No benefit with glucocorticoid injection for spinal stenosis

1. The use of epidural glucocorticoid injections to treat spinal stenosis has been steadily increasing over time.

2. This randomized, controlled trial demonstrated no significant difference between patients receiving glucocorticoid-lidocaine and lidocaine-only injections in terms of improvement in disability or pain control.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Lumbar spinal stenosis is a debilitating condition resulting from degenerative change of the vertebrae and subsequent narrowing of the spinal canal. These changes lead to nerve compression, thereby resulting in disability from pain and lower extremity weakness. While glucocorticoid injections are being increasingly used to treat spinal stenosis, the evidence supporting this practice is quite scarce. The purpose of this randomized, controlled trial was to assess the efficacy of glucocorticoid-lidocaine epidural injections compared to lidocaine alone.

In patients with spinal stenosis, there were no significant differences between glucocorticoid-lidocaine and lidocaine-only injections in terms of improvement in disability or pain control. Patients receiving glucocorticoids, however, did experience a higher number of adverse events (58 vs. 34, p=0.02). No commercial sponsorship was provided for this study.

Click to read the study, published today in NEJM

Click to read an accompanying editorial in NEJM

Relevant Reading: Lumbar Spinal Stenosis

In-Depth [randomized controlled trial]: This double-blind, randomized, controlled trial was conducted at 16 sites across the United States, and involved 400 patients. Eligible patients were ≥50 years of age, had evidence of central lumbar spinal stenosis on magnetic resonance imaging or computed tomography, had an average pain rating >4 (on a scale from 1-10, with 10 being the worst), had worse pain in the buttock and/or legs compared with their back, and a score ≥7 on the Roland-Morris Disability Questionnaire (RMDQ) (scores range from 0-24 with higher scores indicating greater disability). Patients were excluded if they did not have central stenosis, had spondylolisthesis requiring surgery, or had received epidural glucocorticoid injections in the previous 6 months. Patients were randomized to receive either glucocorticoid-lidocaine or lidocaine-only fluoroscopically guided epidural injections. Two primary outcomes were measured at 6 weeks: 1) Roland-Morris Disability Questionnaire scores and 2) the patient’s rating of average buttock, hip, or leg pain in the previous week.

At 6 weeks, patients receiving glucocorticoid-lidocaine and those receiving lidocaine-only injections both experienced improvements in their RMDQ scores and pain intensity. There were, however, no significant differences between the two groups in either measure. The proportion of patients experiencing adverse events was not significantly different between the two groups, though the number of adverse events was significantly higher in the group receiving glucocorticoids (58 vs. 34, p=0.02).

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