Dear Sir,

We thank Drs. L. Manchikanti and J.A. Hirsch, 2 experts in the field, for their useful comment on our review. In their letter, they raise several points [1].

We agree that epidural injections for sciatica are not necessarily corticosteroid injections; also, local anesthetics (or a mixture of corticosteroids and a local anesthetic) may be effective. In our pain clinics in Zaandam and Amsterdam, the Netherlands, we have a strong preference for the transforaminal epidural injection of methylprednisolone in combination with levobupivacaine. The effectivity of this ‘cocktail' is debatable. Based on the inflammation hypothesis of sciatica, we think the time to treat with corticosteroids is early in the disease. For this reason, we recently started a prospective randomized controlled trial (RCT) in patients with acute sciatica (within 8 weeks after onset) due to a herniated disk as shown by MRI. The STAR-trial (steroids against radiculopathy; NTR 4457) compares 3 treatment groups: (1) medication only; (2) medication with epidural injection of Methylprednisolone and levobupivacaine; (3) medication with epidural injection of levobupivacaine only [2]. We are eager to see if the corticosteroids have a clinically relevant effect on pain and functioning, especially in acute patients.

We also agree with the authors that repeated injections against all kind of low back pain conditions are not evidence based and can even be dangerous [3]. However, this is reality: pain clinics are flourishing and epidural therapy has become increasingly popular over the past few decades.

Safety of the injections remains an important issue. In Europe too, we are aware of the strict FDA regulations [4] and we support the counter reaction by the Multi-Society Pain Workgroup [5]. In the Netherlands, as well as many other countries, epidural corticosteroids are considered safe, as long as they are administered in the lumbosacral region (below L2 level). From this perspective, the STAR-trial was approved by Medical Research Ethics Committees United, Nieuwegein, the Netherlands [6].

Finally, we agree that our article has been subject to some ‘historical bias': in our study of articles and PhD-theses from more than a century ago - the French national library was very helpful here [7], we might have missed some of the most recent RCTs, published after 2012 [8]. We thank the Drs. L. Manchikanti and J.A. Hirsch for keeping us informed and providing us with updated publications.

The authors have no conflicts of interest to disclose.

1.
Manchikanti L, Hirsch JA: Evolution of the epidural treatment of sciatica provides excellent historic review with incomplete modern evidence. Eur Neurol 2016;75:225-226.
2.
Dutch National Trial Register: NTR 4457.
3.
Racoosin JA, Seymour SM, Cascio L, Gill R: Serious neurologic events after epidural glucocorticoid injection - the FDA's risk assessment. N Engl J Med 2015;373:2299-2301.
4.
United States Food and Drug Administration. www.fda.gov.
5.
Manchikanti L, Falco FJ: Safeguards to prevent neurologic complications after epidural steroid injections: analysis of evidence and lack of applicability of controversial policies. Pain Physician 2015;18:E129-E138.
6.
Decision of August 20, 2015, Registration Number: 45805.100.15.
8.
Pinto RZ, Maher CG, Ferreira ML, et al: Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med 2012;157:865-877.
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