Laxmaiah Manchikanti1,2, Nebojsa Nick Knezevic3, Allan Parr4, Alan D Kaye5, Mahendra Sanapati6, Joshua A Hirsch7. 1. Department of Anesthesiology, University of Louisville, Paducah, KY, USA. drlm@thepainmd.com. 2. School of Medicine Anesthesiology and Perioperative Medicine, LSU Health Sciences Center, New Orleans, LA, USA. drlm@thepainmd.com. 3. Department of Anesthesiology; Advocate Illinois Masonic Medical Center, College of Medicine, University of Illinois, Wellington Ave Ste 4815, Chicago, IL, 60657, USA. 4. Louisiana State University School of Medicine, 1541 Kings Hwy, Shreveport, LA, 71103, USA. 5. Department of Anesthesiology, and Pharmacology, LSU Health Science Center, New Orleans, LA, USA. 6. Pain Management Centers of America, Evansville, IN, USA. 7. Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
Abstract
PURPOSE OF REVIEW: Low back and lower extremity pain have been treated since 1901 with local anesthetics alone and since 1952 in combination with steroids. Over the years, multiple randomized controlled trials, systematic reviews with or without meta-analysis have been reaching discordant conclusions regarding the effectiveness of sodium chloride solution, local anesthetics, and steroids in managing spinal pain. Further, related to lack of understanding, multiple reviewers have considered local anesthetics including lidocaine and bupivacaine as equivalent to placebo based on theory that steroid is the only drug effective in the epidural space. In this review, we assessed effectiveness of epidurally administered bupivacaine with or without steroids to rule out misconceptions of placebo and to show the comparative effectiveness of epidural bupivacaine alone compared to epidural bupivacaine with steroids. RECENT FINDINGS: Multiple systematic reviews performed in assessing the effectiveness of epidural injections have converted epidurally administered lidocaine and bupivacaine to placebo. This led to inappropriate conclusions of lack of effectiveness of epidural local anesthetics with or without steroids as showing equal effectiveness when analyzed with conventional dual-arm meta-analysis. Thus, true placebo control trials with injection of an inactive substance into unrelated structures have been almost non-existent. Epidurally administered bupivacaine alone or with steroids are effective in managing low back and lower extremity pain. The findings of this review provide appropriate information of epidurally administered bupivacaine as an active agent (not a placebo) with level 1 evidence and almost equally effective as bupivacaine with steroids with level II evidence.
PURPOSE OF REVIEW: Low back and lower extremity pain have been treated since 1901 with local anesthetics alone and since 1952 in combination with steroids. Over the years, multiple randomized controlled trials, systematic reviews with or without meta-analysis have been reaching discordant conclusions regarding the effectiveness of sodium chloride solution, local anesthetics, and steroids in managing spinal pain. Further, related to lack of understanding, multiple reviewers have considered local anesthetics including lidocaine and bupivacaine as equivalent to placebo based on theory that steroid is the only drug effective in the epidural space. In this review, we assessed effectiveness of epidurally administered bupivacaine with or without steroids to rule out misconceptions of placebo and to show the comparative effectiveness of epidural bupivacaine alone compared to epidural bupivacaine with steroids. RECENT FINDINGS: Multiple systematic reviews performed in assessing the effectiveness of epidural injections have converted epidurally administered lidocaine and bupivacaine to placebo. This led to inappropriate conclusions of lack of effectiveness of epidural local anesthetics with or without steroids as showing equal effectiveness when analyzed with conventional dual-arm meta-analysis. Thus, true placebo control trials with injection of an inactive substance into unrelated structures have been almost non-existent. Epidurally administered bupivacaine alone or with steroids are effective in managing low back and lower extremity pain. The findings of this review provide appropriate information of epidurally administered bupivacaine as an active agent (not a placebo) with level 1 evidence and almost equally effective as bupivacaine with steroids with level II evidence.
Entities:
Keywords:
Bupivacaine; Chronic low back pain; Epidural injections; Lidocaine; Local anesthetic; Placebo effect; Single-arm meta-analysis; Steroids
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