Fluid epidurals for lower-back pain

New research suggests that it may not be the steroids in spinal shots that provide relief from lower-back pain, but the mere introduction of any of a number of fluids, such as anesthetics and saline, to the space around the spinal cord.

Epidural steroid injections are the most common nonsurgical treatment for lower back pain, but placebo-controlled studies found benefit only 60 percent of the time and its long-term pain control is unclear, as is the reduction in the need for surgery. Additionally, steroids are known to raise blood sugar in diabetic patients, slow wound healing in surgical patients and accelerate bone disease in older women.

Steven P Cohen, MD, and colleagues reviewed 43 studies covering medical records of 3,641 patients, and found that epidural injections of any kind were twice as good as intramuscular injections of steroids.

“Just injecting liquid into the epidural space appears to work,” says Cohen, a professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine, in his report in the journal Anesthesiology. “This shows us that most of the relief may not be from the steroid, which everyone worries about.”

Cohen and colleagues say it is too soon to recommend that patients stop receiving epidural steroids, but add that their analysis also suggests that smaller steroid doses can be just as beneficial. Larger studies are needed, they say, to determine whether steroid alternatives can be just as helpful for back pain patients.

Cohen says his new analysis suggests that decades of mixed results of research on epidural steroid injections may have been due to the use of saline or anesthetic injections as the comparison “placebo” treatment. “It’s likely that those studies were actually comparing two treatments, rather than placebo versus treatment,” he says. “Researchers may be wasting millions of dollars and precious time on such studies.”

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