Common interventional procedures for chronic non-cancer spine pain: A systematic review and network meta-analysis of randomised trials

Abstract:Objective: To address the comparative effectiveness of common interventional procedures for chronic non-cancer (axial or radicular) spine pain. Design: Systematic review and network meta-analysis (NMA) of randomised controlled trials (RCTs). Data sources: Medline, Embase, CINAHL, CENTRAL, and Web of Science from inception to 24 January 2023. Study selection: RCTs that enrolled patients with chronic non-cancer spine pain, randomised to receive a commonly used interventional procedure versus sham procedure, usual care, or another interventional procedure. Data extraction and synthesis: Pairs of reviewers independently identified eligible studies, extracted data, and assessed risk of bias. We conducted frequentist network meta-analyses to summarise the evidence and used the GRADE approach to rate the certainty of evidence. Results: Of 132 eligible studies, 81 trials with 7977 patients that explored 13 interventional procedures or combinations of procedures were included in meta-analyses. All subsequent effects refer to comparisons with sham procedures. For chronic axial spine pain, the following probably provide little to no difference in pain relief (moderate certainty evidence): epidural injection of local anaesthetic (weighted mean difference (WMD) 0.28 cm on a 10 cm visual analogue scale (95% CI −1.18 to 1.75)), epidural injection of local anaesthetic and steroids (WMD 0.20 (−1.11 to 1.51)), and joint-targeted steroid injection (WMD 0.83 (−0.26 to 1.93)). Intramuscular injection of local anaesthetic (WMD −0.53 (−1.97 to 0.92)), epidural steroid injection (WMD 0.39 (−0.94 to 1.71)), joint-targeted injection of local anaesthetic (WMD 0.63 (−0.57 to 1.83)), and joint-targeted injection of local anaesthetic with steroids (WMD 0.22 (−0.42 to 0.87)) may provide little to no difference in pain relief (low certainty evidence); intramuscular injection of local anaesthetic with steroids may increase pain (WMD 1.82 (−0.29 to 3.93)) (low certainty evidence). Evidence for joint radiofrequency ablation proved of very low certainty. For chronic radicular spine pain, epidural injection of local anaesthetic and steroids (WMD −0.49 (−1.54 to 0.55)) and radiofrequency of dorsal root ganglion (WMD 0.15 (−0.98 to 1.28)) probably provide little to no difference in pain relief (moderate certainty evidence). Epidural injection of local anaesthetic (WMD −0.26 (−1.37 to 0.84)) and epidural injection of steroids (WMD −0.56 (−1.30 to 0.17)) may result in little to no difference in pain relief (low certainty evidence). Conclusion: Our NMA of randomised trials provides low to moderate certainty evidence that, compared with sham procedures, commonly performed interventional procedures for axial or radicular chronic non-cancer spine pain may provide little to no pain relief. Registration: PROSPERO (CRD42020170667)