Clinical Question

Do epidural glucocorticoid injections improve the symptoms of spinal stenosis?

Bottom Line

Epidural glucocorticoid injections are ineffective for lumbar spinal stenosis. Whether this will change practice for this lucrative procedure will be an interesting question. (Level of Evidence = 1b)

Synopsis

Epidural glucocorticoid injections are a common treatment for patients with lumbar spinal stenosis, but their effectiveness is uncertain. In this study, the researchers identified 400 patients, 50 years and older, with lumbar spinal stenosis (confirmed by magnetic resonance imaging or computed tomography); pain of at least 4 on a scale from 1 to 10 in the buttock or leg; and significant functional disability based on a validated scale. Patients were randomly assigned to receive an epidural injection with lidocaine and a glucocorticoid (betamethasone, 6 to 12 mg; dexamethasone, 8 to 10 mg; or triamcinolone, 60 to 120 mg), or lidocaine alone. All injections were done under fluoroscopic guidance.

Groups were balanced at the start of the study, with the exception of a somewhat shorter duration of pain in the lidocaine-only group, and analysis was by intention to treat. The mean age of participants was 68 years, 55% were women, and 69% were white. Patients could receive a second injection three weeks after the first, and results were evaluated three and six weeks after the initial injection. At three weeks, improvements in pain and disability were slightly greater in the intervention group, but these were not clinically significant, and they disappeared by the six-week assessment. Adverse events were more common in the intervention group.

Study design: Randomized controlled trial (double-blinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (specialty)

Reference: FriedlyJLComstockBATurnerJAet alA randomized trial of epidural gluocorticoid injections for spinal stenosis [published correction appears in N Engl J Med . 2014;371(4):390]. N Engl J Med2014; 371( 1): 11– 21.