In reply: We thank Bogduk for his comments, but, based on previous reviews and some comparative studies,1-4 do not consider the transforaminal route to be clearly and consistently superior to the interlaminar route for radiculopathy.
Further, we note that when the evidence for transforaminal injections is isolated to placebo-controlled trials, the evidence is based on very few studies. The largest of these showed marginal short-term (2-week) improvement in the steroid and local anaesthetic group over the saline group for the primary outcome (leg pain), an effect that was not sustained by 4 weeks.5 Short-term relief is a common finding in studies that use local anaesthetic in the active group.
We consider the evidence for the effectiveness of transforaminal steroids over placebo to be neither strong nor consistent (within or between studies). We suggest that the gem in the bathwater be subject to more scrutiny and weighed against the risks and costs.
We thank Davies and colleagues for their comments about medial branch blocks and transforaminal epidural steroid injections. We have addressed the latter in our response above. Our article does not extend beyond the use of steroids to procedures such as neurotomy, so we have not commented on this procedure here.
Regarding medial branch blocks, we note that in a systematic review mentioned by Davies and colleagues, each of the randomised trials showed no significant difference in the response between groups treated with steroid and those treated with local anaesthetic alone.6 This reinforces our point that steroid injections in the spine have no specific therapeutic effect beyond natural history, the effect of any concomitant treatment or any placebo effect.
- 1. Gharibo CG, Varlotta GP, Rhame EE, et al. Interlaminar versus transforaminal epidural steroids for the treatment of subacute lumbar radicular pain: a randomized, blinded, prospective outcome study. Pain Physician 2011; 14: 499-511.
- 2. Rados I, Sakic K, Fingler M, Kapural L. Efficacy of interlaminar vs transforaminal epidural steroid injection for the treatment of chronic unilateral radicular pain: prospective, randomized study. Pain Med 2011; 12: 1316-1321.
- 3. Abdi S, Datta S, Trescot AM, et al. Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician 2007; 10: 185-212.
- 4. Pinto RZ, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med 2012; 157: 865-877.
- 5. Karppinen J, Malmivaara A, Kurunlahti M, et al. Periradicular infiltration for sciatica: a randomized controlled trial. Spine 2001; 26: 1059-1067.
- 6. Boswell MV, Colson JD, Sehgal N, et al. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician 2007; 10: 229-253.
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