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EPIDURAL STEROID INJECTION THERAPY FOR LOW BACK PAIN: A META-ANALYSIS

Published online by Cambridge University Press:  17 June 2013

Hyun Jin Choi ,
Seokyung Hahn ,
Chi Heon Kim ,
Bo Hyoung Jang ,
Soyoung Park ,
Sang Moo Lee ,
Jung-Yul Park ,
Chun Kee Chung  and
Byung-Joo Park
Hyun Jin Choi
Affiliation:
Department of Preventive Medicine, Seoul National University College of Medicine
Seokyung Hahn
Affiliation:
Department of Medicine, Seoul National University College of Medicine; Medical Research Collaborating Center, Seoul National University Hospital
Chi Heon Kim
Affiliation:
Department of Neurosurgery, Seoul National University College of Medicine
Bo Hyoung Jang
Affiliation:
National Evidence-based Healthcare Collaborating Agency
Soyoung Park
Affiliation:
Department of Preventive Medicine, Seoul National University College of Medicine
Sang Moo Lee
Affiliation:
National Evidence-based Healthcare Collaborating Agency
Jung-Yul Park
Affiliation:
Department of Neurosurgery, Korea University College of Medicine
Chun Kee Chung
Affiliation:
Department of Neurosurgery, Seoul National University College of Medicine
Byung-Joo Park
Affiliation:
Department of Preventive Medicine, Seoul National University College of Medicine; Medical Research Collaborating Center, Seoul National University Hospital
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Abstract

Objectives: The aim of this study was to systematically assess the long-term (≥ 6 months) benefits of epidural steroid injection therapies for patients with low back pain.

Methods: We identified randomized controlled trials by database searches up to October 2011 and by additional hand searches without language restrictions. Randomized controlled trials on the effects of epidurals for low back pain with follow-up for at least 6 months were included. Outcomes considered were pain relief, functional improvement in 6 to 12 months after epidural steroid injection treatment and the number of patients who underwent subsequent surgery. Meta-analysis was performed using a random-effects model.

Results: Twenty-nine articles were selected. The meta-analysis suggested that a significant treatment effect on pain was noted at 6 months of follow-up (weighted mean difference [WMD], −0.41; 95 percent confidence interval [CI], −0.66 to −0.16), but was no longer statistically significant after adjusting for the baseline pain score (WMD, −0.19; 95 percent CI, −0.61 to 0.24). Epidural steroid injection did not improve back-specific disability more than a placebo or other procedure. Epidural steroid injection did not significantly decrease the number of patients who underwent subsequent surgery compared with a placebo or other treatments (relative risk, 1.02; 95 percent CI, 0.83 to 1.24).

Conclusions: A long-term benefit of epidural steroid injections for low back pain was not suggested at 6 months or longer. Introduction of selection bias in the majority of injection studies seems apparent. Baseline adjustment is essential when we evaluate pain as a main outcome of injection therapy.

Keywords

Low back painInjection therapyRadiculopathySystematic reviewMeta-analysis
Type
ASSESSMENTS
Information
International Journal of Technology Assessment in Health Care , Volume 29 , Issue 3 , July 2013 , pp. 244 - 253
Copyright
Copyright © Cambridge University Press 2013 

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References

REFERENCES

1.Andersson, GB. Epidemiological features of chronic low-back pain. Lancet. 1999;354:581–585.CrossRefGoogle ScholarPubMed
2.Chou, R, Huffman, L. Guideline for the evaluation and management of low back pain: Evidence review. Glenview, IL: American Pain Society; 2009.Google Scholar
3.Cohen, SP. Epidural steroid injections for low back pain. BMJ. 2011;343:d5310.CrossRefGoogle ScholarPubMed
4.Staal, JB, de Bie, RA, de Vet, HC, Hildebrandt, J, Nelemans, P. Injection therapy for subacute and chronic low back pain: An updated Cochrane review. Spine (Phila Pa 1976). 2009;34:49–59.CrossRefGoogle ScholarPubMed
5.Croft, PR, Macfarlane, GJ, Papageorgiou, AC, Thomas, E, Silman, AJ. Outcome of low back pain in general practice: A prospective study. BMJ. 1998;316:1356–1359.CrossRefGoogle ScholarPubMed
6.Chou, R, Atlas, SJ, Stanos, SP, Rosenquist, RW. Nonsurgical interventional therapies for low back pain: A review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). 2009;34:1078–1093.CrossRefGoogle ScholarPubMed
7.Manchikanti, L, Singh, V, Derby, R, et al.Reassessment of evidence synthesis of occupational medicine practice guidelines for interventional pain management. Pain Physician. 2008;11:393–482.CrossRefGoogle ScholarPubMed
8.Watts, RW, Silagy, CA. A meta-analysis on the efficacy of epidural corticosteroids in the treatment of sciatica. Anaesth Intensive Care. 1995;23:564–569.CrossRefGoogle ScholarPubMed
9.van Tulder, M, Furlan, A, Bombardier, C, Bouter, L. Updated method guidelines for systematic reviews in the cochrane collaboration back review group. Spine (Phila Pa 1976). 2003;28:1290–1299.CrossRefGoogle ScholarPubMed
10.Trowman, R, Dumville, JC, Torgerson, DJ, Cranny, G. The impact of trial baseline imbalances should be considered in systematic reviews: A methodological case study. J Clin Epidemiol. 2007;60:1229–1233.CrossRefGoogle ScholarPubMed
11.Li, DJ, Wang, J, Gao, Q, Hou, SJ. Treatment of lumbar intervertebral disc protrusion with traction and back stretch press manipulation of lumbar spine alone or combined with extradural injection. J Clin Rehabil Tissue Eng Res. 2007;11:5892–5895.Google Scholar
12.Li, DJ, Gao, Q, Wang, FG, Hou, JS. Evaluation of the curative effects on lubar intervertebral disc protrusion with extradural injection, three dimensional rectification apparatus and their integrated therapy. Chin J Clin Rehab. 2006;10:10–2.Google Scholar
13.Bush, K, Hillier, S. A controlled study of caudal epidural injections of triamcinolone plus procaine for the management of intractable sciatica. Spine (Phila Pa 1976). 1991;16:572–575.CrossRefGoogle ScholarPubMed
14.Sayegh, FE, Kenanidis, EI, Papavasiliou, KA, Potoupnis, ME, Kirkos, JM, Kapetanos, GA. Efficacy of steroid and nonsteroid caudal epidural injections for low back pain and sciatica: A prospective, randomized, double-blind clinical trial. Spine (Phila Pa 1976). 2009;34:1441–1447.CrossRefGoogle ScholarPubMed
15.Manchikanti, L, Cash, KA, McManus, CD, Pampati, V, Abdi, S. Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 4–Spinal stenosis. Pain Physician. 2008;11:833–848.CrossRefGoogle ScholarPubMed
16.Manchikanti, L, Singh, V, Cash, KA, Pampati, V, Damron, KS, Boswell, MV. Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 2–Disc herniation and radiculitis. Pain Physician. 2008;11:801–815.CrossRefGoogle ScholarPubMed
17.Dashfield, AK, Taylor, MB, Cleaver, JS, Farrow, D. Comparison of caudal steroid epidural with targeted steroid placement during spinal endoscopy for chronic sciatica: A prospective, randomized, double-blind trial. Br J Anaesth. 2005;94:514–519.CrossRefGoogle ScholarPubMed
18.Mathews, JA, Mills, SB, Jenkins, VM, et al.Back pain and sciatica: Controlled trials of manipulation, traction, sclerosant and epidural injections. Br J Rheumatol. 1987;26:416–423.CrossRefGoogle ScholarPubMed
19.Iversen, T, Solberg, TK, Romner, B, et al.Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: Multicentre, blinded, randomised controlled trial. BMJ. 2011;343:d5278.CrossRefGoogle ScholarPubMed
20.Manchikanti, L, Cash, KA, McManus, CD, Pampati, V, Smith, HS. One-year results of a randomized, double-blind, active controlled trial of fluoroscopic caudal epidural injections with or without steroids in managing chronic discogenic low back pain without disc herniation or radiculitis. Pain Physician. 2011;14:25–36.CrossRefGoogle ScholarPubMed
21.Koc, Z, Ozcakir, S, Sivrioglu, K, Gurbet, A, Kucukoglu, S. Effectiveness of physical therapy and epidural steroid injections in lumbar spinal stenosis. Spine (Phila Pa 1976). 2009;34:985–989.CrossRefGoogle ScholarPubMed
22.Rogers, P, Nash, T, Schiller, D, Norman, J. Epidural steroids for sciatica. Pain Clinic. 1992;5:67–72.Google Scholar
23.Wilson-MacDonald, J, Burt, G, Griffin, D, Glynn, C. Epidural steroid injection for nerve root compression. A randomised, controlled trial. J Bone Joint Surg Br. 2005;87:352–355.CrossRefGoogle ScholarPubMed
24.Arden, NK, Price, C, Reading, I, et al.A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: The WEST study. Rheumatology (Oxford). 2005;44:1399–1406.CrossRefGoogle ScholarPubMed
25.Snoek, W, Weber, H, Jorgensen, B. Double blind evaluation of extradural methyl prednisolone for herniated lumbar discs. Acta Orthop Scand. 1977;48:635–641.CrossRefGoogle ScholarPubMed
26.Cuckler, JM, Bernini, PA, Wiesel, SW, Booth, RE, Rothman, RH, Pickens, GT. The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study. J Bone Joint Surg Am. 1985;67:63–66.CrossRefGoogle Scholar
27.Carette, S, Leclaire, R, Marcoux, S, et al.Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med. 1997;336:1634–1640.CrossRefGoogle ScholarPubMed
28.Manchikanti, L, Cash, KA, McManus, CD, Pampati, V, Benyamin, RM. Preliminary results of a randomized, double-blind, controlled trial of fluoroscopic lumbar interlaminar epidural injections in managing chronic lumbar discogenic pain without disc herniation or radiculitis. Pain Physician. 2010;13:E279–292.CrossRefGoogle ScholarPubMed
29.Manchikanti, L, Singh, V, Falco, FJ, Cash, KA, Pampati, V. Evaluation of the effectiveness of lumbar interlaminar epidural injections in managing chronic pain of lumbar disc herniation or radiculitis: A randomized, double-blind, controlled trial. Pain Physician. 2010;13:343–355.CrossRefGoogle ScholarPubMed
30.Laiq, N, Khan, MN, Iqbal, MJ, Khan, S. Comparison of epidural steroid injections with conservative management in patients with lumbar radiculopathy. J Coll Physicians Surg Pak. 2009;19:539–543.Google ScholarPubMed
31.Buchner, M, Zeifang, F, Brocai, DR, Schiltenwolf, M. Epidural corticosteroid injection in the conservative management of sciatica. Clin Orthop Relat Res. 2000:149–156.CrossRefGoogle Scholar
32.Teske, W, Zirke, S, Trippe, C, et al.Epidural injection therapy with local anaesthetics versus cortisone in the lumbar spine syndrome: A prospective study. Z Orthop Unfall. 2009;147:199–204.CrossRefGoogle ScholarPubMed
33.Tafazal, S, Ng, L, Chaudhary, N, Sell, P. Corticosteroids in peri-radicular infiltration for radicular pain: A randomised double blind controlled trial. One year results and subgroup analysis. Eur Spine J. 2009;18:1220–1225.CrossRefGoogle Scholar
34.Burgher, AH, Hoelzer, BC, Schroeder, DR, Wilson, GA, Huntoon, MA. Transforaminal epidural clonidine versus corticosteroid for acute lumbosacral radiculopathy due to intervertebral disc herniation. Spine (Phila Pa 1976). 2011;36:E293–300.CrossRefGoogle ScholarPubMed
35.Ghahreman, A, Ferch, R, Bogduk, N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med. 2010;11:1149–1168.CrossRefGoogle ScholarPubMed
36.Vad, VB, Bhat, AL, Lutz, GE, Cammisa, F. Transforaminal epidural steroid injections in lumbosacral radiculopathy: A prospective randomized study. Spine (Phila Pa 1976). 2002;27:11–16.CrossRefGoogle ScholarPubMed
37.Riew, KD, Park, JB, Cho, YS, et al.Nerve root blocks in the treatment of lumbar radicular pain: A minimum five-year follow-up. J Bone Joint Surg Am. 2006;88:1722–1725.CrossRefGoogle Scholar
38.Riew, KD, Yin, Y, Gilula, L, et al.The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, double-blind study. J Bone Joint Surg Am. 2000;82:1589–1593.CrossRefGoogle Scholar
39.Karppinen, J, Malmivaara, A, Kurunlahti, M, et al.Periradicular infiltration for sciatica: A randomized controlled trial. Spine. 2001;26:1059–1067.CrossRefGoogle ScholarPubMed
40.Murata, Y, Kato, Y, Miyamoto, K, Takahashi, K. Clinical study of low back pain and radicular pain pathways by using l2 spinal nerve root infiltration: A randomized, controlled, clinical trial. Spine (Phila Pa 1976). 2009;34:2008–2013.CrossRefGoogle ScholarPubMed
41.Gerszten, PC, Smuck, M, Rathmell, JP, et al.Plasma disc decompression compared with fluoroscopy-guided transforaminal epidural steroid injections for symptomatic contained lumbar disc herniation: A prospective, randomized, controlled trial. J Neurosurg Spine. 2010;12:357–371.CrossRefGoogle ScholarPubMed
42.Henschke, N, Kuijpers, T, Rubinstein, SM, et al.Injection therapy and denervation procedures for chronic low-back pain: A systematic review. Eur Spine J. 2010;19:1425–1449.CrossRefGoogle ScholarPubMed
43.Quraishi, NA. Transforaminal injection of corticosteroids for lumbar radiculopathy: Systematic review and meta-analysis. Eur Spine J. 2012;21:214–219.CrossRefGoogle ScholarPubMed
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