Ethics in Medicine

Questioning Steroids for Back Pain

Kristen Sparrow • October 22, 2013

San Francisco Acupuncture for Back PainSo a new study shows that injecting epidural saline is just as good as injecting steroids for low back pain.  I think this should be a rather big deal.
This study was painstakingly done reviewing all appropriate studies to date, even taking into account publication bias. The full study here.Epidural_Injections_for_Spinal_Pain__A_Systematic.31
A handy review of what they found is here

What We Already Know about This Topic
• Epidural nonsteroid injections (primarily local anesthetics) may
provide treatment for neuropathic pain via several potential
What This Article Tells Us That Is New
• This systematic review of the literature found that the few
available trials directly comparing epidural nonsteroid with
nonepidural injections showed no benefit
• Indirect comparisons of the techniques from a larger number
of trials suggested epidural nonsteroid injections may confer
some benefit

Having just experienced the excruciating standards for acupuncture studies, the need for appropriate control arms to distinguish effect from nonspecific effects and placebo, this study underscores what I refer to as “the tyranny of the model.”  Meaning, if a treatment makes sense according to current paradigms it is embraced.  Epidural steroids have been injected into patient’s epidural spaces for over 50 years, yet it turns out no steroids would have been just as effective (safer) and probably non epidural injections (safer still) and perhaps acupuncture too (safest.)  This falls into the category of “believing in treatments that don’t work.”  Need I remind people of the meningitis cases from a few years ago??
A discussion follows though I don’t think it’s entirely accurate.

Questioning Steroid Shots for Back Pain

Injecting steroids into the area around the spinal cord, known as an epidural, is the most commonly used treatment for back pain, but a new review of studies suggests that injecting any liquid, even plain saline solution, works just as well.
Researchers pooled the results of 43 studies involving more than 3,600 patients who got various kinds of injections for back pain. As they expected, they found some evidence that epidural steroid injections provided more relief than steroid injections into the muscles.
But the study, published online in Anesthesiology, also found that there was little difference between the amount of relief provided by steroidal and nonsteroidal epidural injections.