Rafael Zambelli Pinto, MSc; Chris G. Maher, PhD; Manuela L. Ferreira, PhD; Mark Hancock, PhD; Vinicius C. Oliveira, MSc; Andrew J. McLachlan, PhD; Bart Koes, PhD; Paulo H. Ferreira, PhD
Financial Support: Mr. Pinto is a PhD student supported by Capes Foundation, Ministry of Education of Brazil. Dr. Maher is supported by a research fellowship funded by the Australian Research Council.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1381.
Requests for Single Reprints: Rafael Zambelli Pinto, MSc, PO Box M201, Missenden Road, Camperdown, Sydney, New South Wales 2050, Australia; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Pinto, Maher, and M.L. Ferreira: The George Institute for Global Health, PO Box M201, Missenden Road, Camperdown, Sydney, New South Wales 2050, Australia.
Dr. Hancock: Faculty of Human Sciences, Macquarie University, 75 Talavera Road, Macquarie Park, Sydney, New South Wales 2109, Australia.
Drs. P.H. Ferriera and Oliveira: Faculty of Health Sciences, University of Sydney, 75 East Street, Lidcombe, Sydney, New South Wales 2141, Australia.
Dr. McLachlan: Pharmacy Building (A15), Science Road, Faculty of Pharmacy, University of Sydney, Sydney, New South Wales 2006, Australia.
Dr. Koes: Department of General Practice, Erasmus Medical Centre, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands.
Author Contributions: Conception and design: R.Z. Pinto, C.G. Maher, M.L. Ferreira, M. Hancock, V.C. Oliveira, B. Koes, P.H. Ferreira.
Analysis and interpretation of the data: R.Z. Pinto, C.G. Maher, M.L. Ferreira, V.C. Oliveira, A.J. McLachlan, B. Koes, P.H. Ferreira.
Drafting of the article: R.Z. Pinto, C.G. Maher, A.J. McLachlan.
Critical revision of the article for important intellectual content: R.Z. Pinto, C.G. Maher, M.L. Ferreira, M. Hancock, V.C. Oliveira, A.J. McLachlan, B. Koes, P.H. Ferreira.
Final approval of the article: R.Z. Pinto, C.G. Maher, M.L. Ferreira, M. Hancock, V.C. Oliveira, A.J. McLachlan, B. Koes, P.H. Ferreira.
Statistical expertise: R.Z. Pinto, C.G. Maher, M.L. Ferreira.
Administrative, technical, or logistic support: C.G. Maher, P.H. Ferreira.
Collection and assembly of data: R. Zambelli Pinto, C.G. Maher, M. Hancock, V.C. Oliveira.
Pinto RZ, Maher CG, Ferreira ML, Hancock M, Oliveira VC, McLachlan AJ, et al. Epidural Corticosteroid Injections in the Management of Sciatica: A Systematic Review and Meta-analysis. Ann Intern Med. 2012;157:865-877. doi: 10.7326/0003-4819-157-12-201212180-00564
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Published: Ann Intern Med. 2012;157(12):865-877.
Existing guidelines and systematic reviews provide inconsistent recommendations on epidural corticosteroid injections for sciatica. Key limitations of existing reviews are the inclusion of trials with active controls of unknown efficacy and failure to provide an estimate of the size of the treatment effect.
To determine the efficacy of epidural corticosteroid injections for sciatica compared with placebo.
International Pharmaceutical Abstracts, PsycINFO, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL.
Randomized, placebo-controlled trials assessing the efficacy of epidural corticosteroid injections in participants with sciatica.
Two independent reviewers extracted data and assessed risk of bias. Leg pain, back pain, and disability were converted to common scales from 0 (no pain or disability) to 100 (worst possible pain or disability). Thresholds for clinically important change in the range of 10 to 30 have been proposed for these outcomes. Effects were calculated for short-term (>2 weeks but ≤3 months) and long-term (≥12 months) follow-up.
Data were pooled with a random-effects model, and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used in summary conclusions. Twenty-five published reports (23 trials) were included. The pooled results showed a significant, although small, effect of epidural corticosteroid injections compared with placebo for leg pain in the short term (mean difference, −6.2 [95% CI, −9.4 to −3.0]) and also for disability in the short term (mean difference, −3.1 [CI, −5.0 to −1.2]). The long-term pooled effects were smaller and not statistically significant. The overall quality of evidence according to the GRADE classification was rated as high.
The review included only English-language trials and could not incorporate dichotomous outcome measures into the analysis.
The available evidence suggests that epidural corticosteroid injections offer only short-term relief of leg pain and disability for patients with sciatica. The small size of the treatment effects, however, raises questions about the clinical utility of this procedure in the target population.
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Back Pain, Endocrine and Metabolism, Neurology, Neuropathy, Rheumatology.
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