What is the evidence for the efficacy of paravertebral intramuscular injections, epidural injections, nerve blocks, and nerve ablation procedures in managing chronic spine pain?

From the Guidelines

The use of paravertebral intramuscular injections, epidural injections, nerve blocks, and nerve ablation procedures for managing chronic spine pain is supported by recent guidelines, but with varying degrees of recommendation and evidence, emphasizing the need for careful patient selection and a comprehensive treatment approach. When considering these interventional procedures, it's crucial to weigh the potential benefits against the risks, as highlighted by the 2022 American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain 1. This guideline provides strong recommendations in favor of epidural injections, trigger point injections, sacroiliac joint injection, conventional or cooled lumbar radiofrequency ablation, sacroiliac joint denervation/ablation, and basivertebral nerve ablation for specific conditions such as chronic low back pain due to disc disease, spinal stenosis, or post-surgical syndrome.

Key Recommendations and Evidence

• Epidural injections are strongly recommended for chronic low back pain due to disc disease, spinal stenosis, or post-surgical syndrome, with moderate to strong evidence supporting their use for short-term pain relief in conditions like disc herniation and spinal stenosis 1.
• Trigger point injections are recommended for chronic back pain, with the caveat that glucocorticosteroids are not recommended for use in trigger point injections, as per the 2021 American College of Occupational and Environmental Medicine Low Back Disorders Guideline 1.
• Sacroiliac joint injections and denervation/ablation are supported for short-term relief and treatment of sacroiliac joint dysfunction pain, respectively, based on strong recommendations from the 2022 ASPN guideline 1.
• Radiofrequency ablation procedures, including conventional or cooled lumbar radiofrequency ablation and sacroiliac joint denervation/ablation, are recommended for specific conditions, with evidence suggesting they can provide relief for several months 1.

Considerations for Clinical Practice

• Patient selection is critical, with better outcomes when interventions target specific pain generators confirmed through diagnostic blocks.
• These procedures should be part of a comprehensive treatment approach rather than used in isolation.
• Patients should be informed about the limitations of these procedures, particularly regarding the durability of pain relief.
• The mechanisms of action, such as reducing inflammation around compressed nerves or interrupting pain signal transmission, should be considered when choosing the appropriate intervention.

Given the most recent and highest quality evidence, the 2025 study published in the BMJ provides the most current guidance, emphasizing the importance of evidence-based recommendations for interventional procedures in managing chronic spine pain 1. This study underscores the need for clinicians to consult with qualified pain management specialists to determine the potential appropriateness of specific interventional procedures for their patients' indications and clinical circumstances, as also suggested by the 2022 CDC clinical practice guideline for prescribing opioids for pain 1.

From the Research

Evidence for Paravertebral Intramuscular Injections, Epidural Injections, Nerve Blocks, and Nerve Ablation Procedures

• The use of epidural injections, nerve blocks, and other interventional procedures for managing chronic spine pain is supported by various studies 2, 3, 4, 5, 6.
• Epidural injections of local anesthetic or corticosteroid are frequently used to diagnose and treat patients with radicular pain originating from any spinal level, with the best-quality evidence supporting a transforaminal approach in the lumbar spine 2.
• Selective nerve blocks with local anesthetic alone can identify the spinal nerve mediating the patient's pain, and many patients experience substantial benefit from a single therapeutic injection 2.
• Epidural steroid injections and lumbar nerve root block/steroid injection are commonly performed interventional treatments for spine-related pain, and can provide sustained pain relief in a substantial number of patients 3.
• The use of gabapentinoids, such as pregabalin and gabapentin, after transforaminal epidural steroid injection can help relieve remnant pain in patients with lumbar radiculopathy, with both medications showing equal effectiveness 4.
• Paravertebral intramuscular Ozone injection and caudal epidural steroid-hyaluronidase injection can both reduce pain in patients with lumbosacral spinal stenosis, with Ozone injection showing more significant improvements in pain severity at 8-week follow-up 5.
• Epidural injections with or without steroids for radiculopathy have shown significant effectiveness, with Level I or strong evidence for local anesthetic with steroids and Level II to I or moderate to strong evidence with local anesthetic alone 6.

Types of Procedures

• Epidural injections: can be used to diagnose and treat patients with radicular pain, and can provide sustained pain relief in a substantial number of patients 2, 3, 6.
• Nerve blocks: can be used to identify the spinal nerve mediating the patient's pain, and can provide diagnostic information as well as deliver targeted steroid treatment 2, 3.
• Paravertebral intramuscular injections: can be used to reduce pain in patients with lumbosacral spinal stenosis, and have shown more significant improvements in pain severity at 8-week follow-up compared to caudal epidural steroid-hyaluronidase injection 5.
• Nerve ablation procedures: are not directly mentioned in the provided studies, but may be used in conjunction with other interventional procedures to manage chronic spine pain.

Patient Selection and Outcomes

• Patients who have failed conservative therapy or are not candidates for surgical intervention can be considered for epidural steroid injections to relieve their radicular pain temporarily 2.
• Patients with lumbar radiculopathy who undergo transforaminal epidural steroid injection can experience significant pain relief with the use of gabapentinoids, such as pregabalin and gabapentin 4.
• Patients with lumbosacral spinal stenosis can experience significant pain relief with paravertebral intramuscular Ozone injection or caudal epidural steroid-hyaluronidase injection, with Ozone injection showing more significant improvements in pain severity at 8-week follow-up 5.