What type of back pain in adults over 50 with conditions like lumbar spondylosis, degenerative disc disease, or facet joint osteoarthritis requires Radiofrequency Ablation (RFA) or epidural steroids?

Indications for RFA and Epidural Steroids in Back Pain

The 2025 BMJ guideline strongly recommends AGAINST both radiofrequency ablation and epidural steroid injections for chronic axial (non-radicular) spine pain in adults, regardless of age or degenerative findings like spondylosis, degenerative disc disease, or facet osteoarthritis. 1

Critical Distinction: Axial vs. Radicular Pain

The type of back pain fundamentally determines appropriateness of these interventions:

For Chronic Axial (Non-Radicular) Back Pain

• Strong recommendation AGAINST epidural steroids for pure axial low back pain without radicular symptoms 1
• Strong recommendation AGAINST radiofrequency ablation for chronic axial spine pain 1
• This applies even when imaging shows lumbar spondylosis, degenerative disc disease, or facet joint osteoarthritis 1
• The 2020 NICE guideline explicitly states: "Do not offer spinal injections for managing low back pain" 1

For Chronic Radicular Pain (Sciatica with Leg Symptoms)

Epidural steroid injections may be considered when:

• Disc herniation/bulge causes radicular leg pain 1, 2
• Spinal stenosis produces radiculopathy 1
• Post-surgical syndrome with radicular symptoms 1
• Significant leg pain predominates over back pain 1

The 2022 American Society of Pain and Neuroscience provides strong support for epidural injections (interlaminar, transforaminal, or caudal) specifically for radicular pain from these conditions 1

Specific Scenarios Where RFA May Be Considered

Radiofrequency ablation should ONLY be performed after:

1. Positive diagnostic medial branch block showing >50-80% pain relief 1

   • Note: Diagnostic blocks carry false positive rates up to 60% 1

2. Failed conservative treatment including physical therapy and medications 1

3. Suspected facet-mediated pain with specific clinical features:

   • Pain worse with extension and rotation 3
   • Tenderness over facet joints 3
   • Pain relief with diagnostic blocks 1

The 2020 NICE guideline states: "Only perform radiofrequency denervation for chronic low back pain after a positive response to a medial branch block" 1

Sacroiliac Joint Pain Exception

RFA for sacroiliac joint dysfunction receives stronger support:

• Strong recommendation for SI joint denervation/ablation after failed conservative treatment 1
• Consider after failed SI joint intraarticular steroid injection 1
• Requires positive diagnostic SI joint injection 1

Key Clinical Pitfalls

Common errors to avoid:

• Do not offer these procedures based solely on imaging findings (spondylosis, disc degeneration, facet arthritis on MRI/CT) without appropriate pain pattern 1

• Do not bypass diagnostic blocks before RFA - the false positive rate makes clinical diagnosis alone unreliable 1

• Do not confuse radicular with axial pain - epidural steroids are contraindicated for pure axial pain but may help radiculopathy 1, 2

• Recognize limited durability - even when appropriate, RFA typically provides 3-6 months relief requiring repeat procedures 1, 4

Harm Considerations

These procedures carry non-trivial risks:

• Prolonged pain/stiffness (8.6%) 4
• Temporary altered consciousness (2.1%) 4
• Dural puncture (1.4%) 4
• Deep infection (0.7%) 4
• Rare catastrophic complications including paralysis and death 1, 4

Evidence Quality Context

The 2025 BMJ guideline analyzed 81 randomized trials (7,977 patients) and found interventional procedures provide minimal benefit for axial pain, with median baseline pain of 6.8/10 and median pain duration of 46 months 1. The strong recommendation against these procedures reflects that harms and costs outweigh minimal benefits for non-radicular pain 1.