For a few years in my mid-20s, I was debilitated by sciatica caused by herniated disks. It came on gradually, with no clear precipitating event. It was horrendous, but I had the good fortune to not have many responsibilities: no kids, no job. I managed to hobble around — I could barely walk for some time — and to do most of my graduate work lying down or standing. Sitting was impossible. I cannot even describe the oddity of the lower back and leg sensations. It’s as if my right leg had been taken away and replaced with somebody else’s. I just couldn’t make it work right.
I was also fortunate to be under the care of a wise, nearly retired orthopedist from the UK’s National Health Service. He advised physical therapy, thought yoga was a good idea, encouraged me to swim, and said no to surgery. I also did not receive any corticosteroid injections. I ingested my weight in ibuprofen, however.
So, the results of the new, systematic review of corticosteroid injections for sciatica in the Annals of Internal Medicine are of interest to me.
Background: Existing guidelines and systematic reviews provide inconsistent recommendations on epidural corticosteroid injections for sciatica. Key limitations of existing reviews are the inclusion of trials with active controls of unknown efficacy and failure to provide an estimate of the size of the treatment effect.
Purpose: To determine the efficacy of epidural corticosteroid injections for sciatica compared with placebo.
Data Sources: International Pharmaceutical Abstracts, PsycINFO, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL.
Study Selection: Randomized, placebo-controlled trials assessing the efficacy of epidural corticosteroid injections in participants with sciatica.
Data Extraction: Two independent reviewers extracted data and assessed risk of bias. Leg pain, back pain, and disability were converted to common scales from 0 (no pain or disability) to 100 (worst possible pain or disability). Thresholds for clinically important change in the range of 10 to 30 have been proposed for these outcomes. Effects were calculated for short-term (>2 weeks but ≤3 months) and long-term (≥12 months) follow-up.
Data Synthesis: Data were pooled with a random-effects model, and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used in summary conclusions. Twenty-five published reports (23 trials) were included. The pooled results showed a significant, although small, effect of epidural corticosteroid injections compared with placebo for leg pain in the short term (mean difference, −6.2 [95% CI, −9.4 to −3.0]) and also for disability in the short term (mean difference, −3.1 [CI, −5.0 to −1.2]). The long-term pooled effects were smaller and not statistically significant. The overall quality of evidence according to the GRADE classification was rated as high quality.
Limitation: The review included only English-language trials and could not incorporate dichotomous outcome measures into the analysis.
Conclusion: The available evidence suggests that epidural corticosteroid injections offer only short-term relief of leg pain and disability for patients with sciatica. The small size of the treatment effects, however, raises questions about the clinical utility of this procedure in the target population.
I’m not surprised that corticosteroids aren’t all that effective. They don’t treat the underlying cause, which in my case was a weak back, or the contributing factors, like a sedentary lifestyle. Though it took me about 5 years to largely recover from my sciatic episode, I’ve not had any serious back issues science. It’s an N=1 result, but I credit the strength I’ve gained through various exercise. Good back health is one of the reasons I now stand at work. I highly recommend it.