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Epidural Steroids Ineffective for Sciatica

#1 User is offline   hukildaspida 

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Posted 15 November 2012 - 12:38 AM

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http://www.medpageto...Neurology/35927

Epidural Steroids Ineffective for Sciatica

By Charles Bankhead, Staff Writer, MedPage Today
Published: November 13, 2012
Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania
Action Points

This study reviewed randomized placebo-controlled trials to determine the efficacy of epidural corticosteroid injections for sciatica.
The pooled results showed a significant, though small, effect of epidural corticosteroid injections compared to placebo for leg pain in the short term.

Patients with sciatica derived minimal benefit from epidural corticosteroids, raising questions about the value of the treatment for the condition, authors of a meta-analysis concluded.

Pooled results of 23 clinical trials showed a small but statistically significant short-term improvement in leg pain with epidural injection of corticosteroids versus placebo, according to Rafael Zambelli Pinto, MSc, of the University of Sydney in Australia, and coauthors.


Long-term effects were even more modest and did not achieve statistical significance. Epidural corticosteroids had no effect on back pain, they reported online in Annals of Internal Medicine.

"The small effects were less than the proposed thresholds for clinically important change in pain and disability, which range from a reduction of 10 to 30 points on a 0 to 100 scale," the authors wrote of their findings.

"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," they added. "This conservative care should preferably follow evidence-based guidelines, such as those for neuropathic pain.

"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."

Generally considered a condition with a self-limiting course, sciatica can persist and progress to disabling symptoms in some patients. Persistent, severe sciatica confers a four-fold increased risk of back surgery compared with patients who have persistent nonspecific low-back pain, the authors noted in their introduction.

Steroid treatment for back pain has been prominent in the news recently due to a fungal meningitis outbreak among back pain patients receiving tainted steroid injections from a Massachusetts compounding company.

Most clinical authorities recommend conservative treatment as the initial approach to sciatica, but patient series and case reports have suggested that pharmacologic and non-interventional therapies are ineffective or have only small effects.

Consequently, use of more invasive treatment, such as epidural corticosteroids, has become increasingly common as initial or early therapy, the authors continued.

Recent clinical guidelines and systematic reviews have reflected inconsistent views about the quality of evidence for epidural corticosteroid injection for sciatica.

"An important barrier to interpreting the results of many clinical trials investigating the use of epidural corticosteroid injections is that the comparator is often an active treatment of unknown effectiveness, rather than an inert placebo," the authors wrote.

"Another limitation is that even those guidelines recommending shared decision-making when considering the epidural corticosteroid injections as a short-term treatment options have failed to consider the size of the treatment effects, expressed in terms of patient-relevant outcomes."

Moreover, previous studies and reviews failed to take into account the efficacy of all three approaches to epidural injections: caudal, interlaminar, and transforaminal.

To address the limitations of available evidence, Pinto and colleagues performed a systematic review of reported studies of epidural corticosteroid injections for persistent sciatica. They limited the search to placebo-controlled trials that permitted use of any of the three approaches to epidural injection.

Eligibility criteria did not stipulate a symptom duration, but study participants' symptomatology was classified as acute (<6 weeks), subacute (6 to 12 weeks), chronic (≥12 weeks), or mixed. Pinto and colleagues excluded trials that included patients who had undergone surgery for sciatica or who had sciatic symptoms associated with spinal canal stenosis.

Investigators converted reported scores for pain intensity and disability to a scale of 0 (no pain or disability) to 100 (worst possible pain or disability). They calculated results for short-term (2 weeks to 3 months) and long-term (≥12 months) follow-up.

The final analyses comprised 25 publications and 23 clinical trials. The meta-analysis of short-term outcomes included 14 trials and 1,316 patients. Pooled data showed a mean decrease in leg-pain scores of 6.2 for epidural corticosteroids versus placebo. Analysis of pooled data from six trials showed no difference between treatment groups for back pain.

Short-term disability improved modestly but significantly, as reflected in a mean difference of 3.1 in favor of epidural corticosteroids in an analysis of 10 trials that included 1,154 patients.

Analyses of long-term outcomes showed no significant differences between treatment groups for leg pain, back pain, or disability.

Studies included in the analyses of short- and long-term follow-up met criteria for high-quality evidence.

"The small size of the treatment effects raises questions about the clinical utility of this procedure in the target population," Pinto and co-authors wrote in conclusion.

The authors had no relevant disclosures.

Primary source: Annals of Internal Medicine
Source reference:
Pinto RZ, et al "Efficacy of epidural corticosteroid injections in the management of sciatica: Systematic review and meta-analysis of placebo-controlled trials" Ann Intern Med 2012.

Add Your Knowledge ™

Charles Bankhead

Staff Writer

Working from Houston, home to one of the world's largest medical complexes, Charles Bankhead has more than 20 years of experience as a medical writer and editor. His career began as a science and medical writer at an academic medical center. He later spent almost a decade as a writer and editor for Medical World News, one of the leading medical trade magazines of its era. His byline has appeared in medical publications that have included Cardio, Cosmetic Surgery Times, Dermatology Times, Diagnostic Imaging, Family Practice, Journal of the National Cancer Institute, Medscape, Oncology News International, Oncology Times, Ophthalmology Times, Patient Care, Renal and Urology News, The Medical Post, Urology Times, and the International Medical News Group newspapers. He has a BA in journalism and MA in mass communications, both from Texas Tech University.
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#2 User is offline   hukildaspida 

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Posted 15 November 2012 - 12:41 AM

http://annals.org/ar...ticleID=1390546

Reviews | 13 November 2012

Epidural Corticosteroid Injections in the Management of Sciatica: A Systematic Review and Meta-analysis
ONLINE FIRST
Rafael Zambelli Pinto, MSc; Chris G. Maher, PhD; Manuela L. Ferreira, PhD; Mark Hancock, PhD; Vinicius C. Oliveira, MSc; Andrew J. McLachlan, PhD; Bart Koes, PhD; and Paulo H. Ferreira, PhD
[+] Article and Author Information
Ann Intern Med. 13 November 2012
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Comments

Background: Existing guidelines and systematic reviews provide inconsistent recommendations on epidural corticosteroid injections for sciatica. Key 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.

Purpose: To determine the efficacy of epidural corticosteroid injections for sciatica compared with placebo.

Data Sources: International Pharmaceutical Abstracts, PsycINFO, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL.

Study Selection: Randomized, placebo-controlled trials assessing the efficacy of epidural corticosteroid injections in participants with sciatica.

Data Extraction: 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). Thresholds for clinically important change in the range of 10 to 30 have been proposed for these outcomes. Effects were calculated for short-term (>2 weeks but ≤3 months) and long-term (≥12 months) follow-up.

Data Synthesis: Data were pooled with a random-effects model, and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used in summary conclusions. Twenty-five published reports (23 trials) were included. The pooled results showed a significant, although small, effect of epidural corticosteroid injections compared with placebo for leg pain in the short term (mean difference, −6.2 [95% CI, −9.4 to −3.0]) and also for disability in the short term (mean difference, −3.1 [CI, −5.0 to −1.2]). 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.

Limitation: The review included only English-language trials and could not incorporate dichotomous outcome measures into the analysis.

Conclusion: 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.

Primary Funding Source: None.



This article was published at www.annals.org on 13 November 2012.

From The George Institute for Global Health, Sydney Medical School, University of Sydney, Macquarie University, Centre for Education and Research on Ageing, and Concord Hospital, Sydney, Australia, and Erasmus Medical Centre, Rotterdam, the Netherlands.

Editor's Note: This is an online-first article. This version may differ from the print version.

Financial Support: Mr. Pinto is a PhD student supported by Capes Foundation, Ministry of Education of Brazil. Dr. Maher is supported by a research fellowship funded by the Australian Research Council.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1381.

Requests for Single Reprints: Rafael Zambelli Pinto, MSc, PO Box M201, Missenden Road, Camperdown, Sydney, New South Wales 2050, Australia; e-mail, [email protected]

Current Author Addresses: Drs. Pinto, Maher, and M.L. Ferreira: PO Box M201, Missenden Road, Camperdown, Sydney, New South Wales 2050, Australia.

Dr. Hancock: 75 Talavera Road, Macquarie Park, New South Wales 2109, Australia.

Drs. P.H. Ferriera and Oliveira: 75 East Street, Faculty of Health Sciences, University of Sydney, Lidcombe, New South Wales 2141, Australia.

Dr. McLachlan: Pharmacy Building (A15), Science Road, Faculty of Pharmacy, University of Sydney, New South Wales 2006, Australia.

Dr. Koes: Department of General Practice, Erasmus Medical Centre, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands.

Author Contributions: Conception and design: R.Z. Pinto, C.G. Maher, M.L. Ferreira, M. Hancock, V.C. Oliveira, B. Koes, P.H. Ferreira.

Analysis and interpretation of the data: R.Z. Pinto, C.G. Maher, M.L. Ferreira, V.C. Oliveira, A.J. McLachlan, B. Koes, P.H. Ferreira.

Drafting of the article: R.Z. Pinto, C.G. Maher, A.J. McLachlan.

Critical revision of the article for important intellectual content: R.Z. Pinto, C.G. Maher, M.L. Ferreira, M. Hancock, V.C. Oliveira, A.J. McLachlan, B. Koes, P.H. Ferreira.

Final approval of the article: R.Z. Pinto, C.G. Maher, M.L. Ferreira, M. Hancock, V.C. Oliveira, A.J. McLachlan, B. Koes, P.H. Ferreira.

Statistical expertise: R.Z. Pinto, C.G. Maher, M.L. Ferreira.

Administrative, technical, or logistic support: C.G. Maher, P.H. Ferreira.

Collection and assembly of data: R. Zambelli Pinto, C.G. Maher, M. Hancock, V.C. Oliveira.


https://www.acponlin...?msNum=M12-1381


Annals now requires authors who submit manuscripts for consideration to complete the International Committee of Medical Journal Editors (ICMJE) conflict of interest disclosure form. This form, which is discussed further at www.icmje.org/format.pdf, is intended to facilitate detailed reporting of conflicts of interest and standardize the format of reporting across ICMJE member journals. Individual forms for an article are published online on the day of publication for readers to access disclosure information. The forms for this article are listed below.
ICMJE Forms:

Pinto-73718.pdf
Oliveira-74384.pdf
Ferreira-74383.pdf
Maher-74381.pdf
McLachlan-74385.pdf
Ferreira-74382.pdf
Hancock-84816.pdf
Koes-22989.pdf



©2011 American College of Physicians.
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