MARCH 29, 2016
Ensuring diagnosis matches the indication is key, experts emphasize
Properly used, epidural spinal injections are an effective way to manage chronic spinal pain, according to the results of a systematic review of the available literature.
Published in Pain Physician (2015;18:E939-E1004), the study’s investigators, including first author and that journal’s editor-in-chief Alan Kaye, MD, PhD, wrote that their findings show “the efficacy of epidural injections in managing a multitude of chronic spinal conditions.”
Dr. Kaye, who also chairs the Department of Anesthesia at the Louisiana State University School of Medicine, in New Orleans, added that “as a clinician, I have seen the benefits of epidural steroid injections over the last 25 years,” and that the results of the review did not surprise him.
The researchers included 52 randomized controlled trials in their review, pulled from PubMed searches for studies published between 1966 and August 2015, as well as from Cochrane reviews and manual searches of bibliographies of primary and review articles. They assessed each article using both Cochrane review criteria and the Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment, and conducted a best-evidence synthesis based on the qualitative level of evidence (Level I through V, with I being the highest quality).
The analysis found Level II to III evidence to support the use of epidural injections in managing a number of painful spinal conditions, such as disk herniation, axial or diskogenic pain, central spinal stenosis and postsurgery syndrome. Level II indicates “Evidence obtained from at least one relevant high-quality randomized controlled trial or multiple relevant moderate- or low-quality randomized controlled trials,” and Level III denotes “Evidence obtained from at least one relevant moderate- or low-quality randomized controlled trial with multiple relevant observational studies.”
The authors expect that the findings of this review will have a significant influence on clinical practice, said Laxmaiah Manchikanti, MD, medical director of the Pain Management Centers of Paducah, Ky., and founder and chairman of the American Society of Interventional Pain Physicians, and the study’s second author.
“We expect the results to provide more validity to the value of epidural injections—not necessarily just steroids—to provide appropriate value in managing chronic spinal pain, with or without extremity pain,” Dr. Manchikanti said.
He added that previous studies concluding epidural injections to be ineffective are fundamentally flawed, because they used a local anesthetic injection as a placebo, “even though there are now two systematic reviews”—one by Manchikanti et al. (Surg Neurol Int 2015;6:S194-S235) and one by Bicket et al. (Anesthesiology 2013;119:907-931)—“which show that local anesthetics may be even better than the steroids themselves.” Using a treatment with equal or greater efficacy as a baseline, Dr. Manchikanti said, ensured a finding that epidural injections are not effective.
Others in the field agreed with the findings of the review. Timothy Deer, MD, president and CEO of the Center for Pain Relief Inc., in Charleston, W.Va., said epidural steroids “are helpful in some cases,” but cautioned they should be used carefully, “for the right populations and for particular symptoms,” adding that they sometimes were overused in the past.
Dr. Deer emphasized the role of epidural injections as just one tool in a comprehensive interventional pain strategy.
“The problem is, with short-acting epidural steroid injections, they last only a few weeks,” Dr. Deer said. “So we have a few critical points here. You have to go to physical therapy [after] you get the injection to gain any long-term benefits. And we usually couple that with home exercise or some form of surgical rehabilitation.”
In the long term, “what we really need is longer-acting steroids by some other mechanism,” Dr. Deer said. “Epidural steroids can certainly help people avoid back surgery, but that’s only when [they are] coupled with physical rehabilitation.”
—Ajai Raj