Oral opioid analgesics vs. spinal steroid injections in the treatment of low back pain syndromes.
OBJECTIVE
The aim of this study was to examine the outcomes related to analgesia, function, mortality, and adverse effects of oral opioid analgesics and spinal steroid injections on low back pain syndromes.


METHODS
Databases including Medline, EMBASE, PubMed, and Cochrane Library were searched in September 2009 using combinations of terms related to spinal pain and its treatment. A systematic review was performed of randomized controlled trials that enrolled patients with low back pain syndromes and that evaluated patient outcomes after intervention using either oral opioids or spinal steroid injections.


RESULTS
Eight high-quality and ten moderate-quality randomized controlled trials were identified. One high-quality study on oral opioid therapy showed significant improvements in pain relief and patient function. Those on spinal steroid injections had a decreased Visual Analog Scale pain score by 7.18 (95% confidence interval, 2.21-12.1) points more than the control group at 1 mo or less and by 0.429 (95% confidence interval, -4.41 to 5.27) points at 1-3 mos. At more than 6 mos, there was no significant benefit: 0.930 (95% confidence interval, -5.03 to 6.89). Spinal steroids decreased the Oswestry Disability Index by 3.53 (95% confidence interval, 0.480-6.57) at 1 mo or less, by -0.281 (95% confidence interval, -3.18 to 2.62) at 1-3 mos, by -11.0 (95% confidence interval, -14.8 to -7.16) at 3-6 mos, and by -0.205 (95% confidence interval, -3.50 to 3.09) compared with the control group at 6 mos or more, suggesting that there was improvement in function. All-cause mortality was low in our analysis of patients attending specialty clinics. It was difficult to assess the adverse effects of opioid therapy because they influenced up to 28% of patients to withdraw from the original studies. In terms of spinal steroid injections, headache appeared to be the most common adverse effect. However, there was no significantly increased risk of headaches associated with spinal steroids compared with control injections: odds ratio, 1.29 (95% confidence interval, 0.69-2.39).


CONCLUSIONS
Oral opioid therapy may be helpful for the treatment of low back pain, but it is unclear from the high-quality literature whether there are limitations from adverse effects. Spinal steroid injections are beneficial for low back pain and disability in the short-term. The high dropout rates caused by insufficient pain relief and adverse effects suggest that opioids may not be as effective as spinal steroid injections. There is more high-quality literature to support the use of spinal steroid injections compared with oral opioids in this condition.
Division of Pain Management, VA New York Harbor Healthcare System, New York10010, USA
Devi E
DE
Nampiaparampil
Geetha M
GM
Nampiaparampil
Robert G
RG
Nampiaparampil
D000284:Administration, Oral; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects; D004185:Disability Evaluation; D005938:Glucocorticoids / Q000008:administration & dosage* / Q000009:adverse effects; D006261:Headache / Q000139:chemically induced; D006801:Humans; D007278:Injections, Spinal; D017116:Low Back Pain / Q000188:drug therapy*; D010147:Pain Measurement; D016032:Randomized Controlled Trials as Topic
D000701:Analgesics, Opioid; D005938:Glucocorticoids