Steroid Injections Result in Only Limited Short-Term Benefits for Sciatica
Considering that I see sciatica on a daily basis in my office, this study does not surprise me. What does surprise me is how people still does consider chiropractic when considering options for sciatic pain. I’m proud to say that I have not had a single patient that stuck with me for sciatic pain due to a disc herniation go to surgery. Some of the case were tough, but all resolved without surgery. Also, I have occasionally sent patients for epidurals, but not as the only therapy. That may have been the problem with this study. As one tool to lower the level of inflammation, it can allow other therapies to be more effective. The same goes for shoulders. In now way, shape or form do drugs or injections fix whatever was wrong with the problem.
ACR 66th annual meeting: Abstract 530. Presented Oct. 26, 2002.
In patients with sciatica, epidural injections of corticosteroids appear to produce only limited relief and no sustained benefit, according to findings from the largest randomized controlled trial of its kind.Nigel K. Arden, MD, a senior lecturer in rheumatology at the University of Southampton, U.K., and colleagues presented their research here Saturday at the American College of Rheumatology (ACR) 66th Annual Scientific Meeting. According to Dr. Arden, the procedure is fairly common. “In the U.K., for every million population that comes into the hospital, we are doing 800 epidurals,” he said. To evaluate the efficacy of corticosteroid epidurals, the researchers recruited 228 patients with clinical evidence of unilateral sciatica from four hospitals. At baseline, patients from two of the hospitals underwent magnetic resonance imaging (MRI) of the lumbar spine. Patients were stratified based on whether they had acute or chronic sciatica and were then randomized to receive either three weekly lumbar epidural injections of triamcinolone acetonide 80 mg and bupivacaine or three injections of saline into the interspinous ligament.Patients were assessed at 0, 3, and 12 weeks. Both groups improved at 3 weeks, but the active group had a slightly greater but nonsignificant improvement compared with the placebo group (Oswestry score, 33.5 vs. 38.9; P=.053). At three weeks, 60.8% of the participants in the active group and 39.8% of those in the placebo group reported that their sciatica had improved (P=.03). But at 6 weeks and 12 weeks, the differences were no longer significant (P=0.5 and 0.7, respectively). In addition, the researchers also performed several a priori subgroup analyses to explore predictors of response, such as duration and severity of sciatica at study entry, presence of a significant MRI lesion, and the presence of neurological dysfunction; however, none of these predicted a response.”This study was meant to be the definitive study,” Dr. Arden said. “We used the highest dose and most potent steroid possible,” he said. “We even powered it so that we could pick up a nonclinically significant effect,” he added.”There is no quick fix or magic injection,” says Dr. Arden. According to Dr. Arden, the answer may be to combine pain relief with physiotherapy. “Only a small amount of this condition is physical, so if the patient is also depressed, they should also see a psychologist,” he added. Dr. Arden pointed out that pain consultants tend to think these injections work whereas “rheumatologists tend to think they do not work.”Sidney Block, MD, the session moderator and a rheumatologist in private practice in Bangor, Maine, agreed. “I think it has to do with the perspective of the physician,” he said. “Orthopedists, who are not anxious to operate on a patient’s back, will frequently turn to this as a method of pain relief hoping that it will delay the need for surgery.” “Rheumatologists may also turn to this before surgery, but this study raises the question as to whether this therapy is effective,” he said.