Thoughts on evidence-based medicine and interlaminar epidural injections.

To the Editor: Recently, I was asked to co-author a review of the scientific evidence for, or against, the use of epidural steroid injections to treat pain. Although there have been many studies published over the years showing efficacy for interlaminar epidural injections, none met the criteria for our report because most were not randomized and none evaluated injections using fluoroscopy. On the other hand, recent studies of epidural injection have focused on the fluoroscopically-guided, transforaminal approach, and hence, high quality scientific articles evaluating the use of transforaminal epidural injections are available for review. After analysis of the extant scientific literature, our panel of experts concluded that there are randomized, controlled data to support the use of transforaminal epidural injections to treat lumbar radicular pain, but there are no randomized, controlled studies of fluoroscopically-guided interlaminar epidural injections to support or refute the use of this procedure (1). Within two weeks of the publication of our review, a large health plan in our state informed pain physicians that they would no longer pay for interlaminar epidural injections and would only reimburse for transforaminal epidurals. The medical director of the plan cited our published review identifying lack of evidence to support interlaminar epidural injection as the basis for the health plan’s decision. I responded to the health plan’s policy with a letter discussing my views on evidencebased medicine in general, and epidural steroid injections in particular, and I would like to share my thoughts with the readers of Pain Physician journal.