Poster Presentation 50th International Society for the Study of the Lumbar Spine Annual Meeting 2024

Interventional procedures for chronic noncancer spine pain: a systematic review and network meta-analysis of randomised trials (#60)

Xiaoqin Wang 1 , grace Martin 2 , Behnam Sadeghirad 1 3 4 , Yaping Chang 3 , Ivan D Florez 5 , rachel Couban 1 3 4 , Fatemeh Mehrabi 6 , Holly N Crandon 7 , Meisam Abdar Esfahani 3 , Laxsanaa Sivananthan 8 , Neil Sengupta 2 , Elena Kum 3 , Preksha Rathod 2 , Rami Z Morsi 9 , Brett R Stacey 10 , Norman Buckley 1 2 4 , Gordon H Guayatt 7 , Y. Raja Y Rampersaud 11 12 , Christopher J Standaert 13 , Stephane Genevay 14 , Thomas Agoritsas 2 15 , Jason W Busse 1 3 4 16
  1. Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
  2. Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
  3. Department of Health Research Methods, Evidence, and Impact, McMAster University, Hamilton, Ontario, Canada
  4. Department of Anesthesia, Faculty of Health Sciences, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
  5. Department of Pediatrics, Universidad de Antioquia, Medellin, Colombia
  6. Pharmaceutic Research Center Kerman University of Medical Sciences, University of Medical Sciences, Kerman, Iran
  7. Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
  8. Graduate Entry Medical School, , University of Limerick, Limerick, Ireland
  9. Department of Neurology, University of Chicago, Chicago, Illinois, USA
  10. Center for Pain Relief, Department of Anesthesiology, , University of Washington, Seatle, WA, USA
  11. Arthritis Program, Krembil Research Institute, Division of Orthopaedics, , University Health Network, Toronto, Ontario, Canada
  12. Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  13. Department of Physical Medicine and Rehabilitation, , University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
  14. Division of Rheumatology, University Hospital Geneva, Geneva, Switzerland
  15. Division General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
  16. Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, Ontario, Canada

Introduction

Interventional procedures are frequently used to manage chronic spine pain (CSP) despite controversy concerning their effectiveness. We conducted a systematic review and network meta-analysis to establish the comparative effectiveness of frequently used procedures for chronic, axial or radicular, spine-related pain.

Method

We searched MEDLINE, EMBASE, CINAHL, CENTRAL, and Web of Science databases up to 24 January 2023, and included randomised controlled trials comparing different interventional procedures used to treat patients with CSP, or an interventional procedure vs. sham or usual care, and captured outcomes at ≥1 month follow-up. We excluded studies on chronic spine pain associated with cancer, infection, fracture or inflammatory rheumatic disease.

We collected data on pain relief at the follow-up time closest to, but not exceeding, 3-months for injections and the timepoint closest to, but not exceeding, 6-months for nerve ablation procedures. We conducted frequentist network meta-analyses to summarise the evidence and used the GRADE approach to rate the certainty of evidence.

Results

A total of 81 trials with 7,977 patients that explored 15 procedures were included in meta-analyses. All subsequent effects refer to comparisons with sham procedures and are provided as the weighted mean difference [WMD] on a 10cm VAS for pain; the minimally important difference is 1.5cm.

For axial spine pain, moderate certainty evidence shows that epidural injection of local anesthetic (WMD 0.28 [95% CI -1.18 to 1.75]), epidural injection of local anesthetic and steroids (WMD 0.20 [95% CI -1.11 to 1.51]), radiofrequency of the dorsal root ganglion (WMD 0.50 [95% CI -1.31 to 2.31), and joint-targeted steroid injection (WMD 0.83 [95% CI -0.26 to 1.93]) result in little to no difference in pain relief. Low certainty evidence suggests that intramuscular injection of local anesthetic (WMD -0.53 [95% CI -1.97 to 0.92]), epidural steroid injection (WMD 0.39 [95% CI -0.94 to 1.71]), joint-targeted injection of local anesthetic (WMD 0.63 [95% CI -0.57 to 1.83]), and joint-targeted injection of local anesthetic with steroids (WMD 0.22 [95% CI -0.42 to 0.87]) may provide little to no difference in pain relief; intramuscular injection of local anesthetic with steroids may increase pain (WMD 1.82 [95% CI -0.29 to 3.93]). Effects for joint radiofrequency ablation were supported by only very low certainty evidence.

For radicular pain, moderate certainty evidence shows that epidural injection of local anesthetic and steroids (WMD -0.49 [95% CI -1.54 to 0.55]) and radiofrequency of the dorsal root ganglion (WMD 0.15 [95% CI -0.98 to 1.28]) results in little to no difference in pain relief. Low certainty evidence suggests that epidural injection of local anesthetic (WMD -0.26 [95% CI -1.37 to 0.84]) or epidural injection of steroids (WMD -0.56 [95% CI -1.30 to 0.17]) results in little to no difference in pain relief. Effects for joint radiofrequency ablation and joint-targeted injection of steroids were supported by only very low certainty evidence.

Discussion

All interventional procedures supported by low to moderate certainty evidence showed no evidence of improved pain relief, compared to sham procedures, for axial or radicular chronic spine pain.