BMJ  2004;329:E321 (11 September), doi:10.1136/bmj.329.7466.E321

BMJ USA: Letter

Letter

RAPID RESPONSES FROM BMJ.COM

Following is an edited excerpt from one of the Rapid Responses generated by this editorial, all of which can be read in their entirety at http://bmj.bmjjournals.com/cgi/eletters/328/7455/1509.—Editor

Unfortunately the Samanta editorial about epidural steroid injection missed our recent review.¹ Having reviewed the seven extant controlled trials of epidural spinal injection (ESI), including 468 subjects, we concluded, "Intraspinal steroid therapy is not effective therapy for back pain or radicular syndromes, because steroid formulations, placebos, and sham injections have similar outcomes." More recently, Arden et al² reported similar conclusions from a controlled study of 228 patients. They stated, "We used the highest dose and the most potent steroid possible, even powered it so that we could pick up a nonclinically significant effect. There is no quick fix or magic injection." No cure.

Whether short term improvement is due only to the placebo effect or possibly also to toxic effects from the usual ad hoc hypertonic injectate containing steroid, steroid preservative agents, local anesthetic, and often, a radiological contrast agent, is unknown. We found no supportive evidence to confirm the theory that spinal pathological processes associated with herniated nucleus pulposus are inflammatory, as was proved to be the case in studies of rheumatic joints. No pathological rationale.

In regard to the dangers of ESI, there are no certain epidemiological data. Whatever the precise prevalence of serious complications from ESI, several of the Rapid Response submissions [not reprinted here] speak of the tragic permanence of chronic pain and movement disability resulting from arachnoiditis, radiculopathy, and myelopathy. Obviously, there is no guarantee against such risks.

We conclude that ethical considerations require that informed consent be obtained from patients to whom ESI is recommended. The incidence of therapeutic cure and the prevalence of catastrophic complication risk should be defined and accepted.

Washington University Medical School St Louis, MO

References

1. Nelson DA, Landau WM. Intraspinal steroids: history, efficacy, accidentality and controversy with review of United States Food and Drug Administration reports. J Neurol Neurosurg Psychiatry 2001;70: 433-443.[Free Full Text]
2. Arden NK, et al. October 26, 2002 Annual ACR meeting. Program Abstract 530. Medscape Medical News. November 11, 2002.

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