Expensive drugs show poor results. Dr. Cohen’s study involved 81 people who’d had sciatica for at least a month. On average, the patients were in their early 40s and were being treated at one of four military medical centers and two civilian hospitals.
Study participants were then split into three treatment groups, each given two spinal injections, two week apart of:
• The steroid methylprednisolone, for the first group
• Etanercept, for the second group
• Saline solution or normal salty water, for the third group
Neither the patients nor the doctors treating them knew who got which type of injection.
Pain experts thought that administering epidural or spinal injection for sciatica would bathe the spinal nerve roots directly in a medication designed to reduce inflammation and pain — thus giving the body time to heal itself, Dr. Cohen says. Theoretically, this would allow for better pain relief at lower doses — and in turn, fewer side effects than when the drugs are given by mouth or intravenously.
After one month, the researchers did a follow up and found that for all patients — regardless of which treatment they’d received — had back and leg pain reduced by a similar amount on a 10-point scale:
• Back pain scores fell by an average of one to two points
• Leg pain scores dropped by two to four points
One finding that came as a surprise was that, compared to those who were given etanercept, patients who received steroid or saline injections reported more improvements in how well they could get around and perform daily activities.
Dr. Cohen says this lack of any significant benefit with etanercept — compared to a saline solution — was “disappointing.”
Healing on their own
“These drugs are expensive, and even though they may be safer than steroids, they’re not devoid of risk,” he points out. Steroid or etanercept injections cost about US$500 to US$700 each and either comes with nasty and dangerous side effects: etanercept can weaken the immune system, while steroids can cause stomach problems and alter blood sugar levels.
But these side effects didn’t show up in study participants — largely because they received low doses of either drug. Between one and six patients in each group had mild side effects — including worsening pain, a rash or infection, but none were serious.
Commenting on the results, Dr. Roger Chou, an associate professor of general internal medicine at Oregon Health and Science University in Portland, emphasized to HealthDay that the benefits seen from steroids were only short term. “I think it underscores our previous (APS) recommendation to consider epidural steroids as a potential option for patients who are looking for short-term pain relief,” he says.
But doctors have to be “very clear to patients that these benefits do not appear to last and they have a good chance of improving without the injection,” Chou adds. “I think a lot of doctors (and patients) think that epidural steroid injections are much more effective (and longer lasting) than the evidence shows that they really are.”
“People do heal on their own (from sciatica),” he stresses, but they need pain relief.
Dr. Cohen says that future studies will then investigate whether higher doses of etanercept are safe. “But for the dose deemed safe, so far, it’s not panning out.”
The researchers also says that patients treated with regular saline may have gotten pain relief because the injection washed out the spine and increased blood flow to nerve roots. This leads Dr. Cohen to say, that in the end, whether or not patients’ sciatica pain improves may be more up to their own behavior than what type of injections they get — if any.
“The treatment that has the strongest evidence behind it is actually exercise programs,” he points out –as well as losing weight, for people who are too heavy. “It’s kind of a long, slow process. People have to have realistic expectations,” he tells Reuters Health.
Daryll Dykes, spokesman for the American Academy of Orthopedic Surgeons, who was not involved in the study, says many people with back pain “do heal on their own without treatment. But for the people who suffer from this kind of pain, and it can be intense, it is important to know studies are looking at different options.”
The study was funded by the John P. Murtha Neuroscience and Pain Institute, the International Spinal Intervention Society and the Center for Rehabilitation Sciences Research.