Interventional Treatments for Low Back Pain

Publication Date: December 5, 2022
Last Updated: December 12, 2022

Summary of Recommendations

Epidural Steroid Injections

Recommendation Grade Level Level of certainty
Interlaminar epidural injections for treatment of low back and radicular pain originating from disc disease, spinal stenosis and for chronic back/leg pain after surgical intervention A I-A High
Transforaminal epidural injections for treatment of low back and radicular pain originating from disc disease, spinal stenosis and for chronic back/leg pain after surgical intervention A I-A High
Caudal epidural injections for treatment of low back and radicular pain originating from disc disease, spinal stenosis and for chronic back/leg pain after surgical intervention when interlaminar or transforaminal approaches are not feasible A I-A High
Use of either steroid or local anesthetic or the two classes of medication in combination for use in epidural injections for treatment of low back and radicular pain originating from disc disease, spinal stenosis and for chronic back/leg pain after surgical intervention A I-A High

Trigger Point Injections

Recommendation Grade Level Level of certainty
The type of medication for TPI does not make a significant difference in pain outcomes A I-A Strong
Eliciting a localized twitch response for needle placement predicts best outcomes A I-A Strong
In medically refractory cases, TPI with BTXA may be of benefit C I-B Moderate
Dilute local anesthetic concentrations may result in less injection pain I II Weak
Novel injectables may be of benefit for MPS I II Weak
Adjunct therapies may be of use to prolong the relief of TPI for MPS I II Weak

Intra-Articular Facet Injections

Recommendation Grade Level Level of certainty
Intra-articular facet steroid injections do not replace or delay the need for RFA. C I-A Strong
Intra-articular facet steroid injections can be prognostic for RFA C I-A Strong
In acute cases of facet mediate pain, facet steroid injections may help due to possible inflammatory component C I-B Moderate
Combining facet steroid injections with oral NSAIDs can be more effective than injection therapy alone B II Moderate
Image guided facet steroid injections are more effective than blind injections A I-A Strong
Do not use intra-articular facet joint steroid injections as sole therapy for facet-mediated pain. B I-A Strong
Whitacre needles can reduce the risk of IV injection during MBB C I-A Moderate
Lumbar Medial Branch Blocks can be prognostic for RFA A I-A Strong

Regenerative Therapies

Recommendation Grade Level Level of certainty
Intradiscal PRP in the treatment of discogenic LBP I I-B Low
Intradiscal allogeneic mesenchymal stem cells in the treatment of discogenic LBP I I-B Low
Intradiscal bone marrow derived MSCs I I-B Low
Intradiscal adipose tissue derived MSCs I I-C Low

Sacroiliac Joint Injections

Recommendation Grade Level Level of certainty
Sacroiliac joint injections have been associated with positive predictive value in diagnosis of SIJ dysfunction A I-A Strong
Sacroiliac joint injections demonstrate short term relief of SIJ dysfunction B I-B Moderate

PILD Injections

Recommendation Grade Level Level of certainty
Percutaneous lumbar decompression for ligamentum flavum hypertrophy with the diagnosis of lumbar spinal stenosis A I-A Strong

Interspinous Spacers, Indirect Decompression

Recommendation Grade Level Level of certainty
Stand-alone interspinous spacers for indirect decompression are safe and effective for the treatment of mild to moderate lumbar spinal stenosis if no contraindications exist A I-A High

Percutaneous and Endoscopic Procedures

Recommendation Grade Level Level of certainty
Microendoscopic Discectomy B I-a High
Percutaneous Endoscopic Discectomy B I-a High
Tubular Discectomy B I-a High

Interspinous/Interlaminar Fusion Devices

Recommendation Grade Level Level of certainty
ISF can be used as a stand- alone device for decompression. B I-B Moderate
ISF can be used as a stand- alone device for spinal fusion C I-B Moderate
ISF is a suitable option to those patients not suited for pedicle screw fixation, non- surgical candidates, and those early in the treatment paradigm B I-B Moderate

Minimally Invasive Sacroiliac Joint Fixation

Recommendation Grade Level Level of certainty
Minimally Invasive Sacroiliac Fusion A I-A High

Vertebral Augmentation

Recommendation Grade Level Level of certainty
Vertebral Augmentation A I-A High

Spinal Cord Stimulation

Recommendation Grade Level Level of certainty
SCS following lumbar spinal surgery A I-A Strong
SCS in the treatment of non-surgical LBP B I-C Moderate
SCS in the treatment of patients with predominate lumbar spinal stenosis C I-C Moderate

Intrathecal Drug Delivery Systems

Recommendation Grade Level Level of certainty
Intrathecal drug delivery is safe and effective in chronic refractory pain of spinal origin. B I-B Moderate
Intrathecal drug delivery is safe and effective in refractory failed back surgery syndrome. A I-A High
Intrathecal ziconotide is safe and effective for chronic non-cancer pain management. A I-A High
Intrathecal opioids are safe and effective in chronic non-cancer pain management. B I-B Moderate
Intrathecal bupivacaine is safe and effective for chronic non-cancer pain management. B I-C Moderate
Intrathecal drug delivery can help minimize medication utilization through oral route B I-B Moderate
Intrathecal combination drug therapy is effective in chronic refractory pain of spinal origin. B I-C Moderate
Intrathecal drug therapy can help improve function and quality of life in chronic refractory pain of spinal origin. B I-C Moderate
Intrathecal ziconotide can augment opioid analgesic effect B I-B Moderate
Intrathecal combination (opioids + local anesthetic ± ziconotide) therapy can prolong the development of intrathecal opioid tolerance C I-C Moderate
Shared decision making should be utilized if contemplating intrathecal drug therapy in patients with multiple co-morbidities affecting cardiopulmonary function, hematopoietic function, or central nervous function. A I-C Moderate

Multifidus Activation via Medial Branch Nerve Stimulation

Recommendation Grade Level Level of certainty
The incidence of serious procedure or device related complications is favorable to other neuromodulation techniques B 1-B Moderate
Improvements in baseline are clinically significant at both 1 and 2 years after implant in a cohort of patients with severe, disabling chronic LBP B 1-B Moderate
Improvements in pain and disability increase the longer duration of treatment B 1-B Moderate
The infection rate of non-coiled leads is 25 times higher than rate for coiled leads C I-C Moderate
Percutaneous 60 day PNS may provide sustained improvements in pain and function C I-C Moderate
Percutaneous PNS may reduce or eliminate need for analgesics in individuals with chronic LBP C II Low

Peripheral Nerve Field Stimulation

Recommendation Grade Level Level of certainty
PNFS can be considered in patients with chronic axial low back, with and without radicular symptoms in their lower extremities, who have failed other treatment modalities. C I-B Moderate

Lumbar Radiofrequency Ablation

Recommendation Grade Level Level of certainty
Conventional radiofrequency ablation is effective for low back pain A I-A High
Conventional RFA is superior to pulsed RFA B I-B Moderate
Pulsed RFA is not efficacious D I-B Moderate
Conventional RFA and cooled RFA are equally efficacious A I-A Strong

Sacroiliac Radiofrequency Ablation

Recommendation Grade Level Level of certainty
SI joint denervation/ablation is effective in treatment of SI joint dysfunction pain and is superior to sham in RCT B I-A Strong

Basivertebral Nerve Ablation

Recommendation Grade Level Level of certainty
Basivertebral nerve ablation A I-A High

Tables

Disease Indications for Intrathecal Drug Delivery

Having trouble viewing table?
Axial neck or back pain (not a surgical candidate)
- Multiple compression fractures
- Discogenic pain
- Spinal stenosis
- Diffuse multiple-level spondylosis
Failed back surgery syndrome/Post-laminectomy syndrome
Trunk pain
- Postherpetic neuralgia
- Post-thoracotomy syndromes
Abdominal/pelvic pain
- Visceral
- Somatic
Extremity pain
- Radicular
- Joint
Complex regional pain syndrome (CRPS)
Cancer pain, primary invasion, metastasis, and treatment (chemotherapy, radiation)-related
Analgesic efficacy with systemic opioid delivery complicated by intolerable side effects

Key Considerations for Patient Selection

Having trouble viewing table?
Contraindications Indications
Immunocompromised patients or active infection Chronic pain with a clear, appropriate diagnosis resulting in significant interference with of ADLs including ability to work and overall QOL
Severe psychological conditions, including untreated significant addiction; active psychosis; major uncontrolled depression or anxiety; active suicidal or homicidal behavior; severe cognitive deficits; severe sleep disturbances Has tried and failed to achieve sufficient analgesia with less invasive therapies
Inability to comply with medication refill schedule Optimization of all preexisting comorbidities
Current or anticipated lack of insurance coverage or mean to pay for ongoing management of the pump Absence of severe or uncontrolled psychological conditions
Patients in which oral opioid therapy is contraindicated

Complications Associated with IDDS

Having trouble viewing table?
Catheter-related
  • Catheter damaged/severed/nicked/broken/fractured
  • Catheter kink/twisting
  • Catheter migration
  • Catheter occlusion
  • Catheter disconnection
  • Fluid collection around the catheter

Pump-related
  • Motor stall
  • Corrosion
  • Gear wear
  • Pump flipped
  • Pump empty/low volume
  • Premature battery depletion
  • MRI compatibility issues

Drug-related
  • Drug withdrawal
  • Drug overdose
  • Nausea/vomiting
  • Diaphoresis
  • Pruritus
  • Sedation/somnolence/lethargy
  • Cardiovascular events
  • Respiratory depression
  • Edema of lower limbs
  • Urinary retention/incontinence
  • Sexual dysfunction/hypogonadotropic hypogonadism
  • Osteoporosis
  • Neuroendocrine dysfunction
  • Constipation
  • Hyperalgesia or allodynia
  • Neuropsychiatric events

Procedural/Biological causes
  • Granuloma
  • Bleeding/epidural hematoma/spinal hematoma/pocket hematoma
  • Meningitis
  • Infection/erosion
  • CSF leak/hygroma/post dural puncture headache
  • Intracranial hypotension
  • Seroma
  • Allergic reaction
  • Pump site discomfort

Recommendation Grading

Overview

Title

Interventional Treatments for Low Back Pain

Authoring Organization

American Society of Pain and Neuroscience

Publication Month/Year

December 5, 2022

Last Updated Month/Year

October 23, 2024

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Document Objectives

The objective of the American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline for Interventional Treatments of low back pain (LBP) is to provide evidence-based recommendations to address the appropriate utilization of interventional treatments for LBP. This guideline is intended to represent a comprehensive review of the spectrum of interventional treatments for LBP. The guideline is based upon the highest quality of clinical evidence available at the time of publication. The goals of the guideline are to assist clinicians in delivering the highest quality evidenced back interventional treatments, as well as understanding the known risks and complications of interventional treatments. The ASPN Back Guideline is intended to be updated periodically to maintain relevance with the current treatment landscape and empirical literature. Although the guideline represents a comprehensive review of the majority of the interventional treatments for LBP, it is important to note that not all interventional techniques were included. Exclusion of any particular technique does not necessarily suggest that the omitted therapies are inappropriate clinical use. The ASPN Back Guideline does not represent a standard of care. Treatment should be based on an individual patient’s need and the physician’s professional judgement and experience. This guideline is not intended to be used as the sole reason for denial or approval of treatment or services.

Target Patient Population

Patients with low back pain (LBP)

Target Provider Population

HCPs treating patients with LBP. This includes physicians from the core specialties of anesthesiology, neurosurgery, physical medicine and rehabilitation, and radiology.

Inclusion Criteria

Male, Female, Adolescent, Older adult

Health Care Settings

Ambulatory, Outpatient, Radiology services

Intended Users

Nurse, nurse practitioner, physical therapist, physician, physician assistant

Scope

Treatment, Management, Rehabilitation

Diseases/Conditions (MeSH)

D017116 - Low Back Pain

Keywords

low back pain, low back pain (LBP), LBP

Source Citation

Sayed D, Grider J, Strand N, Hagedorn JM, Falowski S, Lam CM, Tieppo Francio V, Beall DP, Tomycz ND, Davanzo JR, Aiyer R, Lee DW, Kalia H, Sheen S, Malinowski MN, Verdolin M, Vodapally S, Carayannopoulos A, Jain S, Azeem N, Tolba R, Chang Chien GC, Ghosh P, Mazzola AJ, Amirdelfan K, Chakravarthy K, Petersen E, Schatman ME, Deer T. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res. 2022;15:3729-3832
https://doi.org/10.2147/JPR.S386879