Table 1 Limitations of existing reviews identified by a systematic search of literature
Serial No | Main Objective | Relevant Findings and Limitations | Studies relevant to our Review |
|---|---|---|---|
1 | A systematic review and meta-analysis of RCTs evaluating the "control" injections in epidural injections for spinal pain [35]. | FINDINGS: As control injections, epidural non-steroid injections may provide some benefit, but were inferior to ESI, but superior to non-epidural injections. | Anderberg 2007 [80]; Beliveau 1971[81]; Brevik 1996 [82]; Cohen 2012 [83]; Cuckler 1985 [84]; Ghahreman 2010 [85]; Klenerman 1984 [86]; Manchikanti 2008 [87], 2011 [88], 2012abcd [89–92]; Nam & Park 2011 [93]; Ng 2005 [94]; Rogers 1992 [95]; Sayegh 2009 [96]; Tafazal 2009 [97] |
LIMITATIONS: All LA and saline comparators were grouped as epidural non-steroid agents. | |||
2 | To assess comparative effectiveness studies in ESI for Lumbar Spinal Stenosis and to estimate reimbursement amounts [37]. | FINDINGS: Both, ESIs or LA epidural injections alone, resulted in better short term improvement (pain and walking distance); no longer term difference. | |
LIMITATIONS: Included both RCTs and OSs; no metaanalysis. | |||
3 | Effectiveness of cervical epidural injections in the management of chronic neck and upper extremity pain [38]. | FINDINGS: Similar effectiveness with both LA only and LA+ steroid injections, except for slightly better results with radiculitis from disc herniations | 4 by Manchikanti: 2010 [100]; 2012a; 2012b; 2012c [101–103] |
LIMITATIONS: Included RCTs had differences in the injectate used with intervention and control arms; no metaanalysis. | |||
5 | Effectiveness and risks of image guided cervical TFESI [30]. | FINDINGS: Limited evidence exists and no conclusion on effectiveness and risks can be observed. | Anderberg 2007 [80] |
LIMITATIONS: Included three RCTs, only one of which compared LA+ steroid with LA only | |||
6 | Role of ESIs in the prevention of surgery for spinal pain [36]. | FINDINGS: ESIs may provide a small surgery-sparing effect in the short term compared with control injections. | Hegihara 2008 [104]; Klenerman 1984 [86]; Cohen 2012 [83]; Cuckler 1985 [84]; Ghahreman 2010 [85]; Riew 2000 [105]; Sayegh 2009 [96]; Tafazal 2009 [97]; |
LIMITATIONS: Looked only at surgery sparing effects; no metaanalysis | |||
7 | ESIs in the management of sciatica [6]. | FINDINGS: Small short term benefit in pain control with ESIs. | Manchikanti 2010a,b; Ghahreman 2010 [85]; Tafazal 2009 [97]; Ng 2005 [94]; Rogers 1992 [95]; Cuckler 1985 [84]; Klenerman 1984 [86]; Swerdlow 1970 [106] |
LIMITATIONS: No differentiation was made with the injectate used in control and treatment arm. Could not incorporate dichotomous outcome measures into pooling. | |||
8 | The effectiveness of lumbar interlaminar ESIs in managing chronic low back and lower extremity pain [33]. | FINDINGS: Similar results with both LA only and LA+ steroid injections, except for slightly better results with radiculitis from disc herniations. | |
LIMITATIONS: Included both RCTs and OSs without any pooling. | |||
9 | Predicting ESIs with lab markers and imaging techniques [68]. | LIMITATIONS: Only aimed at prognostic accuracy of certain predictive methods used to determine ESI outcomes. | None |
10 | A systematic evaluation of thoracic ESIs [34]. | FINDING: The single RCT showed similar effectiveness with LA or LA +steroid. | Manchikanti. 2010 [109] |
LIMITATIONS: Only one RCT, and one OS were included | |||
11 | Effectiveness of TFESI for lumbar radiculopathy [39]. | FINDINGS: Small improvement with steroids in pain only (short term); long term follow up showed no difference with steroids. | |
LIMITATIONS: Included only five RCTs, and for pooling control groups included both LA and Saline; outcomes as SMD | |||
12 | Evaluation of therapeutic lumbar TFESIs [42]. | FINDINGS: Lack of evidence | |
LIMITATIONS: Only four RCTs; no metaanalysis; comparators varied in each study | |||
13 | Efficacy of lumbosacral TFESIs: a systematic review [49]. | FINDINGS: Fair evidence supporting TFESIs as superior to placebo for treating radicular symptoms. | |
LIMITATIONS: Evaluation specific to TFESI; no metaanalysis; varied comparators. | |||
14 | Evaluation of perineural steroids for trauma and compression-related peripheral neuropathic pain [41]. | FINDINGS: At 1–3 months post-interventions, steroid group reported lower pain scores than those who received LA or conventional care. | Karakadas 2011, 2012 [111, 112]; Eker 2012 [113]; Thomson 2013 [114] |
LIMITATIONS: Review limited to compression neuropathies; comparators for pooling included no injection, or LA, or placebo (saline). | |||
16 | Evaluation of PNBs and TPIs in headache [40]. | FINDINGS: Lack of studies and inherent limitations within the included studies. | Ashkenazi 2008 [115] |
LIMITATIONS: Did not identify any study on TPI; both RCTs and non-RCTS were included; no assessment of risk; no metaanalysis. | |||
17 | Treatment of carpal tunnel syndrome [43]. | FINDINGS: Local steroid injection is recommended before surgery. | Armstrong 2004 [116] |
LIMITATIONS: A report as guidelines for management based on previous systematic reviews; however no differentiation between steroids with or without LA. | |||
18 | Neural blockade for persistent pain after breast cancer surgery [69]. | FINDINGS: Lack of evidence. | None |
LIMITATIONS: Only two RCTs on stellate ganglion block. | |||
19 | Occipital nerve blocks: when and what to inject [52]. | LIMITATIONS: Narrative review with search obtained from google scholar and MD consult | Afridi 2006 [117]; Ambrosini 2005 [118]; Ashkenazi 2008 [115] |
20 | IA infiltration therapy for patients with glenohumeral osteoarthritis [70]. | FINDINGS: No clear conclusions on the use of IA steroid due to lack of evidence. | None |
LIMITATIONS: Studies of all kinds of injection treatments; only two RCTs of IA injection involving hyaluronic acid. | |||
21 | A metaanalysis of steroid injections for painful shoulder [32]. | FINDINGS: Subacromial injections of steroids are effective for improvement for rotator cuff tendonitis, and are better than NSAIDS and placebo injections. | |
LIMITATIONS: Out of five RCTs included for pooling only three compared LA + steroid vs LA; results not considered separately. | |||
22 | Review of glenohumeral steroid injections in adhesive capsulitis [71]. | FINDINGS: Steroids injections offer good short-term outcomes when compared to physical therapy and other treatments. | None |
LIMITATIONS: Although 16 RCTs were included, none of them compared LA + steroid with only LA. | |||
23 | Assessment of Subacromial steroid injections in the treatment of rotator cuff disease [44]. | FINDINGS: Little reproducible evidence to support the efficacy of subacromial steroid injections in managing rotator cuff disease. | Akgun 2004 [122]; Alvarez 2005 [123]; Blair 1996 [119]; Petri 1987 [124]; Withrington 1985 [125] |
LIMITATIONS: Out of nine RCTs, three involved patients with acute pain; no metaanalysis; varying comparators within the studies. | |||
24 | IA cortisone injection for osteoarthritis of the hip. Is it effective and safe [46]? | FINDINGS: Lack of clear evidence; steroid injections are better in refractory pain; of the four RCTs- two of the trials showed opposite results with LA vs LA + steroid | |
LIMITATIONS: Identified only four RCTs; no metaanalysis. | |||
25 | Is anesthetic Hip Joint Injection Useful in Diagnosing Hip Osteoarthritis? A Meta-Analysis of Case Series [72]. | LIMITATIONS: Only non-RCTs, and does not allow for clear conclusions or directions. | None |
26 | Injection therapies in LE: a systematic review and network meta-analysis of RCTs [45]. | FINDINGS: No statistically significant difference in benefit compared with placebo for steroid injections. LIMITATIONS: Network meta-analysis involving 10 trials of steroid injections; LA was not considered as a separate comparison group vs LA+ steroid. | Dogramaci 2009 [128]; Lindenhovious 2008 [129]; Newcomer 2001 [130]; Price 1991a,b [131, 132] |
27 | Treating LE with steroid injections or physiotherapy: a systematic review [48]. | FINDINGS: For steroid vs LA injection, the evidence is conflicting; steroid injections have a short term beneficial effect, but a negative effect in the intermediate term. | Lindenhovious 2008 [129]; Newcomer 2001 [130]; Price 1991 [131] |
LIMITATIONS: Outcomes pooled separately, and expressed as SMD for continuous and RD for dichotomous | |||
28 | To assess the effectiveness of interventions for cubital tunnel syndrome, radial tunnel syndrome, instability, or bursitis of the elbow: a systematic review [73]. | FINDINGS: No or limited evidence found for the effectiveness of nonsurgical and surgical interventions; lack of good controlled studies. | None |
LIMITATIONS: Various interventions with varying comparators; no studies relevant to LA vs LA +steroid; no metaanalysis. | |||
30 | To evaluate the effectiveness of corticosteroid injections for lateral epicondylitis [51]. | FINDINGS: For studies (3) comparing LA vs steroid, beneficial effects were found favoring steroid injections. | Price 1991 [131] |
LIMITATIONS: Out of 15 RCTs, five compared LA with LA and steroid. Outcomes with various comparators pooled together. | |||
31 | Non-surgical treatment of LE: a systematic review of RCTs [50]. | FINDINGS: Existing literature does not provide conclusive evidence for a preferred mode of nonsurgical treatment. | Lindenhovious 2008 [129]; Newcomer 2001 [130]; Dogramaci 2009 [128]; Altay 2002 [130] |
LIMITATIONS: Various non-surgical treatments were considered together; no metaanalysis | |||
32 | Assessing the efficacy and safety of steroid injections and other injections for management of tendinopathy [12]. | FINDINGS: For LE: Steroid injections reduced pain in the short term; but studies comparing only LA showed conflicting results; rotator tendinopathy results are conflicting; Achilles and Patellar tendinopathies-no studies of comparison; ME-no benefit from steroid injection. | LE: Lindenhovious 2008 [129]; Newcomer 2001 [130]; Price 1991 [131] |
ME: Stahl 1997 [134] | |||
LIMITATIONS: The effect of steroid injections were compared using all comparators; no separate analysis with LA + steroid vs only LA. | RT: Adebajo 1990 [135]; Alvarez 2005 [123]; Blair 1996 [119]; Ekeberg 2009 [136]; Mclnerney 2003 [137] | ||
33 | Evaluation of minimally invasive therapies in the management of chronic calcific tendinopathy of the rotator cuff. [74]. | FINDINGS: Lack of evidence. | None |
LIMITATIONS: Did not identify any studies comparing steroid injection with LA. | |||
34 | Efficacy of treatment of trochanteric bursitis: a systematic review [75]. | FINDINGS: Lack of evidence. | None |
LIMITATIONS: Only one RCT for steroid injection assessing image guidance. | |||
35 | Evaluation of non-operative management of discogenic back pain [76]. | FINDINGS: Lack of evidence. | None |
LIMITATIONS: Identified only two RCTs performing intradiscal steroid injections; no study compared LA + steroid vs LA | |||
36 | Evaluation of various modes of diagnosis and treatment of suspected discogenic pain [77]. | FINDINGS: There is lack of diagnostic criteria and lack of studies with uniform treatment strategies. | None |
LIMITATIONS: Did not identify any suitable RCTs. | |||
37 | Evaluation of therapeutic thoracic facet joint interventions [47]. | FINDINGS: Paucity of evidence, but one trial showed no difference between LA+ steroid vs LA. | Manchikanti 2012 [138] |
LIMITATIONS: Identified only one RCT on nerve block; no study on joint injections | |||
38 | Effectiveness of therapeutic lumbar facet joint interventions [53]. | FINDINGS: Paucity of evidence, but one trial showed no difference between LA+ steroid vs LA. | Manchikanti 2001 [139] |
LIMITATIONS: Identified only one RCT on nerve block; no study on joint injections. | |||
39 | Emerging concepts in the treatment of myofascial pain: a review of medications, modalities, and needle-based interventions [78]. | FINDINGS: There is insufficient evidence for both medications and needle based interventions for myofascial pain. | None |
LIMITATIONS: Did not identify any RCT comparing LA + steroid vs LA. | |||
40 | To assess the efficacy and safety of using TPI to treat patients with chronic non-malignant musculoskeletal pain [79]. | FINDINGS: No clear evidence to support the use of TPI. | None |
LIMITATIONS: Did not identify any RCT comparing LA + steroid vs LA. | |||
41 | To compare the efficacy of saline, LA, and steroids in epidural and facet joint injections for the management of spinal pain [18]. | FINDINGS: LA with steroids and LA alone were equally effective except in disc herniation, where the superiority of LA with steroids was demonstrated over LA alone. | Anderberg 2007 [80]; Beliveau 1971 [81]; Brevik 1996 [82]; Cohen 2012 [83]; Cuckler 1985 [84]; Ghahreman 2010 [85]; Klenerman 1984 [86]; Manchikanti 2008 [87], 2011 [88], 2012abcd [89–92]; Nam & Park 2011 [93]; Ng 2005 [94]; Rogers 1992 [95]; Sayegh 2009 [96]; Tafazal 2009 [97] |
LIMITATIONS: RCTs involving the injections of sodium chloride solution was also included as active comparator, along with LA alone injections. | |||
Studies were not excluded based on the duration of chronic pain. | |||
No metaanalysis was done. | |||
42 | To assess the benefits and harms of ESIs in adults with radicular low back pain or spinal stenosis of any duration [31]. | FINDINGS: For radiculopathy, small effect favoring the use of steroids for short term reduction in pain and function. No evidence of benefit in spinal stenosis. | Anderberg 2007 [80]; Beliveau 1971 [81]; Brevik 1996 [82]; Cohen 2012 [83]; Cuckler 1985 [84]; Ghahreman 2010 [85]; Klenerman 1984 [86] |
LIMTATIONS: Combined all non-steroid agents as placebo comparators. | |||
Focused on radicular pain, but included studies of any duration. |