Trial shows short-term benefit of corticosteroid injection for sciatica
Aug 22, 2005
Allison Gandey
Southampton, UK - Overturning previous findings of no demonstrable advantage of epidural steroids, the Wessex Epidural Steroids Trial (WEST) study group reports first-time positive results in its large randomized controlled trial. In an advance access paper published online July 19, 2005 in Rheumatology, the group reports that epidural corticosteroids offer short-term relief of symptoms in patients with sciatica at three weeks [1]. But they also point out that the injections did not offer any medium- or long-term benefit in terms of symptoms, function, return to work, or the need for surgery. "Traditionally sciatica has been considered to be a self-limiting condition by many clinicians. However, our results suggest that this is not the case, as most patients had significant pain and disability at the end of the study," comment the researchers, led by Dr Nigel Arden (University of Southampton, UK). "The majority of patients in this pragmatic study had been in pain for over three months at the time of referral to secondary care and can therefore be defined as suffering from chronic pain."
"Many clinicians involved in low-back pain and sciatica treatment were waiting for the complete report of this very interesting study," Dr Jean-Pierre Valat (Hôpital Trousseau, Tours, France) told rheumawire. Approached for comment because he has led previous studies in this area, Valat says that he has been waiting on the WEST results since preliminary findings were first presented at the American College of Rheumatology meeting in 2002. "The results presented here seem quite different from those shown at the ACR meeting, as the improvement with epidural steroid injection reaches here a clear statistical significance at week three on leg pain and function."
Common treatment for sciatica
In their paper, Arden and colleagues define sciatica as unilateral, well-localized leg pain in the dermatomal distribution of the sciatic nerve that normally radiates to the foot or toes. It is often associated with numbness or paresthesia. They write that sciatica was initially thought to occur as a result of a prolapsed lumbar vertebral disk causing compression of the nerve root, leading to neural ischemia, edema, and eventually chronic inflammation, scarring, and perineural fibrosis. But it is now believed that sciatica can occur in the absence of direct nerve-root compressionpossibly as a result of the release of phospholipase A2 and other proinflammatory agents from a damaged disk, leading to nerve-root inflammation and edema.
The premise behind epidural injections is that the corticosteroid will reduce perineural inflammation and stop perineural fibrosis and therefore prevent chronic pain. Valat points out that steroid injections are an easy outpatient technique very commonly used to treat sciatica. "It is safe compared with high-dose NSAIDs or opioids," he added.
The trial involved 228 patients and lasted 12 months. Participants from four secondary pain-care clinics in the Wessex region had a clinical diagnosis of unilateral sciatica lasting one to 18 months. They were randomized to either three lumbar epidural steroid injections of triamcinolone acetonide or interligamentous saline injections at intervals of three weeks. The main outcome measure was the Oswestry low-back pain disability questionnaire (ODQ).
Arden and his team found that at three weeks, the epidural-steroid-injections group demonstrated a transient benefit over the placebo group. They report that patients achieved a 75% improvement in ODQ, 12.5% vs 3.7%, with a number needed to treat of 11.4. They observed no benefit of treatment from six to 52 weeks. The group also found that injections did not improve physical function, hasten return to work, or reduce the need for surgery. And there was no benefit of repeated vs single injection.
Injections appear to be justified when analgesics prove insufficient
Commenting on the study, Valat said, "The use of epidural injections seems justified for the management of acute sciatica when simple analgesics are not sufficient. This large pragmatic study demonstrates a short-term benefit useful in clinical practice."
The researchers say that despite a thorough search for clinical predictors of response, they were unable to identify any. "We conclude that there is no simple, clinically identifiable group of patients with sciatica that can be identified as being appropriate for an epidural steroid injection."
Valat explained that in his group's previous work, which, unlike this study, did not find a significant benefit of treatment, a different comparator was used [2]. "We used epidural saline injections, which is probably not an inactive treatment," Valat told rheumawire. He notes that in a previous New England Journal of Medicine study, Carette et al had also used epidural saline as a comparator yet had found a statistically significant effect of epidural steroid injections on leg pain at week six, but not at further evaluation [3]. "The comparator used by Ardeninterligamentous salineis probably a much better one," Valat said. "The aim of epidural steroid injections is to obtain a symptomatic short-term effect on pain and disability, and it is achieved in the present study."
Sources
Arden NK, Price C, Reading I, et al. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: The WEST study. Rheumatology 2005; DOI: 10.1093/rheumatology/kei028. Available at: http://intl-rheumatology.oxfordjournals.org.
Valat JP, Giraudeau B, Rozenberg S, et al. Epidural corticosteroid injections for sciatica: A randomised, double blind, controlled clinical trial. Ann Rheum Dis 2003; 62:639-643.
Carette S, Leclaire R, Marcoux S, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med 1997; 336:1634-1640.
Allison Gandey
Southampton, UK - Overturning previous findings of no demonstrable advantage of epidural steroids, the Wessex Epidural Steroids Trial (WEST) study group reports first-time positive results in its large randomized controlled trial. In an advance access paper published online July 19, 2005 in Rheumatology, the group reports that epidural corticosteroids offer short-term relief of symptoms in patients with sciatica at three weeks [1]. But they also point out that the injections did not offer any medium- or long-term benefit in terms of symptoms, function, return to work, or the need for surgery. "Traditionally sciatica has been considered to be a self-limiting condition by many clinicians. However, our results suggest that this is not the case, as most patients had significant pain and disability at the end of the study," comment the researchers, led by Dr Nigel Arden (University of Southampton, UK). "The majority of patients in this pragmatic study had been in pain for over three months at the time of referral to secondary care and can therefore be defined as suffering from chronic pain."
"Many clinicians involved in low-back pain and sciatica treatment were waiting for the complete report of this very interesting study," Dr Jean-Pierre Valat (Hôpital Trousseau, Tours, France) told rheumawire. Approached for comment because he has led previous studies in this area, Valat says that he has been waiting on the WEST results since preliminary findings were first presented at the American College of Rheumatology meeting in 2002. "The results presented here seem quite different from those shown at the ACR meeting, as the improvement with epidural steroid injection reaches here a clear statistical significance at week three on leg pain and function."
Common treatment for sciatica
In their paper, Arden and colleagues define sciatica as unilateral, well-localized leg pain in the dermatomal distribution of the sciatic nerve that normally radiates to the foot or toes. It is often associated with numbness or paresthesia. They write that sciatica was initially thought to occur as a result of a prolapsed lumbar vertebral disk causing compression of the nerve root, leading to neural ischemia, edema, and eventually chronic inflammation, scarring, and perineural fibrosis. But it is now believed that sciatica can occur in the absence of direct nerve-root compressionpossibly as a result of the release of phospholipase A2 and other proinflammatory agents from a damaged disk, leading to nerve-root inflammation and edema.
The premise behind epidural injections is that the corticosteroid will reduce perineural inflammation and stop perineural fibrosis and therefore prevent chronic pain. Valat points out that steroid injections are an easy outpatient technique very commonly used to treat sciatica. "It is safe compared with high-dose NSAIDs or opioids," he added.
The trial involved 228 patients and lasted 12 months. Participants from four secondary pain-care clinics in the Wessex region had a clinical diagnosis of unilateral sciatica lasting one to 18 months. They were randomized to either three lumbar epidural steroid injections of triamcinolone acetonide or interligamentous saline injections at intervals of three weeks. The main outcome measure was the Oswestry low-back pain disability questionnaire (ODQ).
Arden and his team found that at three weeks, the epidural-steroid-injections group demonstrated a transient benefit over the placebo group. They report that patients achieved a 75% improvement in ODQ, 12.5% vs 3.7%, with a number needed to treat of 11.4. They observed no benefit of treatment from six to 52 weeks. The group also found that injections did not improve physical function, hasten return to work, or reduce the need for surgery. And there was no benefit of repeated vs single injection.
Injections appear to be justified when analgesics prove insufficient
Commenting on the study, Valat said, "The use of epidural injections seems justified for the management of acute sciatica when simple analgesics are not sufficient. This large pragmatic study demonstrates a short-term benefit useful in clinical practice."
The researchers say that despite a thorough search for clinical predictors of response, they were unable to identify any. "We conclude that there is no simple, clinically identifiable group of patients with sciatica that can be identified as being appropriate for an epidural steroid injection."
Valat explained that in his group's previous work, which, unlike this study, did not find a significant benefit of treatment, a different comparator was used [2]. "We used epidural saline injections, which is probably not an inactive treatment," Valat told rheumawire. He notes that in a previous New England Journal of Medicine study, Carette et al had also used epidural saline as a comparator yet had found a statistically significant effect of epidural steroid injections on leg pain at week six, but not at further evaluation [3]. "The comparator used by Ardeninterligamentous salineis probably a much better one," Valat said. "The aim of epidural steroid injections is to obtain a symptomatic short-term effect on pain and disability, and it is achieved in the present study."
Sources
Arden NK, Price C, Reading I, et al. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: The WEST study. Rheumatology 2005; DOI: 10.1093/rheumatology/kei028. Available at: http://intl-rheumatology.oxfordjournals.org.
Valat JP, Giraudeau B, Rozenberg S, et al. Epidural corticosteroid injections for sciatica: A randomised, double blind, controlled clinical trial. Ann Rheum Dis 2003; 62:639-643.
Carette S, Leclaire R, Marcoux S, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med 1997; 336:1634-1640.
posted by Ricardo Pocurull at 6:38 AM
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