Abstract
PurposeThe purpose of this systematic review and meta-analysis was to determine whether epidural steroid injections (ESI) are superior to epidural or non-epidural placebo injections in sciatica patients.MethodsThe PubMed, Embase, Cochrane Library, and Web of science databases were searched for trials comparing ESI to epidural or non-epidural placebo. Risk of bias was assessed using the Cochrane RoB 2 tool. The primary outcome measures were pooled using a random-effects model for 6-week, 3-month, and 6-month follow-up. Secondary outcomes were described qualitatively. Quality of evidence was graded using GRADE classification.ResultsSeventeen out of 732 articles were included. ESI was superior compared to epidural placebo at 6 weeks (− 8.6 [− 13.4; − 3.9]) and 3 months (− 5.2 [− 10.1; − 0.2]) for leg pain and at 6 weeks for functional status (− 4.1 [− 6.5; − 1.6]), though the minimally clinical important difference (MCID) was not met. There was no difference in ESI and placebo for back pain, except for non-epidural placebo at 3 months (6.9 [1.3; 12.5]). Proportions of treatment success were not different. ESI reduced analgesic intake in some studies and complication rates are low.ConclusionThe literature indicates that ESI induces larger improvements in pain and disability on the short term compared to epidural placebo, though evidence is of low to moderate quality and MCID is not met. Strong conclusions for longer follow-up or for comparisons with non-epidural placebo cannot be drawn due to general low quality of evidence and limited number of studies. Epidural injections can be considered a safe therapy.
Highlights
Sciatica is a common spinal condition with high reported lifetime prevalence and is generally caused by a lumbosacral disc herniation (LDH) [1]
Since a statistical analysis plan was unavailable for all studies, these five trials were judged as low risk (ESM 3)
This review has demonstrated that epidural steroid injections (ESI) results in significantly greater leg pain relief and functional improvement compared to epidural placebo at 6 weeks in patients with sciatica
Summary
Sciatica is a common spinal condition with high reported lifetime prevalence and is generally caused by a lumbosacral disc herniation (LDH) [1]. Patients usually present with unilateral leg pain with ensuing disabilities. Despite the debilitating physical burden, sciatica has a favourable prognosis due to Communicated by NETHERLANDS. It is assumed that sciatica symptoms are triggered by a complex interaction of compression-related, inflammatory, and immunological mechanisms [4]. Physical impingement of a nerve root from LDH is not necessarily sufficient to induce pain, as a substantial group of patients presents with neural compromise on imaging in absence of clinical symptoms and vice versa [5–7]. In addition to nerve root compression, immunological and inflammatory processes play a key role. Exposure to nucleus pulposus tissue is assumed to cause an auto-immune response leading to cytokine production and involvement of pro-inflammatory cells. Vertebral end plate devascularization may strengthen this response [8–12]
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