Epidural corticosteroid injections for lumbosacral radicular pain

Transforaminal Steroid Injection After Dorsal Root Ganglion Pulsed Radiofrequency (DRG-PRF): Impact on Pain Intensity and Disability

INTRODUCTION

Dorsal root ganglion pulsed radiofrequency (DRG-PRF) is frequently used for the treatment of chronic lumbar radicular pain with good outcomes in terms of pain management. Transforaminal epidural steroid injection (TFESI) is often administered immediately after DRG-PRF to increase the anti-inflammatory effects, but support for the synergic mechanism is lacking in the literature. The aim of this study was to investigate the potential role of TFESI immediately after DRG-PRF and its possible role on pain intensity and patient disability.

METHODS

A database of patients who underwent DRG-PRF with or without TFESI immediately after DRG-PRF was retrospectively analysed; propensity score matching was applied to the analysis to reduce possible bias. Pain intensity (numerical rating scale [NRS]) and Oswestry disability index (ODI) were recorded pre-operatively and at the 1- and 3-month follow-up in the two groups of patients.

RESULTS

A total of 252 patients were included in this retrospective analysis, 126 patients in the DRG-PRF + TFESI group and 126 patients in the DRG-PRF group after propensity score matching. Both groups displayed a significant reduction in pain intensity (NRS score reduction; p < 0.0001) and improvement in the ODI (p < 0.0001) from baseline at the 3-month follow-up. Interestingly, the use of TFESI after DRG-PRF was not associated with any clinical benefit as no difference in NRS and ODI was found between the two groups at the 1- and 3-month follow-ups.

CONCLUSIONS

Our study revealed a significant pain reduction and disability improvement after DRG-PRF in patients with lumbar radicular pain. Interestingly, no positive role of TFESI immediately after DRG-PRF was observed. These findings suggest that DRG-PRF provides substantial pain relief, and no added benefit is obtained with subsequent steroid injection. Future prospective studies with expanded follow-up periods are needed to confirm these findings.

Prevalence of weakness and factors mediating discrepancy between reported and observed leg weakness in people with sciatica

PURPOSE

To establish the prevalence and agreement between reported and observed leg weakness in people with sciatica. To establish which factors mediate any identified difference between reported and observed leg weakness in people with sciatica.

METHODS

68 people with a clinical diagnosis of sciatica, records from spinal service, secondary care NHS Hospital, England, UK reviewed. Primary outcome measures were the sciatica bothersome index for reported leg weakness and the Medical Research Council scale for observed weakness. Agreement was established with Cohen's Kappa and intraclass correlation coefficient. Potential factors that may mediate a difference between reported and observed weakness included leg pain, sciatica bothersome index sensory subscale, age, hospital anxiety and depression subscale for anxiety.

RESULTS

85% of patients reported weakness but only 34% had observed weakness. Cohen's Kappa (0.066, 95% CI - 0.53, 0.186; p = 0.317)] and ICC 0.213 (95% CI - 0.26, 0.428, p = 0.040) both showed poor agreement between reported and observed weakness. The difference between reported and observed measures of weakness was mediated by the severity of leg pain (b = 0.281, p = 0.024) and age (b = 0.253, p = 0.042).

CONCLUSION

There is a high prevalence of reported leg weakness in people with sciatica, which is not reflected in observed clinical measures of weakness. Differences between reported and observed weakness may be driven by the severity of leg pain and age. Further work needs to establish whether other objective measures can detect patient reported weakness.

Efficacy of epidural steroid injection in the treatment of sciatica secondary to lumbar disc herniation: a systematic review and meta-analysis

Epidural steroid injection for the treatment of sciatica caused by disc herniation is increasingly used worldwide, but its effectiveness remains controversial. The review aiming to analyze the efficacy of epidural steroid injection on sciatica caused by lumbar disc herniation. Randomized controlled trials (RCTs) investigating the use of epidural steroid injections in the management of sciatica induced by lumbar disc herniation were collected from PubMed and other databases from January, 2008 to December, 2023, with epidural steroid injection in the test group and epidural local anesthetic and/or placebo in the control group. Pain relief rate, assessed by numerical rating scale (NRS) and visual analogue scale (VAS) scores, and function recovery, evaluated by Roland Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI) scores, were recorded and compared. Meta-analysis was performed by Review Manager. In comparison to the control group, epidural steroid injections have been shown to be effective for providing short- (within 3 months) [MD = 0.44, 95%CI (0.20, 0.68), p = 0.0003] and medium-term (within 6 months) [MD = 0.66, 95%CI (0.09,1.22), p = 0.02] pain relief for sciatica caused by lumbar disc herniation, while its long-term pain-relief effect were limited. However, the administration of epidural steroid injections did not lead to a significant improvement on sciatic nerve function in short- [MD = 0.79, 95%CI = (0.39, 1.98), p = 0.19] and long-term [MD = 0.47, 95% CI = (-0.86, 1.80), p = 0.49] assessed by IOD. Furthermore, the analysis revealed that administering epidural steroid injections resulted in a reduction in opioid usage among patients with lumbar disc herniation [MD = -14.45, 95% CI = (-24.61, -4.29), p = 0.005]. The incidence of epidural steroid injection was low. Epidural steroid injection has demonstrated notable efficacy in relieving sciatica caused by lumbar disc herniation in short to medium-term. Therefore, it is recommended as a viable treatment option for individuals suffering from sciatica.

Cost-effectiveness of Transforaminal epidural steroid injections for patients with ACUTE sciatica: a randomized controlled trial

BACKGROUND

Transforaminal epidural injections with steroids (TESI) are increasingly being used in patients sciatica. The STAR (steroids against radiculopathy)-trial aimed to evaluate the (cost-) effectiveness of TESI in patients with acute sciatica (< 8 weeks). This article contains the economic evaluation of the STAR-trial.

METHODS

Participants were randomized to one of three study arms: Usual Care (UC), that is oral pain medication with or without physiotherapy, n = 45); intervention group 1: UC and transforaminal epidural steroid injection (TESI) 1 ml of 0.5% Levobupivacaine and 1 ml of 40 mg/ml Methylprednisolone and intervention group 2: UC and transforaminal epidural injection (TEI) with 1 ml of 0,5% Levobupivacaine and 1 ml of 0.9% NaCl (n = 50). The primary effect measure was health-related quality of life. Secondary outcomes were pain, functioning, and recovery. Costs were measured from a societal perspective, meaning that all costs were included, irrespective of who paid or benefited. Missing data were imputed using multiple imputation, and bootstrapping was used to estimate statistical uncertainty.

RESULTS

None of the between-group differences in effects were statistically significant for any of the outcomes (QALY, back pain, leg pain, functioning, and global perceived effect) at the 26-weeks follow-up. The adjusted mean difference in total societal costs was €1718 (95% confidence interval [CI]: - 3020 to 6052) for comparison 1 (intervention group 1 versus usual care), €1640 (95%CI: - 3354 to 6106) for comparison 2 (intervention group 1 versus intervention group 2), and €770 (95%CI: - 3758 to 5702) for comparison 3 (intervention group 2 versus usual care). Except for the intervention costs, none of the aggregate and disaggregate cost differences were statistically significant. The maximum probability of all interventions being cost-effective compared to the control was low (< 0.7) for all effect measures.

CONCLUSION

These results suggest that adding TESI (or TEI) to usual care is not cost-effective compared to usual care in patients with acute sciatica (< 8 weeks) from a societal perspective in a Dutch healthcare setting.

TRIAL REGISTRATION

Dutch National trial register: NTR4457 (March, 6th, 2014).

Preoperative conservative treatment is insufficiently described in clinical trials of lumbar fusion: a scoping review

PURPOSE

To identify how pre-surgical conservative care is characterized and reported in randomized controlled trials of adults undergoing elective lumbar fusion, including duration and type of treatment.

METHODS

The study design is a scoping review. Data sources include PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid Medline, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL). All randomized controlled trials published in English between January 1, 2005, and February 15, 2022, assessing lumbar fusion as the intervention were included in this review.

RESULTS

Of 166 studies, 62.0% reported a failure in conservative care prior to lumbar fusion, but only 15.1% detailed the type of specific conservative care received. None of the trials provided sufficient details to understand the nature of the pre-surgical conservative treatment, such as frequency, recency/timing, or dosage of conservative interventions.

CONCLUSION

Although roughly two-thirds of trials reported that patients failed conservative care prior to receiving a lumbar fusion, few studies named the conservative intervention provided and no studies provided any details regarding dosing or recency of care. This lack of information creates ambiguity in the surgical decision-making process, setting the assumption that all patients received adequate conservative care prior to surgery. Details about pre-surgical conservative care should be disclosed to allow for appropriate clinical application, decision-making, and interpretation of treatment effects.

The Kumar Technique: A Novel and Effective Approach to Transforaminal Epidural Steroid Injections

Background Transforaminal epidural steroid injections (TFESIs) are widely used as a minimally invasive treatment for lumbar radicular pain. This study presents an alternative approach for lumbar TFESI, the Kumar Technique, which utilizes a more lateral and inferior needle starting point to better align the trajectory of the needle with the neural foramen. We hypothesize the Kumar Technique will result in safer and more effective outcomes than the traditional approach to TFESI. This article was previously presented as a poster at the 2023 University of Florida College of Medicine Celebration of Research on February 27-28, 2023, and as an abstract and poster at the 2023 University of Florida Department of Anesthesiology Celebration of Research on March 29, 2023. Methods The charts for 1,424 patients who received lumbar TFESIs were retrospectively reviewed, and patients were stratified into groups receiving either the traditional approach or the Kumar Technique. Outcomes measures included numerical pain scores, measures of functional status and activity limitations, duration of pain relief, and procedural complications. Results Compared to the group undergoing the traditional approach, patients receiving the Kumar Technique reported a significantly greater decrease in average pain (-2.3 (95% CI: -3.0 to -1.6) vs -1.1 (95% CI: -1.4 to -0.7)) and maximum pain (-2.4 (95% CI: -3.2 to -1.6) vs -1.3 (95% CI: -1.8 to -0.9)). Patients receiving the Kumar Technique had a significantly greater likelihood of reporting any pain relief (OR: 2.10, 95% CI:1.59 to 2.79) compared to those undergoing the traditional approach. In addition, a greater percentage of patients receiving the Kumar Technique experienced at least one month of pain relief compared to the traditional approach (54% vs 40%; z = 3.85, p < 0.001). The occurrence of complications did not significantly vary between the modified (4.1%) and the traditional (3.0%) approaches. Conclusions The Kumar Technique is a modified TFESI approach that allows for improved access to the nerve roots through a more lateral and inferior needle entry point. The analysis supports the benefits of the Kumar Technique with patients experiencing a greater reduction in pain and longer durations of pain relief without increasing the risk of complications.

Management of Lumbar Disc Herniation: A Systematic Review

A herniated disc in the spine is a condition during which a nucleus pulposus is displaced from intervertebral space. It is a common cause of back pain. The patients who experience pain related to a herniated disc often remember an inciting event that caused their pain. This activity reviews the evaluation and management of lumbar disc herniation and discusses the role of the healthcare team in evaluating and improving care for patients with this condition. Data sources were PubMed/Medline and Embase. Our review investigated English-language articles (from 2010 to 2023) according to the PRISMA guidelines. Overall, there were seven articles. Surveys and analyses of national databases were the most widely used methods (n=7). The search identified 777 studies; 7 were eligible for inclusion in the analysis. Further understanding of spinal disc herniation and treatment protocols may help improve evaluation and management in the future. Our research covered a range of management options. Disc herniation is a frequent problem for internists, emergency department doctors, nurse practitioners, and primary care physicians. To manage efficiently, an interprofessional team is needed. The first course of treatment is conservative, with paracetamol and anti-inflammatories being frequently used to relieve pain. A chemist must supervise the use of opioid analgesics in certain situations. Although surgery is sometimes the final option, patients frequently have neurological damage and lingering discomfort. In circumstances where physical treatment is not working, MRI interpretation becomes necessary. Primary care physicians or mental health professionals should handle back pain as it is frequently linked to mental health issues. Results can be enhanced by regular exercise and preserving a healthy body weight.

Efficacy of Percutaneous Adhesiolysis in Managing Low Back and Lower Extremity Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials

INTRODUCTION

Chronic refractory low back and lower extremity pain recalcitrant to conservative management and epidural injections secondary to postsurgery syndrome, spinal stenosis, and disc herniation are sometimes managed with percutaneous adhesiolysis. Consequently, this systematic review and meta-analysis was undertaken to assess the efficacy of percutaneous adhesiolysis in managing low back and lower extremity pain.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was performed. A comprehensive literature search of multiple databases from 1966 to July 2022, including manual searches of the bibliography of known review articles was performed. Quality assessment of the included trials, meta-analysis, and best evidence synthesis was performed. The primary outcome measure was a significant reduction in pain (short term up to 6 months and long term more than 6 months).

RESULTS

The search identified 26 publications, with 9 trials meeting the inclusion criteria. The results of dual-arm and single-arm analyses showed significant improvement in pain and function at 12 months. Opioid consumption was also significantly reduced at 6 months with dual-arm analysis, whereas single-arm analysis showed a significant decrease from baseline to treatment at the 3-, 6-, and 12-month analyses. At 1 year follow-up, seven of seven trials were positive for improvements in pain relief, function, and diminution of opioid use.

DISCUSSION

Based on the present systematic review of nine RCTs, the evidence level is I to II, with moderate to strong recommendation for percutaneous adhesiolysis in managing low back and lower extremity pain. The limitations of the evidence include paucity of literature, lack of placebo-controlled trials, and the majority of the trials studying post lumbar surgery syndrome.

CONCLUSION

The evidence is level I to II or strong to moderate based on five high-quality and two moderate-quality RCTs, with 1 year follow-up that percutaneous adhesiolysis is efficacious in the treatment of chronic refractory low back and lower extremity pain.

Neurological pain relief interventional radiology procedures

Neurological interventions have taken on a significant role in interventional radiology (IR) practice. Indications fall under three main categories: (1) intraprocedural pain management, (2) cancer pain palliation, and (3) chronic non-cancer pain control. Short-term regional anaesthesia can be achieved with local anaesthetics, while longer-term pain control can be attained with radiofrequency neuromodulation (pulsed or otherwise) or thermal/chemical neurolysis. This review article summarises the therapeutic options, applications, and techniques of commonly used peripheral nerve and plexus interventions in IR.

The Benefit of Early Epidural Corticosteroid Injections for Acute Sciatica-Associated Lower Back Pain: A Four-Year Case Series in Lebanon

Background Early epidural steroid injections are currently widely used for patients experiencing lumbago. However, there is uncertainty about their efficacy, such as the limitation of continuous drug infusion and the need for well-trained physicians on this technique. The main objective of this study was to evaluate the effectiveness of early epidural steroid injections in treating patients with acute sciatica in the lower back in terms of symptom relief and recurrence rate. Methods A case series was conducted in Lebanon from 2015 to 2019. We recruited 98 patients suffering from sciatica due to disc disease over three-time intervals: two weeks, one, and three months. The immediate results accounted for the intensity of various symptoms (numerical rating scale (NRS) for pain) and the assessment of patient satisfaction (Macnab criteria). Results The clinical results showed at least a three-point pain relief according to Numerical Rating Scale (NRS) and a good grade according to MacNab (P <0.001), with only 10.4% of the total population having a positive leg raise test post-injection. The maximum benefit was noted after two weeks from the injection with a 5.7 mean change in NRS (p<0.001) with a good/excellent response in MacNab and a 4.9 change with only a good response after one month. This study noticed a rebound phenomenon where around half of the patients needed two steroid injections after three months (39.6 % after three months and 17.9 % after six months). Conclusion Even though current guidelines worldwide may suggest the use of conservative treatment for low back pain with acute sciatica, our study has demonstrated the effectiveness of epidural steroid injections in the Lebanese population with a significant outcome.

[Multiprofessional treatment approach in chronic back pain]

International guidelines recommend involving various professions and disciplines at an early stage in the event of chronic back pain. In connection with this, terms such as multiprofessional or interprofessional interventions are often mentioned without a uniform idea of what they mean. This article is intended to provide an overview of multiprofessional interventions for patients with chronic back pain and the integration into a meaningful interdisciplinary and interprofessional multimodal treatment concept. This is illustrated in a biopsychosocial pillar model, which should be pursued for each patient individually.

Dorsal root ganglion pulsed radiofrequency using bipolar technology in patients with lumbosacral radicular pain duration ≥ 2 years

BACKGROUND

Transforaminal epidural steroid injection (TFESI) or dorsal root ganglion pulsed radiofrequency (PRF) are alternative treatments for lumbosacral radicular pain (LSRP). This study aimed to investigate the clinical efficacy of TFESI combined with dorsal root ganglion PRF using bipolar technology to treat LSRP in patients with pain duration ≥ 2 years.

METHODS

This prospective single-armed cohort study included 20 patients with LSRP duration ≥ 2 years, who underwent treatment of TFESI combined with bipolar PRF. The primary outcomes included numerical rating scale (NRS) and successful treatment rate (pain relief ≥50%). The secondary outcomes included Oswestry Disability Index (ODI), patient satisfaction using the modified MacNab criteria, severe complications, hospital stay and total costs. The final follow-up was 6 months postoperatively.

RESULTS

The successful treatment rate and average pain relief at 6 months postoperatively were 80% and 73.0% ± 17.5%, respectively. The successful treatment rates in patients with and without prior intervention history at 6 months postoperatively were 77.8% and 81.8%, respectively. The mean NRS score significantly decreased from 6.5 ± 0.8 to 1.1 ± 0.7 at 2 weeks postoperatively, to 1.3 ± 0.7 at 3 months postoperatively, and to 1.7 ± 1.0 at 6 months postoperatively (all P < 0.001), while the mean ODI score significantly decreased from 43.5 ± 2.5 to 22.5 ± 4.3 at 2 weeks postoperatively, to 20.0 ± 3.5 at 3 months postoperatively, and to 19.5 ± 3.6 at 6 months postoperatively (all P < 0.001). The excellent and good patient satisfaction at 6 months postoperatively was 85%. No severe complications were observed in this cohort. The average hospital stay and total costs were 3.0 ± 0.5 days and 3.36 ± 0.77 thousand dollars, respectively.

CONCLUSION

The treatment of TFESI combined with PRF using bipolar technology might be an alternative option to treat chronic LSRP in patients with pain duration ≥ 2 years after a failure of conservative treatments, with a favorable 6-month efficacy and inexpensive total costs. However, long-term outcomes and superiority of bipolar procedure over monopolar procedure in patients with longer pain duration should be further investigated in future studies.

309 patients treated with fluoroscopy-guided caudal epidural injection for lumbar disc herniation

Objective

To present our experience, discuss the complications, and assess early vs long-term outcomes of fluoroscopy-guided caudal epidural injection for lumbar disc herniation (LDH).

Methods

This was a prospective study of 309 patients who underwent fluoroscopy-guided caudal epidural injection from 2014 to 2020. The inclusion criteria were LDH diagnosis by magnetic resonance imaging, surgical treatment not required, age >18 years, and history of low back or leg pain despite >6 weeks of treatment comprising a combination of analgesics, anti-inflammatories, and physical therapy. The epidural injection solution comprised 8 mL of 0.5% bupivacaine hydrochloride (HCL), 2 mL dexamethasone, and 10 mL saline. Each patient completed a questionnaire comprising a visual analog scale (VAS) and the Back Pain Functional Scale (BPFS) at baseline, and 1 month and 1 year after injection.

Results

The VAS and BPFS scores indicated significantly less pain at 1 month and 1 year compared with the pre-procedure baseline values. Complications developed in 11 patients (reversible paresis in 7 patients, arrhythmia in 1 patient, headache in 1 patient, seizure in 1 patient, spondylodiscitis in 1 patient).

Conclusions

Fluoroscopy-guided caudal epidural injection for LDH is safe, and the procedure reduced pain and improved functional capacity compared with baseline.

Knowledge and Attitude of Sciatica Pain and Treatment Methods among Adults in Saudi Arabia

Background. Sciatica is a relatively common condition, with a lifetime incidence varying from 13% to 40%. The corresponding annual incidence of an episode of sciatica ranges from 1% to 5%. The exact cause of sciatica is unknown to this day; treatment methods and practices differ between individuals based on their cultural background, socioeconomic status, and religious beliefs. This study aimed to assess the knowledge and attitude toward sciatica pain among adults in Saudi Arabia. Methods. A cross-sectional study was conducted among the adult population in Saudi Arabia. A self-administered questionnaire was distributed among the study population using an online survey. Questions were divided into four groups, each containing multiple questions covering the following aspects: demographic data, past medical history, and the assessment of knowledge and attitudes regarding sciatica. Results. A total of 3,764 respondents were involved in this study, with an age range of 18–65 years old (females 59.8%). The mean knowledge score was 3.8 (SD 2.1), with the majority having poor knowledge (60.1%). The most common source of sciatica information was an orthopedic or a neurosurgeon, while the most common self-treatment used was painkiller medications (30.8%). The mean attitude score was 35.8 (SD 5.3), with most respondents having a neutral attitude (80.3%). The factors correlated with an increase in knowledge and attitude were having a bachelor’s or higher degree and living in an urban area. Conclusion. While the attitude of the adult population toward sciatica pain seems adequate, their knowledge was shown to be deficient. Furthermore, when comparing diagnosed individuals living in cities with those in rural areas, both knowledge and attitudes were shown to be better in individuals living in cities. Awareness programs by health institutions and healthcare professionals are needed to enhance patients knowledge. Various media can be utilized to enhance patients knowledge including social media platforms.

Comparing the therapeutic effects of pregabalin and gabapentin after transforaminal epidural nerve block in lumbar radiculopathy

Lumbar radiculopathy can be presented as low back pain and radiating pain. Transforaminal epidural steroid injection (TFESI) has been used to treat radicular pain, and after the injection, additional medications such as gabapentinoids including pregabalin (PGB) and gabapentin (GBP) can be administered to relieve remnant pain. However, little is known about the effectiveness of gabapentinoids in relieving pain after transforaminal epidural steroid injection. This study was conducted to compare the effect of pregabalin and gabapentin in lumbar radiculopathy patients who underwent transforaminal epidural steroid injection. One hundred seven patients who received TFESI and had taken PGB or GBP after the intervention at Daegu Catholic University Medical Center from January 2013 to August 2021 were included in this study. Visual Analogue Scale (VAS) was evaluated in all patients. Among 107 patients, 57 (53.3%) patients took PGB and 50 (46.7%) patients took GBP after TFESI. The PGB and GBP groups showed reduced VAS scores according to visit (P < .001). However, no statistically significant differences in VAS scores according to the types of medication (P = .811) and change aspects according to visit were observed between the PGB and GBP groups (P = .947). The study findings suggest that both pregabalin and gabapentin can be equally used to reduce pain in lumbar radiculopathy patients who underwent TFESI. Further studies with larger sample size are needed to generalize the findings of this study.

What Is New in the Clinical Management of Low Back Pain: A Narrative Review

Low back pain (LBP) is a prevalent condition associated with disability. Treating patients with LBP becomes further complicated by the potential presence of underlying conditions, such as cancer or traumatic injury, or biopsychosocial aspects. LBP usually has a neuropathic component that must be assessed and treated appropriately. Pharmacological management of LBP requires a thorough knowledge of the available agents and the mechanisms of the LBP. Although there are effective pharmacological treatments for LBP, it is important to consider safety issues. Fixed-dose combination products may be helpful, as they can reduce opioid consumption without sacrificing analgesic benefits. Neuromodulation is an important and sometimes overlooked treatment option for LBP and may be appropriate for chronic LBP requiring long-term treatment. Imaging studies support neuroplastic changes in the brain as a result of neuromodulation. Interventional approaches to chronic LBP are numerous and must be appropriately selected based on the individual patient. Evidence in support of epidural injections for LBP is strong for short-term pain control but moderate to limited for long-term relief. Rehabilitation for LBP can be an important element of long-term care, and new forms of rehabilitation programs are being developed using telemedicine. A variety of new and established treatments are available for patients with LBP, and clinicians and patients may benefit from emerging new treatment modalities.

Clinical Outcome of Pulsed-Radiofrequency Combined With Transforaminal Epidural Steroid Injection for Lumbosacral Radicular Pain Caused by Distinct Etiology

BACKGROUND

Lumbosacral radicular pain (LSRP) can be caused by disc herniation, spinal stenosis, and failed back surgery syndrome. The clinical effect of pulsed-radiofrequency (PRF) combined with transforaminal epidural steroid injection (TESI) for radiating pain in different population remains unclear.

METHODS

We retrospectively reviewed the medical recordings of patients with LSRP caused by different etiologies, who underwent PRF and TESI treatment. The primary clinical outcome was assessed by a 10-point Visual Analog Scale (VAS) pre- and post-treatment.

RESULTS

A total of 34 LSRP patients were identified and classified into 3 subgroups (disc herniation, spinal stenosis, and failed back surgery syndrome). The overall immediate pain reduction was 4.4 ± 1.1 after procedure. After a median follow-up of 9.5 months, the VAS decreased from 6.5 ± 1.0 to 2.4 ± 1.9 at the last follow-up.

CONCLUSION

PRF combined with TESI is an effective approach to treat persistent LSRP in distinct population.

Prediction of successful caudal epidural injection using color Doppler ultrasonography in the paramedian sagittal oblique view of the lumbosacral spine

Background

Ultrasound-guided caudal epidural injection (CEI) is limited in that it cannot confirm drug distribution at the target site without fluoroscopy. We hypothesized that visualization of solution flow through the inter-laminar space of the lumbosacral spine using color Doppler ultrasound alone would allow for confirmation of drug distribution. Therefore, we aimed to prospectively evaluate the usefulness of this method by comparing the color Doppler image in the paramedian sagittal oblique view of the lumbosacral spine (LS-PSOV) with the distribution of the contrast medium observed during fluoroscopy.

Methods

Sixty-five patients received a 10-mL CEI of solution containing contrast medium under ultrasound guidance. During injection, flow was observed in the LS-PSOV using color Doppler ultrasonography, following which it was confirmed using fluoroscopy. The presence of contrast image at L5-S1 on fluoroscopy was defined as “successful CEI.” We then calculated prediction accuracy for successful CEI using color Doppler ultrasonography in the LS-PSOV. We also investigated the correlation between the distribution levels measured via color Doppler and fluoroscopy.

Results

Prediction accuracy with color Doppler ultrasonography was 96.9%. The sensitivity, specificity, positive predictive value, and negative predictive value were 96.7%, 100%, 100%, and 60.0%, respectively. In 52 of 65 patients (80%), the highest level at which contrast image was observed was the same for both color Doppler ultrasonography and fluoroscopy.

Conclusions

Our findings demonstrate that color Doppler ultrasonography in the LS-PSOV is a new method for determining whether a drug solution reaches the lumbosacral region (i.e., the main target level) without the need for fluoroscopy.

Recommendations for Diagnosis and Treatment of Lumbosacral Radicular Pain: A Systematic Review of Clinical Practice Guidelines

The management of patients with lumbosacral radicular pain (LRP) is of primary importance to healthcare professionals. This study aimed to: identify international clinical practice guidelines on LRP, assess their methodological quality, and summarize their diagnostic and therapeutic recommendations. A systematic search was performed (August 2019) in MEDLINE, PEDro, National Guideline Clearinghouse, National Institute for Health and Clinical Excellence (NICE), New Zealand Guidelines Group (NZGG), International Guideline Library, Guideline central, and Google Scholar. Guidelines presenting recommendations on diagnosis and/or treatment of adult patients with LRP were included. Two independent reviewers selected eligible guidelines, evaluated quality with Appraisal of Guidelines Research & Evaluation (AGREE) II, and extracted recommendations. Recommendations were classified into 'should do', 'could do', 'do not do', or 'uncertain'; their consistency was labelled as 'consistent', 'common', or 'inconsistent'. Twenty-three guidelines of varying quality (AGREE II overall assessment ranging from 17% to 92%) were included. Consistent recommendations regarding diagnosis are ('should do'): Straight leg raise (SLR) test, crossed SLR test, mapping pain distribution, gait assessment, congruence of signs and symptoms. Routine use of imaging is consistently not recommended. The following therapeutic options are consistently recommended ('should do'): educational care, physical activity, discectomy under specific circumstances (e.g., failure of conservative treatment). Referral to a specialist is recommended when conservative therapy fails or when steppage gait is present. These recommendations provide a clear overview of the management options in patients with LRP.

Diagnosis and Treatment of Sciatica in the Netherlands: A Survey among Neurologists and Anesthesiologists

BACKGROUND

This study aimed to assess how Dutch neurologists and anesthesiologists diagnose and treat people with sciatica in secondary care and to evaluate their adherence to the newest guidelines.

METHODS

We conducted a cross-sectional survey. Respondents were asked about their current clinical practice related to sciatica. Three authors rated the respondents' adherence to the guidelines on a three-point Likert scale.

RESULTS

Eighty neurologists and 44 anesthesiologists completed the questionnaire. Neurologists diagnose their sciatica patients primarily using a magnetic resonance imaging (89%). Selective diagnostic nerve blocks are considered useful by 81% of the neurologists. Neurologists primarily treat patients with pain medication, and 40% of them think epidural steroid injections are effective in 40-60% of injected patients. Twenty-nine percent of neurologists refer patients to a neurosurgeon after 4 months. Anesthesiologists consider a selective diagnostic nerve root block to have a higher diagnostic value than mapping. The most reported side effect of epidural injections is exacerbation of pain (82%). Pulse radiofrequency is applied in 9-11% of acute cases. The results also indicate that Dutch neurologists and anesthesiologists follow an evidence-based approach that is strictly or broadly in line with the guideline.

CONCLUSIONS

Neurologists treat sciatica patients initially with pain medication and physiotherapy, followed by epidural steroid injections and referral for surgery. Anesthesiologists treat sciatica patients with one or more steroid injections or may perform a selective nerve root block. Imaging, selective nerve root blocks, medication, physiotherapy, and pulse radiofrequency are topics of further research.

Are epidural corticosteroid injections effective for lumbosacral radicular pain? A Cochrane Review summary with commentary

BACKGROUND

Epidural corticosteroid injection is one of the most common non-surgical procedures for lumbosacral radicular pain.

OBJECTIVE

To assess efficacy and safety of epidural corticosteroid injections compared with placebo injections in patients with lumbosacral radicular pain.

METHODS

A summary and commentary of a Cochrane Review by Oliveira et al.RESULTS:25 studies with a total of 2740 participants were included in the review. Moderate quality evidence pointed out a small effect on leg pain at immediate and short-term follow-up and on disability at short-term and intermediate follow-up. Adverse events were not different between corticosteroid and placebo injections.

CONCLUSIONS

Epidural corticosteroid injection is slightly more effective than placebo for leg pain and disability at short-term follow up. Clinicians and patients however should be informed of the small effect size of the treatment.

OASIS-a randomised, placebo-controlled trial of oral glucocorticoids for leg pain in patients with acute sciatica: trial protocol

INTRODUCTION

Sciatica is a lower spine condition characterised by radiating leg pain below the knee. It may be accompanied by motor and sensory loss in the distribution of a spinal nerve. There are few effective treatments for sciatica. Orally administered glucocorticoids have shown some promise, however, any beneficial effects need to be confirmed and weighed against drug safety and cost-effectiveness, in a high-quality, definitive trial.

METHODS AND ANALYSIS

The Oral Steroids In Sciatica (OASIS) trial is a randomised, placebo-controlled, double-blind trial that will evaluate a tapering regimen of oral prednisolone in 200 participants with acute sciatica. Participants will be recruited on presentation to general practice, specialist outpatient clinics or hospital emergency departments and randomised to receive orally administered prednisolone 50 mg per day, up to 3 days then tapering to cessation over 10 days, or placebo, for a maximum of 13 days, in addition to guideline advice. Participants will be followed for 1 year. The primary endpoint will be leg pain intensity at 2 weeks. Secondary outcomes will include back pain intensity, disability, time to recovery, quality of life and treatment success rate. Adverse events will be assessed and a cost-effectiveness analysis will be conducted.

ETHICS AND DISSEMINATION

Ethical approval has been granted from the Human Research Ethics Committee, The University of Sydney. Trial results will be disseminated by publications and conference presentations and via the media.

TRIAL REGISTRATION NUMBER

ACTRN12619001716156.