How should I order a lateral branch block for a patient with chronic axial back pain (>3 months) refractory to physical therapy, NSAIDs, and activity modification, and imaging-confirmed facet joint degeneration?

Do Not Order Lateral Branch Blocks for Chronic Axial Back Pain

Based on the most recent and highest quality evidence, you should NOT order lateral branch blocks (medial branch blocks or facet joint interventions) for this patient with chronic axial back pain. The 2025 BMJ guideline provides a strong recommendation against all facet joint interventions for chronic axial spine pain, including joint radiofrequency ablation with or without joint-targeted injections, and joint-targeted injections of local anesthetic, steroids, or their combination 1.

Why This Recommendation Matters

The 2025 BMJ guideline represents the most rigorous evidence-based assessment available, explicitly 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.

This recommendation applies specifically to:

• Patients with chronic axial spine pain (≥3 months duration) 1
• Pain not associated with cancer or inflammatory arthropathy 1
• Patients who have failed conservative management including physical therapy, NSAIDs, and activity modification 1

Understanding the Conflicting Evidence

There is significant controversy in this area, with older guidelines providing contradictory recommendations:

Guidelines recommending AGAINST facet interventions:

• 2025 BMJ guideline (most recent, highest quality): Strong recommendation against all facet joint interventions for chronic axial pain 1
• 2021 American College of Occupational and Environmental Medicine: Recommended against therapeutic facet block injections and radiofrequency neurotomy for chronic low back pain 1
• 2020 NICE guideline: Do not offer spinal injections for managing low back pain 1

Guidelines recommending FOR facet interventions:

• 2022 American Society of Pain and Neuroscience: Strong recommendation in favor of conventional or cooled lumbar radiofrequency ablation 1
• 2020 ASIPP guidelines: Level II evidence with moderate strength recommendation for therapeutic lumbar facet joint nerve blocks 2

Why Prioritize the 2025 BMJ Guideline

The 2025 BMJ guideline should take precedence because 1:

• It is the most recent (2025 vs. 2020-2022)
• It explicitly addresses patient-important outcomes (morbidity, mortality, quality of life)
• It notes that consensus-based guidelines (like many pro-intervention guidelines) "are more likely to produce recommendations that violate the principles of evidence based medicine" 1
• It incorporates patient values and preferences, finding that patients would be "disinclined to receive treatment with an interventional procedure for which there is very low certainty of evidence" 1

Critical Safety Considerations

Potential harms of facet joint interventions include 1:

• Small risk of moderate to serious harms: deep infection, temporary altered level of consciousness
• Very small risk of catastrophic harms: paralysis and death following epidural steroid injection
• Cost barriers and need for repeated procedures (every 2 weeks to 3 months for injections, every 6 months for ablation procedures)

What to Do Instead

While the evidence provided focuses on what NOT to do, the clinical context suggests continuing or optimizing conservative management. The 2025 BMJ guideline emphasizes that these recommendations apply after failure of conservative treatment but still recommend against interventional procedures 1.

Important Caveats

• This recommendation does NOT apply to: Acute spine pain, cancer-related pain, or inflammatory arthropathy 1
• Diagnostic blocks are different: Some guidelines distinguish between diagnostic and therapeutic blocks, though the 2025 BMJ guideline recommends against both for chronic axial pain 1
• Future research may change recommendations: The guideline acknowledges that further research is warranted and may alter recommendations, particularly regarding subtypes of chronic spine pain 1

If You Must Consider Facet Interventions

If you are in a jurisdiction or practice setting where you must consider these procedures despite the 2025 BMJ recommendation, the 2020 consensus guidelines suggest 3:

• Fluoroscopic or CT guidance is mandatory for all facet joint interventions
• Diagnostic medial branch blocks should precede radiofrequency ablation
• Avoid opioid analgesics during diagnostic procedures
• A three-month follow-up after diagnostic blocks is required to avoid false positives 4

However, the strongest current evidence recommends against ordering these procedures at all for chronic axial back pain 1.