title: Local anesthetic injections with or without steroid for chronic non-cancer pain: a protocol for a systematic review and meta-analysis of randomized controlled trials.
abstract: BACKGROUND
  Steroids are often combined with local anesthetic (LA) and injected to reduce pain associated with various chronic non-cancer pain (CNCP) complaints. The biological rationale behind injection of a steroid solution is unclear, and it is uncertain whether the addition of steroids offers any additional benefits over injection of LA alone. We propose to conduct a systematic review and meta-analysis to summarize the evidence for using steroids and LA vs. LA alone in the treatment of CNCP.
  
  
  METHODS
  An experienced librarian will perform a comprehensive search of EMBASE, MEDLINE, and the Cochrane Central Registry of Controlled Trials (CENTRAL) databases with search terms for clinical indications, LA, and steroid agents. We will review bibliographies of all relevant published reviews in the last 5 years for additional studies. Eligible trials will be published in English and randomly allocate patients with CNCP to treatment with steroid and LA injection therapy or injection with LA alone. We will use the guidelines published by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) to inform the outcomes that we collect and present. Teams of reviewers will independently and in duplicate assess trial eligibility, abstract data, and assess risk of bias among eligible trials. We will prioritize intention to treat analysis and, when possible, pool outcomes across trials using random effects models. We will report our findings as risk differences, weighted mean differences, or standardized mean differences for individual outcomes. Further, to ensure interpretability of our results, we will present risk differences and measures of relative effect for pain reduction based on anchor-based minimally important clinical differences. We will conduct a priori defined subgroup analyses and use the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to evaluate the certainty of the evidence on an outcome-by-outcome basis.
  
  
  CONCLUSIONS
  Our review will evaluate both the effectiveness and the adverse events associated with steroid plus LA vs. LA alone for CNCP, evaluate the quality of the evidence using the GRADE approach, and prioritize patient-important outcomes guided by IMMPACT recommendations. Our results will facilitate evidence-based management of patients with chronic non-cancer pain and identify key areas for future research.
  
  
  BACKGROUND
  PROSPERO CRD42015020614.
authors.affiliation: Department of Anesthesia, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada. shanthh@mcmaster.ca.|The Michael G. DeGroote Institute for Pain Research and Care, Hamilton, Canada. shanthh@mcmaster.ca.
authors.forename: Harsha
authors.initials: H
authors.lastname: Shanthanna
authors.affiliation: Department of Anesthesia, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada. bussej@mcmaster.ca.|The Michael G. DeGroote Institute for Pain Research and Care, Hamilton, Canada. bussej@mcmaster.ca.|Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada. bussej@mcmaster.ca.
authors.forename: Jason W
authors.initials: JW
authors.lastname: Busse
authors.affiliation: Department of Anesthesia, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada. thabanel@mcmaster.ca.|Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada. thabanel@mcmaster.ca.
authors.forename: Lehana
authors.initials: L
authors.lastname: Thabane
authors.affiliation: Department of Anesthesia, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada. jep@icloud.com.|The Michael G. DeGroote Institute for Pain Research and Care, Hamilton, Canada. jep@icloud.com.
authors.forename: James
authors.initials: J
authors.lastname: Paul
authors.affiliation: Department of Anesthesia, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada. rcouban@mcmaster.ca.|The Michael G. DeGroote Institute for Pain Research and Care, Hamilton, Canada. rcouban@mcmaster.ca.
authors.forename: Rachel
authors.initials: R
authors.lastname: Couban
authors.affiliation: Department of Orthopedics, McMaster University, Hamilton, Canada. harman.choudhry@medportal.ca.
authors.forename: Harman
authors.initials: H
authors.lastname: Choudhary
authors.affiliation: Department of Anesthesia, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada. alka_kaushal@yahoo.com.
authors.forename: Alka
authors.initials: A
authors.lastname: Kaushal
authors.affiliation: Research Institute - Hospital do Coração (HCor), São Paulo, Brazil. esuzumura@yahoo.com.br.
authors.forename: Erica
authors.initials: E
authors.lastname: Suzumura
authors.affiliation: Michael G. DeGroote School of Medicine, McMaster University, Ontario, Hamilton, Canada. Isabel.kim@medportal.ca.
authors.forename: Isabel
authors.initials: I
authors.lastname: Kim
authors.affiliation: Department of Anesthesia, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada. harshap@mcmaster.ca.
authors.forename: Prathiba
authors.initials: P
authors.lastname: Harsha
mesh_terms: D000305:Adrenal Cortex Hormones; D000779:Anesthetics, Local; D059350:Chronic Pain / Q000188:drug therapy*; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D000078202:Systematic Reviews as Topic; D015201:Meta-Analysis as Topic
chemical_list: D000305:Adrenal Cortex Hormones; D000779:Anesthetics, Local
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