title: Epidural injections for spinal pain: a systematic review and meta-analysis evaluating the "control" injections in randomized controlled trials.
abstract: BACKGROUND
  Epidural steroid injection is the most frequently performed pain procedure. This study of epidural steroid "control" injections aimed to determine whether epidural nonsteroid injections constitute a treatment or true placebo in comparison with nonepidural injections for back and neck pain treatment.
  
  
  METHODS
  This systematic review with direct and indirect meta-analyses used PubMed and EMBASE searches from inception through October 2012 without language restrictions. Study selection included randomized controlled trials with a treatment group receiving epidural injections of corticosteroids or another analgesic and study control groups receiving either an epidural injection devoid of treatment drug or a nonepidural injection. Two reviewers independently extracted data including short-term (up to 12 weeks) pain scores and pain outcomes. All reviewers evaluated studies for eligibility and quality.
  
  
  RESULTS
  A total of 3,641 patients from 43 studies were included in this systematic review and meta-analysis. Indirect comparisons suggested epidural nonsteroid were more likely than nonepidural injections to achieve positive outcomes (risk ratio, 2.17; 95% CI, 1.87-2.53) and provide greater pain score reduction (mean difference, -0.15; 95% CI, -0.55 to 0.25). In the very limited direct comparisons, no significant differences were noted between epidural nonsteroid and nonepidural injections for either outcome (risk ratio [95% CI], 1.05 [0.88-1.25]; mean difference [95% CI], 0.22 [-0.50 to 0.94]).
  
  
  CONCLUSIONS
  Epidural nonsteroid injections may provide improved benefit compared with nonepidural injections on some measures, though few, low-quality studies directly compared controlled treatments, and only short-term outcomes (≤12 weeks) were examined.
authors.affiliation: * Resident, ‡ Assistant Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland. † Associate Professor and Medical Director, University Pain Institute, Department of Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania. § Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, and Professor, Walter Reed National Military Medical Center, Bethesda, Maryland.
authors.forename: Mark C
authors.initials: MC
authors.lastname: Bicket
authors.forename: Anita
authors.initials: A
authors.lastname: Gupta
authors.forename: Charlie H
authors.initials: CH
authors.lastname: Brown
authors.forename: Steven P
authors.initials: SP
authors.lastname: Cohen
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000627:therapeutic use*; D000700:Analgesics / Q000008:administration & dosage / Q000627:therapeutic use*; D001416:Back Pain / Q000188:drug therapy*; D006801:Humans; D007267:Injections; D007268:Injections, Epidural; D019547:Neck Pain / Q000188:drug therapy*; D010919:Placebos; D016032:Randomized Controlled Trials as Topic / Q000379:methods*
chemical_list: D000305:Adrenal Cortex Hormones; D000700:Analgesics; D010919:Placebos