Volume 199 - Issue 11
Time to reconsider steroid injections in the spine?
Authors: Ian A Harris and Rachelle Buchbinder
Med J Aust 2013; 199 (11): 754. || doi: 10.5694/mja13.11159
Published online: 16 December 2013
Published online: 16 December 2013
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.
Competing interests
No relevant disclosures.
References
- 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.
- 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.
- 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.
- 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. CBBDDHHA
- Karppinen J, Malmivaara A, Kurunlahti M, et al. Periradicular infiltration for sciatica: a randomized controlled trial. Spine 2001; 26: 1059-1067. CBBBIEBI
- 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. CBBHDHJI
Motor Neuron Disease Mortality Trends in Australia From 1986 to 2023: A Population-Based Study
Carol M. Y. Lee, Rupendra N. Shrestha, Julian Gold, Mark Stevenson, Kelly L. Williams, Lyndal Henden, Sandrine K. K. Chan Moi Fat, Zoe Zussa, Amanda Wright, Martin Jude, Mark A. S. Laidlaw, Willem J. R. Fokkink, Dominic B. Rowe
Mild traumatic brain injury and concussion and persisting post‐concussion symptoms: new guidelines to support evidence‐based assessment and management in Australia and Aotearoa New Zealand
Karen M Barlow, Jennie L Ponsford, Alice Theodom, Gill Cowen, Gavin A Davis, Vicki Anderson, Franz E Babl, David Cole, Jennifer Cullen, Stuart R Dalziel, Melinda Fitzgerald, Howard Flavell, Caroline Yates, Rebecca Kimble, John H Olver, Rhonda Orr, Mark Ralfe, Michael Rose, Nick Rushworth, Julia Treleaven, Gary Browne, Nathan Delang, Sarah Harris, Gary Mitchell, Sean Tweedy
The prevalence of and variation in indicators of the quality and safety of long term aged care in Australia, 2019: a cross‐sectional population‐based study
Tesfahun C Eshetie, Gillian E Caughey, Catherine Lang, Olivia Ryan, Renuka Visvanathan, Craig Whitehead, Keith Evans, Janet K Sluggett, Jyoti Khadka, Carolyn Dawkins, Helena Williams, Miranda Starke, Sara Blunt, Anne Liddell, Megan Corlis, Anna Sheppeard, Penelope Lello, Marilyn Thien, Steven L Wesselingh, Maria C Inacio
Health and economic benefits of improving pre‐hospital identification of stroke in Australian women: a modelling study
Thomas Gadsden, Lei Si, Emily R Atkins, Cheryl Carcel, Xia Wang, Stephen Jan, Mark Woodward, Laura E Downey
Symptom burden, quality of life, and diagnostic journey of people with postural orthostatic tachycardia syndrome, Australia, 2021–24: a descriptive patient registry data study
Marie‐Claire Seeley, Gemma Wilson, Eric Ong, Amy Langdon, Jonathan Chieng, Danielle Bailey, Kristina Comacchio, Amanda Page, Dennis H Lau, Celine Gallagher
The intersection of rurality and dementia prevalence in Australia for Aboriginal and Torres Strait Islander and non‐Indigenous peoples
Antonia J Clarke, Marwan Ahmed, Judith M Katzenellenbogen, John Towney (Wiradjuri), Anna H Balabanski, Adrienne Withall (Dharawal Yuin), Kylie Radford, Amy Brodtmann