Epidural steroid injections for radicular lumbosacral pain: a systematic review

Effect of local epidural application of methylprednisolone acetate on time to ambulation in non-ambulatory dogs with thoracolumbar intervertebral disc disease: A prospective randomised, blinded control trial

BACKGROUND

The objective of this study was to analyse the potential benefit of the epidural application of steroids on time to ambulation in non-ambulatory dogs affected by intervertebral disc disease (IVDD) treated with decompressive surgery.

METHODS

This prospective, randomised, blinded control trial involved 41 dogs with thoracolumbar disc extrusion, which were randomly allocated into two groups. In the control group, saline was locally applied after surgical decompression of the spinal cord (n = 23). In the treatment group (n = 18), local epidural application of methylprednisolone acetate (1 mg/kg) was used. Ambulation time was the primary outcome measure, defined as the ability to take 10 independent steps.

RESULTS

The median number of days to ambulation was 7 days (range: 1‒17 days) for the control group and 3 days (range: 1‒8 days) for the treatment group. One dog from the treatment group developed discospondylitis and abscess formation.

LIMITATIONS

The study's heterogeneity in dog breeds, ages and pre-existing health conditions could affect the generalisability of the findings.

CONCLUSION

Epidural methylprednisolone acetate applied locally at the time of surgery may accelerate recovery in dogs following IVDD surgery.

Clinical Relevance of Epidural Steroid Injections on Lumbosacral Radicular Syndrome-related Synptoms: Systematic Review and Meta-Analysis

OBJECTIVES

Epidural steroid injections (ESIs) can be used to reduce lumbosacral radicular syndrome (LRS) related pain. The clinical relevance of ESIs are currently unknown. This systematic review and meta-analyses aims to assess whether ESIs are clinically relevant for patients with LRS.

MATERIALS AND METHODS

Comprehensive literature searches for randomized controlled trials regarding steroid injections for LRS were conducted in PudMed, EMBASE, CINAHL, and CENTRAL from their inception to September 2018 (December 2019 for PubMed). For each homogenous comparison, the outcomes function, pain intensity and health-related quality of life at different follow-up intervals were pooled separately. The GRADE approach was used to determine the overall certainty of the evidence.

RESULTS

Seventeen studies were included. Two different homogenous comparisons were identified for which the randomized controlled trials could be pooled. In 36 of the 40 analyses no clinically relevant effect was found. The certainty of evidence varied between very low to high. Four analyses found a clinically relevant effect, all on pain intensity and health-related quality of life, but the certainty of the evidence was either low or very low. Two of the 33 subgroup analyses showed a clinically relevant effect. However, according to the GRADE approach the certainty of these findings are low to very low.

DISCUSSION

On the basis of the analyses we conclude there is insufficient evidence that ESIs for patients with LRS are clinically relevant at any follow-up moment. High-quality studies utilizing a predefined clinical success are necessary to identify potential clinically relevant effects of ESIs. Until the results of these studies are available, there is reason to consider whether the current daily practice of ESIs for patients with LRS should continue.

Patient-Reported Physician Treatment Recommendations and Compliance Among U.S. Adults with Low Back Pain

Objectives: Numerous recently published clinical care guidelines, including the 2017 American College of Physicians (ACP) Guideline for Low Back Pain (LBP), call for nonpharmacological approaches to pain management. However, little data exist regarding the extent to which these guidelines have been adopted by patients and medical doctors. The study objective was to determine patient-reported treatment recommendations by medical doctors for LBP and patient compliance with those recommendations. Design: This study used a cross-sectional web and mail survey. Settings/Location: The study was conducted among Gallup Panel members across the United States. Subjects: Survey participants included 5377 U.S. adults randomly selected among Gallup Panel members. Of those, 545 reported a visit to a medical doctor within the past year for low back pain and were asked a series of follow-up questions regarding treatment recommendations. Interventions: Participants were asked about medical doctor recommendations for both drug (acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs], opioids, benzodiazepines, Gabapentin, Neurontin, and cortisone injections) and nondrug (self-care treatments, massage, acupuncture, spinal manipulation, and physical therapy) treatments. Outcome Measures: Participants were asked to indicate if their medical doctor recommended each drug and nondrug therapy for their LBP and if they had followed each of those treatment recommendations. Results: Ninety-six percent of patients who visited a medical doctor for LBP received a recommendation for one or more pain treatments, with 81% reporting that their medical doctor recommended both drug and nondrug therapies. Seventy-six percent of respondents were recommended acetaminophen or NSAIDs, 79% were recommended self-care treatments, 37% were recommended massage, acupuncture, or spinal manipulation, and 60% were recommended physical therapy. Nearly two-thirds of our sample reported that their doctor had recommended prescription medications, including opioids, benzodiazepines, Gabapentin, Neurontin, or cortisone injections. Reported adherence to treatment recommendations ranged from 68% for acupuncture to 94% for NSAIDs. Conclusions: One year after publication of the ACP's Guideline on LBP, patients report that medical doctors recommended both pharmacological and nonpharmacological treatment approaches to patients with LBP. In the majority of cases, a combination of prescription medications and self-care were recommended, illustrating the need for additional research on the effectiveness of multi-modal treatment strategies. Patients reported that they were largely compliant with medical doctor recommendations, underscoring the influence that medical doctors have in directing patient care for LBP. These findings indicate that further work is also needed to explore the impact of personal experience, training, clinical evidence, sociocultural factors, and health plans on medical doctors therapeutic recommendations in the context of back pain.

Transforaminal epidural steroid injection combined with radio frequency for the treatment of lumbar disc herniation: a 2-year follow-up

Background

To assess the therapeutic efficacy of transforaminal epidural steroid injection (TFESI) combined with radio frequency (RF) for the treatment of lumbar disc herniation (LDH).

Methods

A total of 230 patients participated in the study: TFESI (Group T, n = 110), TFESI combined with RF (Group TR, n = 120). Visual analogue scale (VAS), Oswestry disability index (ODI) and Global perceived effect (GPE) scale were measured pre-operation, 1, 3, 6, 12 and 24 months after the operation. Hospitalization time, treatment time, complications, and recurrence were compared between the two groups.

Results

The VAS and ODI at each observation point of the post-operation were significantly decreased compared with the pre-operation in both groups (P < 0.05). There was no statistically difference of VAS and ODI between the two groups at 1 and 3 months of the post-operation (P > 0.05). However, The VAS and ODI scores in Group TR were significantly lower than that in Group T at 6, 12 and 24 months of the post-operation (P < 0.05). The GPE in group TR was high in the early days, while that at 1 and 3 months after treatment was significantly higher than that in group T (P < 0.05). The recurrence rate in Group TR was lower than that in Group T (P = 0.002). There was no significant difference in hospitalization time, complications, VAS and ODI score at the pre-operation between the two groups (P > 0.05).

Conclusion

These findings suggest that TFESI combined with RF could effectively improve the pain and function, and had a long-term satisfactory effect for the treatment of LDH.

Infection Risk of Lumbar Epidural Injection in the Operating Theatre Prior to Lumbar Fusion Surgery

Purpose

To determine the association between preoperative lumbar epidural injections (LEIs) in the operating theater (OR) and the occurrence of surgical site infection (SSI) after posterior lumbar instrumented fusion surgery.

Methods

This study was performed from January 2015 to September 2019. We enrolled 2312 patients who underwent lumbar surgery without LEIs (control group) and 469 patients who underwent lumbar surgery after LEIs in the OR. We further separated the patients by the time interval between the LEIs and surgery: 1) for the 0–1 M group, lumbar surgery was performed within 1 month after the LEIs, and 2) for the >1 M group, it was performed more than 1 month after the LEIs.

Results

The postoperative infection rate in the 0–1 M group was considerably higher than that in the control group (p = 0.0101). We further subdivided the 0–1 M and >1 M groups into four subgroups: a) the 0–1 MNS group included patients in the 0–1 M group who did not receive steroids; b) the 0–1 MS group who received steroids; c) the >1 MNS group included patients in the >1 M group who did not receive steroids; d) the >1 MS group who received steroids. The postoperative infection rate in the 0–1 MS subgroup was considerably higher than that in the control group (p = 0.0018). However, the infection rate was lower in the >1 MS subgroup (p = 0.1650). There were no statistically significant differences in the postoperative infection rate between the control group and the two non-steroid groups (0–1 MNS group, p = 0.4961; 1 MNS group, p = 0.7381).

Conclusion

The administration of LEIs without steroids in the OR before lumbar instrumented fusion does not significantly increase patients’ risk of postoperative infection. We recommend avoiding steroid injections administered within 1 month before lumbar instrumented fusion.

Epidural corticosteroid injections for lumbosacral radicular pain

BACKGROUND

Lumbosacral radicular pain (commonly called sciatica) is a syndrome involving patients who report radiating leg pain. Epidural corticosteroid injections deliver a corticosteroid dose into the epidural space, with the aim of reducing the local inflammatory process and, consequently, relieving the symptoms of lumbosacral radicular pain. This Cochrane Review is an update of a review published in Annals of Internal Medicine in 2012. Some placebo-controlled trials have been published recently, which highlights the importance of updating the previous review.

OBJECTIVES

To investigate the efficacy and safety of epidural corticosteroid injections compared with placebo injection on pain and disability in patients with lumbosacral radicular pain.

SEARCH METHODS

We searched the following databases without language limitations up to 25 September 2019: Cochrane Back and Neck group trial register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and two trial registers. We also performed citation tracking of included studies and relevant systematic reviews in the field.

SELECTION CRITERIA

We included studies that compared epidural corticosteroid injections of any corticosteroid drug to placebo injections in patients with lumbosacral radicular pain. We accepted all three anatomical approaches (caudal, interlaminar, and transforaminal) to delivering corticosteroids into the epidural space. We considered trials that included a placebo treatment as delivery of an inert substance (i.e. one with no pharmacologic activity), an innocuous substance (e.g. normal saline solution), or a pharmacologically active substance but not one considered to provide sustained benefit (e.g. local anaesthetic), either into the epidural space (i.e. to mimic epidural corticosteroid injection) or adjacent spinal tissue (i.e. subcutaneous, intramuscular, or interspinous tissue). We also included trials in which a local anaesthetic with a short duration of action was used as a placebo and injected together with corticosteroid in the intervention group.

DATA COLLECTION AND ANALYSIS

Two authors independently performed the screening, data extraction, and 'Risk of bias' assessments. In case of insufficient information, we contacted the authors of the original studies or estimated the data. We grouped the outcome data into four time points of assessment: immediate (≤ 2 weeks), short term (> 2 weeks but ≤ 3 months), intermediate term (> 3 months but < 12 months), and long term (≥ 12 months). We assessed the overall quality of evidence for each outcome and time point using the GRADE approach.

MAIN RESULTS

We included 25 clinical trials (from 29 publications) investigating the effects of epidural corticosteroid injections compared to placebo in patients with lumbosacral radicular pain. The included studies provided data for a total of 2470 participants with a mean age ranging from 37.3 to 52.8 years. Seventeen studies included participants with lumbosacral radicular pain with a diagnosis based on clinical assessment and 15 studies included participants with mixed duration of symptoms. The included studies were conducted mainly in North America and Europe. Fifteen studies did not report funding sources, five studies reported not receiving funding, and five reported receiving funding from a non-profit or government source. Eight trials reported data on pain intensity, 12 reported data on disability, and eight studies reported data on adverse events. The duration of the follow-up assessments ranged from 12 hours to 1 year. We considered eight trials to be of high quality because we judged them as having low risk of bias in four out of the five bias domains. We identified one ongoing trial in a trial registry. Epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing leg pain at short-term follow-up (mean difference (MD) -4.93, 95% confidence interval (CI) -8.77 to -1.09 on a 0 to 100 scale; 8 trials, n = 949; moderate-quality evidence (downgraded for risk of bias)). For disability, epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing disability at short-term follow-up (MD -4.18, 95% CI -6.04 to -2.17, on a 0 to 100 scale; 12 trials, n = 1367; moderate-quality evidence (downgraded for risk of bias)). The treatment effects are small, however, and may not be considered clinically important by patients and clinicians (i.e. MD lower than 10%). Most trials provided insufficient information on how or when adverse events were assessed (immediate or short-term follow-up) and only reported adverse drug reactions - that is, adverse events that the trialists attributed to the study treatment. We are very uncertain that epidural corticosteroid injections make no difference compared to placebo injection in the frequency of minor adverse events (risk ratio (RR) 1.14, 95% CI 0.91 to 1.42; 8 trials, n = 877; very low quality evidence (downgraded for risk of bias, inconsistency and imprecision)). Minor adverse events included increased pain during or after the injection, non-specific headache, post-dural puncture headache, irregular periods, accidental dural puncture, thoracic pain, non-local rash, sinusitis, vasovagal response, hypotension, nausea, and tinnitus. One study reported a major drug reaction for one patient on anticoagulant therapy who had a retroperitoneal haematoma as a complication of the corticosteroid injection.

AUTHORS' CONCLUSIONS

This study found that epidural corticosteroid injections probably slightly reduced leg pain and disability at short-term follow-up in people with lumbosacral radicular pain. In addition, no minor or major adverse events were reported at short-term follow-up after epidural corticosteroid injections or placebo injection. Although the current review identified additional clinical trials, the available evidence still provides only limited support for the use of epidural corticosteroid injections in people with lumbosacral radicular pain as the treatment effects are small, mainly evident at short-term follow-up and may not be considered clinically important by patients and clinicians (i.e. mean difference lower than 10%). According to GRADE, the quality of the evidence ranged from very low to moderate, suggesting that further studies are likely to play an important role in clarifying the efficacy and tolerability of this treatment. We recommend that further trials should attend to methodological features such as appropriate allocation concealment and blinding of care providers to minimise the potential for biased estimates of treatment and harmful effects.

Nonsurgical treatments for patients with radicular pain from lumbosacral disc herniation

BACKGROUND CONTEXT

Lumbosacral disc herniation (LDH) is one of the most frequent musculoskeletal diseases causative of sick leave in the workplace and morbidity in daily activities. Nonsurgical managements are considered as first line treatment before surgical treatment.

PURPOSE

This clinical practice guideline (CPG) is intended to provide physicians who treat patients diagnosed with LDH with a guideline supported by scientific evidence to assist in decision-making for appropriate and reasonable treatments.

STUDY DESIGN/SETTING

A systematic review.

PATIENT SAMPLE

Studies of human subjects written in Korean or English that met the following criteria were selected: patients aged ≥18 years, clinical presentation of low back and radicular leg pain, diagnosis of LDH on radiological evaluation including computed tomography or magnetic resonance imaging.

OUTCOMES MEASURES

Pain and functional evaluation scales such as visual analogue scale, numeric rating scale, and Oswestry disability index METHODS: The MEDLINE (PubMed), EMBASE, Cochrane Review, and KoreaMed databases were searched for articles regarding non-surgical treatments for LDH published up to July 2017. Of the studies fulfilling these criteria, those investigating clinical results after non-surgical treatment including physical and behavioral therapy, medication, and interventional treatment in terms of pain control and functional improvements were chosen for this study.

RESULTS

Nonsurgical treatments were determined to be clinically effective with regards to pain reduction and functional improvement in patients with LDH. Nevertheless, the evidence level was generally not evaluated as high degree, which might be attributed to the paucity of well-designed randomized controlled trials. Exercise and traction were strongly recommended despite moderate level of evidence. Epidural injection was strongly recommended with high degree of evidence and transforaminal approach was more strongly recommended than caudal approach.

CONCLUSIONS

This CPG provides new and updated evidence-based recommendations for treatment of the patients with LDH, which suggested that, despite an absence of high degrees of evidence level, non-surgical treatments were clinically effective.

T2 mapping of lumbosacral nerves in patients suffering from unilateral radicular pain due to degenerative disc disease

OBJECTIVE

Lumbosacral radicular syndrome (LRS) is a very common condition, often requiring diagnostic imaging with the aim of elucidating a structural cause when symptoms are longer lasting. However, findings on conventional anatomical MRI do not necessarily correlate with clinical symptoms, and it is primarily performed for the qualitative evaluation of surrounding compressive structures, such as herniated discs, instead of to evaluate the nerves directly. The present study investigated the performance of quantitative imaging by using magnetic resonance neurography (MRN) in patients with LRS.

METHODS

Eighteen patients (55.6% males, mean age 64.4 ± 10.2 years), with strict unilateral LRS matching at least one dermatome and suspected disc herniation, underwent high-resolution 3-T MRN using T2 mapping. On T2 maps, the presumably affected and contralateral unaffected nerves were identified; subsequent regions of interest (ROIs) were placed at preganglionic, ganglionic, and postganglionic sites; and T2 values were extracted. Patients then underwent an epidural steroid injection (ESI) with local anesthetic agents at the site of suspected nerve affection. T2 values of the affected nerves were compared against the contralateral nerves. Furthermore, receiver operating characteristics were calculated based on the measured T2 values and the responsiveness to ESI.

RESULTS

The mean T2 value was 77.3 ± 1.9 msec for affected nerves and 74.8 ± 1.4 msec for contralateral nerves (p < 0.0001). In relation to ESI performed at the site of suspected nerve affection, MRN with T2 mapping had a sensitivity/specificity of 76.9%/60.0% and a positive/negative predictive value of 83.3%/50.0%. Signal alterations in affected nerves according to qualitative visual inspection were present in only 22.2% of patients.

CONCLUSIONS

As one of the first of its kind, this study revealed elevated T2 values in patients suffering from LRS. T2 values of lumbosacral nerves might be used as more objective parameters to directly detect nerve affection in such patients.

Factors Predicting Favorable Short-Term Response to Transforaminal Epidural Steroid Injections for Lumbosacral Radiculopathy

Background and Objectives: The purpose of this retrospective study was to identify predictors of short-term outcomes associated with a lumbosacral transforaminal epidural steroid injection (TFESI). Materials and Methods: The medical records of 218 patients, who were diagnosed with lumbosacral radiculopathy and treated with a TFESI, were reviewed in this retrospective study. A mixture of corticosteroid, lidocaine, and hyaluronidase was injected during TFESI. Patients with >50% pain relief on the numerical rating scale compared with the initial visit constituted the good responder group. Demographic, clinical, MRI, and electrodiagnostic data were collected to assess the predictive factors for short-term outcomes of the TFESI. Results: A multivariate logistic regression analysis demonstrated that a shorter duration of symptoms and a positive sharp wave (PSW)/fibrillation (Fib) observed in electrodiagnostic study (EDx) increased the odds of significant improvement 2–4 weeks after the TFESI. Conclusions: Shorter duration of symptoms and PSW/Fib on EDx were predictors of favorable short-term response to TFESI.

Outcome measurement in patients with low back pain undergoing epidural steroid injection

Objectives

This study aims to evaluate the outcomes of epidural steroid injection (ESI) in patients with low back pain.

Patients and methods

This prospective study included a total of 82 patients (51 females; 31 males; mean age 50.8±14.2 years; range, 17 to 86 years) who underwent ESI due to lumbar disc hernia-induced radiculopathy between September 2014 and May 2015. The Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), Istanbul Low Back Pain Disability Index (ILBPDI), and the Short Form-36 (SF-36) were administered to all patients before and three weeks and three months after ESI.

Results

The mean scores of all scales were significantly lower at three weeks and three months following ESI compared to the baseline scores. There were no significant differences between the mean scores at three weeks and three months. The NRS yielded the highest post-ESI change from baseline.

Conclusion

Our study results showed that all scales used in this study were effective tools for the evaluation of outcomes of EPI in patients with low back pain. Although the NRS yielded the highest sensitivity for detecting change, evaluating functional state and quality of life is essential for multivariate analyses.

Lumbar epidural steroid injections for herniation and stenosis: incidence and risk factors of subsequent surgery

BACKGROUND CONTEXT

Lumbosacral epidural steroid injections (ESIs) have increased dramatically despite a narrowing of the clinical indications for use. One potential indication is to avoid or delay surgery, yet little information exists regarding surgery rates after ESI.

PURPOSE

The purpose of this research was to determine the proportion of patients having surgery after lumbar ESI for disc herniation or stenosis and to identify the timing and factors associated with this progression.

STUDY DESIGN/SETTING

This study was a retrospective review of nationally representative administrative claims data from the Truven Health MarketScan databases from 2007 to 2014.

PATIENT SAMPLE

The study cohort was comprised of 179,025 patients (54±15 years, 48% women) having lumbar ESIs for diagnoses of stenosis and/or herniation.

OUTCOME MEASURES

The primary outcome measure was the time from ESI to surgery.

METHODS

Inclusion criteria were ESI for stenosis and/or herniation, age ≥18 years, and health plan enrollment for 1 year before ESI to screen for exclusions. Patients were followed longitudinally until they progressed to surgery or had a lapse in enrollment, at which time they were censored. Rates of surgery were assessed with the Kaplan-Meier survival curves. Demographic and treatment factors associated with surgery were assessed with multivariable Cox proportional hazard models. No external funding was procured for this research and the authors' conflicts of interest are not pertinent to the present work.

RESULTS

Within 6 months, 12.5% of ESI patients underwent lumbar surgery. By 1 year, 16.9% had surgery, and by 5 years, 26.1% had surgery. Patients with herniation had surgery at rates of up to five-fold to seven-fold higher, with the highest rates of surgery in younger patients and those with both herniation and stenosis. Other concomitant spine diagnoses, male sex, previous tobacco use, and residence a rural areas or regions other than the Northeastern United States were associated with higher surgery rates. Medical comorbidities (previous treatment for drug use, congestive heart failure, obesity, chronic obstructive pulmonary disease, hypercholesterolemia, and other cardiac complications) were associated with lower surgery rates.

CONCLUSIONS

In the long term, more than one out of every four patients undergoing ESI for lumbar herniation or stenosis subsequently had surgery, and nearly one of six had surgery within the first year. After adjusting for other patient demographics and comorbidities, patients with herniation were more likely have surgery than those with stenosis. The improved understanding of the progression from lumbar ESI to surgery will help to better inform discussions regarding the value of ESI and aid in the shared decision-making process.

The Effect of Preoperative Symptom Duration on Postoperative Outcomes After a Tubular Lumbar Microdiscectomy

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

This study aims to characterize the effect of preoperative symptom duration on postoperative outcomes after minimally invasive lumbar microdiscectomy (MIS LD).

SUMMARY OF BACKGROUND DATA

It is unknown whether extended nonoperative treatment before MIS LD has implications for long-term clinical outcomes even after surgery is performed.

MATERIALS AND METHODS

A prospectively maintained surgical registry of patients undergoing MIS LD by a single surgeon between 2013 and 2017 was reviewed. Preoperative symptom duration was dichotomized into 2 groups (≤6 and >6 mo). Only patients with full clinical data at 6 months postoperative follow-up were included in the study. Clinical outcomes were assessed at 6, 12 weeks, and 6 months after surgery. The number of patients obtaining a minimum clinically important difference was assessed. Groups were compared with the χ analysis and the student t tests for categorical and continuous data, respectively.

RESULTS

In total, 94 patients were identified. A total of 45 patients (47.9%) had symptom duration ≤6 months. No differences in baseline characteristics were found (P>0.05). Patients with shorter symptom duration had significantly greater improvement in Oswestry Disability Index scores at 6 weeks (P=0.004), 12 weeks (P=0.022), and 6 months (P=0.005). Patients with shorter duration of symptoms also obtained minimum clinically important difference for Oswestry Disability Index at a greater rate than those with longer duration of symptoms (P=0.015).

CONCLUSIONS

Although patients who underwent MIS LD within 6 months of symptom onset had similar baseline characteristics compared with patients who underwent surgery after 6 months of symptoms, the patients with longer preoperative symptom duration had worse functional outcomes at 6 months after surgery. These results suggest that earlier MIS lumbar microdiscectomy may provide a functional benefit for patients. Further studies should therefore evaluate the efficacy of nonoperative treatment in the setting of lumbar herniated nucleus pulposus, as prolonged conservative management may potentially impair functional recovery after surgery.

Mineralocorticoid Antagonist Improves Glucocorticoid Receptor Signaling and Dexamethasone Analgesia in an Animal Model of Low Back Pain

Low back pain, a leading cause of disability, is commonly treated by epidural steroid injections that target the anti-inflammatory glucocorticoid receptor (GR). However, their efficacy has been controversial. All currently used epidural steroids also activate the pro-inflammatory mineralocorticoid receptor (MR) with significant potency. Local inflammation of the dorsal root ganglia (DRG), a rat model of low back pain, was used. This model causes static and dynamic mechanical allodynia, cold allodynia and guarding behavior (a measure of spontaneous pain), and activates the MR, with pro-nociceptive effects. In this study, effects of local Dexamethasone (DEX; a glucocorticoid used in epidural injections), and eplerenone (EPL; a second generation, more selective MR antagonist) applied to the DRG at the time of inflammation were examined. Mechanical and spontaneous pain behaviors were more effectively reduced by the combination of DEX and EPL than by either alone. The combination of steroids was particularly more effective than DEX alone or the model alone (3-fold improvement for mechanical allodynia) at later times (day 14). Immunohistochemical analysis of the GR in the DRG showed that the receptor was expressed in neurons of all size classes, and in non-neuronal cells including satellite glia. The GR immunoreactivity was downregulated by DRG inflammation (48%) starting on day 1, consistent with the reduction of GR (57%) observed by Western blot, when compared to control animals. On day 14, the combination of DEX and EPL resulted in rescue of GR immunoreactivity that was not seen with DEX alone, and was more effective in reducing a marker for satellite glia activation/neuroinflammation. The results suggest that EPL may enhance the effectiveness of clinically used epidural steroid injections, in part by enhancing the availability of the GR. Thus, the glucocorticoid-mineralocorticoid interactions may limit the effectiveness of epidural steroids through the regulation of the GR in the DRG.

Injectable Corticosteroids in Sport

OBJECTIVE

To review the literature guiding all aspects of the use of injectable corticosteroids for painful musculoskeletal conditions, with a focus on the treatment of athletes.

DATA SOURCES

An extensive search of the literature was completed including search terms of corticosteroid, steroid, athlete, and injection, among others. Additional articles were used after being identified from previously reviewed articles.

MAIN RESULTS

Injections of corticosteroids for a variety of painful conditions of the extremities and the axial spine have been described. Numerous minor and major complications have been reported, including those with a high degree of morbidity. There is a dearth of published research on the use of corticosteroid injections in athletes, with most of the research on this topic focused on older, nonathlete populations. Generally, these injections are well tolerated and can provide short-term pain improvement with little or no long-term benefits.

CONCLUSIONS

Corticosteroid injections should be used cautiously in athletes and only after a full consideration of the pharmacology, pathogenesis of disease, potential benefits, complications, factors specific to the athlete, and rules of athletic governing bodies. Corticosteroid injections are just one component of a comprehensive rehabilitation plan available to the physician providing care to athletes.

Etiology, Evaluation, and Treatment of Failed Back Surgery Syndrome

The study aimed to review the etiology of failed back surgery syndrome (FBSS) and to propose a treatment algorithm based on a systematic review of the current literature and individual experience. FBSS is a term that groups the conditions with recurring low back pain after spine surgery with or without a radicular component. Since the information on FBSS incidence is limited, data needs to be retrieved from old studies. It is generally accepted that its incidence ranges between 10% and 40% after lumbar laminectomy with or without fusion. Although the etiology of FBSS is not completely understood, it is possibly multifactorial, and the causative factors may be categorized into preoperative, operative, and postoperative factors. The evaluation of patients with FBSS symptoms should ideally initiate with reviewing the patients’ clinical history (observing “red flags”), followed by a detailed clinical examination and imaging (whole-body X-ray, magnetic resonance imaging, and computed tomography). FBSS is a complex and difficult pathology, and its accurate diagnosis is of utmost importance. Its management should be multidisciplinary, and special attention should be provided to cases of recurrent disc herniation and postoperative spinal imbalance.

Interventional Approaches to Low Back Pain

Chronic low back pain (LBP) places a tremendous economic burden on society due to both direct and indirect costs. Health care costs for adults with chronic LBP have steadily increased over the past 20 years, coinciding with a large increase in the utilization of spinal injections, surgical interventions, opioid medications, and physical therapy. The treatment of LBP is best approached by a multimodal and even multidisciplinary approach with a combination of physical rehabilitation, pharmacologic management, psychological intervention, spinal injections, and surgical intervention with a goal of improving the functional status of the patient. In this review, we discuss the interventional management of LBP secondary to herniated nucleus pulposus, spinal stenosis, facet mediated pain, sacroiliitis, and discogenic pain.

The Long-Term Course of Outcomes for Lumbar Intervertebral Disc Herniation following Integrated Complementary and Alternative Medicine Inpatient Treatment: A Prospective Observational Study

A prospective observational study was conducted in 524 lumbar intervertebral disc herniation (LDH) inpatients to report the long-term effects of complementary and alternative medicine (CAM) treatment. Participants received integrative CAM treatment during hospitalization, from June 2012 to May 2013, and long-term outcomes were assessed from July to August 2016. Numerical rating scales (NRSs) of back and leg pain, the Oswestry disability index (ODI), satisfaction, surgery, recurrence, and current care status were investigated. Baseline characteristics were analyzed to determine factors that predicted long-term satisfaction. A total of 367 patients were available for follow-up. The long-term change in NRS of back and leg pain and ODI was 3.53 (95% CI, 3.22, 3.83), 2.72 (2.34, 3.11), and 32.89 (30.21, 35.57), respectively, showing that improvements were well sustained. Regarding satisfaction, 86.11% responded that they were “slightly improved” or better. Range of lumbar flexion ≤ 60° and both legs' pain at admission were significant predictors of “much improved” or better satisfaction in the long term. Overall, LDH patients who received CAM treatment maintained favorable states in the long term. However, as an uncontrolled observational study, further studies with placebo and/or active controls are warranted. Trial Registration. This trial is registered with ClinicalTrials.gov  NCT02257723 (date of registration: October 2, 2014).

The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery

OBJECTIVE

Lumbar epidural steroid injections (LESIs) are performed for both diagnostic and therapeutic purposes for a variety of indications, including low-back pain, the leading cause of disability and expense due to work-related conditions in the US. The steroid agent used in epidural injections is reported to relieve nerve root inflammation, local ischemia, and resultant pain, but the injection may also have an adverse impact on spinal surgery performed thereafter. In particular, the possibility that preoperative epidural injections may increase the risk of surgical site infection after lumbar spinal fusion has been reported but has not been studied in detail. The goal of the present study was to use a large national insurance database to analyze the association of preoperative LESIs with surgical site infection after lumbar spinal fusion.

METHODS

A nationwide insurance database of patient records was used for this retrospective analysis. Current Procedural Terminology codes were used to query the database for patients who had undergone LESI and 1- or 2-level lumbar posterior spinal fusion procedures. The rate of postoperative infection after 1- or 2-level posterior spinal fusion was analyzed. These study patients were then divided into 3 separate cohorts: 1) lumbar spinal fusion performed within 1 month after LESI, 2) fusion performed between 1 and 3 months after LESI, and 3) fusion performed between 3 and 6 months after LESI. The study patients were compared with a control cohort of patients who underwent lumbar fusion without previous LESI.

RESULTS

The overall 3-month infection rate after lumbar spinal fusion procedure was 1.6% (1411 of 88,540 patients). The infection risk increased in patients who received LESI within 1 month (OR 2.6, p < 0.0001) or 1–3 months (OR 1.4, p = 0.0002) prior to surgery compared with controls. The infection risk was not significantly different from controls in patients who underwent lumbar fusion more than 3 months after LESI.

CONCLUSIONS

Lumbar spinal fusion performed within 3 months after LESI may be associated with an increased rate of postoperative infection. This association was not found when lumbar fusion was performed more than 3 months after LESI.

Mineralocorticoid Receptor, A Promising Target for Improving Management of Low Back Pain by Epidural Steroid Injections

AIM OF REVIEW

Low back pain is a major health problem in United States and worldwide. In this review, we aim to show that mineralocorticoid receptor (MR) activation has a critical role in the initiation of immune and inflammatory responses, which in turn can impact the effectiveness of the currently used steroids for epidural injections in low back pain management since most steroids activate MR in addition to the primary target, glucocorticoid receptor (GR). Moreover, we would like to determine some of the benefits of blocking the MR-induced negative effects. Overall, we propose a novel therapeutic approach for low back pain management by using a combination of a MR antagonist and a GR agonist in the epidural injections.

METHOD

We will first introduce the societal cost of low back pain and discuss how epidural steroid injections became a popular treatment for this condition. We will then describe several preclinical models used for the study of low back pain conditions and the findings with respect to the role of MR in the development of inflammatory low back pain.

RECENT FINDINGS

MR has pro-inflammatory effects in many tissues which can counteract the anti-inflammatory effects induced by GR activation. Blocking MR using the selective MR antagonist eplerenone can reduce pain and sensory neuron excitability in experimental models of low back pain. Moreover, combining the MR antagonist with clinically used steroids is more effective in reducing pain behaviors than using the steroids alone.

SUMMARY

MR antagonists are promising candidates to increase the effectiveness of currently used steroids. Since the activation of the MR is evident in preclinical models of low back pain, blocking its deleterious effects can be beneficial in managing inflammatory pain conditions.

Preoperative epidural injections are associated with increased risk of infection after single-level lumbar decompression

BACKGROUND CONTEXT

Lumbar epidural steroid injections (LESIs) are often performed as a treatment option for lumbar stenosis and radiculopathy before lumbar decompression surgery. Several case series have reported spinal infections after LESIs. There is lack of literature on the rate of postoperative infections after lumbar decompression in patients who had prior LESIs.

PURPOSE

The goal of the present study is to employ a large national database to determine if there is an association between preoperative LESIs at various time intervals before lumbar decompression and the incidence of postoperative infection.

STUDY DESIGN/SETTING

Retrospective case control database study, Level III was used in this study.

PATIENT SAMPLE

This study comprised Medicare patients over age 65 years who had a LESI within 1 year of single-level lumbar decompression surgery.

OUTCOME MEASURES

International Classification of Diseases, 9th Revision diagnosis codes for postoperative infection and Current Procedural Terminology procedure codes for treatment of postoperative infection were the outcome measures for this study.

METHODS

The PearlDiver Patient Records Database, an insurance-based database of patient records, was used for this study. The database was queried for LESI and single-level lumbar decompression procedures using Current Procedural Terminology codes. These study patients were then divided into four separate cohorts: (1) lumbar decompression within 1 month following LESI, (2) lumbar decompression between 1 and 3 months following LESI, (3) lumbar decompression between 3 and 6 months following LESI, and (4) lumbar decompression between 6 and 12 months following LESI. Unique control groups for each study cohort were created with patients who underwent single-level lumbar decompression without previous LESI and matched for major risk factors for infection, including age, gender, smoking status, diabetes, and obesity.

RESULTS

Overall, the rate of postoperative infection after single-level lumbar decompression after LESI remained relatively low, ranging between 0.8% and 1.7%. The incidence of 90-day postoperative infection after lumbar decompression was significantly higher than matched controls in groups with LESI within 1 month (OR=3.2, p<.0001) and 1-3 months before surgery (OR=1.8, p<.0001). The incidence of 90-day postoperative infection was not significantly different from matched controls in groups with LESI between 3-6 months (OR=1.3, p=.15) and 6-12 months before decompression surgery (OR=1.3, p=.18) CONCLUSIONS: Single-level lumbar decompression within 3 months after LESI may be associated with an increased rate of postoperative infection. Increasing the time interval between LESI and single-level lumbar decompression surgery to at least 3 months may decrease postoperative infection rates.

Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis

BACKGROUND

Use of epidural corticosteroid injections is increasing.

PURPOSE

To review evidence on the benefits and harms of epidural corticosteroid injections in adults with radicular low back pain or spinal stenosis of any duration.

DATA SOURCES

Ovid MEDLINE (through May 2015), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, prior systematic reviews, and reference lists.

STUDY SELECTION

Randomized trials of epidural corticosteroid injections versus placebo interventions, or that compared epidural injection techniques, corticosteroids, or doses.

DATA EXTRACTION

Dual extraction and quality assessment of individual studies, which were used to determine the overall strength of evidence (SOE).

DATA SYNTHESIS

30 placebo-controlled trials evaluated epidural corticosteroid injections for radiculopathy, and 8 trials were done for spinal stenosis. For radiculopathy, epidural corticosteroids were associated with greater immediate-term reduction in pain (weighted mean difference on a scale of 0 to 100, -7.55 [95% CI, -11.4 to -3.74]; SOE, moderate), function (standardized mean difference after exclusion of an outlier trial, -0.33 [CI, -0.56 to -0.09]; SOE, low), and short-term surgery risk (relative risk, 0.62 [CI, 0.41 to 0.92]; SOE, low). Effects were below predefined minimum clinically important difference thresholds, and there were no longer-term benefits. Limited evidence showed no clear effects of technical factors, patient characteristics, or comparator interventions on estimates. There were no clear effects of epidural corticosteroid injections for spinal stenosis (SOE, low to moderate). Serious harms were rare, but harms reporting was suboptimal (SOE, low).

LIMITATIONS

The review was restricted to English-language studies. Some meta-analyses were based on small numbers of trials (particularly for spinal stenosis), and most trials had methodological shortcomings.

CONCLUSION

Epidural corticosteroid injections for radiculopathy were associated with immediate reductions in pain and function. However, benefits were small and not sustained, and there was no effect on long-term surgery risk. Limited evidence suggested no effectiveness for spinal stenosis.

Treatment of failed back surgery syndrome in a forty-three-year-old man with high-dose oxycodone/naloxone

Introduction:

Failed back surgery syndrome (FBSS) is an increasing cause of chronic pain in most countries. This poses high costs to both patients and National Health Organizations.

Case Presentation:

In this report, multimodal pain management based on daily high-dose oxycodone/naloxone (OXN 180/90 mg) led to reduced patient's pain score and improved quality of life.

Conclusions:

Oxycodone/naloxone can be a good alternative for the management of FBSS when other interventional or pharmacologic strategies have failed. In this case report, higher doses than those recommended as a maximum daily ceiling (80/40 mg) were safely used in one selected patient with noncancer severe pain.