Systematic Review on Epidural Steroid Injections: Quo Vadis?

The recently published "Clinical Relevance of Epidural Steroid Injections on Lumbosacral Radicular Syndrome-Related Complaints: Systematic Review and Meta-Analysis"1 questions whether the current practice of epidural steroid injections (ESIs) for patients suffering from lumbosacral radicular syndrome should continue. Considering the high number of epidural steroid injections that are performed yearly, the methodology may require further assessment. The authors make some statement about the evolution, the cause and the treatment algorithm of lumbosacral radicular pain, that are not completely correct. The papers included in this review are not all of high scientific quality. Papers dealing with patients who suffer lumbosacral radicular pain of 6 weeks to 21 months, which is for beyond the recommended period for the indication of sub-Acute lumbosacral radicular pain. More than one-Third of the studies included in this systematic review reported no medical imaging prior to performing the epidural injection. This heavily compromises the results of the study and the validity of the recommendation. The use of minimal important change (MIC) as an outcome parameter is inappropriate because this outcome measurement was developed to identify clinically meaningful changes within groups or individuals, not to determine significant changes between groups The authors performed 40 meta-Analyses, but most of them were based on 1-3 RCTs. Whereas meta-Analyses containing few studies can yield useful information when the studies evaluate similar patient populations, the procedures are standardized, and the outcome measures are similar, performing meta-Analyses in the presence of significant study heterogeneity, as is present in ESI clinical trials, is a roadmap for showing a biased lack of efficacy.