Epidural steroid injections reported to be ineffective in relieving sciatica
Epidural steroid injections for back pain have risen to the forefront of public attention following the outbreak of deadly fungal meningitis. To date, the Centers for Disease Control and Prevention (CDC) has reported the number of cases has grown to 438 cases, including 32 deaths, in 19 states. Now, a new study reports that epidural steroid injections are ineffective in relieving sciatica. An international team of researchers published their findings online on November 13 in the Annals of Internal Medicine.
The authors noted that existing guidelines and review studies have provided inconsistent recommendations on epidural corticosteroid injections for sciatica. They point out that limitations of existing reviews are the inclusion of trials with active controls of unknown efficacy and failure to provide an estimate of the size of the treatment effect. Therefore, the researchers conducted a study to determine the efficacy of epidural corticosteroid injections for sciatica compared with a placebo.
The researchers obtained their data from: International Pharmaceutical Abstracts, PsycINFO, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL. Included in the study were randomized, placebo-controlled trials assessing the efficacy of epidural corticosteroid injections in patients with sciatica. Two independent reviewers extracted data and assessed risk of bias. Leg pain, back pain, and disability were converted to common scales from 0 (no pain or disability) to 100 (worst possible pain or disability). They note that thresholds for clinically important change in the range of 10 to 30 have been proposed for these outcomes. Effects were calculated for short-term (less than two weeks but less than or equal to three months) and long-term (more than 12 months) follow-up.
The data were pooled with a random-effects model, and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used in summary conclusions. (A random effects model is a method of analyzing panel that assumes no individual-specific effects; thus, its goal is to determine results free from bias.) A total of 25 published reports (23 trials) were included. The pooled results revealed a significant, although small, effect of epidural corticosteroid injections compared with placebo for leg pain in the short term and also for disability in the short term. The long-term pooled effects were smaller and not statistically significant. The overall quality of evidence according to the GRADE classification was rated as high quality.
The authors concluded that the available evidence suggests that epidural corticosteroid injections offer only short-term relief of leg pain and disability for patients with sciatica. The small size of the treatment effects, however, raises questions about the clinical utility of this procedure in the target population.
Take home message:
This study notes that steroid injections only offer short-term relief of back pain and relatively ineffective for long-term relief. Thus, the 13,000 individuals who received steroid injections with possible fungal contamination not only were not only exposed to a risk of serious illness or death but also received a treatment with unlikely long-term benefits.
Reference: Annals of Internal Medicine