Corticosteroid Plus Lidocaine Injections Do Not Alleviate Pain in Central Lumbar Spinal Stenosis

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Choice of corticosteroid included betamethasone, 6 to 12 mg; dexamethasone, 8 to 10 mg; methylprednisolone, 80 to 120 mg; or triamcinolone, 60 to 120 mg.
Choice of corticosteroid included betamethasone, 6 to 12 mg; dexamethasone, 8 to 10 mg; methylprednisolone, 80 to 120 mg; or triamcinolone, 60 to 120 mg.

In patients with central lumbar spinal stenosis, adding corticosteroids to epidural lidocaine injections does not improve patient-reported pain or function at 12 months, according to a study published in the Journal of Bone & Joint Surgery.

Janna L. Friedly, MD, from the Department of Rehabilitation Medicine, at the University of Washington in Seattle, and colleagues, conducted a randomized, blinded controlled trial to assess whether the addition of corticosteroids to local anesthetic epidural injections reduces pain and disability at 12 months. The researchers identified 400 patients ≥50 years of age (mean age, 68 years; 55% women) who were referred for an epidural corticosteroid injection and had central lumbar spinal stenosis on cross-sectional imaging, neurogenic claudication-related symptoms, leg pain intensity rating >4 (range, 0 [no pain] to 10 [worst pain imaginable]). Exclusion criteria included previous lumbar surgery, need for surgery for spondylolisthesis, or receipt of epidural corticosteroid injections in the past 6 months.

Patients were allocated to a 1- to 3-mL epidural injection of corticosteroid plus 0.25% to 1% lidocaine (n = 200) or lidocaine alone (n = 200). Patients received 1 to 2 injections for 6 weeks and 0 to 2 additional injections between 6 and 12 weeks. Patients could cross over to the blinded alternate treatment at 6 weeks.

The primary outcomes were RDQ score and leg pain intensity rating at 12 months. Secondary outcomes included patients with ≥50% improvement on RDQ or leg pain intensity.

A total of 89% of patients completed the 12-month follow-up. At 6 weeks, 30% of the corticosteroid-lidocaine group and 45% of the lidocaine-only group crossed over to the alternate treatment. At 12 months, groups did not differ for change in disability or pain intensity scores from baseline or proportions of patients with ≥50% improvement in disability or pain scores.

In a corresponding editorial, Nitin B. Jain, MD, MSPH, from Vanderbilt University Medical Center in Nashville, stated, “Considering the half-life of corticosteroids or lidocaine, the use of either agent would be expected to provide maximum relief in the first few weeks after an injection. Therefore, corticosteroid spinal injections could have a role in clinical practice, even if they do not lead to better outcomes at 1 year of follow-up, if they can provide better symptomatic relief at 6 weeks.”

References

  1. Friedly JL, Comstock BA, Turner JA, et al. In lumbar spinal stenosis, adding corticosteroids to lidocaine epidural injections did not improve pain or function at 12 months. J Bone Joint Surg Am. 2018 May 16;100(10):884. doi: 10.2106/JBJS.18.00170
  2. Jain NB. Commentary: In lumbar spinal stenosis, adding corticosteroids to lidocaine epidural injections did not improve pain or function at 12 months. J Bone Joint Surg Am. 2018 May 16;100(10):884. doi: 10.2106/JBJS.18.00170
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