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The Impact of Epidural Steroid Injections on the Outcomes of Patients Treated for Lumbar Disc HerniationA Subgroup Analysis of the SPORT Trial
Kristen Radcliff, MD1; Alan Hilibrand, MD1; Jon D. Lurie, MD2; Tor D. Tosteson, ScD2; Lawrence Delasotta, MD1; Jeffrey Rihn, MD1; Wenyan Zhao, PhD2; Alexander Vaccaro, MD, PhD1; Todd J. Albert, MD1; James N. Weinstein, MD2
1 Department of Orthopedic Surgery, Thomas Jefferson University, Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107. E-mail address for K. Radcliff: Radcliffk@gmail.com
2 Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756
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Investigation performed at the Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, and the Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

This article was chosen to appear electronically on June 27, 2012, before publication of the final, definitive version.

A commentary by Theodore J. Choma, MD, is linked to the online version of this article at jbjs.org.

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Aug 01;94(15):1353-1358. doi: 10.2106/JBJS.K.00341
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The Spine Patient Outcomes Research Trial (SPORT) is a prospective, multicenter study of operative versus nonoperative treatment of lumbar intervertebral disc herniation. It has been suggested that epidural steroid injections may help improve patient outcomes and lower the rate of crossover to surgical treatment.


One hundred and fifty-four patients included in the intervertebral disc herniation arm of the SPORT who had received an epidural steroid injection during the first three months of the study and no injection prior to the study (the ESI group) were compared with 453 patients who had not received an injection during the first three months of the study or prior to the study (the No-ESI group).


There was a significant difference in the preference for surgery between groups (19% in the ESI group compared with 56% in the No-ESI group, p < 0.001). There was no difference in primary or secondary outcome measures at four years between the groups. A higher percentage of patients changed from surgical to nonsurgical treatment in the ESI group (41% versus 12% in the No-ESI, p < 0.001).


Patients with lumbar disc herniation treated with epidural steroid injection had no improvement in short or long-term outcomes compared with patients who were not treated with epidural steroid injection. There was a higher prevalence of crossover to nonsurgical treatment among surgically assigned ESI-group patients, although this was confounded by the increased baseline desire to avoid surgery among patients in the ESI group. Given these data, we concluded that more studies are necessary to establish the value of epidural steroid injection for symptomatic lumbar intervertebral disc herniation.

Level of Evidence: 

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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