Summary of intervention
Spinal injections of local anaesthetic and steroid in people with non-specific low back pain without sciatica.
Number of CCG intervention 201718
Spinal injections of local anaesthetic and steroid should not be offered for patients with non-specific low back pain.
For people with non-specific low back pain the following injections should not be offered:
- Facet joint injections
- Therapeutic medial branch blocks
- Intradiscal therapy
- Trigger point injections with any agent, including botulinum toxin
- Epidural steroid injections for chronic low back pain or for neurogenic claudication in patients with central spinal canal stenosis
- Any other spinal injections not specifically covered above
Radiofrequency denervation can be offered according to NICE guideline (NG59) if all non-surgical and alternative treatments have been tried and there is moderate to severe chronic pain that has improved in response to diagnostic medial branch block.
Epidurals (local anaesthetic and steroid) should be considered in patients who have acute and severe lumbar radiculopathy at time of referral.
Alternative and less invasive options have been shown to work e.g. exercise programmes, behavioural therapy, and attending a specialised pain clinic. Alternative options are suggested in line with the National Back Pain Pathway.
For further information,
NICE Guidance [NG 59] Low back pain and sciatica in over 16s: assessment and management
Rationale for recommendation
NICE guidelines recommend that spinal injections should not be offered for non- specific low back pain.
Radiofrequency denervation (to destroy the nerves that supply the painful facet joint in the spine) can be considered in some cases as per NICE guidance.
Exclusion criteria for the NICE (NG59) include:
Conditions of a non-mechanical nature, including;
- Inflammatory causes of back pain (for example, ankylosing spondylitis or diseases of the viscera)
- Serious spinal pathology (for example, neoplasms, infections or osteoporotic collapse)
- Neurological disorders (including cauda equina syndrome or mononeuritis)
- Adolescent scoliosis.
Not covered were conditions with a select and uniform pathology of a mechanical nature (e.g. spondylolisthesis, scoliosis, vertebral fracture or congenital disease) Other agreed exclusions by the GDG are: Pregnancy-related back pain, Sacroiliac joint dysfunction, Adjacent-segment disease, Failed back surgery syndrome, Spondylolisthesis and Osteoarthritis.
NICE recommends the following approach for non-surgical invasive treatments for low back pain and sciatica in over 16s.
1.3.1 Do not offer spinal injections for managing nonspecific low back pain
1.3.2 Consider referral for assessment for radiofrequency denervation for people with non-specific low back pain when non-surgical treatment has not worked for them and the main source of pain is thought to come from structures supplied by the medial branch nerve and they have moderate or severe levels of localised back pain (rated as 5 or more on a visual analogue scale, or equivalent) at the time of referral.
1.3.3 Only perform radiofrequency denervation in people with non-specific low back pain after a positive response to a diagnostic medial branch.
1.3.4 Do not offer imaging for people with non-specific low back pain with specific facet join pain as a prerequisite for radiofrequency denervation.