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Does Epidural Bupivacaine with or Without Steroids Provide Long-Term Relief? A Systematic Review and Meta-analysis

  • Other Pain (AD Kaye and N Vadivelu, Section Editor)
  • Published:
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Abstract

Purpose of Review

Low back and lower extremity pain have been treated since 1901 with local anesthetics alone and since 1952 in combination with steroids. Over the years, multiple randomized controlled trials, systematic reviews with or without meta-analysis have been reaching discordant conclusions regarding the effectiveness of sodium chloride solution, local anesthetics, and steroids in managing spinal pain. Further, related to lack of understanding, multiple reviewers have considered local anesthetics including lidocaine and bupivacaine as equivalent to placebo based on theory that steroid is the only drug effective in the epidural space. In this review, we assessed effectiveness of epidurally administered bupivacaine with or without steroids to rule out misconceptions of placebo and to show the comparative effectiveness of epidural bupivacaine alone compared to epidural bupivacaine with steroids.

Recent Findings

Multiple systematic reviews performed in assessing the effectiveness of epidural injections have converted epidurally administered lidocaine and bupivacaine to placebo. This led to inappropriate conclusions of lack of effectiveness of epidural local anesthetics with or without steroids as showing equal effectiveness when analyzed with conventional dual-arm meta-analysis. Thus, true placebo control trials with injection of an inactive substance into unrelated structures have been almost non-existent.

Summary

Epidurally administered bupivacaine alone or with steroids are effective in managing low back and lower extremity pain. The findings of this review provide appropriate information of epidurally administered bupivacaine as an active agent (not a placebo) with level 1 evidence and almost equally effective as bupivacaine with steroids with level II evidence.

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Authors and Affiliations

  1. Department of Anesthesiology, University of Louisville, Paducah, KY, USA

    Laxmaiah Manchikanti

  2. School of Medicine Anesthesiology and Perioperative Medicine, LSU Health Sciences Center, New Orleans, LA, USA

    Laxmaiah Manchikanti

  3. Department of Anesthesiology; Advocate Illinois Masonic Medical Center, College of Medicine, University of Illinois, Wellington Ave Ste 4815, Chicago, IL, 60657, USA

    Nebojsa Nick Knezevic

  4. Louisiana State University School of Medicine, 1541 Kings Hwy, Shreveport, LA, 71103, USA

    Allan Parr

  5. Department of Anesthesiology, and Pharmacology, LSU Health Science Center, New Orleans, LA, USA

    Alan D. Kaye

  6. Pain Management Centers of America, Evansville, IN, USA

    Mahendra Sanapati

  7. Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Joshua A. Hirsch

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Correspondence to Laxmaiah Manchikanti.

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Laxmaiah Manchikanti, Nebojsa Nick Knezevic, Allan Parr, III, and Mahendra Sanapati declare no conflict of interest. Dr. Kaye is on the Speakers Bureau for Merck Pharmaceuticals. Dr. Hirsch is a consultant for Medtronic. Dr. Kaye is a Section Editor for Current Pain and Headache Reports. He has not been involved in the review process for this article.

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Manchikanti, L., Knezevic, N.N., Parr, A. et al. Does Epidural Bupivacaine with or Without Steroids Provide Long-Term Relief? A Systematic Review and Meta-analysis. Curr Pain Headache Rep 24, 26 (2020). https://doi.org/10.1007/s11916-020-00859-7

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  • DOI: https://doi.org/10.1007/s11916-020-00859-7

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