No Benefit of Steroids for Spinal Stenosis in Randomized Trial

Friedly JL, Comstock BA, Turner JA, et al.A Randomized Trial of Epidural Glucocorticoid Injections for Spinal Stenosis.  N Engl J Med (2014) 371:11-21 July 3, 2014 doi: 10.1056/NEJMoa1313265

Andersson GBJ. Editorial: Epidural Glucocorticoid Injections in Patients with Lumbar Spinal Stenosis.N Engl J Med  (2014) 371:75-76 July 3, 2014 doi: 10.1056/NEJMe1405475

Lamas D Glucocorticoid Injections for Spinal StenosisNow@NEJM. July 2, 2014

Glucorticoids had no clinically significant benefit over placebo after six weeks for 400 patients with lumbar central spinal stenosis and moderate-to-severe leg pain and disability, the primary outcomes of the study.

The editorial recommends informing patients about the lack of evidence and risks.

There were small differences in favor of glucocorticoids in secondary outcomes, subgroup analyses and post-hoc analysis. For example, glucocorticoids had a (statistically significant but clinically insignificant) improvement in pain and disability at 3 weeks, but not at 6 weeks.

Conversely, there were more (minor, reversible) reported adverse events in the glucocorticoid group, but serious adverse events were rare. Glucocorticoid injections can have catastrophic complications in the community, which were beyond the scope of this study.

Many insurance companies require epidural injections as part of nonsurgical treatment before surgery is approved. The editorial suggests that this requirement be “reconsidered.”

Four hundred patients were randomized to receive either epidural injections of glucocorticoids plus lidocaine or lidocaine alone. The primary outcomes were the score on the Roland-Morris Disability Questionnaire and a rating of 1 to 10 on a leg pain intensity scale. At six weeks, there was improvement in both primary outcomes, pain and disability, but the differences between the groups was not statistically significant.