What is the best treatment option, radiofrequency ablation (RFA) or epidural injection, for a patient with bilateral lumbar and lower back pain?

Treatment for Bilateral Lumbar and Lower Back Pain: RFA vs Epidural Injections

For patients with bilateral lumbar and lower back pain, neither radiofrequency ablation nor epidural injections are recommended as first-line treatments for chronic axial spine pain based on the most recent evidence. 1

Current Guideline Recommendations

The 2025 BMJ guideline provides strong recommendations against both interventions for chronic axial spine pain:

• Strong recommendations AGAINST epidural injections for chronic axial spine pain 1
• Strong recommendations AGAINST joint radiofrequency ablation with or without joint targeted injection for chronic axial spine pain 1

These recommendations are based on evidence showing:

• Very low certainty of benefit or low certainty of no benefit
• Moderate to high certainty evidence of risk of harm and/or burden

Understanding the Pain Pattern

The treatment approach should be determined by whether the pain is:

1. Axial pain (localized to the back without radiation)
2. Radicular pain (radiating pain following nerve distribution)

For the described bilateral lumbar and lower back pain without mention of radiation, this suggests primarily axial pain, for which both interventions are not recommended.

Potential Risks and Considerations

Epidural Injections

• Small risk of moderate to serious harms including deep infection
• Very small but catastrophic risks including paralysis and death 1
• Requires repeat procedures every 2-3 months if perceived effective

Radiofrequency Ablation

• Requires positive response to diagnostic medial branch blocks first 2
• Risks include infection, hemorrhage, numbness, and worsening pain 3
• Repeat procedures needed approximately every 6 months 1

Alternative Approaches

Given the strong recommendations against both procedures for axial pain, alternative approaches should be considered:

1. Conservative management focusing on:

   • Physical rehabilitation with paraspinal muscle strengthening 2
   • Non-opioid analgesics
   • Activity modification

2. Diagnostic workup to determine if there is a radicular component:

   • If radicular symptoms are present, a transforaminal epidural steroid injection (TFESI) may be considered 2, 4
   • Imaging to rule out specific pathology requiring different management

Special Circumstances

If the pain has both axial and radicular components:

• A sequential approach may be considered, addressing radicular pain first with TFESI, then reassessing 2
• For patients with confirmed facet-mediated pain through positive diagnostic blocks, RFA might be considered despite the general recommendation against it 2

Cost and Access Considerations

• Both procedures require specialized facilities and providers
• Expense may be a barrier without insurance coverage
• Repeated visits are necessary for continued effect 1

Bottom Line

Based on the most recent and highest quality evidence, neither radiofrequency ablation nor epidural injections are recommended for patients with bilateral lumbar and lower back pain that is primarily axial in nature. Conservative management should be the primary approach, with careful assessment for any radicular component that might benefit from targeted intervention.