Roger Chou, MD; Robin Hashimoto, PhD; Janna Friedly, MD; Rongwei Fu, PhD; Christina Bougatsos, MPH; Tracy Dana, MLS; Sean D. Sullivan, BScPharm, PhD; Jeffrey Jarvik, MD, MPH
Disclaimer: The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of the Agency for Healthcare Research and Quality (AHRQ). No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Grant Support: By the Agency for Healthcare Research and Quality (contract no. HHSA290201200014i).
Disclosures: Dr. Chou reports grants from AHRQ during the conduct of the study and royalties from UpToDate, Inc., outside the submitted work. Dr. Hashimoto reports grants from AHRQ during the conduct of the study. Dr. Fu reports grants from AHRQ during the conduct of the study. Ms. Dana reports grants from AHRQ during the conduct of the study and outside the submitted work. Dr. Sullivan reports funds from AHRQ during the conduct of the study. Dr. Jarvik reports grants from AHRQ and PCORI, being cofounder of and a stockholder in PhysioSonics (an ultrasonography-based technology company), personal fees from the GE Healthcare-CER Advisory Board (stopped in September 2012) and HealthHelp (a radiology benefits management company) outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0934.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Requests for Single Reprints: Roger Chou, MD, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code BICC, Portland, OR 97239; e-mail, email@example.com.
Current Author Addresses: Drs. Chou and Bougatsos and Ms. Dana: Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code BICC, Portland, OR 97239.
Dr. Hashimoto: Spectrum Research, 705 South 9th Street, Suite 203, Tacoma, WA 98405.
Dr. Friedly: University of Washington, 325 9th Avenue, Box 359859, Seattle, WA 98104.
Dr. Fu: Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code CSB669, Portland, OR 97239.
Dr. Sullivan: University of Washington, 1959 NE Pacific Avenue, H-364, Box 357631, Seattle, WA 98195-7630.
Dr. Jarvik: University of Washington, 325 9th Avenue, Box 359728, Seattle, WA 98104-2499.
Author Contributions: Conception and design: R. Chou.
Analysis and interpretation of the data: R. Chou, R. Hashimoto, R. Fu, C. Bougatsos, T. Dana, S.D. Sullivan.
Drafting of the article: R. Chou, R. Fu, C. Bougatsos, T. Dana.
Critical revision of the article for important intellectual content: R. Chou, R. Hashimoto, S.D. Sullivan, J. Jarvik.
Final approval of the article: R. Chou, R. Fu, C. Bougatsos, T. Dana, S.D. Sullivan, J. Jarvik.
Statistical expertise: R. Chou, R. Fu.
Obtaining of funding: R. Chou, S.D. Sullivan.
Administrative, technical, or logistic support: C. Bougatsos, T. Dana.
Collection and assembly of data: R. Chou, R. Hashimoto, C. Bougatsos, T. Dana, S.D. Sullivan.
Use of epidural corticosteroid injections is increasing.
To review evidence on the benefits and harms of epidural corticosteroid injections in adults with radicular low back pain or spinal stenosis of any duration.
Ovid MEDLINE (through May 2015), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, prior systematic reviews, and reference lists.
Randomized trials of epidural corticosteroid injections versus placebo interventions, or that compared epidural injection techniques, corticosteroids, or doses.
Dual extraction and quality assessment of individual studies, which were used to determine the overall strength of evidence (SOE).
30 placebo-controlled trials evaluated epidural corticosteroid injections for radiculopathy, and 8 trials were done for spinal stenosis. For radiculopathy, epidural corticosteroids were associated with greater immediate-term reduction in pain (weighted mean difference on a scale of 0 to 100, −7.55 [95% CI, −11.4 to −3.74]; SOE, moderate), function (standardized mean difference after exclusion of an outlier trial, −0.33 [CI, −0.56 to −0.09]; SOE, low), and short-term surgery risk (relative risk, 0.62 [CI, 0.41 to 0.92]; SOE, low). Effects were below predefined minimum clinically important difference thresholds, and there were no longer-term benefits. Limited evidence showed no clear effects of technical factors, patient characteristics, or comparator interventions on estimates. There were no clear effects of epidural corticosteroid injections for spinal stenosis (SOE, low to moderate). Serious harms were rare, but harms
reporting was suboptimal (SOE, low).
The review was restricted to English-language studies. Some meta-analyses were based on small numbers of trials (particularly for spinal stenosis), and most trials had methodological shortcomings.
Epidural corticosteroid injections for radiculopathy were associated with immediate reductions in pain and function. However, benefits were small and not sustained, and there was no effect on long-term surgery risk. Limited evidence suggested no effectiveness for spinal stenosis.
Chou R, Hashimoto R, Friedly J, Fu R, Bougatsos C, Dana T, et al. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med. 2015;163:373–381. doi: 10.7326/M15-0934
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Published: Ann Intern Med. 2015;163(5):373-381.
Endocrine and Metabolism, Neurology, Neuropathy.
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