TY - JOUR
T1 - Responses to Letters to the Editor by Prof Bogduk and Dr Davies. Time to reconsider steroid injections in the spine?
AU - Harris, Ian A
AU - Buchbinder, Rachelle
PY - 2013
Y1 - 2013
N2 - IN REPLY: We thank Bogduk for his
comments, but, based on previous
reviews and some comparative
studies,1-4 do not consider the
transforaminal route to be clearly and
consistently superior to the
interlaminar route for radiculopathy.
Further, we note that when the
evidence for transforaminal injections
is isolated to placebo-controlled trials,
the evidence is based on very few
studies. The largest of these showed
marginal short-term (2-week)
improvement in the steroid and local
anaesthetic group over the saline
group for the primary outcome (leg
pain), an effect that was not sustained
by 4 weeks.5 Short-term relief is a
common finding in studies that use
local anaesthetic in the active group.
We consider the evidence for the
effectiveness of transforaminal
steroids over placebo to be neither
strong nor consistent (within or
between studies). We suggest that the
gem in the bathwater be subject to
more scrutiny and weighed against
the risks and costs.
We thank Davies and colleagues for
their comments about medial branch
blocks and transforaminal epidural
steroid injections. We have addressed
the latter in our response above. Our
article does not extend beyond the
use of steroids to procedures such
as neurotomy, so we have not
commented on this procedure here.
Regarding medial branch blocks,
we note that in a systematic review
mentioned by Davies and colleagues,
each of the randomised trials showed
no significant difference in the
response between groups treated with
steroid and those treated with local
anaesthetic alone.6 This reinforces our
point that steroid injections in the
spine have no specific therapeutic
effect beyond natural history, the
effect of any concomitant treatment
or any placebo effect.
AB - IN REPLY: We thank Bogduk for his
comments, but, based on previous
reviews and some comparative
studies,1-4 do not consider the
transforaminal route to be clearly and
consistently superior to the
interlaminar route for radiculopathy.
Further, we note that when the
evidence for transforaminal injections
is isolated to placebo-controlled trials,
the evidence is based on very few
studies. The largest of these showed
marginal short-term (2-week)
improvement in the steroid and local
anaesthetic group over the saline
group for the primary outcome (leg
pain), an effect that was not sustained
by 4 weeks.5 Short-term relief is a
common finding in studies that use
local anaesthetic in the active group.
We consider the evidence for the
effectiveness of transforaminal
steroids over placebo to be neither
strong nor consistent (within or
between studies). We suggest that the
gem in the bathwater be subject to
more scrutiny and weighed against
the risks and costs.
We thank Davies and colleagues for
their comments about medial branch
blocks and transforaminal epidural
steroid injections. We have addressed
the latter in our response above. Our
article does not extend beyond the
use of steroids to procedures such
as neurotomy, so we have not
commented on this procedure here.
Regarding medial branch blocks,
we note that in a systematic review
mentioned by Davies and colleagues,
each of the randomised trials showed
no significant difference in the
response between groups treated with
steroid and those treated with local
anaesthetic alone.6 This reinforces our
point that steroid injections in the
spine have no specific therapeutic
effect beyond natural history, the
effect of any concomitant treatment
or any placebo effect.
UR - https://www.mja.com.au/journal/2013/199/11/time-reconsider-steroid-injections-spine-1
U2 - 10.5694/mja13.11159
DO - 10.5694/mja13.11159
M3 - Letter
VL - 199
SP - 754
EP - 754
JO - Medical Journal of Australia
JF - Medical Journal of Australia
SN - 0025-729X
IS - 11
ER -