Despite the growing popularity of steroid injections to treat various
kinds of back pain in recent years, a new review of past research finds the
shots do little to alleviate sciatica, a common condition that causes leg and
back pain.
A woman experiences back pain (BSIP/UIG via Getty Images / November 12, 2012)
Analyzing results from nearly two dozen clinical trials on thousands of
patients, Australian researchers found that epidural injections (into the
spine) of corticosteroids had no long- or short-term effect on sciatica back
pain, and such a small short-term effect on leg pain it would make no
difference to the patient. "I think it's pretty clear that this treatment
is not good to do," said Chris Maher, of The George Institute for Global
Health in Sydney, Australia, who worked on the study.
Nonetheless, the use of epidural steroid injections to treat back pain
of all sorts among Medicare patients nearly doubled from 741,000 in 2000 to
about 1,438,000 in 2004, according to the researchers. In the U.S., the cost of
one shot can be several hundred dollars. And a tainted supply of one of the
steroids included in the trials under analysis - methylprednisolone - recently
caused a nationwide outbreak of fungal meningitis that infected 400 people and
led to 31 deaths, according to the Centers for Disease Control and Prevention.
For sciatica, which is thought to be caused by nerve damage, past
studies have already questioned the effectiveness of spinal steroid shots. In
April, for instance, a study of 81 people found that whether they received
steroids or a placebo for sciatica, their condition ended up improving about
the same amount. (see Reuters Health article of April 16, 2012.) Maher and his
colleagues set out to see whether past studies supported the use of epidural
corticosteroid injections to help manage sciatica, and collected results from
"gold standard" randomized controlled trials.
Overall, 23 trials were included in the final analysis, which
represented about 2,300 patients, whose pain was ranked on a scale from zero to
100 - with higher scores representing worse pain. For the back pain component
of sciatica, the researchers found that the injections didn't seem to make a
difference over short or long periods of time. When it came to leg pain, there
was no difference a year or so after the injection, but there was a
statistically significant six-point drop in pain scores over the short term -
about 2 weeks to 3 months.
But that, according to Maher, is not enough to mean anything to a doctor
or patient. "You can appreciate that six points on a hundred-point scale
is a tiny difference, and in our view that is probably not clinically
important," he said. "We really think the question is closed,"
said Maher. "So in terms of our research agenda, we're moving on to other
treatments for sciatica.” Maher told Reuters Health that, instead of steroid
injections, people suffering with sciatica should consult their doctor, but
other options include simple pain relievers, such as acetaminophen, drugs that
treat pain by working throughout a person's nervous system and, as a last
resort, surgery.
Not everyone agrees that steroid injections should be excluded from the
hierarchy of treatments for sciatica. "In general, I think we've learned
over the years that the epidural injections are turning out to be less and less
successful but there are times when they should be considered," said Dr.
Kirkham B. Wood, chief of the orthopedic spine service at Boston's
Massachusetts General Hospital. He told Reuters Health that he believes an
injection should be considered, for example, in someone with sciatica resulting
from a relatively recent herniated disc, "who time and medication has not
helped." Wood does believe, however, that the injections are overused, and
said there was a time when the injections were the go-to treatment for simple
back pain. "I think the pendulum is certainly swinging away from their
broad use," he said.
The meningitis outbreak in the U.S. will also likely dampen enthusiasm
for the shots, researchers acknowledged. "If this was a treatment that
worked, then you'd have to weigh the benefits and the harm," Maher said,
but it doesn't work (for sciatica), he emphasized. Maher and his team, who
published their results in the Annals of Internal Medicine on Monday, hope doctors
will pick up on their findings. But Maher told Reuters Health that it may take
some time to change how doctors see the injections. "It's been around for
decades and it will take a while to stop," he said.
Source: Chicago Tribune
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