Caudal Epidural Steroid Injection Is Ineffective for Chronic Lumbar Radiculopathy
At 1 year, persistent radiculopathy was similar in the sham- and steroid-treated groups.
Epidural steroid injections (ESIs; interlaminar, transforaminal, or caudal) are used to treat patients with radicular low back pain. Presumably, ESIs work by decreasing swelling and inflammation of nerves in the epidural space. In this multicenter trial, Norwegian investigators assessed the effectiveness of caudal ESIs versus saline injections in patients with chronic lumbar radiculopathy (>12 weeks of back and leg pain with associated sensory, reflex, or motor deficits in a nerve root distribution).
The 116 participants were randomized to subcutaneous sham injection of saline, caudal epidural injection of saline, or caudal epidural injection of triamcinolone (40 mg) plus saline; each participant received two injections within a 2-week period. At 6, 12, and 52 weeks, no differences among groups were noted for a disability index, a quality-of-life measure, or low back and leg pain scores. At 52 weeks, 50% of study participants reported feeling much or somewhat better, and only 27% had persistent radiculopathy; again, no intergroup differences were found.
In this study, caudal ESI was ineffective for chronic lumbar radiculopathy. These results are consistent with those from a recent systematic review (Spine (Phila Pa 1976) 2009; 34:49) and an American Academy of Neurology guideline. Nevertheless, an editorialist believes selected patients might respond to a targeted approach (e.g., transforaminal) and highlights a potential study flaw: A local anesthetic (e.g., lidocaine), commonly used in combination with ESI in clinical practice in order to "break the cycle of pain," was not used in this study.
Paul S. Mueller, MD, MPH, FACP
Published in Journal Watch General Medicine October 13, 2011
Citation(s): Iversen T et al. Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: Multicentre, blinded, randomised controlled trial. BMJ 2011 Sep 13; 343:d5278.