down the certainty of evidence for radiofrequency ablation vs. sham for high risk of bias.
Krieg notes that interventional procedures may have a role in minimizing surgical involvement, which is beyond the scope of our work. Pseudoradicular pain was not reported among trials eligible for our review. We agree that readers looking for specific patterns of radiculopathy per spinal level would be well-served to seek out information sources beyond our infographic.
We agree with Ashar et al. that non-specific effects are an important aspect of clinical care that should be optimized. The use of non-deceptive placebos remains controversial and seldom practiced. We agree with Ashar et al.’s criteria for their use that include very low risk and inexpensive, criteria that the procedures we studied would fail.
Jason W. Busse, Stéphane Genevay, Gordon H. Guyatt, and Thomas Agoritsas; on behalf of the Rapid Recommendation authors.
References
1. Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation’s direction and strength. J Clin Epidemiol. 2013; 66: 726-35.
2. Busse JW, Genevay S, Agarwal A, et al. Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline. BMJ. 2025; 388: e079970.
3. Turner JA, Comstock BA, Standaert CJ, et al. Can patient characteristics predict benefit from epidural corticosteroid injections for lumbar spinal stenosis symptoms? Spine J. 2015; 15(11): 2319-31.
4. Perez FA, Quinet S, Jarvik JG, et al. Lumbar Spinal Stenosis Severity by CT or MRI Does Not Predict Response to Epidural Corticosteroid versus Lidocaine Injections. AJNR Am J Neuroradiol. 2019; 40(5): 908-915.
5. Ballantyne JC. Spinal interventions for chronic back pain. BMJ. 2025; 388: r179.
6. Wang X, Martin G, Sadeghirad B, et al. Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials. BMJ. 2025; 388:e079971.
7. Buchbinder R, Underwood M, Hartvigsen J, Maher CG. The Lancet Series call to action to reduce low value care for low back pain: an update. Pain. 2020; 161 Suppl 1(1): S57-S64.
Competing interests: No competing interests
Dear Editor,
It was with great interest that we read the recent review of spinal interventions published in the BMJ [1]. This made wide ranging recommendations against the usage of such techniques. Moderate or severely disabling chronic pain is thought to affect 14% of UK adults [2]. As pain clinicians we hear detailed accounts in every clinic of the debilitating effects that chronic pain has on patients and their families. Many of us will experience this condition personally.
Our understanding of chronic pain has evolved with the biopsychosocial model to reflect its complexity and is it widely acknowledged as sometimes exceedingly difficult to treat. The effects of interventional treatments, similar to other methodologies of pain treatment, are often better characterised as ‘responders’ and ‘non-responders’ compared to a mean change in pain score. Perhaps a more constructive way of looking at these treatments might be engage our efforts in trying to better identify which patient groups are most likely to benefit.
Pain management services combine different approaches with psychology, physiotherapy input, medication optimisation, education and interventional treatments. Most of these approaches are not life changing for most of our patients, however the strength of such services is through being able to combine these treatments. In other settings such as critical care or enhanced recovery programs after surgery, interventions are combined together as care bundles which allows the combination of techniques to produce clinically relevant benefits. Removing individual parts of such combinations that might not stand up to scrutiny in isolation undermines the underlying principle.
The comparison in the review article to sham procedures is misleading, as the placebo response is well recognised across medicine, and remains important. A better comparator to the effects of the input of pain management services might be a primary care appointment where it is explained to the patient that nothing can be done for them.
None of the study authors are from the UK and although the study is published in the British Medical Journal, it is difficult to see how the way that interventions are used in the UK system has been considered. The motivations of pain physicians are also questioned. The comment that clinicians are likely to be influenced by the tariff paid for procedures does demonstrate a lack of applicability of the recommendations to the UK healthcare system, as NHS physicians are unlikely to be influenced by such factors.
Persistent pain is a challenging and complex problem which causes significant suffering and will impact most of us personally, as well as our patients. Its treatment is an under resourced area. We should consider very carefully how to use the few treatments we have available as the implications of recommendations will be widely and deeply felt. Further work is recommended to identify how to use these treatments better.
1. Busse J W, Genevay S, Agarwal A, Standaert C J, Carneiro K, Friedrich J et al. Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline BMJ 2025; 388 :e079970 doi:10.1136/bmj-2024-079970
2. Fayaz A, Croft P, Langford RM, et al Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies BMJ Open 2016;6:e010364. doi: 10.1136/bmjopen-2015-010364
Competing interests: No competing interests
Dear Editor,
The recent guideline by Busse et al. advocating against interventional procedures for chronic spine pain suffers from critical methodological and analytical flaws that undermine its conclusions. (1)
1. Statistical Limitations
The entire body of work is based on a meta-analysis by Wang et al., which pooled 81 trials with a median sample size of 64 participants—a cohort prone to Type II errors due to inadequate statistical power. (2) The authors acknowledge that unblinded trials reported significantly larger effect sizes (−1.74 vs. −0.23 cm pain reduction, P = 0.005) but still included these biased studies in primary analyses. This inflated heterogeneity, distorted effect estimates, and violated PRISMA-NMA standards. Furthermore, the GRADE framework was applied inconsistently, disproportionately downgrading certainty for interventional studies while maintaining equipoise for sham controls—a clear double standard that artificially favors null hypotheses.
2. Methodological Bias
The panel’s composition raises concerns regarding specialty bias, as it lacks sufficient representation from interventional specialists. The lead author is a chiropractor, the second author a rheumatologist, the third a resident in internal medicine, and the last author specializes in health policy. This composition likely undervalues the procedural nuances of interventional pain management. Similar specialty-driven biases have been documented in previous reviews, where different specialties evaluating the same data have reached opposing conclusions. (3)
3. Restrictive and Flawed Recommendations
By issuing strong recommendations against interventional procedures based on low-to-moderate certainty evidence, the guideline effectively denies patients access to therapies that may benefit specific subgroups, particularly those refractory to pharmacotherapy. This absolutist approach is inconsistent with JAMA Guidelines Trust criteria, which advise conditional recommendations when evidence remains uncertain.
Additionally, we strongly oppose the misinterpretation of our 2022 American Society of Pain & Neuroscience (ASPN) guidelines in the article. (4) The authors aggressively position their work as “trustworthy” while subtly discrediting opposing guidelines, revealing an underlying agenda-driven purpose rather than an objective scientific review.
4. BMJ’s Role and the Need for Retraction
It is surprising that this article met BMJ’s rigorous acceptance criteria, given its methodological flaws and lack of robust biostatistical analysis. At best, this publication represents a “narrative opinion” rather than an evidence-based clinical practice guideline.
The BMJ editorial leadership bears immense responsibility for ensuring that published content maintains scientific integrity. Disseminating low-quality research may have far-reaching consequences, including restricting insurance coverage for non-opioid, evidence-based pain treatments. In the midst of the opioid epidemic, such misguided guidelines may lead to patient harm and medicolegal challenges.
Conclusion
The statistical errors, specialty bias, and unbalanced harms assessment within this guideline perpetuate the very inconsistencies it claims to address. In the interest of scientific integrity, we respectfully urge BMJ’s editorial team to retract this article and restore its legacy as a trusted source of evidence-based medicine. (5)
Hemant Kalia, MD, MPH (Vice President, Reimbursement & Regulatory Affairs, American Society of Pain & Neuroscience)
Dawood Sayed, MD (Vice Chairman, American Society of Pain & Neuroscience)
Tim Deer, MD (Chairman, American Society of Pain & Neuroscience)
References
1. Busse JW, Genevay S, Agarwal A, et al. Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline. BMJ. 2025;388:e079970. doi: 10.1136/bmj-2024-079970.
2. Wang X, Martin G, Sadeghirad B, et al. Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials. BMJ. 2025;388.
3. Cohen SP, Bicket MC, Jamison D, et al. Epidural steroids: a comprehensive, evidence-based review. Reg Anesth Pain Med. 2013;38(3):175-200.
4. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) evidence-based clinical guideline of interventional treatments for low back pain. J Pain Res. 2022:3729-3832.
5. BMJ Group. Journal retracts six further articles and corrects two others authored by former editor. Available at: https://bmjgroup.com/journal-retracts-6-further-articles-and-corrects-2-....
Competing interests: No competing interests
Dear Editor,
All or nearly all well-informed interventional pain physicians would recommend against these harrowing recommendations. The authors’ guidelines are quite bombastic and with a high certainty of confidence, we urge all well-informed readers to dissect the material before acting.(1,2) A recommendation without any solution leaves our patients where? To the informed reader, not every intervention or medical treatment is indicated for every person or condition. A critical limitation of this guideline is the absence of board-certified interventional pain specialists on the expert panel. While the panel included physiatrists, anesthesiologists, rheumatologists, general internists, and methodologists, there was no mention of board-certified specialists in interventional pain medicine from recognized subspecialty boards. This omission is a glaring oversight that undermines the credibility of the recommendations. The exclusion of such experts raises concerns regarding whether the full clinical complexity and technical aspects of interventional procedures were adequately considered as can be seen by the grouping of injections and conditions. Without specialized expertise, the guideline misrepresents the efficacy and clinical utility of these treatments, significantly weakening its validity.
Furthermore, as previously reported, how can recommendations be based on a network meta-analysis (NMA) where the basic assumptions are not respected.(1) The transitivity assumption is violated when the common comparator is different as is the case for differing placebo response. Interventional procedures vary considerably in terms of invasiveness and placebo response.(3–5) This is essential because most of the direct comparisons with placebo were indirect. For example, pain relief for axial chronic spine pain, the main direct comparator with placebo was radiofrequency ablation, a more invasive yet still minimally invasive technique. By this means, most interventions indirectly compared themselves with the high placebo response expected after sham radiofrequency ablation.
The NMA reports no statistical intransitivity, but only investigates age, sex, and baseline pain as effect modifiers, overlooking the differing nature of the common comparator, which is arguably the most important effect modifier.(6,7) Even if this had been attempted taken into consideration the sparsity of data makes it very difficult to account. This sows concern about the validity of the indirect comparisons and thereby the results of the NMA. In addition, it is well known that intransitivity can often not be adequately tested in small NMAs, due to a lack of power.(7) Intransitivity should therefore be based upon reasonable judgement.
The issues continue which include completely disparate outcome definitions and methods of assessments between trials, and highly variable durations of follow-ups, factors that generally prohibit a NMA.(6) Other problems relate to the lack of statistical power for many interventions, assessment of only a minority of clinically meaningful outcomes, and unsubstantiated conclusions (as opposed to the authors claim, several interventions proved significantly more efficacious than placebo on multiple outcomes – yet this is entirely omitted from the conclusion). Furthermore, the manner in which the infographic is presented is highly misleading and does not present the variability in certainty of what the authors have reported on. This is essentially a blanket statement on all pain procedures with no room for qualification.
With the highest level of confidence, we are not advocating that interventional procedures be the first-line, but conservative management based on the patients co-morbidities be trialed first. When those may not be sufficient, we employ a multimodal strategy to get the patient back to as close to their baseline functioning level. Per the Hippocratic Oath, we aim to ”Do no harm,” with unnecessary procedures, yet the guidelines may... Without a solution, what is left for the suffering patient.
1. Re: Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials | The BMJ [Internet]. [cited 2025 Feb 26]. Available from: https://www.bmj.com/content/388/bmj-2024-079971/rr-1
2. Wang X, Martin G, Sadeghirad B, Chang Y, Florez ID, Couban RJ, et al. Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials. BMJ [Internet]. 2025 Feb 19 [cited 2025 Feb 26];388:e079971. Available from: https://www.bmj.com/content/388/bmj-2024-079971
3. Cousins S, Blencowe NS, Tsang C, Chalmers K, Mardanpour A, Carr AJ, et al. Optimizing the design of invasive placebo interventions in randomized controlled trials. Br J Surg [Internet]. 2020 Aug 1 [cited 2025 Feb 26];107(9):1114. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7496319/
4. Holtedahl R, Brox JI, Tjomsland O. Placebo effects in trials evaluating 12 selected minimally invasive interventions: a systematic review and meta-analysis. BMJ Open [Internet]. 2015 Jan 1 [cited 2025 Feb 26];5(1):e007331. Available from: https://bmjopen.bmj.com/content/5/1/e007331
5. Klinger R, Colloca L, Bingel U, Flor H. Placebo analgesia: Clinical applications. Pain [Internet]. 2013 [cited 2025 Feb 26];155(6):1055. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4011974/
6. Chaimani A, Salanti G, Leucht S, Geddes JR, Cipriani A. Common pitfalls and mistakes in the set-up, analysis and interpretation of results in network meta-analysis: what clinicians should look for in a published article. Evid Based Ment Health [Internet]. 2017 Aug 1 [cited 2025 Feb 26];20(3):88–94. Available from: https://pubmed.ncbi.nlm.nih.gov/28739577/
7. Cipriani A, Higgins JPT, Geddes JR, Salanti G. Conceptual and technical challenges in network meta-analysis. Ann Intern Med [Internet]. 2013 Jul 16 [cited 2025 Feb 26];159(2):130–7. Available from: https://pubmed.ncbi.nlm.nih.gov/23856683/
Competing interests: No competing interests
Dear Editor,
I highly appreciate the article since it finally deals with treatment options which are well reimbursed but not helpful for long-term improvement of pain for our patients. Thus they are obsolete in most cases in clinical practice.
Due to reimbursement many reimbursement-driven environments have a tendency to use these interventions frequently. Thus, such a clear analysis and article is highly valuable.
The article yet fails in three points:
(1) it does not point out the role of such interventions for presurgical testing to keep surgery as small as possible
(2) the upper left image is wrong: neck pain can be radiculopathy of C2, 3 or 4. This is crucial since it’s overseen in so many patients.
(3) it does not clearly differentiate pseudoradicular pain
Maybe the article would have benefited from including a spine surgeon in the project. As far as I can see, there is none on the authors list.
Sincerely yours,
Sandro Krieg
Competing interests: No competing interests
Dear Editor
Based on a linked systematic review and network meta-analysis, Busse and colleagues demonstrate that commonly used interventional procedures for chronic back, neck, and radicular pain have “little to no benefit on pain relief compared to sham procedures.”(1,2) These procedures are expensive and are accompanied by risk of significant adverse events (e.g., deep infection, dural puncture). Further, these procedures are deceptive, as they are presented procedures as engaging specific mechanisms (e.g. nerve ablation) when their benefits are due to psychosocial components of care shared with placebo treatments. The accompanying editorial by Ballantye calls for significant changes in practice and reimbursement. We agree with these findings and recommendations.
Yet, removing these treatments from the clinician’s repertoire will also reduce the opportunity for clinical benefits from psychosocial (placebo) aspects of treatment. Placebo treatments for chronic pain provide moderate, safe, and inexpensive pain relief relative to no treatment.(3–5) We believe placebo effects should not be eliminated from medicine, but rather capitalized on for the benefit of patients. Beyond systematically removing procedures that are no better than placebo, we advocate for the intentional, ethical, and non-deceptive leveraging of placebo effects.
For clinical application, we argue that placebo treatments must meet four criteria. The placebo should be 1) beneficial above and beyond spontaneous improvement, 2) very low risk, 3) inexpensive, and 4) non-deceptive, i.e., accompanied by transparent informed consent. Though placebo treatments have traditionally involved deception, recent studies of “open-label” placebos (OLP) have shown that deception is not essential. OLP treatments are procedures, often cellulose pills or subcutaneous saline injections, presented to patients as physically inert, with accompanying education describing how placebos can sometimes elicit the body’s natural healing responses even when known to be inert. Randomized clinical trials of OLP vs. control for functional conditions have demonstrated that OLP treatments meet all four above criteria, with mean SMD=0.48 on symptom report across 22 clinical trials (N=1,398).(6)
In chronic back pain specifically, there have been three randomized trials of OLP. The first study, performed in Portugal, randomized 80 adults to either continue usual care (UC) or add ingestion of OLP pills for three weeks. UC controlled for regression to the mean and the patient-physician relationship. OLP was superior to UC with a moderate-to-large effect size of d=0.76.(7) At the end of the 3 weeks, those on UC were switched to OLP and similarly improved. Both groups were followed for five years and showed persistent improvement in pain and decreased medication usage.(7) A second study in Germany randomized 127 patients to pill OLP vs. UC and found a modest but significant improvement with OLP (d=0.45) at three weeks,(8) though effects did not persist at 3-year follow-up.(9) Third, we recently published a trial of 101 adults, finding that a single injection-based OLP treatment vs. UC led to improved back pain intensity at 1-month (d=0.44), and improvements in depression, anger, anxiety, and sleep at 1-year (ds=0.38–0.50). Longitudinal fMRI demonstrated that OLP vs. UC reduced somatomotor activity and increased activity in the medial prefrontal cortex, a region associated with pain regulation, during an evoked back pain task. OLP further increased medial prefrontal cortex connectivity to the rostral ventral medulla, a brainstem region providing descending control of afferent nociceptive input, advancing our understanding of neurobiological OLP mechanisms.(10)
The interventional procedures reviewed by Wang, Busse, and colleagues—mainly nerve ablations and steroid injections—are no longer viable treatments for chronic spinal pain. OLP treatments are effective, safe, inexpensive, and ethical, and may provide a path forward for using—rather than eliminating—placebo treatments for chronic spinal pain.
Yoni K. Ashar, Tor D. Wager, Ted J. Kaptchuk
References
1. Busse JW, Genevay S, Agarwal A, Standaert CJ, Carneiro K, Friedrich J, et al. Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline. BMJ [Internet]. 2025 Feb 19;e079970. Available from: https://www.bmj.com/lookup/doi/10.1136/bmj-2024-079970
2. Wang X, Martin G, Sadeghirad B, Chang Y, Florez ID, Couban RJ, et al. Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials. BMJ [Internet]. 2025 Feb 19 [cited 2025 Feb 27];e079971. Available from: https://www.bmj.com/lookup/doi/10.1136/bmj-2024-079971
3. Kaptchuk TJ, Hemond CC, Miller FG. Placebos in chronic pain: evidence, theory, ethics, and use in clinical practice. Bmj [Internet]. 2020;m1668. Available from: http://www.bmj.com/lookup/doi/10.1136/bmj.m1668
4. de Roode A, Heymans MW, van Lankveld W, Staal JB. The impact of contextual effects in exercise therapy for low back pain: a systematic review and meta-analysis. BMC Med [Internet]. 2024 Oct 23;22(1):484. Available from: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-024-03679-3
5. Ashar YK, Chang LJ, Wager TD. Brain Mechanisms of the Placebo Effect: An Affective Appraisal Account. Annu Rev Clin Psychol [Internet]. 2017;13(1):73–98. Available from: http://www.annualreviews.org/doi/10.1146/annurev-clinpsy-021815-093015
6. Fendel J, Tiersch C, Solder P, Gaab J, Schmidt S. Effects of open-label placebos across outcomes and populations: An updated systematic review and meta-analysis of randomized controlled trials. Res Sq. 2024;
7. Carvalho C, Pais M, Cunha L, Rebouta P, Kaptchuk TJ, Kirsch I. Open-label placebo for chronic low back pain: a 5-year follow-up. Pain. 2020;Publish Ah(00):1–7.
8. Kleine-Borgmann J, Schmidt K, Hellmann A, Bingel U. Effects of open-label placebo on pain, functional disability, and spine mobility in patients with chronic back pain: A randomized controlled trial. Pain. 2019;160(12):2891–7.
9. Kleine-Borgmann J, Dietz T niklas, Schmidt K, Bingel U. placebo treatment for chronic low back pain: a 3-year follow-up of a randomized controlled trial. Pain. 2022;00(00).
10. Ashar YK, Sun M, Knight K, Flood TF, Anderson Z, Kaptchuk TJ, et al. Open-Label Placebo Injection for Chronic Back Pain With Functional Neuroimaging: A Randomized Clinical Trial. JAMA Netw Open [Internet]. 2024;7(9):e2432427–e2432427. Available from: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2823541
Competing interests: No competing interests
Re: Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline
Dear Editor
We thank readers for their comments.
Rittenberg suggests that abandoned procedures were included in our evidence synthesis. Six clinical experts on our guideline panel, blinded to study results, independently reviewed all study interventions and grouped them into categories, excluding trials evaluating procedures that are not commonly used in practice. (1)
He suggests that pooling across spinal regions, procedure approaches, and conditions is inappropriate. We conducted subgroup analyses of these factors and found no evidence for systematic differences in treatment effects. (see Supplementary Table 24 in our network meta-analysis) We acknowledged that, due to limited representation, we were unable to explore subgroup effects for all clinical conditions. We did not, however, find evidence of statistical variability across treatment effects in our outcome networks or in assessments of between-study variances within the closed loops of evidence. (1)
Consider the following example. Epidural steroid injections may be delivered transforaminal, interlaminar, or caudal; however, prior systematic reviews have found no difference in effect based on approach. (2-4) Further, our assessment for subgroup effects on pain relief based on whether epidural injection of local anaesthetic vs. local anaesthetic + steroids for radicular pain differ based on approach (interlaminar, caudal, transforaminal, unclear, or a combination of transforaminal and interlaminar) showed no credible subgroup effect (test of interaction p-value 0.7). (see Figure 1 here: https://mcmasteru365-my.sharepoint.com/:f:/g/personal/wangx431_mcmaster_...) We therefore combined across different approaches for delivering this procedure.
Rittenberg claims “there are not enough high-quality RCTs in interventional spine care to perform a well-powered meta-analysis in this area”. Our review identified 132 RCTs of common interventional procedures for chronic spine pain, and network meta-analysis provided moderate certainty evidence for the lack of effectiveness of five procedures on pain relief and six procedures on physical functioning. (1) We agree with Rittenberg and Shanthanna that further research is warranted and acknowledged that additional evidence may alter recommendations. (1,5)
Rittenberg advises that many patients elect to receive interventional procedures when informed of “their potential to provide meaningful pain relief and functional improvement”. We agree that advising patients that interventional procedures can be effective will convince many to pursue these treatments. However, such claims are not supported by the current best evidence, which shows that all common interventional procedures supported by moderate or low certainty evidence provide little to no improvement in pain relief or physical functioning compared with sham procedures. (1)
Jason W. Busse, Stéphane Genevay, Gordon H. Guyatt, and Thomas Agoritsas; on behalf of the Rapid Recommendation authors.
References
1. Wang X, Martin G, Sadeghirad B, et al. Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials. BMJ. 2025; 388: e079971.
2. Chang-Chien G, et al. Transforaminal versus interlaminar approaches to epidural steroid injections: a systematic review of comparative studies for lumbosacral radicular pain. Pain Physician. 2014; 17(4): E509-24.
3. Liu J, Zhou H, Lu L, et al. The effectiveness of transforaminal versus caudal routes for epidural steroid injections in managing lumbosacral radicular pain: A systematic review and meta-analysis. Medicine (Baltimore). 2016;95(18): e3373
4. Lee JH et al. Comparison of clinical efficacy of transforaminal and caudal epidural steroid injection in lumbar and lumbosacral disc herniation: A systematic review and meta-analysis. Spine J. 2018 Dec;18(12):2343-2353.
5. Busse JW, Genevay S, Agarwal A, et al. Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline. BMJ. 2025; 388: e079970.
Competing interests: No competing interests