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Systematic review

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Injection therapy for subacute and chronic low back pain: An updated cochrane review

Journal Spine
Year 2009
Links Pubmed DOI

This article is included in 1 Structured summary of systematic reviews 17 Structured summaries of systematic reviews (1 reference)

This article includes 17 Primary studies 17 Primary studies (17 references)

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STUDY DESIGN.: A systematic review of randomized controlled trials (RCTs). OBJECTIVE.: To determine if injection therapy is more effective than placebo or other treatments for patients with subacute or chronic low back pain. SUMMARY OF BACKGROUND DATA.: The effectiveness of injection therapy for low back pain is still debatable. Heterogeneity of target tissue, pharmacological agent, and dosage, generally found in RCTs, point to the need for clinically valid comparisons in a literature synthesis. METHODS.: We updated the search of the earlier systematic review and searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE databases up to March 2007 for relevant trials reported in English, French, German, Dutch, and Nordic languages. We also screened references from trials identified. RCTs on the effects of injection therapy involving epidural, facet, or local sites for subacute or chronic low back pain were included. Studies that compared the effects of intradiscal injections, prolotherapy, or ozone therapy with other treatments were excluded unless injection therapy with another pharmaceutical agent (no placebo treatment) was part of one of the treatment arms. Studies about injections in sacroiliac joints and studies evaluating the effects of epidural steroids for radicular pain were also excluded. RESULTS.: Eighteen trials (1179 participants) were included in this review. The injection sites varied from epidural sites and facet joints (i.e. intra-articular injections, peri-articular injections and nerve blocks) to local sites (i.e. tender-and trigger points). The drugs that were studied consisted of corticosteroids, local anesthetics, and a variety of other drugs. The methodologic quality of the trials was limited with 10 of 18 trials rated as having a high methodologic quality. Statistical pooling was not possible because of clinical heterogeneity in the trials. Overall, the results indicated that there is no strong evidence for or against the use of any type of injection therapy. CONCLUSION.: There is insufficient evidence to support the use of injection therapy in subacute and chronic lowback pain. However, it cannot be ruled out that specific subgroups of patients may respond to a specific type of injection therapy. © 2008, Lippincott Williams & Wilkins.

Systematic review

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Injection therapy for subacute and chronic low-back pain

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Journal Cochrane database of systematic reviews (Online)
Year 2008
Links Pubmed DOI PubMed Central

This article is included in 1 Broad synthesis 19 Broad syntheses (1 reference)

This article includes 19 Primary studies 19 Primary studies (19 references)

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Background: The effectiveness of injection therapy for low-back pain is still debatable. Heterogeneity of target tissue, pharmacological agent and dosage generally found in randomized controlled trials (RCTs) points to the need for clinically valid comparisons in a literature synthesis. Objectives: To determine if injection therapy is more effective than placebo or other treatments for patients with subacute or chronic low-back pain. Search strategy: We updated the search of the earlier systematic review and searched the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE databases from January 1999 to March 2007 for relevant trials reported in English, French, German, Dutch and Nordic languages. We also screened references from trials identified. Selection criteria: RCTs on the effects of injection therapy involving epidural, facet or local sites for subacute or chronic low-back pain were included. Studies which compared the effects of intradiscal injections, prolotherapy or Ozone therapy with other treatments, were excluded unless injection therapy with another pharmaceutical agent (no placebo treatment) was part of one of the treatment arms. Studies about injections in sacroiliac joints and studies evaluating the effects of epidural steroids for radicular pain were also excluded. Data collection and analysis: Two review authors independently assessed the quality of the trials. If study data were clinically and statistically too heterogeneous to perform a meta-analysis, we used a best evidence synthesis to summarize the results. The evidence was classified into five levels (strong, moderate, limited, conflicting or no evidence), taking into account the methodological quality of the studies. Main results: 18 trials (1179 participants) were included in this updated review. The injection sites varied from epidural sites and facet joints (i.e. intra-articular injections, peri-articular injections and nerve blocks) to local sites (i.e. tender- and trigger points). The drugs that were studied consisted of corticosteroids, local anesthetics and a variety of other drugs. The methodological quality of the trials was limited with 10 out of 18 trials rated as having a high methodological quality. Statistical pooling was not possible due to clinical heterogeneity in the trials. Overall, the results indicated that there is no strong evidence for or against the use of any type of injection therapy. Authors' conclusions: There is insufficient evidence to support the use of injection therapy in subacute and chronic low-back pain. However, it cannot be ruled out that specific subgroups of patients may respond to a specific type of injection therapy. Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Systematic review

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Injection therapy for subacute and chronic benign low back pain.

Journal Spine
Year 2001
Links Pubmed DOI

This article is included in 1 Structured summary of systematic reviews 17 Structured summaries of systematic reviews (1 reference) 1 Broad synthesis 17 Broad syntheses (1 reference)

This article includes 17 Primary studies 17 Primary studies (17 references)

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STUDY DESIGN: The Medline and Embase databases containing randomized controlled trials of injection therapy published to 1998 were systematically reviewed. OBJECTIVES: To evaluate the effectiveness of injection therapy with anesthetics, steroids, or both in patients with low back pain persisting longer than 1 month. METHODS: Two reviewers independently assessed the trials for the quality of their methods. The primary outcome measure was pain relief. Subgroup analyses were performed between trials with different control groups (placebo and active injections), with different injection sites (facet-joint, epidural, and local injections), and with timing of outcome measurement (short- and long-term). Within the resulting 12 (2 x 3 x 2) subcategories of studies, the overall relative risks and corresponding 95% confidence intervals were estimated, using the random effects model of DerSimonian and Laird. In the case of trials using active injections as a control, the results were not pooled. RESULTS: This review included 21 randomized trials. All the studies involved patients with low back pain persisting longer than 1 month. Only 11 studies compared injection therapy with placebo injections (explanatory trials). The methodologic quality of many studies was low: Only eight studies had a methodologic score of 50 points or more. There were only three well-designed explanatory clinical trials: one on injections into the facet joints with a short-term relative risk of 0.89 (95% confidence interval = 0.65-1.21) and a long-term relative risk of 0.90 (95% confidence interval = 0.69-1.17), one on epidural injections with a short-term relative risk of of 0.94 (95% confidence interval = 0.76-1.15) and a long-term relative risk of 1.00 (95% confidence interval = 0.71-1.41), and one on local injections with a long-term relative risk of 0.79 (95% confidence interval = 0.65-0.96). Within the six subcategories of explanatory studies, the pooled relative risks were as follows: facet joint, short-term: relative risk = 0.89 (95% confidence interval = 0.65-1.21); facet joint, long-term: relative risk = 0.90 (95% confidence interval = 0.69-1.17); epidural, short-term: relative risk = 0.93 (95% confidence interval = 0.79-1.09); epidural, long-term: relative risk = 0.92 (95% confidence interval = 0.76-1.11); local, short-term: relative risk = 0.80 (95% confidence interval = 0.40-1.59); and local, long-term: relative risk = 0.79 (95% confidence interval = 0.65-0.96). CONCLUSIONS: Convincing evidence is lacking regarding the effects of injection therapy on low back pain. Additional well-designed explanatory trials in this field are needed.