Revisión del tratamiento con corticoides en el dolor de espalda según la medicina basada en la evidencia

摘要

Objective: To evaluate the effectiveness of steroid injections associated or not with local anesthesia via the cervical, thoracic, lumbar or caudal epidural routes in cervical, thoracic, lumbar and sacral facet joints and spinal branches, as well as in the sacroiliac joint, in the treatment of back and upper and lower extremity pain. Material and methods: The following terms were used for the search: "epidural steroid injections or blocks", "caudal injections or blocks", "selective nerve root injections or blocks", "transforaminal injections or blocks", "facet injections or blocks", "medial nerve blocks" and "low back pain". The search was performed in the Trip Database, SUMSearch, National Guidelines Clearinghouse, Cochrane and centers drawing up clinical practice guidelines. Clinical practice guidelines with levels of evidence, systematic reviews, meta-analyses and cross references among publications reviewed in Spanish or English from 1979 to 2009 were accepted. Results: Five clinical practice guidelines and nine systematic reviews were selected. Analysis of these articles indicated that intradiscal injections cannot be recommended in the treatment of chronic low back pain. The evidence on lumbar, cervical and thoracic medial branch injection in the treatment of lumbar, cervical and dorsal back pain is moderate for short- and long-term improvement. The evidence for sacroiliac joint injection is limited. Cervical interlaminar epidural injection provides significant and prolonged relief in chronic intractable cervical pain. There is level II-2 evidence for lumbar interlaminar epidural steroid injection, without fluoroscopy, in providing short-term relief and level II evidence for long-term relief. Transforaminal epidural steroid injection is effective in postlaminectomy syndrome (level IV evidence). There is moderate evidence for short- and long-term improvement in cervical radicular pain. Transforaminal epidural injection provides significant relief in chronic low back pain and radicular lumbar pain with level II-1 evidence for short-term improvement and level II-2 evidence for long-term improvement, with strong level 1C recommendation. Caudal epidural steroid injection was effective in producing short-term improvement (level II evidence) as well as long-term relief (level III evidence). Pain relief was achieved in postlaminectomy low back pain and spinal canal stenosis (level IV evidence). Conclusions: There are differences in the effectiveness, level of evidence and grade of recommendation for steroid use, associated or not with local anesthetics, according to the technique performed. Medial branch injection is more effective than facet joint injection. Epidural steroid injection is effective in back pain due to the different routes of access (interlaminar, transforaminal and caudal) when appropriately indicated and administered in well-selected patients. The most effective technique among those reviewed was intradiscal steroid injection. We recommend steroid administration as close as possible to the site of the lesion and the use of radiological vision to perform the distinct techniques, including epidural procedures.