Is injection-based pain management medically indicated for spinal stenosis and chronic pain?

Medical Necessity Assessment for Injection-Based Pain Management

Based on the most recent 2025 BMJ guidelines, injection-based pain management is NOT medically indicated for this patient with spinal stenosis (M47.814) and chronic pain (G89.4) when the procedures requested are CPT codes 64633,64634, and 01939, as these represent medial branch blocks and radiofrequency ablation procedures that have strong recommendations AGAINST their use for chronic axial spine pain. 1

Critical Analysis of Requested Procedures

CPT Code Interpretation

• CPT 64633/64634: These codes represent paravertebral facet joint nerve destruction by neurolytic agent (radiofrequency ablation) 1
• CPT 01939: This is an anesthesia code for nerve blocks 1
• The diagnosis codes indicate spondylosis with radiculopathy (M47.814) and chronic pain syndrome (G89.4) 1

Evidence-Based Contraindications

The 2025 BMJ guidelines provide a STRONG RECOMMENDATION AGAINST these specific interventions for chronic axial spine pain, stating that "all or nearly all well-informed people would likely not want such interventions" and that "such interventions should therefore not be offered outside of a clinical trial." 1

Specifically contraindicated procedures include:

• Joint radiofrequency ablation with or without joint targeted injection of local anesthetic and steroids 1
• Joint-targeted injection of local anesthetic, steroids, or their combination 1
• Epidural injection of local anesthetic steroids, or their combination for chronic axial spine pain 1

Conflicting Guideline Evidence

There is significant divergence in the literature that must be acknowledged:

Supporting evidence (older guidelines):

• The 2022 American Society of Pain and Neuroscience (ASPN) provided a strong recommendation IN FAVOR of conventional or cooled lumbar radiofrequency ablation for low back pain 1
• The 2021 ASIPP guidelines provided moderate to strong recommendations for epidural injections in spinal stenosis 1

Opposing evidence (most recent and authoritative):

• The 2025 BMJ guideline (the most recent and highest quality evidence) provides strong recommendations AGAINST these procedures based on very low certainty of evidence for benefit and moderate to high certainty evidence of risk of harm 1
• The 2021 American College of Occupational and Environmental Medicine recommended AGAINST radiofrequency neurotomy for chronic low back pain, even when confirmed with diagnostic blocks 1
• The 2020 NICE guidelines state to only perform radiofrequency denervation after a positive response to a medial branch block 1

Specific Recommendations by Pain Type

For Spinal Stenosis with Radicular Pain

If the patient has TRUE radicular symptoms (pain radiating below the knee in a dermatomal pattern):

• Epidural injections may be considered with moderate to strong evidence supporting fluoroscopically guided epidural injections for spinal stenosis 1
• However, lumbar interlaminar epidural injections are superior to caudal approaches, with 72-84% response rates versus 38-51% for caudal 2
• The evidence shows only 38% of spinal stenosis patients report improvement with epidural steroid injections compared to 61% for herniated disc patients 3

For Chronic Axial (Non-Radicular) Pain

The requested procedures (medial branch blocks and radiofrequency ablation) are NOT indicated:

• The 2025 BMJ guidelines explicitly recommend against these procedures for chronic axial spine pain 1
• Patients would be disinclined to receive treatment with very low certainty of evidence for benefit and moderate to high certainty evidence of risk of harm 1

Risk-Benefit Analysis

Documented Risks

• Small risk of moderate to serious harms including deep infection and temporary altered level of consciousness 1
• Very small risk of catastrophic harms including paralysis and death following epidural steroid injection 1
• These risks are only acceptable when there is at least a 1.5 cm improvement on a 10 cm visual analogue scale 1

Limited Benefits

• The evidence shows very low certainty for benefit in chronic axial spine pain 1
• Even when effective, epidural steroid injections provide only short-term pain relief of approximately 2 weeks with no significant improvement over baseline at 2 months 4

Alternative Treatment Pathway

Before considering any interventional procedures, the following must be documented:

1. Conservative management failure including:

   • Structured physical therapy for at least 4 weeks 4
   • Appropriate oral medications (NSAIDs, acetaminophen) 1
   • Patient education and psychosocial support 4

2. If radicular pain is present, consider:

   • Fluoroscopically guided lumbar interlaminar epidural injections (NOT the requested medial branch blocks) 2, 5
   • Limit to one or two injections maximum, as multiple injections do not improve outcomes and may delay definitive care 6

3. If facet-mediated pain is suspected:

   • Diagnostic medial branch blocks must show positive response BEFORE considering radiofrequency ablation 1
   • Even then, the 2025 BMJ guidelines recommend against this approach 1

Common Pitfalls to Avoid

• Do not proceed with radiofrequency ablation without documented positive response to diagnostic blocks 1
• Do not offer multiple epidural steroid injections as this delays care without improving outcomes 6
• Do not use these procedures for non-radicular axial back pain as the evidence strongly recommends against this 1
• Do not confuse older guideline recommendations with the most recent 2025 evidence which supersedes previous recommendations 1

Final Determination

The requested procedures (CPT 64633,64634,01939) representing medial branch blocks and radiofrequency ablation are NOT medically necessary for this patient based on the strongest and most recent evidence from the 2025 BMJ guidelines. 1 If the patient has true radicular symptoms, fluoroscopically guided epidural injections may be considered as an alternative, but only after conservative management failure and with realistic expectations of short-term benefit only. 4, 2