Steroid Injections for Lumbosacral Pain Have Limited Role

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 conclusion [of the AAN report] is that these injections are not overwhelmingly therapeutic, and I would say that is fair—they don't cure this problem—but they help certain patients, and I think when all is said and done, you have a better chance of helping someone [with epidural steroid injections] than harming them,” Dr. David Borenstein, a Washington rheumatologist who specializes in low back pain, said during an interview.

“When it comes down to the clinical situation, I think what's important is the risk benefit ratio,” said Dr. Borenstein, also of George Washington University, Washington.

The guidelines were drafted by the academy's (AAN's) Therapeutics and Technology Assessment Subcommittee and are 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 reported that all four studies were consistent regarding 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.

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, said Dr. Borenstein, during the interview.

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.

The authors noted that current data on the use of epidural steroid injections to treat cervical radicular pain are inadequate to make recommendations.

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 conclusion [of the AAN report] is that these injections are not overwhelmingly therapeutic, and I would say that is fair—they don't cure this problem—but they help certain patients, and I think when all is said and done, you have a better chance of helping someone [with epidural steroid injections] than harming them,” Dr. David Borenstein, a Washington rheumatologist who specializes in low back pain, said during an interview.

“When it comes down to the clinical situation, I think what's important is the risk benefit ratio,” said Dr. Borenstein, also of George Washington University, Washington.

The guidelines were drafted by the academy's (AAN's) Therapeutics and Technology Assessment Subcommittee and are 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 reported that all four studies were consistent regarding 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.

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, said Dr. Borenstein, during the interview.

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.

The authors noted that current data on the use of epidural steroid injections to treat cervical radicular pain are inadequate to make recommendations.

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 conclusion [of the AAN report] is that these injections are not overwhelmingly therapeutic, and I would say that is fair—they don't cure this problem—but they help certain patients, and I think when all is said and done, you have a better chance of helping someone [with epidural steroid injections] than harming them,” Dr. David Borenstein, a Washington rheumatologist who specializes in low back pain, said during an interview.

“When it comes down to the clinical situation, I think what's important is the risk benefit ratio,” said Dr. Borenstein, also of George Washington University, Washington.

The guidelines were drafted by the academy's (AAN's) Therapeutics and Technology Assessment Subcommittee and are 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 reported that all four studies were consistent regarding 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.

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, said Dr. Borenstein, during the interview.

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.

The authors noted that current data on the use of epidural steroid injections to treat cervical radicular pain are inadequate to make recommendations.