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lopathy; 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 MultiSociety Pain Workgroup [5] . In the Netherlands, as well as many other counDear 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 radicuReceived: April 1, 2016 Accepted: April 1, 2016 Published online: April 28, 2016

european neurology

Author's Reply to the Letter of Manchikanti and Hirsch, Entitled ‘Evolution of the Epidural Treatment of Sciatica Provides Excellent Historic Review with Incomplete Modern Evidence'