Background Among various modalities applied in the management of painful conditions of the spine, epidural injections (EI) are one of the most commonly utilized interventions. EI can be administered in the lumbar spine by either caudal (CEI), interlaminar (IEI), or transforaminal (TEI) approaches and various steroids have been used in these injections(1,2). The purpose of EI is to provide analgesia for a varying duration, whilst making it easier for the patient to undergo a rehabilitation program during this time(1).
Objectives The aim of this review is to evaluate the efficacy of the different types of EI in patients suffering from chronic sciatica, based on the evidence published over the past 5 years.
Methods Relevant studies were retrieved by searching PubMed, Medline, The Cochrane Library and UpToDate. Publications from 2012 to 2016 which specified the use of EI to treat chronic sciatica were considered, and all the studies selected were written in the English language only.
A total of 11 articles were gathered, of which 5 were excluded after analysis of their title and abstract. Of the 6 papers included in this study, 5 are systematic reviews and 1 is a meta-analysis of 10 randomized controlled trials.
The outcomes measured were improvement in pain and functional status. The Numeric Rating Scale (NRS) and Visual Analogue Scale (VAS) were the most commonly used baseline scales for pain evaluation. The Oswestry Disability Index (ODI) was the most used scale for the functional disability scoring system in the literature.
Results 4 of the 6 papers included in this review reported improvements in pain ranging from 30 to 83% and in functional status ranging from 26 to 86% from the pre-injection state, with follow-up periods lasting up to 2 years after the EI. 2 of these 4 studies showed Level II evidence for EI for long-term efficacy in managing chronic sciatica, with no significant difference among CEI, IEI or TEI.
The remaining 2 papers (out of the total 6) associated EI with immediate improvements in both pain and function, but found the benefits to be unsustained.
1 paper reported 1 serious adverse event in one of the trials analyzed and found the data on harms to be sparse on most trials. Another paper concluded that injecting local anesthetic alone might be preferable to injecting local anesthetic with steroid as omitting the steroid could lessen the risk of rare, but possibly fatal complications.
Conclusions Despite variability in the studies included and methods used for data synthesis, most of the articles included in this review showed positive results for both pain relief and improvement in functional status with EI.
Although no studies found significant difference among CEI, IEI or TEI in terms of efficacy, each approach has its advantages and these should be taken into account when choosing the best approach for each patient.
As supporting evidence, this review shows that EI with or without steroids are a fast, safe and clinically effective treatment method for patients with chronic sciatica.
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Pinto R, et al. Epidural Corticosteroid Injections in the Management of Sciatica: A Systematic Review and Meta-analysis. Ann Intern Med. 2012, 157:865–877.
Disclosure of Interest None declared