Nelemans P J, de Bie R A, de Vet H C W, Sturmans F
University of Maastricht, Epidemiology, Debyeplein 1, Maastricht, Netherlands, 6200 MD.
Cochrane Database Syst Rev. 2007 Jul 18(2):CD001824. doi: 10.1002/14651858.CD001824.pub2.
Injection with anaesthetics and/or steroids is one of the treatment modalities used in patients with chronic low back pain which needs evaluation with respect to the effectiveness on short and long term pain relief.
To evaluate the effectiveness of injection therapy in patients with low back pain lasting longer than one month. We distinguished between three injection sites: facet joint, epidural or local injections.
We searched the Medline and Embase databases up to 1996 and other search methods as advocated by the Back Review Group search strategy. Abstracts and unpublished studies were not included.
Randomized controlled trials of injection therapy for pain relief (although additional treatments were allowed) in patients with benign low back pain lasting longer than one month and not originating from cancer.
Two authors independently assessed the trials for methodological quality. Subgroup analyses were made between trials with different control groups (placebo and active injections), with different injection site (facet joint, epidural and local injection), and timing of outcome measurement (short and long term). Within the resulting 12 subcategories of studies (232), the overall relative risks and corresponding 95% confidence intervals were estimated, using a random effects model (DerSimonian and Laird). In the case of trials in which control groups were active injections, we refrained from pooling the results.
Twenty-one randomized trials were included in this review. All studies involved patients with low back pain lasting longer than one month. Only 11 studies compared injection therapy with placebo injections (explanatory trials). The methodologic quality of many studies was low: only 8 studies had a methodologic score of 50 or more points. There were only three well designed explanatory clinical trials: one on injections into the facet joints with a short-term RR of 0.89 (95% CI: 0.65-1.21) and a long-term RR of 0.90 (95% CI: 0.69-1.17); one on epidural injections with a short-term RR of 0.94 (95% CI: 0.76-1.15) and a long-term RR of 1.00 (95% CI: 0.71-1.41); and one on local injections with a long-term RR of 0.79 (95% CI: 0.65-0.96). Within the 6 subcategories of explanatory studies the pooled RRs with 95% confidence intervals were: facet joint, short-term: RR=0.89 (0.65-1.21); facet joint, long-term: RR=0.90 (0.69-1.17); epidural, short-term: RR=0.93 (0.79-1.09); epidural, long-term: RR=0.92 (0.76-1.11); local, short-term: RR=0.80 (0.40-1.59); local, long-term: RR=0.79 (0.65-0.96).
AUTHORS' CONCLUSIONS: Convincing evidence is lacking on the effects of injection therapies for low back pain. There is a need for more, well designed explanatory trials in this field.
注射麻醉剂和/或类固醇是用于慢性下腰痛患者的治疗方式之一，需要对其短期和长期缓解疼痛的效果进行评估。
评估注射疗法对持续时间超过1个月的下腰痛患者的有效性。我们区分了三个注射部位：小关节、硬膜外或局部注射。
我们检索了截至1996年的Medline和Embase数据库以及循证医学回顾小组检索策略所倡导的其他检索方法。不包括摘要和未发表的研究。
针对持续时间超过1个月且非癌症引起的良性下腰痛患者进行的注射疗法缓解疼痛的随机对照试验（尽管允许采用其他治疗方法）。
两位作者独立评估试验的方法学质量。在不同对照组（安慰剂和活性注射剂）、不同注射部位（小关节、硬膜外和局部注射）以及结果测量时间（短期和长期）的试验之间进行亚组分析。在由此产生的12个研究亚组（2×3×2）中，使用随机效应模型（DerSimonian和Laird）估计总体相对风险及相应的95%置信区间。对于对照组为活性注射剂的试验，我们未汇总结果。
本综述纳入了21项随机试验。所有研究均涉及持续时间超过1个月的下腰痛患者。只有11项研究将注射疗法与安慰剂注射进行了比较（解释性试验）。许多研究的方法学质量较低：只有8项研究的方法学得分达到50分或更高。只有三项设计良好的解释性临床试验：一项是小关节注射，短期相对风险为0.89（95%置信区间：0.65 - 1.21），长期相对风险为0.90（95%置信区间：0.69 - 1.17）；一项是硬膜外注射，短期相对风险为0.94（95%置信区间：0.76 - 1.15），长期相对风险为1.00（95%置信区间：0.71 - 1.41）；一项是局部注射，长期相对风险为0.79（95%置信区间：0.65 - 0.96）。在解释性研究的6个亚组中，汇总的相对风险及95%置信区间为：小关节，短期：相对风险 = 0.89（0.65 - 1.21）；小关节，长期：相对风险 = 0.90（0.69 - 1.17）；硬膜外，短期：相对风险 = 0.93（0.79 - 1.09）；硬膜外，长期：相对风险 = 0.92（0.76 - 1.11）；局部，短期：相对风险 = 0.80（0.40 - 1.59）；局部，长期：相对风险 = 0.79（0.65 - 0.96）。
缺乏关于注射疗法对下腰痛疗效的确凿证据。该领域需要更多设计良好的解释性试验。
