Epidural injections in prevention of surgery for spinal pain: Systematic review and meta-analysis of randomized controlled trials

Background context Low back pain is debilitating and costly, especially for patients not responding to conservative therapy and requiring surgery. Purpose Our objective was to determine whether epidural steroid injections (ESI) have a surgery-sparing effect in patients with spinal pain. Study design/setting The study design was based on a systematic review and meta-analysis. Methods Databases searched included Cochrane, PubMed, and EMBASE. The primary analysis evaluated randomized controlled trials (RCTs) in which treatment groups received ESI and control groups underwent control injections. Secondary analyses involved RCTs comparing surgery with ESI, and subgroup analyses of trials comparing surgery with conservative treatment in which the operative disposition of subjects who received ESI were evaluated. Results Of the 26 total studies included, only those evaluating the effect of ESI on the need for surgery as a primary outcome examined the same patient cohort, providing moderate evidence that patients who received ESI were less likely to undergo surgery than those who received control treatment. For studies examining surgery as a secondary outcome, ESI demonstrated a trend to reduce the need for surgery for short-term (<1 year) outcomes (risk ratio, 0.68; 95% confidence interval, 0.41-1.13; p=.14) but not long-term (≥1 year) outcomes (0.95, 0.77-1.19, p=.68). Secondary analyses provided low-level evidence suggesting that between one-third and half of patients considering surgery who undergo ESI can avoid surgery. Conclusions Epidural steroid injections may provide a small surgery-sparing effect in the short term compared with control injections and reduce the need for surgery in some patients who would otherwise proceed to surgery.