A new report has found that those patients given spinal injections of a combination of lidocaine (a common local anaesthetic) and a steroid reported the same degree of improvement as those given only the lidocaine. These results were found in a large randomized controlled trial published in the July 3 issue of The New England Journal of Medicine. Dr. Janna Friedly, of the Department of Rehabilitation Medicine at the University of Washington, led a large, multi-center group of researchers. (Until now, evidence for the benefits of steroid injections had only come from uncontrolled studies).
The multicenter double-blind study recruited 400 patients 50 or older with moderate-to-severe pain in the buttock or leg. All participants had functional disability with findings of central lumbar spinal stenosis on MRI or CT. Patients who had lumbar surgery or who had received epidural glucocorticoid injections the past 6 months were excluded.
Doctors administered the injections under XRay guidance, and the steroid used was also selected according to the physician's usual practice. Patients were allowed to request an additional injection at 3 weeks. At 3 weeks, patients who had received the steroid injection had reduced pain (0.6-point difference on a 10-point scale, P=0.02) and disability (1.8-point difference on a 24-point scale,P<0.001). However, these results were not clinically significant, Friedly told MedPage Today. Thus, the study s results showed that while at 6 weeks pain and disability scores had significantly improved in both treatment groups, there were no significant differences observed between treatment groups.
There are over 8 million such injections administered in America each year, of which about one-quarter are given to seniors. The study's findings could change management of a condition that is already notoriously difficult to treat. Surgery remains the most effective option, but many patients are older with comorbidities and cannot tolerate an operation. Further, even local steroid injections can, rarely, have serious side effects. Physicians should consider using only lidocaine or alternative treatment altogether, according to Dr. Friedly.
ACSH s Dr. Gil Ross (who practiced rheumatology from the 1970s through the 1990s) had this comment: There are several points that need emphasis in addition to the fairly simple, steroids don t add much if anything to local lidocaine shots for back pain. First, there was inadequate differentiation among these patients as to what exactly were their complaints. Spinal stenosis comprises a multitude of various anatomical and pathological entities, including facet joint arthritis and neurogenic claudication, in which the proliferation of bony growth impinges on the spinal canal and causes pain on walking similar to arterial blockage. These entities must be diagnosed correctly and treated quite differently it does not appear that the authors clearly separated these types of diseases. And, importantly, both groups had significant improvement in symptoms at 6 weeks those given the combination injections and those given lidocaine. So the epidural injections did work, even if transiently still better initially, I think, than major back surgery.