Role of Steroid Shots for Lumbosacral Pain Limited

Epidural steroid injections may provide some short-term pain relief in radicular lumbosacral pain but they are not recommended for long-term relief, improvement of function, or reducing the need for surgery, according to new guidelines from the American Academy of Neurology.

The guidelines were drafted by the AAN's Therapeutics and Technology Assessment Subcommittee, based on a literature review (Neurology 2007;68:723–9).

From an initial 37 studies that were identified, only 4 met the committee's predetermined inclusion criteria of being randomized, double-blinded, and placebo or active-controlled with a clear case definition and clear pain-relief outcomes using a standardized measure, wrote lead author Dr. Carmel Armon, chief of neurology at Baystate Medical Center in Springfield, Mass., and professor of neurology at Tufts University in Boston.

Dr. Armon and colleagues said all four studies were consistent in their findings on epidural steroid injection for radicular lumbosacral pain relief. The findings concluded that when compared with a control group, the injections proved “no efficacy at 24 hours, some efficacy at 2–6 weeks, no difference or rebound worsening at 3 months and 6 months, and no difference at 1 year.”

“While some pain relief is a positive result in and of itself, the extent of leg and back pain relief from epidural steroid injections, on the average, fell short of the values typically viewed as clinically meaningful,” Dr. Armon wrote. The clinically meaningful effect is usually defined as 15 mm on a 100-mm visual analog pain scale, according to the guidelines.

Reported complications of epidural steroid injections are usually minor and transient—most frequently a headache, they reported. Major complications are rare and include aseptic meningitis, arachnoiditis, bacterial meningitis, epidural abscess, and conus medullaris syndrome.

“I think the risk-benefit ratio [is important],” Dr. David Borenstein, clinical professor of rheumatology at George Washington University and a rheumatologist specializing in low back pain, said in an interview. “People should consider exercises and oral therapies first, but if they're not getting better, this relatively noninvasive type of procedure, compared to surgical intervention, would be worthwhile to consider in the appropriate patient.”

“Epidural steroid injections are likely overused,” said Dr. J. D. Bartleson, a neurologist at the spine center of the Mayo Clinic in Rochester, Minn. “There is bias that they are extremely helpful, which is not borne out by the data,” he said in an interview. “I hope neurologists … will gain a better understanding of the modest help that epidural injections can provide.”

Epidural steroid injections may provide some short-term pain relief in radicular lumbosacral pain but they are not recommended for long-term relief, improvement of function, or reducing the need for surgery, according to new guidelines from the American Academy of Neurology.

The guidelines were drafted by the AAN's Therapeutics and Technology Assessment Subcommittee, based on a literature review (Neurology 2007;68:723–9).

From an initial 37 studies that were identified, only 4 met the committee's predetermined inclusion criteria of being randomized, double-blinded, and placebo or active-controlled with a clear case definition and clear pain-relief outcomes using a standardized measure, wrote lead author Dr. Carmel Armon, chief of neurology at Baystate Medical Center in Springfield, Mass., and professor of neurology at Tufts University in Boston.

Dr. Armon and colleagues said all four studies were consistent in their findings on epidural steroid injection for radicular lumbosacral pain relief. The findings concluded that when compared with a control group, the injections proved “no efficacy at 24 hours, some efficacy at 2–6 weeks, no difference or rebound worsening at 3 months and 6 months, and no difference at 1 year.”

“While some pain relief is a positive result in and of itself, the extent of leg and back pain relief from epidural steroid injections, on the average, fell short of the values typically viewed as clinically meaningful,” Dr. Armon wrote. The clinically meaningful effect is usually defined as 15 mm on a 100-mm visual analog pain scale, according to the guidelines.

Reported complications of epidural steroid injections are usually minor and transient—most frequently a headache, they reported. Major complications are rare and include aseptic meningitis, arachnoiditis, bacterial meningitis, epidural abscess, and conus medullaris syndrome.

“I think the risk-benefit ratio [is important],” Dr. David Borenstein, clinical professor of rheumatology at George Washington University and a rheumatologist specializing in low back pain, said in an interview. “People should consider exercises and oral therapies first, but if they're not getting better, this relatively noninvasive type of procedure, compared to surgical intervention, would be worthwhile to consider in the appropriate patient.”

“Epidural steroid injections are likely overused,” said Dr. J. D. Bartleson, a neurologist at the spine center of the Mayo Clinic in Rochester, Minn. “There is bias that they are extremely helpful, which is not borne out by the data,” he said in an interview. “I hope neurologists … will gain a better understanding of the modest help that epidural injections can provide.”

Epidural steroid injections may provide some short-term pain relief in radicular lumbosacral pain but they are not recommended for long-term relief, improvement of function, or reducing the need for surgery, according to new guidelines from the American Academy of Neurology.

The guidelines were drafted by the AAN's Therapeutics and Technology Assessment Subcommittee, based on a literature review (Neurology 2007;68:723–9).

From an initial 37 studies that were identified, only 4 met the committee's predetermined inclusion criteria of being randomized, double-blinded, and placebo or active-controlled with a clear case definition and clear pain-relief outcomes using a standardized measure, wrote lead author Dr. Carmel Armon, chief of neurology at Baystate Medical Center in Springfield, Mass., and professor of neurology at Tufts University in Boston.

Dr. Armon and colleagues said all four studies were consistent in their findings on epidural steroid injection for radicular lumbosacral pain relief. The findings concluded that when compared with a control group, the injections proved “no efficacy at 24 hours, some efficacy at 2–6 weeks, no difference or rebound worsening at 3 months and 6 months, and no difference at 1 year.”

“While some pain relief is a positive result in and of itself, the extent of leg and back pain relief from epidural steroid injections, on the average, fell short of the values typically viewed as clinically meaningful,” Dr. Armon wrote. The clinically meaningful effect is usually defined as 15 mm on a 100-mm visual analog pain scale, according to the guidelines.

Reported complications of epidural steroid injections are usually minor and transient—most frequently a headache, they reported. Major complications are rare and include aseptic meningitis, arachnoiditis, bacterial meningitis, epidural abscess, and conus medullaris syndrome.

“I think the risk-benefit ratio [is important],” Dr. David Borenstein, clinical professor of rheumatology at George Washington University and a rheumatologist specializing in low back pain, said in an interview. “People should consider exercises and oral therapies first, but if they're not getting better, this relatively noninvasive type of procedure, compared to surgical intervention, would be worthwhile to consider in the appropriate patient.”

“Epidural steroid injections are likely overused,” said Dr. J. D. Bartleson, a neurologist at the spine center of the Mayo Clinic in Rochester, Minn. “There is bias that they are extremely helpful, which is not borne out by the data,” he said in an interview. “I hope neurologists … will gain a better understanding of the modest help that epidural injections can provide.”