Subacute and chronic low back pain: Nonsurgical interventional treatment

INTRODUCTION — Up to 84 percent of adults have low back pain at some time in their lives [1,2]. The long-term outcome of low back pain is generally favorable [3], but, given how common low back pain is, persistent symptoms affect millions of individuals. Subacute low back pain is commonly defined as back pain lasting between 4 and 12 weeks and chronic low back pain as pain that persists for 12 or more weeks.

Most patients (>85 percent) who are seen in primary care have "nonspecific low back pain," which is low back pain that cannot reliably be attributed to a specific disease or spinal pathology [4]. Rapid improvement in pain and disability, and return to work, are the norm in the first month [5]. Further improvement generally occurs over three months, after which pain, level of disability, and rates of return to work remain relatively constant. Approximately 5 percent of people with back pain disability account for 75 percent of the costs associated with low back pain [6].

Multiple treatment options for subacute and chronic low back pain are available. Broadly, these are divided into nonpharmacologic and pharmacologic treatments, nonsurgical interventional treatments, and surgical treatments. This topic will address nonsurgical interventional options for patients with subacute and chronic low back pain who have failed conservative management. Several of these involve the injection of medications, commonly glucocorticoids, into the spinal structures. Others involve the destruction of nerves or other tissues in the back presumed to be the source of pain through the application of various types of energy. The noninterventional (pharmacologic and nonpharmacologic) and surgical treatment of subacute and chronic low back pain are discussed elsewhere. (See "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment" and "Subacute and chronic low back pain: Surgical treatment".)

In general, patients with subacute nonspecific low back pain would not be considered candidates for interventional therapies, as they could still improve with noninvasive therapies and there is little evidence on efficacy of invasive therapies in this circumstance [7]. For patients with subacute or chronic radiculopathy, or severe disabling chronic nonspecific low back pain, it is difficult to categorically advise when nonsurgical interventional therapies should be considered. It may be reasonable to consider some nonsurgical interventional therapies for patients who have not responded to noninvasive therapies and who are not interested in surgery or are not considered appropriate candidates for surgery. Relatively few randomized trials have evaluated patients specifically with spinal stenosis [8,9], although a number of trials have evaluated mixed populations.

Treatment of acute low back pain is discussed separately (see "Treatment of acute low back pain").

INTERVENTIONAL DIAGNOSTIC PROCEDURES — Diagnostic procedures involving injections of contrast dye or anesthetic agents, to provoke or temporarily subdue pain, are widely used to guide patient selection for interventional treatments or surgery, despite little evidence to support such a management strategy.

Discography is a diagnostic test in which contrast is injected under fluoroscopy into the nucleus of a disc thought to be the cause of a patient's low back pain, with a positive test based on the reproduction to the patient’s pain. Its reliability is controversial because of the absence of a clearly defined gold-standard reference test and false-positive results in patients without low back pain [10-13].

In our opinion, provocative discography remains unproven as a diagnostic test. Nonetheless, trials of interventional procedures targeting degenerated intervertebral discs have typically selected patients for inclusion based on results of provocative discography. Elimination of pain following injection of a local anesthetic into a degenerated disc (discoblock) has been proposed as an alternative to provocative discography. One small, randomized trial (n = 42) found that patients who underwent fusion surgery based on decreased pain with discoblock experienced superior outcomes compared with those who underwent surgery based on a positive response to discography [14]. Additional validation is needed before discoblock can be recommended to identify patients likely to respond to surgery or other procedures.

Diagnostic nerve root blocks, facet joint blocks, and sacroiliac joint blocks also have been proposed as useful methods for determining the source of low back pain and guiding choice of interventional therapies. However, as with provocative discography, there are no reliable gold standards, and few studies have evaluated whether use of these tests to identify patients for specific procedures improves clinical outcomes compared with use of noninvasive diagnostic methods alone (eg, imaging findings, history, and physical examination) [15]. Evidence on the utility of diagnostic blocks for predicting response to radiofrequency denervation is limited and somewhat inconsistent. As an example, in one randomized trial including 151 patients, there was a lower likelihood of successful lumbar facet joint radiofrequency ablation in patients selected based on positive medial branch (facet joint nerve) block compared with those not undergoing preselection medial branch block [16]. However, in another randomized trial including 229 patients, more people responded positively to radiofrequency denervation if treatment was based upon a positive facet joint block (intraarticular or medial branch) compared with a placebo block [17].

GLUCOCORTICOID AND OTHER INJECTIONS

Epidural injection — Epidural glucocorticoid injections have been used for pain control in patients with radiculopathy, spinal stenosis, and nonspecific low back pain. However, understanding efficacy is difficult due to inconsistent results as well as heterogeneous populations and interventions in randomized trials. In 2014, the US Food and Drug Administration (FDA) issued a drug safety communication about epidural injection of glucocorticoids, noting the potential for rare but serious adverse effects (loss of vision, stroke, paralysis, and death) and that effectiveness has not been established [18,19].

The best evidence for benefit comes from trials for patients with radiculopathy due to a herniated disc, which demonstrate short-term, but not long-term, benefit.

Epidural glucocorticoid injections (also referred to as "corticosteroid injections" or "steroid injections") involve the administration of steroids via a needle inserted in the space between the ligamentum flavum and the dura. Epidural injections can be performed by the translaminar approach (via the interlaminar space in the spine), the transforaminal approach (through the neuroforamen dorsal to the nerve root), or the caudal approach (through the sacral hiatus at the sacral canal) (figure 1). Injections are administered by a number of spine specialists, including anesthesiologists, physiatrists, and interventional radiologists.

The interval or number of injections, optimal steroid dose, technique or site of injection, and whether local anesthetic should also be injected have also not been firmly established in randomized trials. We suggest one or a series of up to three injections at intervals of no less than one month. Additional injections are not indicated if the initial injection does not improve symptoms [20]. More than three injections at the same site within 12 months are usually not recommended because of concerns about potential suppression of the hypothalamic-pituitary-adrenal axis, though there is little objective evidence to support these parameters.

Indications

Acute lumbosacral radiculopathy — Given the usually self-limited natural history of acute lumbosacral radiculopathy and the availability of alternatives, epidural glucocorticoid injections are not recommended during the acute phase of lumbosacral radiculopathy. (See "Acute lumbosacral radiculopathy: Treatment and prognosis", section on 'Options of limited utility'.)

Subacute and chronic lumbosacral radiculopathy

●Glucocorticoids – Epidural glucocorticoid injection may be reasonable for patients with lumbosacral radiculopathy who have not improved with conservative treatment over six weeks and who desire nonsurgical treatment for continued radicular pain.

In trials of epidural glucocorticoid injection for patients with radiculopathy due to a herniated disc, there is short-term, but not long-term, improvement in pain; the average improvement in pain intensity is generally modest. In a 2015 systematic review of randomized, placebo-controlled trials, epidural corticosteroid injections was associated with a small improvement in leg pain (mean difference [MD] 7.6 on pain scale 0 to 100; 95% CI 3.7-11.4) and disability (standardized MD 0.33; 95% CI 0.09-0.56) at two weeks and decreased risk of surgery at up to three months (relative risk [RR], 0.62, 95% CI 0.41-0.92) but no improvement at longer-term follow-up [21]. Results were similar in the subgroup of trials in which the injection was performed using the transforaminal approach with imaging guidance. There were no clear differences in results depending on the types of placebo (eg, epidural steroid, epidural saline, intramuscular steroid or saline, no injection); the trials included heterogeneous groups of patients in terms of duration of symptoms, and both therapeutic and placebo treatments varied considerably between trials. Few trials have compared an epidural glucocorticoid injection against pharmacologic therapies. One randomized trial of 145 patients with lumbosacral radicular pain secondary to a herniated disc or spinal stenosis compared epidural injection and placebo with sham injection and gabapentin [22]. There were no differences in average leg pain at one or three months, though patients treated with epidural injection had decreased worst leg pain at one month.

Despite the relatively small benefit seen on average in clinical trials, our clinical experience suggests that some patients obtain more significant relief, making it reasonable to offer a trial of glucocorticoid injections for patients who have not found relief with more conservative approaches, particularly for patients who are not candidates for surgery, or are not interested in surgery. Additional injections are not indicated if the initial injection does not improve symptoms [20].

Potential benefits must be weighed against the risk of rare, but serious adverse effects. (See 'Adverse events' below.)

●Etanercept – There is insufficient evidence to recommend the use of epidural injections of etanercept (tumor necrosis factor [TNF]-alpha inhibitor) for lumbosacral radiculopathy.

Controlled studies of epidural etanercept have had conflicting results. In one trial comparing epidural injections of etanercept (4 mg), glucocorticoids, or saline in 84 patients with subacute lumbosacral radiculopathy, one-month pain relief was similar in those receiving etanercept and saline [23]. In a phase II, placebo-controlled, dose escalation study in 49 patients with lumbosacral radicular pain, patients in the low-dose (0.5 mg etanercept), but not higher-dose, groups had significant relief of pain at six months compared with placebo [24]. Other small studies have suggested a possible benefit for etanercept compared with placebo [25] and a similar benefit when compared with glucocorticoids [26].

Lumbosacral spinal stenosis — The limited available evidence does not support the use of epidural injections in lumbosacral spinal stenosis. (See "Lumbar spinal stenosis: Treatment and prognosis", section on 'Epidural injections'.)

Nonspecific low back pain — According to one systematic review of studies in patients with nonspecific low-back pain, epidural injections were not found to improve pain or disability or to decrease the number of patients who underwent subsequent surgery compared with placebo treatments [27].

Adverse events — Serious complications of epidural glucocorticoid injections are rare and may include dural puncture, infection, and bleeding. A systematic review found that methods for assessing harms in randomized trials were not well reported and harms data were sparse. Thirteen of 30 placebo-controlled trials did not report harms at all or reported no harms. In the randomized trials (2912 patients in total), one serious adverse event (a case of retroperitoneal hematoma in a patient receiving anticoagulation) was reported in one trial [28]. One trial of 120 patients receiving epidural glucocorticoids reported the following frequency of adverse events: post-injection headache, 3.3 percent; postdural puncture headache, 0.8 percent; nausea, 1.7 percent; and other events, 4.2 percent [20].

Large observational studies have found that minor adverse events (eg, bleeding, dural puncture with cerebrospinal fluid leak, transient nerve root irritation) occur in <1 percent of procedures [29,30]. Major complications resulting in permanent neurologic sequelae (eg, spine hematoma, infection) were rare with an incidence of 0.01 percent [30]. Transient systemic glucocorticoid-related effects (eg, blood sugar elevation, gastrointestinal or psychological symptoms, vertigo or dizziness) were observed in 0.1 percent of procedures.

In a retrospective database analysis including 3000 patients, each successive epidural glucocorticoid injection increased the five-year risk of vertebral body fracture compared with a matched cohort of noninjected patients by a factor of 1.21 (95% CI 1.08-1.30) after adjustment of covariates [31]. Patients considering a trial of epidural glucocorticoids should be made aware of a possible modest increase in vertebral fracture risk associated with each injection due to the increased risk of bone fragility.

Contaminated medication used in epidural injections have resulted in severe infections; for example, in 2012, hundreds of patients developed fungal meningitis, in many cases fatal, from epidural injections of contaminated glucocorticoid from a single compounding pharmacy [32]. (See "Central nervous system infections due to dematiaceous fungi (cerebral phaeohyphomycosis)", section on 'Outbreak of fungal meningitis and osteoarticular infections'.)

Intradiscal injection — In general, we do not suggest intradiscal glucocorticoid injections for patients with subacute or chronic low back pain. Although one study [33] found that it may provide short-term pain relief in patients with chronic low back pain associated with radiologic evidence of “active discopathy” (defined by presence of Modic 1 magnetic resonance imaging [MRI] changes, which are characterized by vertebral endplate subchondral bone edema, a marker of acute inflammation), this clinical scenario represents a small fraction of subacute or chronic low back pain.

Intradiscal injection was studied in a prospective, double-blind, randomized controlled trial of 135 patients. The trial found that a single intradiscal injection of prednisolone and contrast resulted in higher rates of response at one month (low back pain intensity less than 40 on a 100-point scale in the previous 48 hours) compared with an injection of contrast alone (55.4 versus 33.3 percent) [33]. The groups did not differ in pain intensity at 12 months or in any secondary outcomes (limitations in activities, quality of life, anxiety and depression, employment status, and use of analgesics) at 1 or 12 months. More research is needed to confirm the reliability and validity of the “active discopathy” designation, to demonstrate reproducible beneficial effects of intradiscal glucocorticoid injection, and to evaluate its potential risks (eg, accelerated disc degeneration) before it can be recommended for use in clinical practice.

A prior study found that, in patients with degenerative disc disease who did not respond to epidural steroid injection, intradiscal steroid injection was superior to discography alone only in the subgroup of patients with Modic 1 MRI changes, but outcomes were poorly reported [34]. Two earlier trials of patients with MRI evidence of degenerative disc disease and a positive response to discography (not selected based on the presence of Modic 1 MRI changes) found no difference between intradiscal steroid and control injection (saline or local anesthetic) [35,36]. Based on these earlier studies, the American Pain Society guideline recommends against intradiscal glucocorticoid injection for chronic low back pain [15].

TNF-alpha has been implicated in the pathogenesis of radiculopathy and discogenic back pain. A small pilot study showed that intradiscal injections of etanercept (interferes with TNF-alpha) did not improve pain or disability scores for patients with lumbosacral radiculopathy or chronic discogenic low back pain [37].

Methylene blue is a compound used as a dye or stain and has been studied for various therapeutic purposes; results of trials evaluating intradiscal methylene blue injections are mixed. As examples, in a randomized trial including 72 patients with discography-positive, presumed discogenic back pain, intradiscal methylene blue injection was associated with large improvements in pain (about 40 points on a 100-point pain scale) and function (about 35 points on the 0 to 100 Oswestry Disability Index) compared with a placebo intradiscal injection; there were no adverse events such as increased pain, radiculopathy, or infection [38]. However, in a subsequent randomized trial including 81 patients with similar inclusion criteria, there were no differences between intradiscal methylene blue versus placebo in pain intensity, likelihood of >30 percent improvement in pain, function, quality of life, or function through six months [39]. Similarly, in another small randomized trial including 24 patients (only published as a thesis), there was no difference between intradiscal methylene blue versus placebo intradiscal injection in pain or function after one month, and over half of the patients treated with methylene blue reported severe pain immediately after the injection [40]. Longer-term results are not available, although the trial was designed to follow patients for one year.

Local or trigger point injection — A systematic review found no clear differences between local or trigger point injections with a local anesthetic, with or without a corticosteroid, and control interventions (saline or dry needle injections, or ethyl chloride plus acupressure) for short-term (seven days to two months) pain relief in three trials of patients with subacute or chronic low back pain [41]. All trials had methodological shortcomings and evaluated heterogeneous injection methods. One trial evaluated an injection over the iliac crest [42], one evaluated injections over the iliolumbar ligament [43], and one evaluated trigger point injections [44]. The limited benefit observed in heterogeneous, low-quality studies does not support their widespread use.

Trigger point injections may be beneficial in patients with tender points (in the back or elsewhere) associated with the myofascial pain syndrome, a disorder that is thought to be related to fibromyalgia and outside the scope of this review. (See "Treatment of fibromyalgia in adults".)

Facet joint injection and medial branch block — Glucocorticoid injections into the facet joint have not been shown to be effective in the treatment of low back pain. A 2009 American Pain Society guideline recommends against their use [15].

A systematic review found no clear differences between an intraarticular facet joint injection with corticosteroid versus saline in pain or function at one to three months, based on two trials [27,45,46]. In one of the trials, results at six months favored the corticosteroid injection, but these findings are difficult to interpret due to greater receipt of cointerventions in the group receiving the corticosteroid injection and no difference in the likelihood of sustained improvement [45]. A subsequent trial found no difference between a facet joint injection with glucocorticoid plus local anesthetic versus saline in pain or function through six months [17]. A trial comparing facet joint glucocorticoid injection and systemic glucocorticoids found no difference in either pain or functional capacity over six months between the groups, although patients receiving facet injections had a decrease in nonsteroidal antiinflammatory drug (NSAID) use [47].

Blocks to the medial branch of the primary dorsal ramus, innervating the facet joints, have been used both diagnostically and therapeutically for presumed facet joint pain (see 'Interventional diagnostic procedures' above). A systematic review found no differences between medial branch corticosteroid injection versus medial branch local anesthetic injection in pain, function, or opioid use through 12 to 24 months, based on two trials [27,48,49]. In a subsequent randomized trial evaluating therapeutic injections, there was no difference between a medial branch block with glucocorticoid plus local anesthetic versus placebo in pain or function through six months [17].

Sacroiliac joint injection — The sacroiliac joints are thought to be the source of low back pain in some patients. Effective methods for diagnosing and treating sacroiliac joint pain in patients without spondyloarthropathy remain controversial [50,51].

Periarticular steroid injection does not require radiographic guidance. One small (n = 24), randomized trial found periarticular sacroiliac joint glucocorticoid injection more effective than local anesthetic injection for pain relief (change in pain of -40 versus -13 mm on a 100 mm visual analogue scale one month after injection) in patients with chronic pain in the sacroiliac joint area and at least one physical exam finding for sacroiliac pain [52]. These results should be considered preliminary, due to the small sample size and relatively short-term follow-up. There are no randomized trials of intraarticular sacroiliac joint steroid injection versus a sham procedure in patients without spondyloarthropathy.

Piriformis syndrome injection — A subset of patients with sciatic symptoms may have pain related to impingement of the sciatic nerve as it passes through the piriformis muscle. However, the diagnosis of piriformis syndrome is not reliably reproducible (see "Evaluation of low back pain in adults"). Although steroid injections placed deeply into the area of maximum tenderness in the buttock have been used, there are no randomized trials evaluating this therapy.

ELECTROTHERMAL AND RADIOFREQUENCY THERAPIES

Intradiscal therapy: IDET and PIRFT — Intradiscal electrothermal therapy (IDET; also known as intradiscal electrothermal annuloplasty) is a technique designed to thermocoagulate and destroy nerves in the intravertebral disc of patients presumed to have discogenic low back pain. A catheter or electrode, placed into the intervertebral disc, is slowly heated and kept at a predetermined temperature for a predetermined time to coagulate and shrink adjacent tissues. Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) is similar to IDET, but heat is generated in surrounding tissues by an alternating radiofrequency current. This modality is no longer commonly performed. A 2007 systematic review found that evidence does not support either IDET or PIRFT in the treatment of low back pain [53]. Two randomized studies have been conducted on IDET. Both trials enrolled patients with chronic back pain and positive responses to provocative discography. In one trial, patients randomized to IDET experienced moderate improvements in pain scores compared with sham IDET but experienced no improvements in functional status [54]. This trial appeared to evaluate a highly selected subset of patients (only 64 patients from a potential cohort of 4253 were enrolled); additionally, data analysis was not performed on an intent-to-treat basis and did not address baseline differences in control and intervention populations [53]. Another trial found no differences between IDET and sham IDET on any outcome [55].

Two small (n = 20 and n = 28) randomized trials found no differences between PIRFT versus a sham procedure on any assessed outcome [56,57]. A second trial found no improvements compared with baseline for different durations of PIRFT but did not include a sham therapy arm [58].

Radiofrequency denervation — We suggest not using radiofrequency denervation for the management of chronic low back pain. The available data are inconsistent and suggest that, compared with placebo, radiofrequency denervation may modestly reduce pain in the short-term; however, there does not appear to be clear long-term benefit [59-68]. When added to a treatment regimen that includes a regular exercise program and psychologic support, radiofrequency denervation provides little additional benefit [69].

Radiofrequency denervation involves destruction of nerves using heat generated by a radiofrequency current. A catheter or electrode is placed near or in the target nerve with position confirmed by fluoroscopy; radiofrequency current is applied to heat and coagulate adjacent tissues, including the target nerve. It has been used most frequently for treatment of presumed facet joint pain (target nerve = medial branch of the primary dorsal ramus). It has also been used for presumed discogenic back pain (ramus communicans), radicular back pain (dorsal root ganglia), and sacroiliac disease (lateral branch nerve).

Small clinical trials evaluating radiofrequency denervation for facet joint pain [59,62-67], discogenic low back pain [70], radicular pain [60], and chronic sacroiliac joint pain [68] have generally shown no effectiveness or modest, mostly short-term, benefit. In a 2015 meta-analysis that included 23 randomized trials, among patients with facet joint pain, radiofrequency denervation modestly improved pain in the short-term compared with placebo (mean difference [MD] -1.47 on a 10-point scale; 95% CI -2.28 to -0.67; 3 trials; low- to moderate-quality evidence) but did not improve long-term pain or function [61]. Studies in patients with discogenic back pain showed conflicting results, and studies of patients with radicular back pain showed no differences compared with placebo in short-term pain control or function [61].

Most of the trials included in the meta-analysis were of low or very low quality, and many had limited duration of follow-up. There were also differences in the radiofrequency denervation technique used. In addition, there was considerable variation in selection criteria among the different trials. For example, in trials of patients with presumed facet joint pain, some trials included patients solely based on clinical findings, other trials required a positive response to a single diagnostic joint block, and other trials required a positive response to two blocks performed on separate occasions to the same joint (double block). The utility of diagnostic facet joint blocks for selection of patients for radiofrequency denervation is uncertain. In a randomized trial that compared the three approaches, patients who underwent radiofrequency denervation without diagnostic joint blocks (based solely on clinical findings) had higher response rates compared with those who underwent single or double diagnostic joint blocks prior to the intervention (33 versus 16 versus 22 percent, respectively) [16].

In a subsequent series of parallel randomized trials in patients with facet joint disease (n = 251), sacroiliac joint disease (n = 228), or a combination of facet joint, sacroiliac joint, or intervertebral disc disease (n = 202) who were unresponsive to conservative management, radiofrequency denervation added to a standardized exercise program, with psychological support as needed, modestly improved pain intensity at three months in the sacroiliac joint group (MD of -0.71 on a 10-pont scale; 95% CI, -1.35 to -0.06) and the combination joint group (MD of -0.99; 95% CI, -1.73 to -0.25) but not the facet joint group (MD of -0.18; 95% CI, -0.76 to 0.40) [69]. In all groups, pain improvement did not reach a level that was considered clinically meaningful (which the study investigators defined a priori as an MD of 2 points). Patients in this study were selected using single facet joint blocks.

Adverse events reported in clinical trials include increased pain, transient lower limb numbness, paraesthesias, and superficial burns [61]. However, most trials were not adequately powered to detect harm.

Prolotherapy — Prolotherapy (also referred to as sclerotherapy) is a technique involving the repeated injection of irritants into ligaments and tendinous attachments in order to trigger an inflammatory response that theoretically will lead to subsequent strengthening of ligaments and decrease in pain and disability. Prolotherapy injections are often supplemented by co-interventions such as trigger point injections, manipulation, and exercises.

One systematic review included five trials of prolotherapy, compared with local anesthetic or saline injections, for chronic low back pain [71]. There was no difference for short- or long-term pain or disability between prolotherapy and control intervention in three of the trials [72-74]. Results from one trial that demonstrated short-term benefit for prolotherapy are difficult to interpret because patients also received a number of co-interventions including forceful manipulation, injection of tender points, and exercise [75]. A fifth trial was confounded by differences in the type of manipulation given to patients in the prolotherapy and control groups [76]. Based on these trial results, a guideline from the American Pain Society recommends against prolotherapy for chronic low back pain [15].

Because of the irritant nature of prolotherapy injections, most patients are expected to experience temporary increases in back pain and stiffness following treatment. Post-injection headaches suggestive of lumbar puncture occurred in 2 to 4 percent of patients in two trials [74,75].

BOTULINUM TOXIN — The effectiveness of paravertebral injection of botulinum toxin A was evaluated in a small (n = 31) randomized trial of patients with chronic low back pain who failed standard therapies [77]. Botulinum toxin A was superior to placebo injection for pain relief and improved function at three and eight weeks (50 percent pain relief at three weeks 73.3 versus 25 percent; at eight weeks 60 versus 16 percent, respectively). However, in most patients, benefits were no longer present after three to four months. These results should be considered preliminary, and further data from randomized trials are needed to confirm findings in a larger number of patients over a longer duration and to evaluate benefits and harms of repeated injections before this treatment can be recommended.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lower spine disorders".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Low back pain in adults (The Basics)")

●Beyond the Basics topics (see "Patient education: Low back pain in adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●We suggest a trial of epidural glucocorticoids for adults with persistent radiculopathy due to a herniated disc who desire intervention for pain relief, understand that benefits are limited and short-term, and are not interested in or are poor candidates for surgery (Grade 2B). Epidural glucocorticoid injections for patients with radiculopathy due to a herniated disc may provide modest short-term improvement in pain and disability but provide no benefit over placebo at longer-term follow-up. (See 'Subacute and chronic lumbosacral radiculopathy' above.)

●Evidence does not support the use of epidural steroid injections in acute lumbosacral radiculopathy and in spinal stenosis. (See 'Lumbosacral spinal stenosis' above and 'Acute lumbosacral radiculopathy' above.)

●We suggest not using epidural steroid injections for nonspecific low back pain (Grade 2C). (See 'Nonspecific low back pain' above.)

●We suggest not performing the following treatments for chronic low back pain (Grade 2C):

•Intradiscal injection of glucocorticoid, anti-tumor necrosis factor (TNF), or methylene blue (see 'Intradiscal injection' above)

•Facet joint injections and medial branch blocks (see 'Facet joint injection and medial branch block' above)

•Sacroiliac joint injection (see 'Sacroiliac joint injection' above)

•Pyriformis syndrome injection (see 'Piriformis syndrome injection' above)

●We also suggest not performing the following treatments for chronic low back pain (Grade 2B):

•Intradiscal electrothermal therapy (IDET) and percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) (see 'Intradiscal therapy: IDET and PIRFT' above)

•Radiofrequency denervation (see 'Radiofrequency denervation' above)

•Prolotherapy (see 'Prolotherapy' above)

•Botulinum toxin injection (see 'Botulinum toxin' above)