Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials

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).