Steroid Injections for Low Back Pain Looking Worse

The use of steroid injections for low back pain is increasing, even though the evidence supporting it is declining.  A newly published review and meta-analysis of the evidence for epidural corticosteroid injections for radiculopathy has found some early improvements in patient outcomes, but the effects were small and not sustained. The epidural corticosteroid injections had no clear effects in patients with spinal stenosis, wrote the authors of the review which appears in the Aug. 24 issue of the Annals of Internal Medicine. “Limited evidence suggests that epidural corticosteroid injections are not effective for spinal stenosis,” wrote the authors who were led by Roger Chou, MD, of Health and Science University in Portland, Ore.[[{"type":"media","view_mode":"media_crop","fid":"41172","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2265387969091","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4307","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":" ","typeof":"foaf:Image"}}]] Chou and colleagues conducted a systematic review and meta-analysis of data from Ovid MEDLINE (through May 2015), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, prior systematic reviews and reference lists. Their review is based on 30 placebo-controlled trials that were evaluated for epidural corticosteroid injections for radiculopathy and eight trials for spinal stenosis. For radiculopathy, epidural corticosteroids were associated with greater immediate-term improvement in pain (weighted mean difference on a scale of 0 to 100, -7.55 [95% CI, -11.4 to -3.74]; SOE, moderate) and function (standardized mean difference after exclusion of an outlier trial, -0.33 [CI, -0.56 to -0.09]; SOE, low), and short-term surgery risk (relative risk, 0.62 [CI, 0.41 to 0.92]; SOE, low).  The effects were below predefined minimum clinically important difference thresholds, and there were no longer-term benefits. Limited evidence showed no clear effects of technical factors, patient characteristics, or comparator interventions on estimates. There were no clear effects of epidural corticosteroid injections for spinal stenosis (SOE, low to moderate). Serious harms were rare, but harms reporting was suboptimal (SOE, low). “Our findings are consistent with those of several recent systematic reviews, despite variability in the studies included and methods used for data synthesis and meta-analysis,” the authors wrote. “In conclusion, epidural corticosteroid injections for radiculopathy are associated with immediate improvements in pain and might be associated with immediate improvements in function, but benefits are small and are not sustained, and there is no effect on long-term surgery risk. Evidence did not suggest that effectiveness varies on the basis of the approach used, corticosteroid, dose, or comparator. Limited evidence suggested that epidural orticosteroid injections are not effective for spinal stenosis.”   

References:

Chou R, Hashimoto R, Friedly J, et al. Reviews: Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Annals of Internal Medicine. Published online Aug. 24, 2015. doi:10.7326/M15-0934.