Epidural Steroids A Comprehensive, Evidence-Based Review
ABSTRACT Epidural steroid injections (ESIs) are the most widely utilized pain management procedure in the world, their use supported by more than 45 placebo-controlled studies and dozens of systematic reviews. Despite the extensive literature on the subject, there continues to be considerable controversy surrounding their safety and efficacy. The results of clinical trials and review articles are heavily influenced by specialty, with those done by interventional pain physicians more likely to yield positive findings. Overall, more than half of controlled studies have demonstrated positive findings, suggesting a modest effect size lasting less than 3 months in well-selected individuals. Transforaminal injections are more likely to yield positive results than interlaminar or caudal injections, and subgroup analyses indicate a slightly greater likelihood for a positive response for lumbar herniated disk, compared with spinal stenosis or axial spinal pain. Other factors that may increase the likelihood of a positive outcome in clinical trials include the use of a nonepidural (eg, intramuscular) control group, higher volumes in the treatment group, and the use of depo-steroid. Serious complications are rare following ESIs, provided proper precautions are taken. Although there are no clinical trials comparing different numbers of injections, guidelines suggest that the number of injections should be tailored to individual response, rather than a set series. Most subgroup analyses of controlled studies show no difference in surgical rates between ESI and control patients; however, randomized studies conducted by spine surgeons, in surgically amenable patients with standardized operative criteria, indicate that in some patients the strategic use of ESI may prevent surgery.
- Regional anesthesia and pain medicine 05/2013; 38(3):171-172. DOI:10.1097/AAP.0b013e31829005f5 · 2.12 Impact Factor
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ABSTRACT: Neuropathic pain (NP) is often refractory to pharmacologic and non-interventional treatment. On behalf of the International Association for the Study of Pain Neuropathic Pain Special Interest Group (NeuPSIG), the authors evaluated systematic reviews, clinical trials, and existing guidelines for the interventional management of NP. Evidence is summarized and presented for neural blockade, spinal cord stimulation (SCS), intrathecal medication, and neurosurgical interventions in patients with the following peripheral and central NP conditions: herpes zoster and postherpetic neuralgia (PHN); painful diabetic and other peripheral neuropathies; spinal cord injury NP; central post-stroke pain; radiculopathy and failed back surgery syndrome (FBSS); complex regional pain syndrome (CRPS); and trigeminal neuralgia and neuropathy. Due to the paucity of high-quality clinical trials, no strong recommendations can be made. Four weak recommendations based on the amount and consistency of evidence, including degree of efficacy and safety, are: (1) epidural injections for herpes zoster; (2) steroid injections for radiculopathy; (3) SCS for FBSS; and (4) SCS for CRPS type 1. Based on the available data, we recommend not to use sympathetic blocks for PHN nor RF lesions for radiculopathy. No other conclusive recommendations can be made due to the poor quality of available of data. Whenever possible, these interventions should either be part of randomized clinical trials or documented in pain registries. Priorities for future research include randomized clinical trials; long-term studies; and head-to-head comparisons among different interventional and non-interventional treatments.Pain 06/2013; 154(11). DOI:10.1016/j.pain.2013.06.004 · 5.84 Impact Factor
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ABSTRACT: Epidural steroid injections (ESIs) are the most commonly performed intervention in pain clinics across the USA and worldwide. In light of the growing use of ESIs, a recent spate of highly publicized infectious complications, and increasing emphasis on cost-effectiveness, the utility of ESI has recently come under intense scrutiny. This article provides an evidence-based review of ESIs, including the most up-to-date information on patient selection, comparison of techniques, efficacy, and complications. The data strongly suggest that ESIs can provide short-term relief of radicular symptoms but are less convincing for long-term relief, and mixed regarding cost-effectiveness. Although some assert that transforaminal ESIs are more efficacious than interlaminar ESIs, and that fluoroscopy can improve treatment outcomes, the evidence to support these assertions is limited. The cost-effectiveness of ESI is the subject of great debate, and similar to efficacy, the conclusions one draws appear to be influenced by specialty. Because of the wide disparities regarding indications and utilization, it is likely that indiscriminate use is cost-ineffective, but that judicious use in well-selected patients can decrease healthcare utilization. More research is needed to better refine selection criteria for ESI, and to determine which approach, what dose, and how many injections are optimal.Current opinion in anaesthesiology 06/2013; 26(5). DOI:10.1097/ACO.0b013e3283628e87 · 2.53 Impact Factor