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Little Benefit From Corticosteroid Injections for Pain of Spinal Stenosis

Treatment fails to enhance lidocaine’s anesthetic effects

The addition of a corticosteroid to epidural injections of an anesthetic does not enhance pain reduction in patients with lumbar spinal stenosis, a common cause of lower back and leg pain, according to a study in the July 3 issue of the New England Journal of Medicine.

The findings come from the first major clinical trial comparing epidural injections of an anesthetic with and without corticosteroids for spinal stenosis.

The study was conducted at 16 hospitals in the U.S. and included 400 patients aged 50 years and older with evidence of lumbar stenosis and at least moderate pain. Half of the patients received epidural injections of lidocaine with a corticosteroid, and the other half received injections without a corticosteroid.

The researchers studied the patients 6 weeks after treatment and found that those whose lidocaine was supplemented with a corticosteroid — a steroid medication often used to relieve swelling — experienced minimal to no additional benefit compared with patients who received injections of an anesthetic alone.

Specifically, the authors observed no significant between-group differences in the Roland–Morris Disability Questionnaire (RMDQ) score. Moreover, the adjusted difference in the average treatment effect between the lidocaine/glucocorticoid group and the lidocaine-only group was –1.0 point (P = 0.07), and the difference in the intensity of leg pain was –0.2 points (P = 0.48).

The researchers also found that patients given lidocaine with a corticosteroid were more likely to report side effects and were more likely to absorb the corticosteroid into their bloodstream. Taken over time, corticosteroids can result in reduced bone density, an increased risk of bone fracture, and immunosuppression.

“The pain associated with lumbar stenosis can be excruciating, and patients are understandably looking for relief,” said Richard Kronick, PhD, Director of the Agency for Healthcare Research and Quality (AHRQ), which funded the investigation. “This study raises questions about the benefits of combining corticosteroids with an anesthetic for patients with lumbar stenosis, and it will help patients and their physicians make better informed decisions about treatment options.”

Lumbar spinal stenosis is a common cause of back-related disability. It is caused by gradual changes, often age-related, that cause the spinal canal to narrow and press against nerves. This leads to back and leg pain, a tingling sensation in the legs, and weakness. It is the leading reason for back surgery in older adults.

Epidural injection of an anesthetic with a corticosteroid is a common treatment for lumbar spinal stenosis. This combination is believed to relieve pain by reducing nerve swelling and by increasing blood flow. It is estimated that more than 2.2 million lumbar epidural steroid injections are performed each year among Medicare patients. Rates and associated costs of the procedure have increased nearly 300% during the last two decades.

Sources: NEJM; July 3, 2014; and PR Newswire; July 2, 2014.

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