Evidence-Based Treatment Modalities for Chronic Spine Pain: Comprehensive Evidence Mapping
Based on the most recent systematic reviews and clinical practice guidelines, here is a comprehensive evidence mapping summary with teaching points for each modality:
Physical Therapy and Exercise
Evidence Level: I-II (High to Moderate Quality)
First-line treatment for chronic spine pain; emphasize remaining physically active and avoiding bed rest
Supporting Evidence: Multiple systematic reviews and clinical practice guidelines recommend non-pharmacologic treatments as first-line therapy. Studies demonstrate that early patient education focusing on physical activity and setting positive treatment expectations improves outcomes.
[1-2]
Chiropractic Care/Spinal Manipulation
Evidence Level: II (Moderate Quality)
Results in small improvements in pain and function comparable to, but not superior to, other recommended therapies
Supporting Evidence: Cochrane reviews and systematic reviews demonstrate that spinal manipulation provides small improvements in pain and function for chronic low back pain, with outcomes comparable to other recommended therapies.
[2]
NSAIDs
Evidence Level: I (High Quality)
Best initial pharmacologic treatment; more effective than placebo for pain and disability
Supporting Evidence: Cochrane reviews demonstrate NSAIDs are more effective than placebo with respect to pain and disability.
[2]
INTERVENTIONAL PROCEDURES - TRADITIONAL
Epidural Steroid Injections (ESI)
For Radicular Pain/Disc Herniation:
For Axial/Non-Radicular Pain:
Radiofrequency Ablation (RFA) - Facet Joint
Facet Joint Injections (Steroid/Local Anesthetic)
Sacroiliac Joint Injections (Steroid)
Spinal Cord Stimulation (SCS)
Evidence Level: II (Moderate Quality for specific indication)
Moderately effective for failed back surgery syndrome with persistent radiculopathy; device-related complications are common
Supporting Evidence: Fair evidence that SCS is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. FDA-approved for chronic pain since 1967.
[1][5]
Peripheral Nerve Stimulation (PNS)
Emerging therapy
Platelet-Rich Plasma (PRP) - Intradiscal
Platelet-Rich Plasma (PRP) - Epidural
Platelet-Rich Plasma (PRP) - Facet Joint
Platelet-Rich Plasma (PRP) - Sacroiliac Joint
Mesenchymal Stem Cells (MSCs) - Intradiscal
Evidence Level: III (Fair Quality)
Moderate consensus-based recommendation; promising but requires high-quality RCTs; not FDA-approved
Not FDA-approved for pain or musculoskeletal conditions; only approved for hematologic malignancies
Bone Marrow Aspirate Concentrate (BMAC) - Intradiscal
Surgery (Discectomy, Fusion, Decompression)
Evidence Level: I-II (High to Moderate Quality for specific indications)
Reserved for patients with specific indications (progressive neurological deficit, cauda equina syndrome, failure of conservative therapy with anatomic correlation)
The 2025 ASIPP guidelines acknowledge the "emerging status of biologic therapies and limited quality of existing studies".
First-Line Approach:
Non-pharmacologic treatments remain first-line for chronic low back pain, with emphasis on remaining physically active, patient education, exercise, physical therapy, and behavioral counseling.
Evidence Quality Gap:
There is a striking disconnect between clinical practice patterns and evidence quality; many commonly performed interventional procedures lack high-quality evidence supporting their use, however, an increasing number of patients benefit from these therapies and seek them as an alternative to opioid medicines, other types of medicines and to avoid the risks of surgery and anesthesia, if possible.