Two Procedures on the same day (mod 59)    | Sample set up:  10ml  + Two (5) 5ml syringes 

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:

CONSERVATIVE TREATMENTS

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]

PHARMACOLOGIC TREATMENTS

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:

• Evidence Level: II (Moderate Quality for short-term benefit)

•   Moderately effective for short-term symptom relief in radicular pain; not effective for long-term relief

• Supporting Evidence:

  • For lumbar radicular pain from disc pathology, Cochrane review found evidence for only small short-term benefits compared to placebo

  • [1]

  • Strong recommendation AGAINST for chronic radicular spine pain (≥3 months) per 2025 BMJ guidelines

  • [3]

  • Network meta-analysis shows epidural injection of local anesthetic and steroids probably provides little to no difference in pain relief (WMD -0.49, 95% CI -1.54 to 0.55; moderate certainty)

  • [4]

  • For neck pain related to disc herniation, moderate evidence supports ESI for long-term improvements

  • [1]

For Axial/Non-Radicular Pain:

• Evidence Level: IV-V (Low to Very Low Quality) 

•   

Radiofrequency Ablation (RFA) - Facet Joint

• Evidence Level: V (Very Low Quality) 

Facet Joint Injections (Steroid/Local Anesthetic)

• Evidence Level: III-IV (Low to Very Low Quality)

Sacroiliac Joint Injections (Steroid)

• Evidence Level: IV (Limited Quality)  

NEUROMODULATION

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 

REGENERATIVE THERAPIES

Platelet-Rich Plasma (PRP) - Intradiscal

• Evidence Level: III (Fair Quality)

•  Moderate consensus-based recommendation 

  • Not FDA-approved; considered off-label use 

Platelet-Rich Plasma (PRP) - Epidural

• Evidence Level: III (Fair Quality)

•  Moderate consensus-based recommendation; emerging evidence suggests potential benefit

•  

Platelet-Rich Plasma (PRP) - Facet Joint

• Evidence Level: IV (Limited Quality)

• Teaching Point: Moderate consensus-based recommendation; limited evidence base

• Supporting Evidence:

  • 2025 ASIPP guidelines: Level IV evidence with moderate consensus-based recommendation

  • [6]

  • 2018 systematic review: Level 4 evidence without meta-analysis

  • [7]

  • Well-designed case-control or cohort studies demonstrate efficacy, but currently level IV evidence

  • [10-11]

Platelet-Rich Plasma (PRP) - Sacroiliac Joint

• Evidence Level: IV (Limited Quality)

• Teaching Point: Low consensus-based recommendation; very limited evidence

• Supporting Evidence:

  • 2025 ASIPP guidelines: Level IV evidence with low consensus-based recommendation

  • [6]

  • 2018 systematic review: Level 4 evidence without meta-analysis

  • [7]

  • PRP compared favorably to steroid injections in sacroiliac joint for chronic low back pain

  • [11]

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

  • [6]

Bone Marrow Aspirate Concentrate (BMAC) - Intradiscal

• Evidence Level: III (Fair Quality)

•  

SURGICAL INTERVENTION

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. 

Status Post =  after or following (ie after it has been completed )