Steroid for epidural injection in spinal stenosis: a systematic review and meta-analysis

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Open Access Full Text Article Steroid for epidural injection in spinal stenosis: a systematic review and meta-analysis This article was published in the following Dove Press journal: Drug Design, Development and Therapy 30 January 2015 Number of times this article has been viewed Kuan Liu* Pengcheng Liu* Run Liu Xing Wu Ming Cai Department of Orthopaedics, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China *These authors contributed equally to this work Introduction Correspondence: Xing Wu; Ming Cai No 301 Middle Yanchang Road, Shanghai Tenth People’s Hospital, Shanghai, 200072, People’s Republic of China Email ; Lumbar spinal stenosis (LSS) is a degenerative disease that affects the lumbar spine. LSS can cause back and leg pain due to the compression of neuronal structures and intraspinal vasculature due to the narrowing of the spinal canal. LSS is quite common in people older than 65 years, and its most significant clinical symptom is intermittent neurogenic claudication. Neurogenic claudication is characterized by pain, paresthesia, and cramping in one or both legs.1 It is caused suddenly by walking and prolonged standing and can be relieved through sitting and bending forward.2,3 Neurogenic claudication is a main reason leading to disability and lost independence in the elderly population.4 The patients with symptomatic LSS not only suffer from back and leg pain, but are also at high risk for developing serious complications. Disability and lost independence may lead to physical deterioration and obesity, which may eventually lead to serious health problems.5 Those afflicted have more serious walking limitations than individuals with knee or hip osteoarthritis.6 Consequently, their restricted ability to walk and stand lead to a significant decrease in quality of life.7–9 The rate of surgery for LSS has risen dramatically, especially in the USA.10,11 Some good outcomes from surgery have been demonstrated, but the literature has also suggested limited long-term benefits when compared to nonsurgical management.12,13 Some conservative treatment is recommended prior to surgical intervention. Researchers have focused on the use of epidural steroid injections to treat pain due to LSS.14–23 707 submit your manuscript | www.dovepress.com Drug Design, Development and Therapy 2015:9 707–716 Dovepress © 2015 Liu et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php http://dx.doi.org/10.2147/DDDT.S78070 Powered by TCPDF (www.tcpdf.org) Purpose: To investigate the effectiveness and safety of epidural steroid injections in patients with lumbar spinal stenosis (LSS). Methods: We performed a search on the CENTRAL, Pubmed, Embase and Cochrane databases up to September 2014. We recovered 17 original articles, of which only 10 were in full compliance with the randomized controlled trial (RCT) criteria. These articles were reviewed in an independent and blinded way by two reviewers who were previously trained to extract data and score their quality by the criteria of the Cochrane Handbook (5.1.0). Results: We accepted ten studies with 1,010 participants. There is minimal evidence that shows that epidural steroid injections are better than lidocaine alone, regardless of the mode of epidural injection. There is a fair short-term and long-term benefit for treating spinal stenosis with local anesthetic and steroids. Conclusions: This meta-analysis suggests that epidural steroid injections provide limited improvement in short-term and long-term benefits in LSS patients. Keywords: lumbar spinal stenosis, epidural injection, steroid, local anesthetic, chronic pain Dovepress Drug Design, Development and Therapy downloaded from https://www.dovepress.com/ by 54.37.163.172 on 12-Jul-2018 For personal use only. Liu et al Because pain and limited walking are the main impaired functions in patients with LSS, decreasing pain and improving walking ability are the primary goals for treatment.3 Two systematic reviews on epidural steroid injections for LSS are available.24,25 However, whether epidural steroid injections can relieve pain and improve walking ability in patients with LSS in short-term and long-term follow-ups is unclear. It is important to evaluate the role of epidural steroid injection treatments to manage patients with LSS. Therefore, we undertook a systematic review and meta-analysis of all the published literature to evaluate the effectiveness and safety of epidural steroid injection interventions for the treatment of LSS. Materials and methods We conducted this systematic review and meta-analysis according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0; Oxford, UK).26 Search strategy The Cochrane library, Google Scholar, CENTRAL, Pubmed and Embase databases were searched independently by two investigators (KL and PCL), and relevant studies published before September 2014 were retrieved. The search strategy was based on a combination of the following medical subject headings (MeSH) and keywords: “steroid”, “spinal stenosis”, “pain”, “epidural injection”, and “local anesthetic”. No restriction to specific languages or years of publication were included. The “related articles” function was used to broaden the search. The reference lists of the selected studies were also examined manually to identify relevant studies that were not discovered during the database searches. The corresponding authors were contacted when additional information was needed. Study selection We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of epidural injections of steroids plus local anesthetic versus local anesthetic alone for the treatment of LSS patients. The inclusion criteria for the systematic review and meta-analysis were as follows: (1) randomized controlled trials in adults with LSS with epidural injection treatment; (2) clinical or radiological diagnosis of LSS; (3) describe neurogenic claudication with back (leg) pain and gait assessment; (4) provide the dosage and route of epidural steroid injection administration; and (5) outcomes measured, such as walking ability, p (...truncated)