Comments on a systematic review and meta-analysis of steroids for epidural injections in spinal stenosis

Abstract

Laxmaiah Manchikanti,1,2 Joshua A Hirsch3,41Pain Management Center of Paducah, Paducah, KY, USA; 2Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA; 3Interventional Care, Minimally Invasive Spine Surgery, Interventional Radiology, NeuroInterventional Services and Neuroendovascular Program, Massachusetts General Hospital, Boston, MA, USA; 4Department of Radiology, Harvard Medical School, Boston, MA, USAWe read with interest the manuscript by Liu et al a systematic review and meta-analysis of steroids for epidural injection in spinal stenosis. The results showed there was fair short- and long-term benefit for treating spinal stenosis with local anesthetic and steroids; however, the authors concluded that the meta-analysis suggested that epidural steroid injections provided limited improvement in short- and long-term benefits in lumbar spinal stenosis patients. This may be confusing to the readership. Fair evidence essentially provides moderate benefits, but the conclusion shows limited improvement.Further, the authors included a wide variety of studies which are not applicable to the meta-analysis. Issues include studies performed with or without fluoroscopy, with short-term and long-term follow-up, with local anesthetic or without local anesthetic, inter-laminar, caudal, and transforaminal approaches, and some very small studies. Multiple studies with variable bias were also included in the meta-analysis. Further, the risk of bias assessment appears to be inappropriate. For example, both studies by Manchikanti et al, even though identical, were rated differently showing variable bias. Further, multiple items were rated inaccurately which differed for each study even though they were identical. These two trials have been assessed in the past in multiple systematic reviews and were rated as high quality, meeting at least 8 of 12 criteria of Cochrane review criteria which have been compressed to 7 in this assessment with one trial scoring 4 of 7 and the second trial scoring 3 of 7 instead of both trials scoring 6 of 7. Further, the highly rated trial by Friedly et al, which has generated significant attention, has been met with criticism for its flawed analysis and extremely short follow-up period.View original paper by Liu and colleagues.