Epidural steroid injections in the management of low-back pain with radiculopathy: An update of their efficacy and safety

Rheumatology Department, Hôpital Beaujon, Clichy, France.
European Spine Journal (Impact Factor: 2.07). 09/2011; 21(2):204-13. DOI: 10.1007/s00586-011-2007-z
Source: PubMed


Epidural steroid injections (ESIs) have been widely used for over 50 years in the treatment of low-back pain with radiculopathy. Most interventional pain physicians strongly believe in their efficacy and safety. Recent Cochrane systematic reviews have disclosed controversial results and have questioned the effectiveness of ESIs. Moreover, a few neurological adverse events have been reported recently.
A literature search of systematic reviews analysing the effectiveness and complications of ESIs was carried out. The scientific quality of the reviews was assessed using the validated index of Oxman and Guyatt. We relied on data abstraction and quality ratings of the placebo-controlled trials as reported by high-quality systematic reviews.
Two types of systematic reviews were found. The Cochrane high-quality systematic reviews combining the three approaches and different pathologies were predominantly non-conclusive. The second type of review, emanating from the US Evidence-based Practice Centers, distinguishing between the routes of administration and between the principal pathologies found a moderate short-term benefit of ESIs versus placebo in patients with disc herniation and radiculitis, in keeping with the clinical experience. ESIs are generally well tolerated and most complications are related to technical problems. Cases of paraplegia, complicating the foraminal route and related to the violation of a radiculomedullary artery, have been recently reported. They are predominantly observed in previously operated patients.
Epidural steroid injections have a moderate short-term effect in the management of low-back pain with radiculopathy. Severe neurological complications are exceptional, but call for research for alternative approaches to the foramen as well as for means to detect an eventual arterial injury.

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    • "It has, however, been shown that therapeutic doses of ASOs can be delivered intrathecally in nonhuman primates [80, 81]. This approach, although more invasive than systemic delivery, is routinely used for common clinical indications such as steroid, analgesia, or anaesthesia delivery [82–84] and suggests that this route may be a clinically feasible option. Delivery into the cerebral ventricles is also a possible option, since they contain the cerebrospinal fluid (CSF) that circulates around the brain and spinal cord approximately 3 times a day [81, 85]. "
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    • "Epidural injection of glucocorticoids has become a relatively common treatment for low back pain that does not respond to more conservative treatments. However, randomized clinical trials of efficacy of epidural steroid injections for various forms of low back pain have had mixed results [59,60]. A relatively common finding is that they are effective in the short term (usually on the order of a month) but not in the longer term (e.g. "
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    ABSTRACT: Chronic low back pain is a major cause of disability and health care costs. Current treatments are inadequate for many patients. A number of preclinical models have been developed that attempt to mimic aspects of clinical conditions that contribute to low back pain. These involve application of nucleus pulposus material near the lumbar dorsal root ganglia (DRG), chronic compression of the DRG, or localized inflammation of the DRG. These models, which are primarily implemented in rats, have many common features including behavioral hypersensitivity of the hindpaw, enhanced excitability and spontaneous activity of sensory neurons, and locally elevated levels of inflammatory mediators including cytokines. Clinically, epidural injection of steroids (glucocorticoids) is commonly used when more conservative treatments fail, but clinical trials evaluating these treatments have yielded mixed results. There are relatively few preclinical studies of steroid effects in low back pain models. One preclinical study suggests that the mineralocorticoid receptor, also present in the DRG, may have pro-inflammatory effects that oppose the activation of the glucocorticoid receptor. Although the glucocorticoid receptor is the target of anti-inflammatory steroids, many clinically used steroids activate both receptors. This could be one explanation for the limited effects of epidural steroids in some patients. Additional preclinical research is needed to address other possible reasons for limited efficacy of steroids, such as central sensitization or presence of an ongoing inflammatory stimulus in some forms of low back pain.
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