DePalma and colleagues (2005) reviewed the evidence on the effectiveness of transforaminal epidural steroid injections (TFESI) or SNRBs to treat lumbosacral radiculopathy. These investigators concluded that there is moderate evidence in support of TFESI in treating painful lumbar radicular symptoms. The authors concluded that current studies support the use of TFESI/SNRB as a safe and minimally invasive adjunct treatment for lumbar radicular symptoms. In a critique of the systematic evidence review by DePalma et al, the Centre for Reviews and Dissemination (2008) stated that relevant data might have been missed as only published English language studies were included in the review. The CRD noted that the authors of this systematic review used published methods to assess the quality of the studies, but it is unclear how the studies were selected and how many reviewers performed the validity assessments; it is therefore difficult to assess the reliability, in terms of reviewer error or bias, of these review methods. The CRD observed that it appears that one study was initially included in the review, but then subsequently excluded from the analysis as it was not a true randomized controlled clinical trial. The CRD stated that, given the variability between the studies, in particular differences between the outcome measures and interventions, the authors' decision to use a narrative synthesis appears reasonable. The authors also noted a number of design problems with the included studies: the lack of a true placebo-control group and the lack of a sham control group. The studies were also limited in size, with only 2 studies having over 50 participants. The CRD concluded that, "[g]iven the variability between the studies, the lack of appropriate controls, and the limited number of studies and participants, the authors' cautious conclusions appear reliable."