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Anesthesiology:
doi: 10.1097/ALN.0000000000000198
Correspondence

Evaluation of Effect on Nonsteroid Epidural Injections

Manchikanti, Laxmaiah M.D.; Falco, Frank J. E. M.D.; Hirsch, Joshua A. M.D.

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To the Editor:

“Epidural Injections for Spinal Pain: A Systematic Review and Meta-analysis Evaluating the ‘Control’ Injections in Randomized Controlled Trials” by Bicket et al.1 is an interesting and thought-provoking article. The authors have provided excellent information in reference to epidural injections of solutions other than steroids. Even though the authors have used an appropriate search strategy and quality assessment, some points of concern persist which may have influenced the conclusions.
As the authors have described, there is a wide variation in design and performance of the trials along with outcome assessments. Thus, it would have been appropriate if they compared local anesthetics versus local anesthetic and steroids, sodium chloride solution versus sodium chloride solution and steroid, sodium chloride solution versus steroid only, local anesthetic versus steroid only, epidural steroid versus intramuscular steroid, and so on in a manner which is much more reliable and understandable.
It seems the authors have missed at least three articles by Manchikanti et al.2–4 and also have used two duplicate articles5–8 providing inadequate analysis. The articles that were missed provided appropriate information similar to that provided by the other nine articles which could bolster the case for equal effectiveness between local anesthetics compared with local anesthetics and steroids.
In addition, the authors have developed an epidural steroid injection technical quality rating. Overall, the quality rating scale seems to be an excellent modality to assess the technical qualities. However, the authors have used some of the qualities which may be inappropriate in some cases such as excluding the patients with previous surgery (studies have been conducted only in postsurgery syndrome) and providing inclusion of patients with pain lasting less than 6 months, two points which are very unusual in chronic pain settings. In addition, the authors have provided only one point for radiographic guidance which should provide much higher importance for fluoroscopic usage and contrast injection, considering that a large number of injections are extra epidural and not target specific.
Hopefully, future studies will address some of the issues raised here.
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Competing Interests

The authors declare no competing interests.
Laxmaiah Manchikanti, M.D., Frank J. E. Falco, M.D., Joshua A. Hirsch, M.D.
University of Louisville, Louisville, Kentucky (L.M.). drlm@thepainmd.com
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References

1. Bicket MC, Gupta A, Brown CH IV, Cohen SP. Epidural injections for spinal pain: A systematic review and meta-analysis evaluating the “control” injections in randomized controlled trials. ANESTHESIOLOGY. 2013;119:907–31

2. Manchikanti L, Singh V, Falco FJ, Cash KA, Pampati V. Evaluation of the effectiveness of lumbar interlaminar epidural injections in managing chronic pain of lumbar disc herniation or radiculitis: A randomized, double-blind, controlled trial. Pain Physician. 2010;13:343–55

3. Manchikanti L, Cash KA, McManus CD, Pampati V, Benyamin RM. A preliminary report of a randomized double-blind, active controlled trial of fluoroscopic thoracic interlaminar epidural injections in managing chronic thoracic pain. Pain Physician. 2010;13:E357–69

4. Manchikanti L, Cash KA, Pampati V, Malla Y. Fluoroscopic cervical epidural injections in chronic axial or disc-related neck pain without disc herniation, facet joint pain, or radiculitis. J Pain Res. 2012;5:227–36

5. Manchikanti L, Singh V, Cash KA, Pampati V, Damron KS, Boswell MV. Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 2—Disc herniation and radiculitis. Pain Physician. 2008;11:801–15

6. Manchikanti L, Singh V, Cash KA, Pampati V, Damron KS, Boswell MV. Effect of fluoroscopically guided caudal epidural steroid or local anesthetic injections in the treatment of lumbar disc herniation and radiculitis: A randomized, controlled, double blind trial with a two-year follow-up. Pain Physician. 2012;15:273–86

7. Manchikanti L, Singh V, Cash KA, Pampati V, Datta S. Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 3—Post surgery syndrome. Pain Physician. 2008;11:817–31

8. Manchikanti L, Singh V, Cash KA, Pampati V, Datta S. Fluoroscopic caudal epidural injections in managing post lumbar surgery syndrome: Two-year results of a randomized, double-blind, active-control trial. Int J Med Sci. 2012;9:582–91

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