Lack of Superiority of Epidural Injections with Lidocaine with Steroids Compared to Without Steroids in Spinal Pain: A Systematic Review and Meta-Analysis

Abstract

Background: Multiple randomized controlled trials (RCTs) and systematic reviews have been conducted to summarize the evidence for administration of local anesthetic (lidocaine) alone or with steroids, with discordant opinions, more in favor of equal effect with local anesthetic alone or with steroids. Objective: To evaluate the comparative effectiveness of lidocaine alone and lidocaine with steroids in managing spinal pain to assess superiority or equivalency. Study Design: A systematic review of RCTs assessing the effectiveness of lidocaine alone compared with addition of steroids to lidocaine in managing spinal pain secondary to multiple causes (disc herniation, radiculitis, discogenic pain, spinal stenosis, and post-surgery syndrome). Methods: This systematic review was performed utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) for literature search, Cochrane review criteria, and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) to assess the methodologic quality assessment and qualitative analysis utilizing best evidence synthesis principles, and quantitative analysis utilizing conventional and single-arm meta-analysis. PubMed, Cochrane Library, US National Guideline Clearinghouse, Google Scholar, and prior systematic reviews and reference lists were utilized in the literature search from 1966 through December 2019. The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. Outcome Measures: A hard endpoint for the primary outcome was defined as the proportion of patients with 50% pain relief and improvement in function. Secondary outcome measures, or soft endpoints, were pain relief and/or improvement in function. Effectiveness was determined as short-term if it was less than 6 months. Improvement that lasted longer than 6 months, was defined as long-term. Results: Based on search criteria, 15 manuscripts were identified and considered for inclusion for qualitative analysis, quantitative analysis with conventional meta-analysis, and single-arm meta-analysis. The results showed Level II, moderate evidence, for short-term and long-term improvement in pain and function with the application of epidural injections with local anesthetic with or without steroid in managing spinal pain of multiple origins. Limitations: Despite 15 RCTs, evidence may still be considered as less than optimal and further studies are recommended. Conclusion: Overall, the present meta-analysis shows moderate (Level II) evidence for epidural injections with lidocaine with or without steroids in managing spinal pain secondary to disc herniation, spinal stenosis, discogenic pain, and post-surgery syndrome based on relevant, high-quality RCTs. Results were similar for lidocaine, with or without steroids. Key Words: Chronic spinal pain, epidural injections, local anesthetic, lidocaine, steroids, active control trials, placebo effect

2. Cervical radicular pain

“…The use of interlaminar epidural corticosteroid injections (CESI) for cervical radicular pain was evaluated in a systematic review, which demonstrated Level II evidence for the effectiveness of interlaminar CESI with local anesthetic with or without steroids based on multiple RCTs 64 . A meta‐analysis failed to demonstrate benefit for the addition of corticosteroids to local anesthetic in interlaminar CESI but this conclusion was based on few available studies and a lack of homogeneity in the included RCTs 65 . The American Society of Interventional Pain Physicians (ASIPP) reported level I evidence for interlaminar CESI with a strong recommendation for long‐term effectiveness with repeated injections 66 .…”

“…64 A meta-analysis failed to demonstrate benefit for the addition of corticosteroids to local anesthetic in interlaminar CESI but this conclusion was based on few available studies and a lack of homogeneity in the included RCTs. 65 The American Society of Interventional Pain Physicians (ASIPP) reported level I evidence for interlaminar CESI with a strong recommendation for long-term effectiveness with repeated injections. 66 The effectiveness of interlaminar CESI was compared to transforaminal CESI in 108 patients with axial pain due to cervical disk herniation.…”

The Influence of Covid-19 on Utilization of Epidural Procedures in Managing Chronic Spinal Pain in the Medicare Population

“…Over the years, literature has provided discordant conclusions of the clinical and cost-utility of epidural procedures, even though extensive literature, including systematic reviews, randomized controlled trials, cost-utility analysis, and guidelines,35–58 have shown appropriate evidence. Discordant conclusions are based on the lack of agreement between proponents and opponents of the effectiveness and indications, with proponents emphasizing inappropriate conclusions as the basis of discordant results.…”

Epidural Corticosteroid Injections for Sciatica: A Cochrane Review of Epidural Corticosteroid Injections Distorts the Truth

“…Systematic reviews have shown showed that there was no superiority of epidural steroids plus local over local anesthetic alone. 3 In addition, epidural injection of sodium chloride solution has been shown to be not a true placebo as it was equally effective as steroids. 4 Cochrane may be propagating a mistake that has the potential to harm patients by limiting access on the basis of flawed interpretation of data.…”

“…Recently, Shanthanna et al 2 in a systematic review of all the studies available showed steroids do not provide any significant additional relief than local anesthetic injections alone. Systematic reviews have shown showed that there was no superiority of epidural steroids plus local over local anesthetic alone 3 . In addition, epidural injection of sodium chloride solution has been shown to be not a true placebo as it was equally effective as steroids 4 .…”