Epidural Steroid Injections Have Limited Effectiveness for Sciatica

Review and meta-analysis of clinical trials on the efficacy of epidural corticosteroid injections by Australian scientists revealed the limited effectiveness of this invasive procedure.

Epidural corticosteroid injections provide limited benefits for patients with sciatica raising questions about the value of such treatment, according to the investigators of a study published in the Annals of Internal Medicine.

Epidural corticosteroid injection (ESI) is a method of relieving pain associated with leg, back, neck and arm caused by inflamed spinal nerves, especially in those people suffering from spinal stenosis, spondylolysis, herniated disc, degenerative disc and sciatica.

Treatment and Exercises for Back Pain
Most cases of back pain can be managed with exercises that help to strengthen the muscles of the back. Very few cases will require operative treatment like surgery for slipped disc to release an entrapped nerve.

Sciatica is a common type of low back pain that radiates down through the hips and buttocks and down the legs – typically only on one side of the body. The pain varies from a mild ache to a sharp burning sensation. Some people experience tingling or numbness or muscle weakness in the affected leg. Sciatica generally occurs when a herniated disc or a bone spur on the spine compresses part of the nerve causing inflammation and pain. Although the pain mostly resolves in a few weeks with conservative care for sciatica, invasive procedures such as ESI is resorted to when the conservative care options fail to offer relief even after six weeks of treatment.

Since existing reviews and guidelines on the efficacy of ESI treatment for sciatica are conflicting, Rafael Zambelli Pinto, of the Sydney Medical School at the University of Sydney, and his colleagues reviewed and conducted meta-analysis of 23 clinical trials to determine the efficacy of epidural corticosteroid injections for sciatica compared with placebo.

They chose the parameters of leg pain, back pain, and disability, which they rated on a scale of zero (no pain or disability) to 100 (worst possible pain or disability). Pain being a subjective sensation, it is difficult to evaluate objectively in clinical trials. Thresholds for clinically important change in the range of 10 to 30 were thus considered for these outcomes. Short term effects ranging from more than 2 weeks but less than 3 months or less and long term effects of 12 months or more were calculated.

Low Back Pain - Spinal Stenosis and Disc pain
Spinal stenosis usually presents with pain radiating beyond the back to the buttocks, thighs or lower legs. The pain is worsened with extension of the lumbar spine and improves with flexion of spine.

The results of the meta-analysis showed a small, but statistically significant, effect of epidural corticosteroid injections for short-term leg pain and for short-term disability as compared with placebo. But the follow up a year later showed that the long-term effects of corticosteroid injections were not significantly different from placebo. Similarly, ESIs showed no significant benefits in relieving back pain associated with sciatica.

‘Despite the statistically significant short-term effects on pain and disability favoring the intervention over the placebo, the small size of the treatment effect challenges the clinical utility of this procedure’, noted the authors.

‘Until the current evidence changes we would recommend patients with acute sciatica receive a course of conservative care before any invasive treatment approach is considered. This conservative care should preferably follow evidence-based guidelines, such as those for neuropathic pain’, they suggested.

‘For those patients who have persistent and disabling sciatica symptoms, epidural corticosteroids and surgery are the available treatment options, with short-term effects that need to be considered in the shared decision-making process.’

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Source: Pinto RZ, Maher CG, Ferreria ML, Hancock M, Oliveira VC, McLachlan AJ, Koes B, Ferreira PH. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Annals of Internal Medicine 2012; doi: 10.7326/0003-4819-157-12-201212180-00564.

Source-Medindia