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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: July 23, 2014
Expiration Date: July 23, 2015

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:

1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD
Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards.

Program ID: 1405237J

Last week 757 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 254 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article was selected by the DynaMed Editorial Team.

Addition of Steroids to Epidural Lidocaine Injection May Not Reduce Disability or Pain at 6-12 Weeks in Patients With Spinal Stenosis
Reference: N Engl J Med 2014 Jul 3;371(1):11 (level 2 [mid-level] evidence)

Although epidural steroid injections are commonly used in patients with spinal stenosis, the evidence supporting its use is limited. The most recent North American Spine Society (NASS) guideline for degenerative lumbar spinal stenosis states that interlaminar epidural steroid injections are suggested to provide short-term symptom relief (2 weeks to 6 months) in patients with neurogenic claudication or radiculopathy (Spine J 2013 Jul;13(7):734). A recent randomized trial compared epidural steroid injection with lidocaine to lidocaine alone at 3 and 6 weeks in 400 patients with spinal stenosis and moderate-to-severe leg pain and disability.

Patients in the steroid group received 1 to 3 mL of triamcinolone (60-120 mg), betamethasone (6-12 mg), dexamethasone (8-10 mg), or methylprednisolone (60-120 mg) at the discretion of the treating physician. Disability was assessed with the Roland-Morris Disability Questionnaire (range 0-24), and leg pain was assessed with the Brief Pain Inventory scale (range 0-10). At baseline, the duration of pain was higher in glucocorticoids plus lidocaine group compared to the lidocaine alone group (p = 0.02). Patients receiving epidural steroids did not achieve a clinically significant improvement in mean pain or disability scores at 3 weeks compared to those not receiving steroids. In addition, there were no clinically or statistically significant between-group differences in these outcomes at 6 weeks. Furthermore, there were no significant differences in the proportions of patients with ≥ 50% improvement in disability or pain scores at 6 weeks. However, in a post-hoc analysis adjusting for baseline pain duration, patients receiving steroid plus lidocaine had a small but significantly greater reduction in disability score at 6 weeks compared to those receiving lidocaine alone (p = 0.03).

The results of this trial are consistent with another recent randomized trial evaluating the addition of betamethasone to lidocaine epidural injections in patients with spinal stenosis (J Spinal Disord Tech 2012 Jun;25(4):226). That trial also found no improvement in disability or pain scores at 12 weeks to 1 year in patients receiving steroid plus lidocaine, but also had potential confounding due to imbalanced patient characteristics at baseline. The results of these two recent randomized trials suggest that any improvement in disability or pain does not persist beyond 6-12 weeks. Moreover, any benefit observed prior to that time must be weighed against an increased risk of adverse events, including potential product contamination, temporary alterations in glucose control, and steroid-induced fluid retention.

For more information see the Epidural steroid injection topic in DynaMed.

Special thanks to Janine Knudsen and Nicole Jackson of Harvard Medical School for their contributions to this week's article.

Earn CME Credit for reading this e-Newsletter. For more information on this educational activity, see the CME sidebar.

EBSCO Health Launches Pediatric Clinical Information Mobile App

PEMSoft Now Available For iPhone, iPad, and Android Devices

A mobile app designed specifically for pediatricians, emergency department physicians, physicians-in-training and other medical providers caring for children with acute illnesses and injury, is now available from EBSCO Health, the leading provider of clinical decision support solutions for the healthcare industry.

Designed by pediatricians, emergency physicians and other medical specialists, PEMSoft is a pediatric evidence-based point-of-care medical reference tool for hospitals, emergency departments, clinics, pediatric group practices, transport services, and medical schools. The vast content in PEMSoft addresses the entire spectrum of neonatal, infant, child, adolescent and young adult health. PEMSoft authors adhere to a strict evidence-based editorial policy focused on systematic identification, evaluation and consolidation of practice-changing clinical literature.

The PEMSoft Mobile app includes explicit step-by-step emergency critical care procedures, information about common pediatric signs and symptoms and content covering pediatric injuries and management approaches. More than 3,000 evidence-based pediatric topics and a similar number of medical illustrations, clinical images and videos are also available via the mobile app.

The PEMSoft Mobile App is accessible from both Apple and Android devices.

For more information and technical support, visit the PEMSoft Mobile Access page. To view the official press release, click here.

DynaMed Careers

Looking for a change? The DynaMed editorial team is expanding and looking for talented and driven individuals. Visit the links below to learn about these exciting opportunities.

Section Editor of Specialty Content

DynaMed Contribution Opportunities

DynaMed Peer Review
Editorial Policies for Reviewers
Education for Clinicians in Training

Call for Peer Reviews

We are currently seeking subspecialty reviewers for our Patient Education Resource Center (PERC). PERC provides fact sheets and discharge instructions for patients leaving the hospital or emergency room. These hand-outs fulfill the meaningful use requirements for the Medicare & Medicare Services Incentive Programs.

Click here to speak with us about becoming a peer reviewer.