- Steven P Cohen, associate professor
- 1Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21029, USA
In the linked randomised trial (doi:10.1136/bmj.d5278), Iversen and colleagues assess the efficacy of caudal epidural steroid and caudal epidural saline injection in the treatment of chronic (>12 weeks’ duration) lumbar radiculopathy.1 Low back pain is the leading cause of disability in the world and a major contributor to a wide range of other problems, such as substance misuse and depression.2 Perhaps the most important distinction to make when categorising low back pain is to distinguish between neuropathic and mechanical causes, because this informs treatment.2 3 Recent studies show that about a third of patients with chronic low back pain have predominantly neuropathic pain.3 Sciatica responds better than non-specific low back pain to interventions, but treating any form of low back pain is challenging.
Epidural steroid injections have been used for more than 50 years to treat low back pain and are the most common intervention in pain clinics throughout the world.4 Yet despite their widespread use, their efficacy is unclear. Of around 35 controlled studies evaluating such injections, slightly more than half show some benefit. Moreover, systematic reviews written by authors who perform epidural steroid injections are more likely to conclude that it is effective than reviews written by those who do not use such …