Volume 199 - Issue 11
Time to reconsider steroid injections in the spine?
Author: Nikolai Bogduk
Med J Aust 2013; 199 (11): 752. || doi: 10.5694/mja13.11077
Published online: 16 December 2013
Published online: 16 December 2013
To the Editor: In their review, Harris and Buchbinder call for a ban on all spinal injections of steroids.1 These injections are not a singular procedure; they differ by indications, technique, and the evidence that serves each.
For the treatment of low back pain, no evidence supports the use of epidural steroids, and intra-articular injections of steroids are clearly no more effective than sham therapy.2 Disavowing ...
To the Editor: In their review, Harris and Buchbinder call for a ban on all spinal injections of steroids.1 These injections are not a singular procedure; they differ by indications, technique, and the evidence that serves each.
For the treatment of low back pain, no evidence supports the use of epidural steroids, and intra-articular injections of steroids are clearly no more effective than sham therapy.2 Disavowing this treatment is, therefore, justified. Ironically, the treatment with the greatest success rate and longest duration of success for chronic low back pain is injection of normal saline.3
For the treatment of radicular pain, multiple studies have shown that epidural injections of steroids are no more effective than sham treatment.4,5 One study showed marginal superiority over placebo at 3 weeks,6 but by 30 days, the number needed to treat is 100.7 Yet, the Faculty of Pain Medicine still endorses this intervention.8
The evidence is different for transforaminal (TF) injection of steroids. The success rate of TF injection of steroids is significantly greater than that of TF injection of bupivacaine or saline, or intramuscular injection of steroids or saline.9 Furthermore, TF steroid therapy has a surgery-sparing effect and is cost-effective.10 A blanket ban on steroid injections would deny patients with radicular pain the only proven alternative to surgery.
The baby’s bathwater is distinctly polluted, but within it is a gem. Before throwing it out, the water needs to be carefully filtered.
Competing interests
I am a Board member of the International Spine Intervention Society; while I am an exponent of the procedures in question, I derive no income from them.
References
- Harris IA, Buchbinder R. Time to reconsider steroid injections in the spine? Med J Aust 2013; 199: 237. CBBEIBAI
- Bogduk N. A narrative review of intra-articular corticosteroid injections for low back pain. Pain Med 2005; 6: 287-296. CBBEHJAA
- Bogduk N. Pharmacological alternatives for the alleviation of back pain. Expert Opin Pharmacother 2004; 5: 2091-2098. CBBHGAEJ
- Bogduk N. Epidural steroid injection. In: Fishman SM, Ballantyne JC, Rathmell JP, editors. Bonica’s management of pain. 4th ed. Philadelphia: Wolters Kluwer, 2010: 1423-1437. CBBBACCC
- International Spine Intervention Society. Lumbar interlaminar epidural access. In: Bogduk N, editor. Practice guidelines for spinal diagnostic and treatment procedures. San Francisco: International Spine Intervention Society, 2013: 539-557. CBBGJDDB
- Price C, Arden N, Coglan L, Rogers P. Cost-effectiveness and safety of epidural steroids in the management of sciatica. Health Technol Assess 2005; 9: 1-74. CBBEGBJF
- Valat JP, Giraudeau B, Rozenberg S, et al. Epidural corticosteroid injections for sciatica: a randomised, double-blind, controlled clinical trial. Ann Rheum Dis 2003; 62: 639-643. CBBEEBII
- Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists. PM03: Lumbar epidural administration of corticosteroids. 2002; Aug. http://www.anzca.edu.au/fpm/resources/professional-documents/documents/pm3 (accessed Nov 2013).
- Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med 2010; 11: 1149-1168. i1142892
- MacVicar J, King W, Landers M, Bogduk N. The effectiveness of lumbar transforaminal injection of steroids: a comprehensive review with systematic analysis of the published data. Pain Med 2013; 14: 14-48. i1142896