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Time to reconsider steroid injections in the spine?

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To the Editor: As surgeons with a combined experience of more than 80 years in managing lumbar disc prolapse, we would like to add to this debate on the place of corticosteroid injection, from the advantage of those who have both seen the problem during surgery and managed the condition non-operatively. The opinions expressed recently in the Journal14 suggest such experience is essential to the understanding of both the pathogenesis and natural history of the disorder.

In the United Kingdom in the 1950s, lumbar disc excision was commonly performed under local anaesthesia with patients lying on their sides and the sciatic side uppermost. Then, it was observed that retracting a normal, white nerve root produced no response whereas retracting an inflamed root taut over a prolapse reproduced the patient’s radicular pain. When the surgery is performed under general anaesthetic, the irritability of the inflamed nerve root is evidenced by twitching in the distal musculature served by the root as it is retracted; a rise in protein levels in cerebrospinal fluid (CSF) is seen in the acute phase.5 Further, and most importantly, when patients with disc prolapses proven on imaging are successfully managed non-operatively without…