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Acute Pain | Chronic Pain | General

Epidural corticosteroids for back pain

Clinical bottom line:

Epidural administration of corticosteroids is effective in the management of sciatica, with a number-needed-to-treat of 7.3 (4.7 to 16) for greater than 75% pain relief in the short-term (1-60 days), and a number-needed-to-treat of 13 (6.6 to 314) for greater than 50% pain relief in the long-term (12 weeks to one year).


Epidural corticosteroids are commonly used in the treatment of low back pain and sciatica, although steroids are not currently licensed for epidural use in the UK. Steroids have a number of anti-inflammatory properties and an inhibitory effect on C-fibre conduction.

Systematic review

The original review by Watts et al has been updated and presented differently by McQuay & Moore:

McQuay H.J,Moore R.A. Chapter 27, Transcutaneous electrical nerve stimulation (TENS) in chronic pain. In: An evidence-based resource for pain relief. Oxford. Oxford University Press, 1998

McQuay H. J, Moore R. A. Epidural steroids for sciatica. Anaesthesia and Intensive Care 1996 24:284-5 (Letter).

Watts R. W, Silagy C. A. A meta-analysis on the efficacy of epidural corticosteroids in the treatment of sciatica. Anaesthesia and Intensive Care. 1995; 23: 564-569.

Inclusion criteria were randomised, double-blind trials of steroid treatment of sciatica; caudal or lumbar epidural.

Data were extracted from original trials and the number of patients improved on active and control were used to calculate odds ratios, relative benefits and numbers-needed-to-treat (NNT) (all with 95% confidence intervals).

Findings

Active treatments included epidural methylprednisolone 80 mg (ten trials), triamcinalone 80 mg (one trial) and hydrocortisone 25 mg (one trial).

Short-term relief

Eleven trials reported on short-term pain relief. Only three of 11 trials showed significant benefit of epidural over placebo. However, when data were pooled, there was an overall significant benefit of 1.5 (1.2 to 1.9). The NNT for greater than 75% pain relief in the short-term (1-60 days) was 7.3 (4.7 to 16).

Figure 1: Epidural steroids for short-term relief (1 to 60 days)

Long-term relief

Six trials reported on long-term pain relief. Only one trial showed significant benefit of epidural over placebo. However, when data were pooled, there was an overall significant benefit of 1.3 (1.1 to 1.5). The NNT for greater than 50% pain relief in the long-term (12 weeks to one year) was 13 (6.6 to 314).


Figure 2: Epidural steroids for long-term relief (12 to 52 weeks)

Adverse effects

Original reports did not compare adverse effects in the active with the placebo groups. Based on seven trials (431 patients), 2.5% suffered dural taps, 2.3% transient headache, 1.9% transient increase in pain, 0.2% irregular menstrual cycle. Long-term effects were not covered in original reports. One reviewer reported evidence from other sources for the risk of neurological sequelae after epidural as 1 in 5,000.

Further References

The following reference is covered by the current review:

Koes B. W, Scholten R. P. M, Mens J. M. A, Bouter L. M. Efficacy of epidural steroid injections for low-back pain and sciatica: a systematic review of randomized clinical trials. Pain. 1995; 63: 279-88.

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