Does interventional pain management include injections as a treatment option for patients with lower back pain?

Interventional Pain Management and Injections for Lower Back Pain

Yes, interventional pain management routinely performs injections for lower back pain, but the appropriateness and type of injection depends critically on whether the pain is radicular (with leg symptoms) versus purely axial (back-only pain), with the most recent high-quality evidence strongly recommending AGAINST most injections for chronic axial spine pain without radiculopathy. 1

Critical Distinction: Radicular vs. Axial Pain

The 2025 BMJ guideline provides the clearest framework and makes strong recommendations AGAINST the following interventions for chronic axial (non-radicular) spine pain 1:

• Epidural injections of local anesthetic, steroids, or their combination
• Joint radiofrequency ablation with or without joint injections
• Joint-targeted injections of local anesthetic and steroids
• Intramuscular injections with or without steroids

These procedures should not be offered outside of clinical trials for axial back pain alone. 1

When Injections ARE Appropriate

For Radicular Pain (Pain Radiating Below the Knee)

Epidural steroid injections are strongly recommended when patients have 1, 2:

• Disc herniation with radicular symptoms
• Spinal stenosis with leg pain
• Post-surgical syndrome with recurrent radiculopathy
• Pain radiating below the knee with MRI-confirmed nerve root compression 2

Technical requirements 2:

• Fluoroscopic guidance is essential for safety and accuracy
• Transforaminal approach delivers medication closest to the affected nerve root
• Patients must fail at least 4 weeks of conservative management first

For Specific Anatomic Diagnoses

Sacroiliac joint injections receive strong recommendations for short-term relief of SI joint dysfunction, followed by radiofrequency ablation for longer-term management 1

Facet-mediated pain requires a diagnostic algorithm 1:

• First: Diagnostic medial branch blocks under fluoroscopy
• Only if positive response: Proceed to radiofrequency ablation
• Therapeutic facet injections alone are NOT recommended 1

Trigger point injections may be considered for chronic back pain not resolving with exercise or NSAIDs, using local anesthetic only (glucocorticosteroids are not recommended in trigger points) 1

Major Guideline Conflicts You Should Know

There is significant disagreement between professional societies 1:

• The 2022 American Society of Pain and Neuroscience gives strong recommendations FOR epidural injections for axial discogenic pain 1
• The 2021 American College of Occupational Medicine recommends AGAINST epidural injections for chronic low back pain without radicular symptoms 1
• The 2020 NICE guideline states: "Do not offer spinal injections for managing low back pain" 1

The most recent (2025) and highest quality evidence from BMJ strongly recommends against these procedures for axial pain, which should guide current practice given the priority on avoiding interventions that don't improve morbidity, mortality, or quality of life 1

Risks That Must Be Discussed

Interventional procedures carry 1:

• Small risk of moderate-to-serious harms: deep infection, altered consciousness
• Very small risk of catastrophic complications: paralysis and death following epidural steroid injection
• Transforaminal approaches have higher risk profiles than interlaminar approaches 2

Practical Algorithm for Decision-Making

Step 1: Determine pain pattern 1, 2

• Radicular (below knee) → Consider injections after conservative management fails
• Axial only (back-confined) → Do NOT offer injections outside research settings

Step 2: If radicular pain present 2:

• Obtain MRI confirming nerve root compression or disc herniation
• Document 4+ weeks of failed conservative treatment
• Proceed with fluoroscopically-guided epidural steroid injection

Step 3: If suspected facet or SI joint pain 1:

• Perform diagnostic blocks under fluoroscopy first
• Only proceed to ablation if diagnostic blocks provide significant relief
• Do not perform therapeutic injections without diagnostic confirmation

Step 4: Evaluate response at 2-4 weeks 2

• If inadequate response, consider alternative diagnoses or surgical consultation
• Maximum of 3 injections spaced at least 15 days apart

Common Pitfalls to Avoid

• Do not inject for "non-specific low back pain" without clear anatomic diagnosis 1
• Do not skip fluoroscopic guidance - blind injections have unacceptable failure rates 1, 2
• Do not perform therapeutic facet injections without diagnostic blocks first 1
• Do not use glucocorticosteroids in trigger point injections 1
• Do not offer epidural injections for axial pain alone - this violates the most recent high-quality evidence 1

The evidence strongly suggests that interventional pain management should be highly selective, reserving injections primarily for radicular pain syndromes with confirmed anatomic pathology, rather than routine use for all lower back pain presentations 1.