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

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Abstract

Introduction

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.

Methods

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.

Results

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.

Conclusions

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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Abbreviations

ESI:

Epidural steroid injection

ODI:

Oswestry disability index

RCT:

Randomized controlled trial

LBP:

Low-back pain

NA:

Not available

P:

Positive

N:

Negative

U.S.P.S.T.F:

U.S. Preventive Services Task Force

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Authors and Affiliations

  1. Rheumatology Department, Hôpital Beaujon, Clichy, France

    Michel Benoist

  2. 1 Allée des Châtaigniers, 92500, Rueil-Malmaison, France

    Michel Benoist

  3. Neurology Department, Pain Unit, Hôpital Beaujon, Clichy, France

    Philippe Boulu

  4. Rheumatology Department, Bichat Teaching Hospital, 46 av Henri Huchard, 75018, Paris, France

    Gilles Hayem

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  1. Michel Benoist
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  2. Philippe Boulu
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  3. Gilles Hayem
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Correspondence to Michel Benoist.

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Benoist, M., Boulu, P. & Hayem, G. Epidural steroid injections in the management of low-back pain with radiculopathy: an update of their efficacy and safety. Eur Spine J 21, 204–213 (2012). https://doi.org/10.1007/s00586-011-2007-z

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  • DOI: https://doi.org/10.1007/s00586-011-2007-z

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