Summary of recommendations of pain intervention for low back pain with radiculopathy

Article information

J Med Life Sci. 2025;22(1):16-21

Publication date (electronic) : 2025 January 31

doi : https://doi.org/10.22730/jmls.2025.22.1.16

Jisoon Huh ¹

, Yun Suk Choi ²

, You-Nam Chung^,¹

¹Department of Neurosurgery, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Republic of Korea

²Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Republic of Korea

Correspondence to You-Nam Chung Department of Neurosurgery, Jeju National University Hospital, Jeju National University College of Medicine, 15 Aran 13-gil, Jeju 63241, Republic of Korea. Tel: 82-64-754-8145 Fax: 82-64-717-1782 E-mail: nsunam@jejunu.ac.kr

Received 2024 August 21; Revised 2024 September 11; Accepted 2024 October 21.

Abstract

To aid in the selection of rationalized pain intervention modalities for low back pain (LBP), treatment guidelines were identified through a systematic search of the MEDLINE electronic database. Structured guidelines from four groups (North American Spine Society [NASS], American Society of Interventional Pain Physicians [ASIPP], American Pain Society/American College of Physicians [APS/ACP], and European), were selected for their detailed reviews of each pain intervention technique. Current popular intervention techniques and their supporting evidence based on recommendations for LBP with radiculopathy were summarized and compared. All guidelines, except those from the European group, endorsed the effectiveness of epidural injections for radicular pain caused by herniated discs and spinal stenosis. Lumbar epidural adhesiolysis was found to be effective for managing spinal stenosis and failed back surgeries. However, intradiscal electrothermal therapy and coblation nucleoplasty showed weak evidence for recommendation. Furthermore, the APS/ACP and European groups advised against the use of intradiscal steroid or glycerol injections for lumbar disc herniation. It is important to select an effective pain intervention technique, because LBP with radiculopathy is a prevalent condition in clinical practice. Consequently, referring to evidence-based guidelines and recommendations is essential to ensure rationalized and effective treatment choices.

Keywords: Back; Guideline; Pain; Radiculopathy; Therapeutics

INTRODUCTION

Low back pain (LBP) is among the most common patient complaints and represents a significant economic burden on society. The global lifetime prevalence of LBP has been reported as 84% [1]. Most general physicians, and spine surgeons frequently encounter challenges in diagnosing and managing LBP. Pain interventions, including preoperative injection therapies, are now routinely used as a part of LBP management. Despite the availability of numerous case reports and randomized studies on various treatment options, most doctors face uncertainty when selecting the most appropriate intervention. Many scientific associations related to spinal care, particularly in the United States and Europe, have published evidence-based clinical guidelines providing diagnostic and therapeutic recommendations for LBP.

To help doctors select rationalized treatment modalities for LBP with radiculopathy, this study presents a comparative analysis of evidence-based guidelines for pain intervention techniques.

METHODS

A systematic search for treatment guidelines was conducted using the MEDLINE electronic database. Keywords are guideline, low back pain, radiculopathy, and treatment. Major structured treatment guidelines were identified and selected, focusing on detailed evidence-based reviews of pain intervention modalities for patients with LBP with radiculopathy.

The following guidelines, published by four scientific associations (year of publication) were included North American Spine Society (NASS) (2014) [2,3], American Society of Interventional Pain Physicians (ASIPP) (2013) [4], American Pain Society/American College of Physicians (APS/ACP) (2009) endorsed by American Academy of Orthopaedic Surgeons [5], and European COST B13 Working Group (2006) [6].

The guidelines specifically address patients with LBP with radiculopathy. The criteria for levels of evidence and recommendations, while largely similar across the guidelines with some variations, are presented in Tables 1-3. The corresponding levels of evidence and recommendations for each treatment modality are listed in Table 4.

Table 1.

Linked levels of evidence and treatment recommendations used in the North American Spine Society (NASS) group [3]

Table 2.

Criteria for levels of evidence and treatment recommendations used in ASIPP and APA/ACP guidelines [5]

Table 3.

The evidence levels and treatment recommendations used in the European guideline [6]

Table 4.

Levels of evidence and recommendations for each treatment option for low back pain with radiculopathy

This study received approval from the Institutional Review Board (IRB) of Jeju National University Hospital (IRB number, 2024-09-017).

RESULTS

All guidelines, except those from the European group, recommended epidural injections as effective for managing radicular pain caused by herniated discs and spinal stenosis. For epidural injection techniques, the transforaminal and interlaminar approaches were recommended for acute pain control (1 to 3 months) in cases for radicular pain associated with disc herniation. The interlaminar approach was also advised for spinal stenosis, providing relief over a relatively short period (up to 6 months).

Lumbar epidural adhesiolysis, also known as epidural neuroplasty, was identified as effective for treating spinal stenosis and failed back surgery syndrome exclusively by the ASIPP group. Most thermal annular procedures and percutaneous disc decompression techniques were considered debatable. The APS/ACP and European groups recommended against the use of intradiscal steroid or glycerol injections for lumbar disc herniation.

DISCUSSION

LBP can be classified as acute, subacute, or chronic, based on its duration, with cut-offs at one and three months. In acute LBP, identifying potentially serious conditions (red flags) is crucial, requiring a differential diagnosis, informed by a focused history and physical examination. Routine use of diagnostic imaging tests, including radiography (X-rays), computed tomography (CT), and magnetic resonance imaging (MRI), is generally not recommended for acute nonspecific LBP [7], as outlined in most guidelines. The pain intervention methods could be considered for chronic pain, despite encouraging activity and medications for acute and subacute pain. Among these, epidural injections have recently emerged as one of the most effective pain intervention techniques and has become the most common procedure worldwide. The NASS and European groups recommend contrast-enhanced fluoroscopy, especially targeting the ventral part of the epidural space near the spinal nerve root, through the transforaminal approach for a herniated lumbar disc. However, the NASS group reported a lack of evidence regarding the optimal frequency or dosage of injections and stated insufficient evidence for the types of injection (caudal, interlaminar, or transforaminal), and their impact on risk or effectiveness.

A recent review of lumbar epidural adhesiolysis showed moderate evidence of its effectiveness for lumbar radiculopathy, spinal stenosis, and failed back surgery syndrome compared to conventional epidural injection techniques [8]. Although the possibility of complications is slightly higher than that with epidural injections, the benefits of lumbar epidural adhesiolysis are attributed to the administration of high volumes and hypertonic saline. The study found insufficient evidence regarding differences in efficacy with or without using an endoscope. The components of adhesiolysis provided strong evidence for high volume, moderately positive evidence for hypertonic saline, conflicting evidence for hyaluronidase, and no evidence for mechanical disruption.

Although a newly emerging technique, lumbar epidural adhesiolysis was not mentioned in most guidelines except those of the ASIPP group. The level of evidence for intradiscal electrothermal therapy (IDET) and coblation nucleoplasty was also addressed only by the ASIPP group, where it was classified as limited to fair. To provide comprehensive treatment guidelines for these new and popular techniques, further high quality cost-effectiveness studies are needed.

Most treatment options for LBP with radiculopathy target the intervertebral disc and the compressed nerve root as the pain source. In contrast, non-radicular LBP can originate from various structures, including the facet joint, sacroiliac joint, intervertebral disc, ligaments, and muscles, complicating diagnosis. Only 15% of cases of LBP without disc herniation can be anatomically localized, but it can be increased up to 60-70% using a diagnostic block [9,10]. In addition to understanding the mechanism of spinal pain transmission, the interest and high suspicion for various pain generators of non-radicular low back pain is crucial for effective diagnosis and management.

LBP is one of the most common complaints encountered by primary physicians. Among the various conservative treatment modalities considered before deciding on surgery for chronic LBP, the role and problems of cost-effectiveness of invasive techniques are increasing. Thus, it is essential to rely on to rationalized evidence-based guidelines and recommendations when selecting pain intervention techniques for patients with LBP with radiculopathy.

Notes

CONFLICT OF INTEREST

The author reports no conflict of interest.

FUNDING

This work was supported by the 2024 education, research and student guidance grant funded by Jeju National University

References

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2. Kreiner DS, Hwang SW, Easa JE, Resnick DK, Baisden JL, Bess S, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J 2014;14:180–91.

3. Kreiner DS, Shaffer WO, Baisden JL, Gilbert TJ, Summers JT, Toton JF, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J 2013;13:734–43.

4. Manchikanti L, Abdi S, Atluri S, Benyamin RM, Boswell MV, Buenaventura RM, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician 2013;16(Suppl 2):S49–283.

5. Chou R, Loeser JD, Owens DK, Rosenquist RW, Atlas SJ, Baisden J, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976) 2009;34:1066–77.

6. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006;15(Suppl 2):S192–300.

7. Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010;19:2075–94.

8. Lee F, Jamison DE, Hurley RW, Cohen SP. Epidural lysis of adhesions. Korean J Pain 2014;27:3–15.

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Table 1.

Linked levels of evidence and treatment recommendations used in the North American Spine Society (NASS) group [3]

Grade of recommendation	Statement	Levels of evidence
A	Recommended	Two or more consistent level I studies
B	Suggested	One level I study with additional supporting level II or III studies
B	Suggested	Two or more consistent level II or III studies
C	May be considered and is an option	One level I, II, or III study with supporting level IV studies
C	May be considered and is an option	Two or more consistent level IV studies
I^*	Insufficient evidence to make recommendation for or against	A single level I, II, III, or IV study without other supporting evidence
I^*	Insufficient evidence to make recommendation for or against	More than one study with inconsistent findings

Insufficient or conflicting evidence.

Table 2.

Criteria for levels of evidence and treatment recommendations used in ASIPP and APA/ACP guidelines [5]

Recommendation	Statement	Level of evidence	Statement
A	The panel strongly recommends that clinicians consider offering the intervention to eligible patients	Good	Evidence includes consistent results from well designed, well-conducted studies in representative populations that directly assess effects on health outcomes (at least two consistent, higher-quality trials).
A	The panel found good evidence that the intervention improves health outcomes and concludes that benefits substantially outweigh harms	Good
B	The panel recommends that clinicians consider offering the intervention to eligible patients	Fair	Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number of quality, size, or consistency of included studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes (at least one higher-quality trial of sufficient sample size, two or more higher quality trials with some inconsistency, at least two consistent, lower-quality trials, or multiple consistent observational studies with no significant methodologic flaws)
B	The panel found at least fair evidence that the intervention improves health outcomes and concludes that benefits moderately outweigh harms, or that benefits are small but there are no significant harms, costs, or burdens associated with the intervention	Fair
C	The panel makes no recommendation for or against the intervention
C	The panel found at least fair evidence that the intervention can improve health outcomes, but concludes that benefits only slightly outweigh harms, or the balance of benefits and harms is too close to justify a general recommendation
D	The panel recommends against offering the intervention	Poor
D	The panel found at least fair evidence that the intervention is ineffective or that harms outweigh benefits	Poor
I	The panel found insufficient evidence to recommend for or against the intervention		Evidence is insufficient to assess effects on health outcomes because of limited number or power of studies, large and unexplained inconsistency between higher-quality trials, important flaws in trial design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes
I	Evidence that the intervention is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined

ASIPP: American Society of Interventional Pain Physicians, APS/ACP: American Pain Society/American College of Physician.

Table 3.

The evidence levels and treatment recommendations used in the European guideline [6]

Recommendation	Statement	Level of evidence^*	Statement
Recommended	Level A/B evidence of effectiveness in relation to sham treatments, treatments considered in the RCTs to be control treatments, or usual care; especially if level A/B evidence that is better than/ as good as other potentially effective treatments, and no known concerns	Level A	Generally consistent (75% of studies showed a similar) result findings
Consider using	Level A/B evidence of effectiveness in relation to sham treatments, treatments considered in the RCTs to be control treatments, or usual care, but with some known concerns, or level A/B evidence that better than/as good as other potentially effective treatments and without known concerns	Level B	Generally consistent findings provided by (a systematic review of) multiple low quality RCTs
We cannot recommend	Level C/D evidence regarding effectiveness in relation to sham treatments, treatments considered in the RCTs to be control treatments, or usual care, with/without known concerns	Level C	One RCT (either high or low quality) or inconsistent findings from (a systematic review of) multiple RCTs
We do not recommend	Level A/B evidence that is not more effective than sham treatments, treatments considered in the RCTs to be control treatments, or usual care, with/without known concerns	Level D	No RCTs

RCT: randomized controlled trial.

Level A, strong evidence; level B, moderate evidence; Level C, limited or conflicting evidence; Level D, no evidence.

Table 4.

Levels of evidence and recommendations for each treatment option for low back pain with radiculopathy

Method	Indication	NASS (2014)	ASIPP (2013)	APS/ACP (2009)	European (2006)
Epidural injections
Caudal	Disc herniation (radiculitis)		Good	Fair/B for short-term (<3 months) relief	Conflicting
	Spinal stenosis	C for medium term (3-36 months) relief with multiple injections	Fair	Poor
	Post surgery syndrome		Fair
Interlaminar	Disc herniation (radiculitis)	C	Good	Fair/B for short-term (<3 months) relief	Conflicting
	Spinal stenosis	B for short-term (2 weeks to 6 months) relief	Fair	Poor
		I for long term (21.5-24 months) relief
	Post surgery syndrome		Fair
Transforaminal	Disc herniation (radiculitis)	A for short term (2-4 weeks) relief	Good	Fair/B for short-term (<3 months) relief	Conflicting
		I for 12-month efficacy
	Spinal stenosis	C for medium term (3-36 months) relief with multiple injections	Poor	Poor
	Post surgery syndrome		Poor
Lumbar epidural adhesiolysis (percutaneous epidural neuroplasty)
Percutaneous (Racz, Navicath catheter)	Post lumbar surgery syndrome		Fair
	Spinal stenosis		Fair
Epiduroscopic	Post lumbar surgery syndrome		Fair
	Spinal stenosis		Fair
Thermal annular procedure
IDET	Discogenic LBP	I	Poor to fair	Poor	Conflicting
PIRFT	Discogenic LBP	I	Poor	Poor	Conflicting
Biacuplasty	Discogenic LBP	I	Poor to fair
Percutaneous disc decompression procedures
APLD	Herniated disc	C	Poor
PLDD	Herniated disc		Poor
Coblation nucleoplasty/plasma disc decompression	Herniated disc	I	Poor to fair	No evidence
Mechanical high RPM device	Herniated disc		Poor
Others
Intradiscal high-pressure saline injection	Herniated disc	I
Intradiscal steroid/glycerol injection	Herniated disc			Good/D	Moderate/do not recommend
Radiofrequency denervation	Herniated disc			Poor
Spinal cord stimulation	FBSS		Fair	Fair	No evidence

NASS: North American Spine Society, ASIPP: American Society of Interventional Pain Physicians, APS/ACP: American Pain Society/American College of Physician, IDET: intradiscal electrothermal therapy, LBP: low back pain, PIRFT: percutaneous intradiscal radiofrequency thermocoagulation, APLD: automated percutaneous mechanical lumbar disc decompression, PLDD: percutaneous lumbar laser disc decompression, FBSS: failed back surgery syndrome.