Commentary & Perspective

Commentary & Perspective on
"Treatment of Lumbar Disc Herniation: Epidural Steroid Injection Compared with Discectomy"
by Glenn R. Buttermann, MD

Commentary & Perspective by
K. Daniel Riew, MD*,
Washington University School of Medicine, St. Louis, Missouri

Because most symptomatic lumbar disc herniations will eventually resolve with nonoperative treatment, most surgeons recommend an initial period of nonoperative management. After six weeks of nonoperative management, some patients will have persistent radicular pain and will require additional treatment. Most experts would agree that it is reasonable to treat such patients with either an epidural steroid injection or a discectomy. But while epidural steroid injection is widely utilized, the short and long-term efficacy of this treatment remains controversial^1-3.

In the current study, patients who had symptoms of a disc herniation and for whom at least six weeks of nonoperative treatment had failed were prospectively randomized to receive either an epidural steroid injection or a discectomy. The diagnosis was confirmed by radiographic studies. To qualify for the study, the disc herniation had to occupy >25% of the cross-sectional area of the spinal canal. The patients were then followed for three years to determine the outcome of treatment. As expected, the patients that were randomized to the discectomy procedure did better than those in the epidural steroid group. Forty-seven of the fifty patients who were treated with discectomy reported that the treatment was effective, whereas only twenty-three of the fifty patients in the epidural steroid group reported the same. Patients for whom an epidural steroid injection had failed and who then underwent discectomy did as well as the patients in the original discectomy group.

This is an important and original work. Although the conclusions of the authors were that epidural steroid injection was not as effective as operative treatment for symptomatic lumbar disc herniations, nearly one-half of the patients treated with an epidural steroid injection reported resolution of symptoms at the three-year follow-up evaluation. These were all patients who, had they not been enrolled in this study, would have undergone lumbar discectomy. These findings are quite similar to a study that we performed on the effect of nerve-root injections for lumbar radicular pain. We also found that approximately one-half of the patients elected to forego the operation following treatments with nerve-root blocks⁴.

Importantly, the authors have also demonstrated that even for those in whom treatment with epidural steroid injection failed, there did not appear to be any deleterious consequences due to the delay in operative intervention. The current study lends further credence to our belief that all patients with lumbar radicular pain without a profound neurologic deficit should first be offered perineural steroid injection.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Cuckler JM, Bernini PA, Wiesel SW, Booth RE Jr, Rothman RH, Pickens GT. The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study. J Bone Joint Surg Am. 1985;67:63-6.
2. Koes BW, Scholten RJ, Mens JM, Bouter LM. Efficacy of epidural steroid injections for low-back pain and sciatica: a systemic review of randomized clinical trials. Pain. 1995;63:279-88.
3. van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions. Spine. 1997;22:2128-56.
4. Riew KD, Yin Y, Gilula L, Bridwell KH, Lenke LG, Lauryssen C, Goette K. The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, double-blind study. J Bone Joint Surg. 2000;82:1589-93.

Copyright © 2004 by the The Journal of Bone and Joint Surgery, Inc.