 There
simply isn't enough evidence to support epidural steroid
injections for chronic low back pain, according to new
recommendations from the American Academy of Neurology
published in the March 6 issue of the journal Neurology.
If you're thinking 'Tell me something
I didn't already know,' you're not alone. But the group
of neurologists who authored the guidelines say that,
in the face of poor quality studies on this treatment,
they felt it was necessary to remind clinicians that
steroid shots probably aren't the best option for patients
with radicular lumbosacral pain, or sciatica. "We wanted
to know for ourselves, as practising neurologists, and
for patients," says lead author Dr Carmel Armon, a neurologist
at Tufts University in Boston.
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What else can you do for low
back pain?
1. Go to the source:
"The first step is to determine the cause of the
radicular pain," says Dr Armon.
2. Heavy duty: "If the
cause of the pain is obesity, you can target this.
It will also help the patient's general health,"
notes Dr Armon.
3. Medicate or hesitate?:
Anti-inflammatory analgesics can help get some
patients back on their feet.
4. Back to school: "There
are a number of non-analgesic approaches," notes
Dr Armon. He says "back schools" are a good example.
These are courses where patients learn about better
posture, ergonomy and simple exercises to relieve
back pain. Physiotherapy, exercise and massage
can all also help.
5. Under the knife: "There's
a debate within the medical community about whether
people should be operated on purely for pain,"
says Dr Armon. "It's not clear — there are
many differing views."
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PATIENT
APPROVED
The new recommendations review all the available studies
on the treatment, which has been around since the 1950s.
During the procedure a needle — guided by fluoroscopy,
if possible — is inserted into the epidural space
where a corticosteroid is injected. The idea is that
the steroid inhibits the release of pro-inflammatory
substances that cause the radiating low back and leg
pain associated with sciatica.
Americans spent nearly $50 million
on the shots in 1999, the authors note. "The general
sense is that use has been rising," says Dr Armon.
One of the big reasons it's so
popular is because patients report that it works. But
Dr Armon points out that while this might be good enough
for them, it shouldn't be good enough for clinicians.
"If you ask a patient to assess the treatment and they
feel better, they'll say the treatment was successful,"
he explains. "But as practitioners, we wouldn't rely
on these subjective measures, we'd use a comparison
group on placebo and ask 'How long did you feel better?
Was there a rebound phenomenon?'" Dr Armon and his colleagues
were surprised at how few high quality studies made
this a priority. The best available data shows "that
the magnitude of benefit was limited and there did seem
to be a rebound phenomenon — that some patients
were worse off than when they started," he says.
The risks associated with the procedure
itself are thought to be relatively minor, but Dr Armon
notes reports of complications are inconsistent at best.
"This is an injection close to neural tissue, so it's
not to be taken lightly," he cautions.
NOT
CONVINCED
Dr Hugh Anton, a physiatrist in Vancouver, says these
recommendations don't hold much sway with him. For one
thing, he says there's nothing new here. For another,
he truly believes epidural steroid injections can help
some patients with sciatica. "If you choose your patients
correctly, there's a good likelihood of a good outcome,"
he says in a phone interview from his office. His faith
in the treatment is based on "clinical experience —
though admittedly anecdotal," he adds.
Dr Anton says using fluoroscopy
to help guide the needle can make a big difference in
efficacy. A lot of smaller centres don't have the equipment
to do this though, so their outcomes might not be as
good. He suspects better studies on fluoroscopy-guided
steroid injections would reveal a more marked benefit.
Still, he emphasizes that steroid
injections are not a cure. "The hope is that it's a
temporizing measure. If it eases a patient's pain and
gets them over the hump, then you can get them into
other things like exercise," he says.
Dr Armon's study questions the
notion — held by many physicians — that the
injections can help avoid surgery, noting that it's
impossible to infer from existing studies if "the treatment
'buys time' for a natural history of improvement. In
general, in the best-designed studies, it didn't appear
to reduce surgical rates," he says.
But until there's better evidence
Dr Anton isn't moved. "This is a very reasonable option,"
he says. "I'd be very surprised if this study changed
my clinical practice."
"This statement doesn't say that
injections don't have a role," stresses Dr Armon. "On
the contrary. But that role needs to be better assessed.
I appreciate how back pain impacts on people's lives
and I hope they can access the best treatment."
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