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Spine: J. Wilson-MacDonald, G. Burt, D. Griffin, and C. Glynn Epidural steroid injection for nerve root compression: A RANDOMISED, CONTROLLED TRIAL J Bone Joint Surg Br 2005; 87-B: 352-355 [Abstract] [Full text] [PDF]

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Letter from Messrs Jain and Garg

Sunil Jain, Sunil Garg   (12 July 2005)

Epidural steroid injection for nerve root compression

Sunil Garg, Sunil Jain   (15 June 2005)

Letter from Messrs Jain and Garg 12 July 2005
Sunil Jain, Consultant Orthopaedic Surgeon FRCS, FRCS (Orth), MCH (Orth), Sunil Garg Send letter to journal: Re: Letter from Messrs Jain and Garg jainmedway{at}blueyonder.co.uk Sunil Jain, et al.	Sir, We wish to clarify some of the points made in our previous letter. We found the account of patients having had previous interventions and those undergoing second epidurals (either because of a failed intramuscular injection, presumably prompting ethical action) and of the epidural steroid injection (ESI) group (the reasons for second injection are not clear) confusing. Perhaps there is an error in Table 1 which shows the number of patients in the ESI group who had undergone previous treatment as five, when the text suggests it was seven? Also, there is a significant discrepancy in the number of patients with (symptomatic) disc pathology with or without an associated stenosis (60) and the number of patients with a positive sciatic stretch test (32). In a conventional practice, the majority if not all of the patients with disc prolapse as the predominant pathology would be expected to have a positive sciatic stretch test in order to justify either an epidural injection or a discectomy. Even if one considers a painless neurological deficit as an indication for decompression, it would be difficult to justify this as an indication for an epidural injection. S. JAIN, FRCS, FRCS(Orth), MCH(Orth) S. GARG, MRCS Medway Maritime Hospital, Gillingham, UK.
Epidural steroid injection for nerve root compression 15 June 2005
Sunil Garg, Specialist Registrar Trauma and Orthopaedics Medway Maritime Hospital, Sunil Jain Send letter to journal: Re: Epidural steroid injection for nerve root compression sunil_garg9{at}hotmail.com Sunil Garg, et al.	Sir, We read this paper with great interest. The authors claim that the strength of their study was randomisation. However, we are not convinced that the methodology of the study allows such conclusions. There were several confounding factors in the two groups: 17% of patients had undergone previous invasive management for back pain, of which almost twice the number were in the control group, 17% of patients received a second injection and 31% of patients in the control group (vs 3% in the edipural spinal injection group) had combined pathology of disc proplapse and stenosis as confirmed on MRI. While this study was conducted in patients with mainly nerve root compression clinical variables such as pain in the leg and neurogenic claudication were completely ignored, with emphasis on MRI. There is no mention of the criteria used for the patients who were listed for surgery at the start of the study. In the papers1,2,3 cited by the authors, there was no correlation between the outcome of open surgical procedures and response to epidural steroids. The authors have used a blind method of epidural injection. 'Blind' epidural steroid injections are frequently misplaced and can be hazardous.4,5,6,7 There is little scientific evidence for the usefulness of an epidural spinal injection.8,9 There are no injectable steroids that are FDA-approved for use in spinal epidural.10,11 The authors have not added any new information, nor have they used the correct methodology to reach the conclusions given in the study. S. GARG, MRCS MS(Orth), DNB(Orth) S. JAIN, FRCS, FRCS(Orth), MCH(Orth) Medway Maritime Hospital Gillingham, UK. 1. Warfield CA, Crews DA. Epidural steroid injection as a predictor of surgical outcome. Surg Gynecol Obstet 1987;164:457–8. 2. Bush K, Hillier S. A controlled study of caudal epidural injections of triamcinolone plus procaine for the management of intractable sciatica. Spine 1991;16:572–5. 3. Carette S, Leclaire R, Marcoux S, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med 1997;336:1634–40. 4. Fredman B, Nun MB, Zohar E, et al. Epidural steroids for treating 'failed back surgery syndrome': is fluoroscopy really necessary? Anesth Analg 1999;88(2):367-72. 5. Price CM, Rogers PD, Prosser AS, Arden NK. Comparison of the caudal and lumbar approaches to the epidural space. Ann Rheum Dis 2000;59(11):879-82. 6. Renfrew DL, Moore TE, Kathol MH, et al. Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration. Am J Neuroradiol 1991;12(5):1003-7. 7. McLain RF, Fry M, Hecht ST. Transient paralysis associated with epidural steroid injection. J Spinal Disord 1997;10(5):441-4. 8. Watts RW, Silagy CA. Meta-analysis and the efficacy of epidural corticosteroids in the treatment of sciatica. Anaesthesia Intens Care 1995;223:564-9. 9. Nelemans PJ, de Bie RA, de Vet HCW, Sturmans F. Injection therapy for subacute and chronic benign low back pain. Cochrane Database Syst Rev 2000;(2):CD001824 10. Depo-Medrone product licence. http://emc.medicines.org.uk/emc/industry/def ault.asp?page=displaydoc.asp&documentid=3549 11. Samanta A, Samanta J. Is epidural injection of steroids effective for low back pain? BMJ 2004;328:1509-10