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Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis

TO THE EDITOR: The publication by Chou and colleagues (1) raises significant concerns among physicians treating patients with radicular pain and associated functional impairment. Fourteen medical societies formulated a consensus response to the Agency for Healthcare Quality and Research's technology assessment, the basis of the current publication, addressing the flawed methodology and resulting aberrant conclusions (2). The authors assert the nihilistic position, without evidence, that back and leg pain are not attributable to a specific cause, and they therefore included studies with patient selection by symptoms, not diagnosis. Current literature demonstrates that radicular and somatic back pain can be specifically diagnosed with systematic application of diagnostic blocks or provocative procedures, synthesized with clinical examination, advanced imaging, and electrophysiology (3). Their position has led to inclusion of heterogeneous study populations; in 29 studies of epidural steroid injection versus placebo, radicular pain alone was specified in 22, a mixture of radicular and back pain in 6, and back pain alone in 1. Correlative imaging findings were required in only 11 studies, leaving the nature of the compressive lesions and degree of compression unknown. With literature demonstrating that these factors influence the natural history and efficacy of epidural steroid injections, it is inappropriate to draw conclusions from these heterogeneous studies. The review is a corruption of evidence-based medicineomitting the best available evidence: high-quality outcome studies of homogenous patients with contrast confirmation of injectate delivery to the target. Rather, it includes decades-old trials of unguided epidural injections by several routes. Only 7 of the 29 placebo-controlled trials used image guidance. Reliance on flawed randomized, controlled trials leads the authors to conclude that there is no evidence supporting the use of image guidance, which conflicts with the U.S. Food and Drug Administration Safe Use Initiative mandating image guidance. The authors' conclusions are based on invalid statistical analyses, primarily changes in mean pain scores, which are insufficient for drawing conclusions about effectiveness. A National Institutes of Health task force recommended using categorical outcomes for studying low back pain (4). When inappropriate statistics are applied to the review of heterogeneous populations given heterogeneous treatments, with equal weight given to outdated procedural techniques, results should be viewed with skepticism. A comprehensive examination of the literature, including high-quality contemporary studies of outcomes in homogeneous patient populations, reveals that in carefully selected patients, epidural steroids injected to exacting procedural standards provide pain relief and functional improvement in patients with radicular pain (5).