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Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5278 (Published 13 September 2011) Cite this as: BMJ 2011;343:d5278

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Re: Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial

Dear Lady, and Sirs:

Indeed most low back pain gets better by itself in 90% of patients without any treatment whatsoever. It has probably been this way for the past 1 million years. Pretty much since we started walking up straight. Many times “treatment” whether non invasive, behavioral, or invasive makes matters worse. Low back, and radiculopathy have numerous well documented etiologies, many with similar overlapping objective and subjective findings. Thus it is very difficult to come up with useful evidence. At the same time, jumping to conclusions can be very counter productive.

At baseline, the patients included in your study have less than 5 pain on a scale VAS 0-10. Personally, I don’t inject patients that don’t have severe pain, as they are likely to get better anyhow. Your study appears to confirm the obvious. I also don’t inject patients that have noticed recent improvement. In fact you had to exclude 23 patients because they improved rapidly, and 17 because they declined.

Your study excludes 328 of 461 patients. Of the exclusion criteria severe pain is the most common one. In my opinion these are the patients that usually respond best. Furthermore, I have many times injected patients with bilateral pain, sever back pain, or pain less than 3 months. Again these 97 patients were excluded in your study. Thus it appears that, you excluded patients that are likely to respond, and included those that were going to get better naturally.

For example, in the study, if a patient had a prior spinal injection they were excluded. Imagine the following scenario: a patient has an acute episode, has partial improvement with the first injection elsewhere, and then is referred to you, this patient is excluded form treatment. Likely, such a patient would have responded positively.

For example, a patient has facet joint pain, disc pain, sacroiliac joint pain, pyriformis pain, etc,. All of these conditions can result in unilateral radicular pain, and would be included in your study. Non of these patients are likely to respond to caudal epidural injection long term.

Your patient referral base is biased. Bias in the patient referral base is created by informing referring surgeons and chiropractors by letter of a trial that is to validate injections.

As far as blinding, I would not want to be on the receiving end of 30 ml’s in the caudal canal, as compared to 2 ml’s subcutaneously. Most of my patients complain quite a bit at 6 ml’s.

Sincerely,

Marc J. Yland, MD

Competing interests: Practice in Interventional Pain Management

19 November 2011
Marc J Yland
Anesthesiologist
2500 Nesconset Highway, Bld24C, Stony Brook, NY, 11790