Bmj Usa Letter


BMJ 2004; 329 doi: (Published 09 September 2004) Cite this as: BMJ 2004;329:E321
  1. William M Landau,
  2. Dewey A Nelson, professor of neurology
  1. Washington University Medical School St Louis, MO

    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—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.


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