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Epidural steroid injections for low back pain

BMJ 2011; 343 doi: (Published 13 September 2011) Cite this as: BMJ 2011;343:d5310

Rapid Response:

Back to the Future

The editorial by Cohen1, reviews epidural steroid injections (ESI)
for low back pain and poses the question of 'where to go' after about 35
studies failing to provide a definitive answer. This is in contrast to the
evidence of benefit for ESI in the cervical region2. Cohen's final
paragraph makes sweeping unreferenced statements advocating fluoroscopy
'always' and suggesting the transforaminal approach is superior. We accept
that in American practice, the risk of litigation is high but in the UK
the increased theatre time and radiology resource may not be justified. In
addition, in a review of the procedure, Allan and Kandala3 suggest a more
considered approach to fluoroscopy particularly in view of the not
inconsiderable potential for harm4. Furthermore the transforaminal
approach not only requires fluoroscopy but has pros and cons which should
be considered for an individual patient.5

Cohen also addresses the dilemma for researchers in designing
clinical trials with the particular issue of placebo. I would suggest
greater use of pragmatic clinical trials for chronic conditions, with more
patient-centred outcomes. Using patient preference allows the best judge
between the balance of benefit and side effect for analgesic studies in
chronic pain6. The problem for complex trial design with placebo is that
patients are less likely to participate and then the results are less
applicable to the population in general. Placebo is a useful therapeutic
strategy providing upto 30% benefit which is highly significant when the
goal of therapy is set at the 50% level by the numbers-needed to treat
philosophy. This also raises the hierarchy of trials with the supremacy of
the randomised placebo-controlled trial. We should give greater
recognition to other study designs if we are to achieve good comparisons
of therapies in chronic back pain to inform both patients and those paying
for medical care.

Current guidelines have not improved management. Indeed, the
controversy on interventional techniques between the Pain Society and the
NICE guidelines in back pain have served to fuel the division between
interventionalists and non-interventionalists. It highlights the pitfall
of committees served by individuals with very personal views and in this
case led to the resignation of the President of the Pain Society, a
Professor of physiotherapy. Optimal care for patients will be best served
by those practitioners able to offer objective advice for all therapies
and have all the skills to carry them out.3

1. Cohen SP. Caudal steroid epidural for low back pain.BMJ;343:d5310.

2. Benyamin RM, Singh V, Parr AT, Conn A, Diwan S, Abdi S. Systemati
Christopher W. Huston. Cervical epidural steroid injections in the
management of cervical radiculitis:interlaminar versus transforaminal. A
review. Car Rev Musculoskelet Med2009 March;2(1):30-42.

3. c review of the effectiveness of cervical epidurals in the
management of chronic neck pain. Pain Physician. 2009 Jan-Feb;12(1):137-

4. Allan L. and Kandala S. Cervical Epidural Block. CPD Anaesthesia

5. Botwin KP, Castellanos R, Raos, Hanna AF, Torres-Ramos FM, Gruber
RD, Bouchlas CG, Fuoco GS. Complications of fluoroscopically guided
interlaminar cervical injections. Arch Phys Med Rehabil 2003;84:627-633.

6. Laurie Allan, Lance Tooke. Giving medicine a fair trial. Patients'
preferences should be assessed. BMJ2000;no7275:1529-30

Competing interests: Previously I accepted funding from numerous pharmaceutical organisations in order to fund my NHS service. Having failed to secure NHS funding the service was lost. I now run an NHS service under the Choose @ Book scheme primarily through the BMI group.

23 September 2011
Laurie G. Allan
consultant anaesthetist
northwick park institute for medical research