Epidural steroid injections ineffective for lumbar spinal stenosis

Clinical Question

Do epidural glucocorticoid injections improve the symptoms of spinal stenosis?

Bottom Line
Unfortunately, epidural glucocorticoid injections are ineffective for lumbar spinal stenosis.Whether this will change practice for this lucrative procedure will be an interesting question. (LOE = 1b)

Reference

Friedly JL, Comstock BA, Turner JA, et al. A randomized trial of epidural gluocorticoid injections for spinal stenosis. N Engl J Med 2014;371(1):11-21.
Study Design Randomized controlled trial (double-blinded) Funding Government
Setting Outpatient (specialty) Allocation Concealed

Synopsis

Epidural glucocorticoid injections are a common treatment for patients with lumbar spinal stenosis, but their efficacy is uncertain. In this study, the researchers identified 400 patients, aged 50 and older, with lumbar spinal stenosis (confirmed by magnetic resonance imaging or computed tomography), pain of at least 4 on a scale from 1 to 10 in the buttock or leg, and significant functional disability based on a validated scale. Patients were randomly assigned to receive an epidural injection with either lidocaine and a glucocorticoid (betamethasone 6 mg to 12 mg, dexamethasone 8 mg to 10 mg, or triamcinolone 60 mg to 120 mg) or lidocaine alone. All injections were done under fluoroscopic guidance. Groups were balanced at the start of the study, with the exception of a somewhat shorter duration of pain in the lidocaine-only group, and analysis was by intention to treat. The mean age of participants was 68 years, 55% were female, and 69% were white. Patients could receive a second injection 3 weeks after the first, and results were evaluated 3 weeks and 6 weeks after the initial injection. At 3 weeks, improvements in pain and disability were slightly greater in the intervention group, but these were not clinically significant, and they disappeared by the 6-week assessment. Adverse events were more common in the intervention group.

Mark H. Ebell, MD, MS
Associate Professor
University of Georgia
Athens, GA

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