Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review

The postoperative clinical effects of utilizing 3D printed (Ti6Al4V) interbody fusion cages in posterior lumbar fusion: A retrospective cohort study

BACKGROUND

The research focused on the postoperative effect of using interbody fusion cage in lumbar posterior lamina decompression and interbody fusion with pedicle screw by comparing the postoperative effect of using 3D printing (Ti6Al4V) and PEEK material interbody fusion cage.

METHODS

Ninety-one patients with lumbar degenerative diseases from the Department of Spine Surgery of Tianjin Hospital were included in the study cohort. They were divided into 3D group (n = 39) and PEEK group (n = 52) according to the use of interbody fusion cage. The imaging data of the patients were collected and the postoperative data of the 2 groups were compared to evaluate patients' health status and the recovery of lumbar structure and function after operation.

RESULTS

Combined with the degree of fusion, the clinical effect of 3D printing titanium alloy interbody fusion cage was comprehensively judged. At the last follow-up, the JOA score, ODI index, VAS, prolo function score, and SF-36 scale of the 2 groups showed that the clinical symptoms were better than those before operation (P < .05). The height of intervertebral disc, the area of intervertebral foramen and the physiological curvature of lumbar vertebrae increased in varying degrees after operation (P < .05). At the last follow-up, the vertebral cage fusion rates were as high as 89.13% and 90.91% in the 3D and PEEK groups, with collapse rates of 6.5% and 4.5%, respectively. There were 10 cases of cage displacement in 3D group and 7 cases of cage displacement in PEEK group. There was no significant difference between the 2 groups (P > .05).

CONCLUSIONS

In conclusion, 3D printed (Ti6Al4V) interbody fusion cage can obtain good clinical effect in the surgical treatment of lumbar degenerative diseases. Posterior lumbar lamina decompression, bilateral pedicle screw fixation combined with 3D printed cage interbody fusion is excellent in rebuilding the stability of lumbar vertebrae. 3D printed interbody fusion cage can be an ideal substitute material for intervertebral bone grafting. The stable fusion time of interbody fusion cage after lumbar fusion is mostly from 3 months to half a year after operation.

A randomized, placebo-controlled trial of long-acting dexamethasone viscous gel delivered by transforaminal injection for lumbosacral radicular pain

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03372161.

1. Lumbosacral radicular pain

INTRODUCTION

Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%.

METHODS

The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized.

RESULTS

Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers.

CONCLUSIONS

The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.

Pro-Con Debate: Superior Versus Inferior Triangle Needle Placement in Transforaminal Epidural Injections

Although transforaminal epidural injections have long been used for radicular pain, there is no universal standard injection approach to the neural foramen. The intervertebral foramen and its surrounding structures comprise an anatomically sensitive area that includes bone and joint structures, the intervertebral disk, blood vessels (in particular, the radicular arteries), the epidural sheath, and the spinal nerve root. Given the relatively high risk of inadvertent injury or injection to these nearby structures, image guidance for transforaminal epidural steroid injections (TFESIs) is standard of care. However, there is a lack of consensus regarding the optimal approach to the neural foramen: from the traditional superior ("safe") triangle or from the inferior (Kambin's) triangle. In this Pro-Con commentary article, we discuss the relative advantages and disadvantages of each approach for TFESIs.

Does a Positive Response to Transforaminal Epidural Steroid Injection Identify Patients Who Can Avoid Surgery for Two Years?

Background

Transforaminal epidural steroid injection (TFESI) is widely used to manage lumbar radiculopathy. In clinical settings, patients often undergo repeated transforaminal epidural injections with or without steroid administration.

Objectives

To examine whether a positive response to TFESI at the first month, can in clinical settings, identify patients with radiculopathy who can avoid surgery for two years. Study Design/Setting. This prospective observational study was conducted at an academic medical center.

Methods

Individuals aged ≥20 years who had been referred to our pain center by spine surgeons were enrolled. All patients were assessed using the Numerical Rating Scale (NRS) at baseline and 1 month after the first TFESI. Patients were divided into two groups according to the NRS decrement: the positive response (PR) group achieved a ≥2.0 decrease on the NRS 1 month after the first TFESI compared to baseline and the no response (NR) group achieved a <2.0 decrease on the NRS. The incidence rates of surgery over two years were compared between the two groups. In addition, we calculated the hazard ratio of the PR group to the NR group regarding the incidence of surgery over two years using the Cox proportional hazard model, adjusting for baseline NRS.

Results

Seventy-six patients completed the two-year follow-up. In total, 8 and 68 patients had bilateral and unilateral radiculopathy, respectively. The PR and NR groups included 35 and 41 patients, respectively. The rate of surgery avoidance was 85.7% and 73.2% in the PR and NR groups, respectively. This difference was not statistically significant (p=0.26). After adjusting for baseline NRS, the hazard ratio of the PR group to the NR group regarding the incidence of surgery within two years was 0.35 (95% confidence interval: 0.11-1.11, p=0.08).

Conclusion

A positive response to TFESI may not identify patients who can avoid surgery for two years.

A comparison between effectiveness of gluteal trigger point and epidural steroid injection in lumbosacral canal stenosis patients: a randomized clinical trial

BACKGROUND

Lumbosacral Spinal Stenosis (LSS) is a degenerative spine disease and a major cause of pain and disability, especially in geriatrics. Primary symptom control in patients with LSS includes conservative treatment and non-surgical methods. In this study, we aimed to compare the effect of steroid injection via epidural and gluteal trigger point techniques.

METHODS

Patients aged 40-75 years old who had pain and other clinical signs of spinal stenosis in the last 6 months were included in our study and divided into two groups of gluteal trigger point (TP) or epidural steroid injection (ESI). The patients were evaluated based on the visual analog scale (VAS), Roland-Morris Disability Questionnaire (RDQ), Oswestry Disability Index (ODI), and the Quebec back pain disability scales during their pre-injection period and 2 weeks after follow-ups till 8 weeks. A P value of less than 0.05 was considered significant.

RESULTS

A total of 44 patients were included in our study. The TP group had a significant decrease in comparison with their follow-ups; however, in the epidural group, the significant decrease was only observed compared to the pre-injection period and the scores did not have any significant decreases after the second week regarding the ODI, RQM, and VAS scales. The TP group demonstrated significantly higher scores of decreases of ODI and Quebec score compared to the epidural group at weeks 4 and 8. Regarding RQM, the TP groups demonstrated significantly higher scores of decreases compared to the epidural group at weeks 2, 4 and 8. (p < 0.001 p = 0.008, and p < 0.001, respectively).

CONCLUSION

Both epidural and TP steroid injection significantly reduced the patients' pain and improved their QoL and function; however, more satisfactory results were observed in the TP group during the patients' follow-ups, while the epidural group demonstrated only statistically significant improvement during the short-term follow-up.

Changes in pain scores and walking distance after transforaminal epidural steroid injection in patients with lumbar foraminal spinal stenosis

Transforaminal epidural steroid injections (TFESI) are widely used in patients with lumbar foraminal spinal stenosis. Previous studies have evaluated the effects of TFESI on lumbar foraminal spinal stenosis using only pain scores. However, no study has evaluated the effect of TFESI on pain scores and walking distance in patients with lumbar foraminal spinal stenosis. This study aimed to assess the effect of TFESI on pain scores and walking distance in patients with lumbar foraminal spinal stenosis stratified according to disease severity. This retrospective study reviewed the medical records of patients who received TFESI for lumbar foraminal spinal stenosis. A total of 128 patients were divided into the moderate and severe groups based on the extent of fat obliteration and the presence of nerve root compression. A significant decrease in the numeric rating scale (NRS) scores was observed in the moderate and severe groups compared with the corresponding baseline values 4 weeks after TFESI; however, the NRS pain scores were lower in the moderate group than those in the severe group. In addition, the proportion of patients who experienced pain reduction (≥50%) was higher in the moderate group than that in the severe group. The moderate and severe groups showed a significant increase in walking distance compared with the baseline values 4 weeks after the treatment. However, the walking distance values did not differ significantly between the moderate and severe groups. Furthermore, the degree of satisfaction was higher in the moderate group than that in the severe group. Lumbar TFESI may reduce pain scores and increase walking distance in patients with moderate or severe lumbar foraminal spinal stenosis. Patients with moderate foraminal stenosis had better pain relief outcomes than those with severe foraminal stenosis.

Measurement of S1 foramen depth for ultrasound-guided S1 transforaminal epidural injection

Background

Ultrasound-guided first sacral transforaminal epidural steroid injection (S1 TFESI) is a useful and easily applicable alternative to fluoroscopy or computed tomography (CT) in lumbosacral radiculopathy. When a needle approach is used, poor visualization of the needle tip reduces the accuracy of the procedure, increasing its difficulty. This study aimed to improve ultrasound-guided S1 TFESI by evaluating radiological S1 posterior foramen data obtained using three-dimensional CT (3D-CT).

Methods

Axial 3D-CT images of the pelvis were retrospectively analyzed. The radiological measurements obtained from the images included 1st posterior sacral foramen depth (S1D, mm), 1st posterior sacral foramen width (S1W, mm), the angle of the 1st posterior sacral foramen (S1A, °), and 1st posterior sacral foramen distance (S1ds, mm). The relationship between the demographic factors and measured values were then analyzed.

Results

A total of 632 patients (287 male and 345 female) were examined. The mean S1D values for males and females were 11.9 ± 1.9 mm and 10.6 ± 1.8 mm, respectively (P < 0.001); the mean S1A 28.2 ± 4.8° and 30.1 ± 4.9°, respectively (P < 0.001); and the mean S1ds, 24.1 ± 2.9 mm and 22.9 ± 2.6 mm, respectively (P < 0.001); however, the mean S1W values were not significantly different. Height was the only significant predictor of S1D (β = 0.318, P = 0.004).

Conclusions

Ultrasound-guided S1 TFESI performance and safety may be improved with adjustment of needle insertion depth congruent with the patient's height.

Selective Nerve Root Block in Treatment of Lumbar Radiculopathy: A Narrative Review

Selective Nerve Root Block (SNRB) is a precise local injection technique that can be utilised to target a particular inflamed nerve root causing lumbar radiculopathy for both diagnostic and therapeutic purposes. Usually, for SNRB to be therapeutic, a combination of a local anaesthetic agent and a steroid is injected under imaging guidance, whereas for diagnostic purposes, just the local anaesthetic agent is injected. While the ideal treatment strategy is to relieve the nerve root from its compressing pathology, local injection of steroids targeted at the affected nerve root can also be attempted to reduce inflammation and thus achieve pain relief. Although the general principle for administering an SNRB remains largely the same across the field, there are differences in techniques depending on the region and level of the spine that is targeted. Moreover, drug combinations utilised by clinicians vary based on preference. The proven benefits of SNRBs largely outweigh their risks, and the procedure is deemed safe and well tolerated in a majority of patients. In this narrative, we explore the existing literature and seek to provide a comprehensive understanding of SNRB as a treatment for lumbar radiculopathy, its indications, techniques, outcomes, and complications.

[Therapeutic injections and manual medicine in low-back pain : Bimodal synergies between evidence and empiricism]

Hintergrund

Angelehnt an die zielorientierte Therapieplanung und -führung in der Versorgung chronisch Rheumakranker, plädiert der Autor bei Patienten mit (chronischem) degenerativem tiefem Rückenschmerz (TRS), orientiert an den differenzialtherapeutischen Grundsätzen der Manuellen Medizin (MM), und unter Kenntnis von Techniken und Evidenzen therapeutischer Lokalinfiltrationen (TLI), für die Etablierung eines strukturierten mechanismenbasierten Therapiekonzeptes im Sinne des „treat to target“ (T2T) im ambulanten schmerztherapeutischen Versorgungsbereich.

Diagnostik

Dies setzt eine konsequente (Primär‑)Diagnostik mit Schmerzanalyse unter der Prämisse, dass TRS, wenn strukturell-funktionell bedingt, immer spezifisch ist, voraus. Eine breite biopsychosoziale Anamnese und strukturbezogene klinisch-bildgebende (Ausschluss‑)Diagnostik mit funktioneller Differenzierung nach MM-Grundsätzen und ggf. interventionelle Blocks, sollten am Ende zur Formulierung einer 3‑Ebenen-Diagnose als Voraussetzung zu einer mechanismenbasiert-zielorientiert-hierarchischen Stufentherapie bei TRS führen. Diese wird in diesem Artikel pragmatisch fallorientiert, unter Implementierung von Techniken und Evidenzen der TLI und MM, vorgestellt.

Team Approach: Management of an Acute L4-L5 Disc Herniation

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Lumbar disc herniation is one of the most common spinal pathologies, often occurring at the L4-L5 and L5-S1 levels. The highest incidence has been reported in patients between the fourth and sixth decades of life.

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The severity of symptoms is influenced by the patient's risk factors, the location, and the extent and type of disc herniation.

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Lumbar disc herniation can be effectively treated with multiple treatment protocols. In most cases, first-line treatment includes oral analgesic medication, activity modification, and physical therapy. When nonoperative treatments do not provide adequate relief, patients may elect to undergo a fluoroscopically guided contrast-enhanced epidural steroid injection. A subgroup of patients whose condition is refractory to any type of nonoperative modalities will proceed to surgery, most commonly an open or minimally invasive discectomy.

»

The treatment algorithm for symptomatic lumbar disc herniation often is a stepwise approach: failure of initial nonoperative measures leads to more aggressive treatment when symptoms mandate and, as such, necessitates the use of a multidisciplinary team approach. The core team should consist of an interventional physiatrist, an orthopaedic surgeon, a physician assistant, and a physical therapist. Additional team members may include nurses, radiologists, neurologists, anesthesiologists, spine fellows, psychologists, and case managers.

»

This review article describes a case scenario that uses a multidisciplinary team approach for the treatment of an acute L4-L5 disc herniation in a 31-year-old patient without any major comorbidities.

Safety of Epidural Steroid Injections for Lumbosacral Radicular Pain: Unmet Medical Need

OBJECTIVE

Epidural steroid injections (ESIs) are a commonly utilized treatment for lumbosacral radicular pain caused by intervertebral disc herniation or stenosis. Although effective in certain patient populations, ESIs have been associated with serious complications, including paralysis and death. In 2014, the US Food and Drug Administration (FDA) issued a safety warning on the risk of injecting corticosteroids into the epidural space. The aims of this article were to review the neurological complications associated with ESIs and to compare the formulations, safety, and effectiveness of commercially available corticosteroids given by transforaminal, interlaminar, or caudal injection.

METHODS

Serious adverse events associated with ESIs were identified by a search of the FDA Adverse Event Reporting System (FAERS) database. A MEDLINE search of the literature was conducted to identify clinical trials comparing the safety and effectiveness of nonparticulate and particulate corticosteroid formulations.

RESULTS

Neurological complications with ESIs were rare and more often associated with the use of particulate corticosteroids administered by transforaminal injection. Among the 10 comparative-effectiveness studies reviewed, 7 found nonparticulate steroids had comparable efficacy to particulate steroids, and 3 studies suggested reduced efficacy or shorter duration of effect for nonparticulate steroids.

DISCUSSION

The risk of complications for transforaminal ESI is greater with particulate corticosteroids. Nonparticulate corticosteroids, which are often recommended as first-line therapy, may have a short duration of effect, and many commercial formulations contain neurotoxic preservatives. The safety profile of ESIs may continue to improve with the development of safer, sterile formulations that reduce the risk of complications while maintaining efficacy.

Diagnosis and Treatment of Transforaminal Epidural Steroid Injection in Lumbar Spinal Stenosis

Objectives:

Transforaminal epidural steroid injection reduces the low back-leg pain and enables daily activities of the patients. In this study, we aim to evaluate the treatment of transforaminal epidural steroid injection for lumbar spinal stenosis, which was mainly performed for lumbar disc herniation and share our diagnostic experience for lumbar spinal stenosis which is treated surgically.

Methods:

In our study, 37 patients were included who were treated by transforaminal epidural steroid injection for Grade B lumbar spinal stenosis in our clinic between June-2014 and June-2018. We evaluated the patients at the second weeks, third/sixth months and one year after the treatment by Oswestry-Disability-Index and Visual-Analogue-Scale and followed up for surgical treatment after one year.

Results:

The mean low back and leg pain Visual Analogue Scale was 5.1±0.3 before the transforaminal epidural steroid injection procedure, and it was 2.7±0.1 after two weeks. It was 2.8±0.2, 3.1±0.1 at three and six months after procedure, respectively. The improvement of low back-leg pain mean Visual-Analogue-Scale is statistically significant at two weeks, three and six months after transforaminal epidural steroid injection procedure, respectively. The mean Oswestry-Disability-Index was 29.6±0.4 before the transforaminal epidural steroid injection procedure, and it was 14.1±0.3 after two weeks. It was 15.3±0.5, 24.4±0.2 at three and six months after procedure, respectively. The improvement of Oswestry-Disability-Index is statistically significant at two weeks, three-six months.

Conclusion:

The transforaminal epidural steroid injection is safe procedure for non-surgical treatment of lumbar spinal stenosis and this procedure may be preferred support to the indication of the surgical treatment of level of lumbar spinal stenosis.

Complications Associated with Lumbar Transforaminal Epidural Steroid Injections

PURPOSE OF REVIEW

Low back pain with radicular symptoms is a common cause of disability in the adult population in the USA. Lumbar transforaminal epidural steroid injection (TFESI) is one of the most frequently used intervention for lumbar radiculitis. The purpose of this review is to evaluate complications associated with lumbar TFESI.

RECENT FINDINGS

Based on the literature review, the reported rate of minor complications was between 2.4 and 9.6%. The major complications including spinal abscess, spinal cord infarct, and epidural hematoma were documented as case reports. Some patients with spinal cord infarct had permanent neurologic deficits, while the other patients had recovery of neurological function after surgical or medical intervention. This review identifies both the minor and major complications related to lumbar transforaminal epidural steroid injections. According to this review, most complications are minor. Lumbar TFESI can be considered a safe treatment in the management of lumbar radicular pain. However, pain specialists should be aware of the potentially devastating major complications. Early recognition and treatment of complications are crucial for improving the outcome.

Outcome of transforaminal epidural steroid injection for lumbar radiculopathy: initial three-year experience at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences, Nepal

Background

The prevalence of low back pain with radiculopathy in general population varies from 9.9% to 25%, which can be due to bony narrowing of the lateral recess or due to prolapsed intervertebral disc. Transforaminal epidural injection of a mixture of long-acting anaesthetic (bupivacaine) and particulate steroids (depomedrol) has been a treatment modality in patients not responding to initial physiotherapy and neuropathic pain medications.

Methods

To analyze the effectiveness of transforaminal epidural steroid injection (TFESI) in the treatment of low back pain with radiculopathy, a retrospective case series evaluating the records of patients that received TFESI (1 mL 0.5% bupivacaine +1 ml/40 mg depomedrol) under C-arm guidance from January 2015 to December 2018 (3 years) at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences (UDM-NINAS), their lumbo-sacral MRI and the pre-procedure, 1-week and 3-month numeric pain rating scale, were analyzed. Successful treatment (reduction of pain scale by more than 50% of baseline at 3 months) in the patients with bony recess stenosis and those with prolapsed intervertebral disc was compared.

Results

Out of 67 patients that received TFESI, 35 (52.23%) could be followed up. The mean age was 55.8 ± 14.39 years and 51.3% were females. 68.57% had L5 and 20% had S1 radiculopathy. Bony recess stenosis was seen in the aged 40% and PIVD was the cause of radiculopathy in 60%. The median duration of radicular pain prior to intervention was 3 months. TFESI was effective as the mean numeric pain scale before injection was 8.97 ± 1.32 which reduced to 3.91 ± 3.23 (paired t test p value < 0.001) at 1 week post injection and 3.23 ± 3.34 (paired t test p value < 0.001) at 3 months post injection. Twenty-six of the 35 patients (75.29%) had more than 50% pain relief compared to baseline at 3 months and were satisfied. Nine patients continued to have pain; however, only one required a surgical intervention. The effectiveness of TFESI was not significantly different in different ages (Fisher’s exact test p value 0.182) and in different anatomic levels (Fisher’s exact test p value 0.241). Six out of eight patients with bony recess stenosis benefited as compared to 14 out of 19 patients with PIVD, though it was not statistically significant (Fischer’s exact test p value 0.688). There were no adverse events recorded.

Conclusion

TFESI is a safe and efficacious treatment modality in patients with radicular low back pain especially in aged patients in whom surgery under general anaesthesia is not free from risk.

Comparing pain relief and functional improvement between methylprednisolone and dexamethasone lumbosacral transforaminal epidural steroid injections: a self-controlled study

Background

Previous studies have shown varying results between lumbosacral transforaminal epidural steroid injections (TFESIs) performed with particulate versus non-particulate corticosteroids. The purpose of this study was to investigate the difference in pain relief and functional improvement between particulate and non-particulate lumbosacral TFESIs in patients who had undergone both injections, sequentially.

Methods

This was a self-controlled, retrospective study of 20 patients who underwent both a methylprednisolone and a dexamethasone TFESI to the same vertebral level and side. Primary outcomes included pain relief according to the visual analogue scale (VAS) and functional improvement determined by a yes/no answer to questions regarding mobility and the activities of daily living. Post-injection data was recorded at 2, 3, and 6 months.

Results

A decrease in VAS scores of –3.4 ± 3.0 (mean ± standard deviation), –3.1 ± 3.1, and –2.8 ± 3.4 was seen for the methylprednisolone group at 2, 3, and 6 months, respectively. Similar decreases of –3.9 ± 3.5, –3.4 ± 2.8, and –2.3 ± 3.4 were seen in the dexamethasone group. There was no significant difference in pain relief at any point between the two medications. The percentage of subjects who reported improved function at 2, 3, and 6 months was 65%, 51%, and 41%, respectively, for the methylprednisolone group and 75%, 53%, and 42% for the dexamethasone group.

Conclusions

These findings support the use of non-particulate corticosteroids for lumbosacral TFESIs in the context of documented safety concerns with particulate corticosteroids.

Single dose epidural methylprednisolone as a treatment and predictor of outcome following subsequent decompressive surgery in degenerative lumbosacral stenosis with foraminal stenosis

Alternative treatments to surgery in canine degenerative lumbosacral stenosis (DLSS) remain limited and reliable predictors of outcome are lacking. The aims of this clinical trial were threefold: to assess the usefulness of single epidural steroid injection (ESI) in DLSS, to compare the outcomes of ESI and decompressive surgery, and evaluate ESI as a predictor of outcome following decompressive surgery. Dogs diagnosed with DLSS were prospectively recruited and administered an ESI. If clinical signs persisted or relapsed, decompressive surgery was recommended. Follow-up was obtained. Thirty-two dogs underwent ESI with 17 having subsequent surgery. Improvement after ESI was seen in 27/32 dogs (84.4%), with 17/22 (77.2%) relapsing within 6 months (n = 15/17 relapsing within 2 months). Five dogs failed to respond to ESI and another five (15.6%) presented a persistent post-ESI favourable response (mean follow-up time, 9.4 months). Post-surgical improvement occurred in all dogs. Outcome appeared more favourable following surgical decompression, with a trend towards reduced pain, increased mobility, and greater quality of life score. This study was unable to demonstrate that ESI could predict surgical outcome. ESI was confirmed as an effective treatment in most but not all cases, leading to transient alleviation of clinical signs for longer than previously reported. ESI provided a complete and apparently long-term sustained resolution of clinical signs in a subset of dogs. Despite this, there was indication that surgical decompression can lead to a more favourable outcome. Epidural steroid injection has a role in the management of DLSS dogs, particularly when surgery is not an option.

Lumbar Radicular Pain Response to First Injection with Non-particulate Steroid

Introduction Recent studies on the use of transforaminal epidural steroid injection (TFESI) to treat lumbar radicular pain have highlighted controversies pertaining to the choice of corticosteroid agent utilized in lumbosacral TFESI, in terms of both safety and efficacy. The primary objective was to characterize the radicular pain response after a first transforaminal injection with dexamethasone. The secondary objective was to document the response of those who failed to respond to a dexamethasone injection when particulate steroid was utilized for a second injection. Methods It was a retrospective study of 94 consecutive patients undergoing transforaminal injection for lumbosacral radicular pain. At two-week follow-up, patients rated their pain response on a clinically oriented five-point survey. First injection non-responders were given a second injection with particulate steroid and again completed the survey. Results Approximately one-third (N = 31/94) of patients received no meaningful relief from a single injection with dexamethasone. No patients achieved lasting and complete pain relief after a single injection. Of initial non-particulate steroid non-responders, approximately two-thirds (N = 19/28) demonstrated a notable or complete response to a second injection with particulate steroid. Conclusions We are now able to better inform patients with regard to their anticipated pain response to an initial dexamethasone injection. Only one-third of patients realized more significant and lasting relief after a single injection. Of those who did not demonstrate a more meaningful response, a second injection with particulate steroid resulted in more pronounced pain relief in two-thirds of patients.

Spinal epidural hematoma occurring at a distance from the transforaminal epidural injection site: A case report

RATIONALE

Transforaminal epidural steroid injection (TFESI) is a conservative method to treat back pain due to radiculopathy. However, epidural hematoma can occur after the procedure by various mechanisms, which can cause serious complications.

PATIENT CONCERNS

An 82-year-old man with spinal stenosis was treated with TFESI in the right intervertebral foramen at the L2-L3 level. The next morning, he experienced severe back pain and diffuse motor deficit.

DIAGNOSIS

Emergency magnetic resonance imaging revealed fluid collection in the posterior epidural space at the T11-L1 level with central-canal stenosis.

INTERVENTIONS

Emergency hematoma evacuation was performed to remove the epidural hematoma.

OUTCOMES

After the surgery, the back pain disappeared.

LESSONS

Epidural hematoma may occur due to causes other than direct needle injury after TFESI. Therefore, careful observation of the patient is necessary after the procedure.

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.

Influence of Epidural Steroid Injection on Adrenal Function

Background

Spinal diseases are self-limited or non-progressive in many cases. Epidural steroid injection (ESI) is a common nonsurgical treatment option for spinal pain. Despite concerns about complications of repeated steroid injection, few studies reported on the adrenal function of spine disease patients undergoing surgery after ESI. We investigated the influence of preoperative multiple ESIs on adrenal function in spine surgery patients.

Methods

This was a retrospective study with prospective data collection. Those who underwent elective spinal operations and had a history of multiple ESIs from January to June 2017 were selected as a study group. Those who underwent knee arthroplasty and did not have a history of ESI and any kind of steroid injection in other areas during 6 months before surgery were selected as a control group. Demographic data were compared to assess homogeneity between groups. We assessed the preoperative serum cortisol level (SCL) to compare the basal adrenal function between groups. Also, we assessed the elevation of SCL postoperatively to evaluate the adrenal response to the surgical stress in each group. For subgroup analysis, we divided all patients into normal (7-28 µg/dL) and subnormal groups according to SCL and analyzed risk factors of adrenal suppression with multivariate logistic regression test.

Results

There were 53 patients in the study group and 130 in the control group. Age and sex were homogeneous between groups. There was significant intergroup difference in preoperative SCL (10.4 ± 4.8 µg/dL in the study group vs. 12.0 ± 4.2 µg/dL in the control group; p = 0.026).The postoperative day one SCL was 11.6 ± 5.0 µg/dL in the study group without significant increase from the preoperative level (p = 0.117), whereas the increase was significant in the control group with a postoperative level of 14.4 ± 4.4 µg/dL (p < 0.001). Among all patients, the SCL was subnormal in 18 patients and within the normal range in 165. Spine surgery was the independent risk factor irrespective of age and sex (odds ratio, 3.472; p = 0.015).

Conclusions

Our results suggest that concern should be raised about the influence of preoperative multiple ESIs on adrenal suppression in spine surgery patients.

Interventional Anesthetic Methods for Pain in Hematology/Oncology Patients

This article reviews anesthetic interventional approaches to the management of pain in hematology and oncology patients. It includes a discussion of single interventions including peripheral nerve blocks, plexus injections, and sympathetic nerve neurolysis, and continuous infusion therapy through implantable devices, such as intrathecal pumps, epidural port-a-caths, and tunneled catheters. The primary objective is to inform members of hematology and oncology care teams regarding the variety of interventional options for patients with cancer-related pain for whom medical pain management methods have not been effective.

The Value of Electrodiagnostic Studies in Predicting Treatment Outcomes for Patients with Spine Pathologies

The utility of electrodiagnostic testing for spine pathologies varies based on the underlying suspected pathology. This article reviews the data on electrodiagnostic testing for common spine pathologies, with a specific focus on the prognostic data with regard to treatment outcomes. This information is placed into context of diagnostic confidence, which is derived from the combination of disease prevalence and the sensitivity and specificity of a test.

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.

Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group

BACKGROUND

Epidural corticosteroid injections are used frequently worldwide in the treatment of radicular pain. Concerns have arisen involving rare major neurologic injuries after this treatment. Recommendations to prevent these complications have been published, but local implementation is not always feasible due to local circumstances, necessitating local recommendations based on literature review.

METHODS

A work group of 4 stakeholder pain societies in Belgium, The Netherlands, and Luxembourg (Benelux) has reviewed the literature involving neurological complications after epidural corticosteroid injections and possible safety measures to prevent these major neurologic injuries.

RESULTS

Twenty-six considerations and recommendations were selected by the work group. These involve the use of imaging, injection equipment particulate and nonparticulate corticosteroids, epidural approach, and maximal volume to be injected.

CONCLUSION

Raising awareness about possible neurological complications and adoption of safety measures recommended by the work group aim at reducing the risks for these devastating events.

Role of Magnetic Resonance Imaging in Ascertaining the Success of Transforaminal Epidural Steroid Injection for Lumbar Radicular Pain

Objective

To explore the outcome differences of lumbar transforaminal epidural steroid injection (TFESI) according to magnetic resonance imaging (MRI) findings in patients with lumbar radicular pain.

Design

Retrospective study.

Setting

Single university-based interventional pain management unit.

Patients

Fifty-nine patients who had lumbar radicular pain with a recent lumbar MRI and three-month follow-up were included.

Methods

MRI findings were reviewed for the following items: herniation type (bulging, protrusion, extrusion), herniation location (central, subarticular, foraminal, extraforaminal), high intensity zone (HIZ), and nerve root impingement (NRI). Pain severity was evaluated using a visual analogue scale (VAS) at time of before injection, then two weeks and three months after.

Results

Pain scores improved significantly in each group ( P  < 0.05) at all time points, but there were no statistically significant differences in improvements according to type or location of disc herniation. Pain scores were significantly lower in patients with HIZ at the second week and in patients with NRI at the third month ( P  < 0.05).

Conclusions

TFESI was an effective treatment method in patients with radicular pain, irrespective of the type or location of disc herniation. However, greater improvement in pain may be expected at the second week in patients with HIZ and at the third month in patients with NRI.

Lumbar Dorsal Root Ganglion Block as a Prognostic Tool Before Pulsed Radiofrequency: A Randomized, Prospective, and Comparative Study on Cost-Effectiveness

OBJECTIVES

In the study, we discuss the predictive value and cost-effectiveness of dorsal root ganglion (DRG) blocks before using dorsal root ganglion pulsed radiofrequency (DRG-PRF) in the treatment of low back pain.

METHODS

The study comprised 60 patients with low back pain who were randomly assigned into 2 groups. Patients in group 1 were screened using DRG block before DRG-PRF treatment for responders. Patients in group 2 underwent DRG-PRF treatment without DRG block. Successful outcome was defined as patient satisfaction, improvement in numerical rating scale, and medication use reduction.

RESULTS

In group 1 (n = 30), 24 patients demonstrated good response to DRG block, and 20 patients had successful outcome at 6 months after DRG-PRF therapy. In group 2 (n = 30), 25 of the patients had successful outcome at 6 months after DRG-PRF therapy. The mean medical costs were NT$ 19,245 and NT$ 16,375 for each successful case in groups 1 and 2, respectively.

CONCLUSIONS

In this comparative cost-effectiveness study, the application of diagnostic DRG blocks before DRG-PRF did not have a significant impact on patient satisfaction, pain index score, or pain medication reduction. Furthermore, the application of diagnostic DRG blocks resulted in overall greater medical costs. These findings suggest that DRG-PRF without screening by DRG block is more cost-effective and less invasive.

Acute effects of anesthetic lumbar spine injections on temporal spatial parameters of gait in individuals with chronic low back pain: A pilot study

This study examined whether epidural injection-induced anesthesia acutely and positively affected temporal spatial parameters of gait in patients with chronic low back pain (LBP) due to lumbar spinal stenosis. Twenty-five patients (61.7±13.6years) who were obtaining lumbar epidural injections for stenosis-related LBP participated. Oswestry Disability Index (ODI) scores, Medical Outcomes Short Form (SF-36) scores, 11-point Numerical pain rating (NRS_pain) scores, and temporal spatial parameters of walking gait were obtained prior to, and 11-point Numerical pain rating (NRS_pain) scores, and temporal spatial parameters of walking gait were obtained after the injection. Gait parameters were measured using an instrumented gait mat. Patients received transforaminal epidural injections in the L1-S1 vertebral range (1% lidocaine, corticosteroid) under fluoroscopic guidance. Patients with post-injection NRS_pain ratings of "0" or values greater than "0" were stratified into two groups: 1) full pain relief, or 2) partial pain relief, respectively. Post-injection, 48% (N=12) of patients reported full pain relief. ODI scores were higher in patients with full pain relief (55.3±21.4 versus 33.7 12.8; p=0.008). Post-injection, stride length and step length variability were significantly improved in the patients with full pain relief compared to those with partial pain relief. Effect sizes between full and partial pain relief for walking velocity, step length, swing time, stride and step length variability were medium to large (Cohen's d>0.50). Patients with LBP can gain immediate gait improvements from complete pain relief from transforaminal epidural anesthetic injections for LBP, which could translate to better stability and lower fall risk.

The Prognostic Value of Enhanced-MRI and Fluoroscopic Factors for Predicting the Effects of Transforaminal Steroid Injections on Lumbosacral Radiating Pain

Objective

To investigate the predictive value of enhanced-magnetic resonance imaging (MRI) and fluoroscopic factors regarding the effects of transforaminal epidural steroid injections (TFESIs) in low back pain (LBP) patients with lumbosacral radiating pain.

Methods

A total of 51 patients who had LBP with radiating pain were recruited between January 2011 and December 2012. The patient data were classified into the two groups ‘favorable group’ and ‘non-favorable group’ after 2 weeks of follow-up results. The favorable group was defined as those with a 50%, or more, reduction of pain severity according to the visual analogue scale (VAS) for back or leg pain. The clinical and radiological data were collected for univariate and multivariate analyses to determine the predictors of the effectiveness of TFESIs between the two groups.

Results

According to the back or the leg favorable-VAS group, the univariate analysis revealed that the corticosteroid approach for the enhanced nerve root, the proportion of the proximal flow, and the contrast dispersion of epidurography are respectively statistically significant relative to the other factors. Lastly, the multiple logistic regression analysis showed a significant association between the corticosteroid approach and the enhanced nerve root in the favorable VAS group.

Conclusion

Among the variables, MRI showed that the corticosteroid approach for the enhanced target root is the most important prognostic factor in the predicting of the clinical parameters of the favorable TFESIs group.

Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study

OBJECTIVES

Evidence comparing the effectiveness of surgical and conservative treatment of symptomatic lumbar disc herniation is controversial. We sought to compare short-term and long-term effectiveness of surgical and conservative treatment in sciatica symptom severity and quality of life in patients with lumbar disc herniation in a routine clinical setting.

METHODS

A prospective cohort study of a routine clinical practice registry consisting of 370 patients. Outcome measures were the North American Spine Society questionnaire and the 36-Item Short-Form Health Survey to assess patient-reported back pain, physical function, neurogenic symptoms and quality of life. Primary outcomes were back pain at 6 and 12 weeks. Standard open discectomy was assessed versus conservative interventions at 6, 12, 52 and 104 weeks. We filled in missing outcome variable values with multiple imputation, accounted for repeated measures within patients with mixed-effects models and adjusted baseline group differences in relevant prognostic indicators by inverse probability of treatment weighting.

RESULTS

Surgical treatment patients reported less back pain at 6 weeks than those receiving conservative therapy (-0.97; 95% CI -1.89 to -0.09), were more likely to report ≥50% decrease in back pain symptoms from baseline to 6 weeks (48% vs 17%, risk difference: 0.34; 95% CI 0.16 to 0.47) and reported less physical function disability at 52 weeks (-3.7; 95% CI -7.4 to -0.1). The other assessments showed minimal between-group differences with CIs, including the null effect.

CONCLUSIONS

Compared with conservative therapy, surgical treatment provided faster relief from back pain symptoms in patients with lumbar disc herniation, but did not show a benefit over conservative treatment in midterm and long-term follow-up.

Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomised, double-blind, controlled trial

Objective

To compare the effect of corticosteroids combined with local anaesthetic versus local anaesthetic alone during infiltrations of the pudendal nerve for pudendal nerve entrapment.

Design

Randomised, double‐blind, controlled trial.

Setting

Multicentre study.

Population

201 patients were included in the study, with a subgroup of 122 women.

Methods

CT‐guided pudendal nerve infiltrations were performed in the sacrospinous ligament and Alcock's canal. There were three study arms: patients in Arm A (n = 68) had local anaesthetic alone, those in Arm B (n = 66) had local anaesthetic plus corticosteroid and those in Arm C (n = 67) local anaesthetic plus corticosteroid with a large volume of normal saline.

Main outcome measures

The primary end‐point was the pain intensity score at 3 months. Patients were regarded as responders (at least a 30‐point improvement on a 100‐point visual analogue scale of mean maximum pain over a 2‐week period) or nonresponders.

Results

Three months’ postinfiltration, 11.8% of patients in the local anaesthetic only arm (Arm A) were responders versus 14.3% in the local anaesthetic plus corticosteroid arms (Arms B and C). This difference was not statistically significant (P = 0.62). No statistically significant difference was observed in the female subgroup between Arm A and Arms B and C (P = 0.09). No significant difference was detected for the various pain assessment procedures, functional criteria or quality‐of‐life criteria.

Conclusions

Corticosteroids provide no additional therapeutic benefits compared with local anaesthetic and should therefore no longer be used.

Tweetable abstract

Steroid infiltrations do not improve the results of local anaesthetic infiltrations in pudendal neuralgia.

Steroid infiltrations do not improve the results of local anaesthetic infiltrations in pudendal neuralgia.

Epidural steroids for spinal pain and radiculopathy: a narrative, evidence-based review

PURPOSE OF REVIEW

Epidural steroid injections (ESIs) are the most commonly performed intervention in pain clinics across the USA and worldwide. In light of the growing use of ESIs, a recent spate of highly publicized infectious complications, and increasing emphasis on cost-effectiveness, the utility of ESI has recently come under intense scrutiny. This article provides an evidence-based review of ESIs, including the most up-to-date information on patient selection, comparison of techniques, efficacy, and complications.

RECENT FINDINGS

The data strongly suggest that ESIs can provide short-term relief of radicular symptoms but are less convincing for long-term relief, and mixed regarding cost-effectiveness. Although some assert that transforaminal ESIs are more efficacious than interlaminar ESIs, and that fluoroscopy can improve treatment outcomes, the evidence to support these assertions is limited.

SUMMARY

The cost-effectiveness of ESI is the subject of great debate, and similar to efficacy, the conclusions one draws appear to be influenced by specialty. Because of the wide disparities regarding indications and utilization, it is likely that indiscriminate use is cost-ineffective, but that judicious use in well-selected patients can decrease healthcare utilization. More research is needed to better refine selection criteria for ESI, and to determine which approach, what dose, and how many injections are optimal.

Ultrasound-Guided Lower Cervical Nerve Root Injectate Volumes Associated With Dorsal Root Ganglion and Epidural Spread

OBJECTIVES

We aimed to estimate the spread of injections for ultrasound-guided cervical nerve root blocks and to determine the optimal injectate volume required in this procedure.

METHODS

A total of 32 ultrasound-guided injections (C5-C8) were made in 4 fresh cadavers. The target on each cervical root was the space between the posterior tubercle and the cervical root at the most proximal location possible on the sonogram. After ultrasound-guided needle insertion, 0.5 mL of a contrast medium was injected 4 times. The dye flow patterns were confirmed with fluoroscopy each time, and we recorded whether the contrast medium reached the dorsal root ganglion level or the epidural space. After the injections, the needle tip location was determined by computed tomography and image reconstruction.

RESULTS

All injections produced typical neurograms. The contrast medium reached the dorsal root ganglion in 29 of 32 (90.6%) injections (mean ± SD, 0.84 ± 0.42 mL of contrast medium) and the epidural space in 10 of 32 (31.3%) injections (1.30 ± 0.54 mL of contrast medium). The mean distance between the needle tip and neural foramen was 9.64 ± 3.68 mm, and this distance correlated positively with the volume of contrast medium necessary to reach the dorsal root ganglion or the epidural space.

CONCLUSIONS

Ultrasound-guided cervical nerve root blocks show potential utility for targeting an anesthetic into the cervical root area. This study may be helpful for deciding the most appropriate volume for the procedure.

Local anesthetic injections with or without steroid for chronic non-cancer pain: a protocol for a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Steroids are often combined with local anesthetic (LA) and injected to reduce pain associated with various chronic non-cancer pain (CNCP) complaints. The biological rationale behind injection of a steroid solution is unclear, and it is uncertain whether the addition of steroids offers any additional benefits over injection of LA alone. We propose to conduct a systematic review and meta-analysis to summarize the evidence for using steroids and LA vs. LA alone in the treatment of CNCP.

METHODS

An experienced librarian will perform a comprehensive search of EMBASE, MEDLINE, and the Cochrane Central Registry of Controlled Trials (CENTRAL) databases with search terms for clinical indications, LA, and steroid agents. We will review bibliographies of all relevant published reviews in the last 5 years for additional studies. Eligible trials will be published in English and randomly allocate patients with CNCP to treatment with steroid and LA injection therapy or injection with LA alone. We will use the guidelines published by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) to inform the outcomes that we collect and present. Teams of reviewers will independently and in duplicate assess trial eligibility, abstract data, and assess risk of bias among eligible trials. We will prioritize intention to treat analysis and, when possible, pool outcomes across trials using random effects models. We will report our findings as risk differences, weighted mean differences, or standardized mean differences for individual outcomes. Further, to ensure interpretability of our results, we will present risk differences and measures of relative effect for pain reduction based on anchor-based minimally important clinical differences. We will conduct a priori defined subgroup analyses and use the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to evaluate the certainty of the evidence on an outcome-by-outcome basis.

DISCUSSION

Our review will evaluate both the effectiveness and the adverse events associated with steroid plus LA vs. LA alone for CNCP, evaluate the quality of the evidence using the GRADE approach, and prioritize patient-important outcomes guided by IMMPACT recommendations. Our results will facilitate evidence-based management of patients with chronic non-cancer pain and identify key areas for future research.

TRIAL REGISTRATION

PROSPERO CRD42015020614.

Multipotent Mesenchymal Stem Cell Treatment for Discogenic Low Back Pain and Disc Degeneration

Low back pain with resultant loss of function, decreased productivity, and high economic costs is burdensome for both the individual and the society. Evidence suggests that intervertebral disc pathology is a major contributor to spine-related pain and degeneration. When commonly used conservative therapies fail, traditional percutaneous or surgical options may be beneficial for pain relief but are suboptimal because of their inability to alter disc microenvironment catabolism, restore disc tissue, and/or preserve native spine biomechanics. Percutaneously injected Multipotent Mesenchymal Stem Cell (MSC) therapy has recently gained clinical interest for its potential to revolutionarily treat disc-generated (discogenic) pain and associated disc degeneration. Unlike previous therapies to date, MSCs may uniquely offer the ability to improve discogenic pain and provide more sustained improvement by reducing disc microenvironment catabolism and regenerating disc tissue. Consistent treatment success has the potential to create a paradigm shift with regards to the treatment of discogenic pain and disc degeneration.

The Role of Invasive Pain Management Modalities in the Treatment of Chronic Pain

Invasive analgesic therapies provide an alternative to medical management of chronic pain. With the increasing incidence of chronic pain not only in the United States but worldwide, more therapies have evolved to address the growing need for pain relief options. These therapies include spinal injections, nerve blocks, radiofrequency ablation, neurostimulation, and intrathecal drug delivery.

Single-Shot Epidural Injections in the Management of Radicular Pain

Epidural injections are commonly used in the treatment of chronic low back pain due to symptomatic lumbar spinal disorders. The aim of the present investigation was to study their therapeutic value for different age subgroups. A consecutive series of 356 patients were treated with at least one injection, and assessed before and after injection. Significant pain reduction was observed in all age groups following a series of injections with the greatest reduction after the first one. Especially in patients younger than 50 years, pain medication could be reduced substantially. Surgery was performed in 19.4% of patients (n=69) following a series of SSPDA injections. In the current study, interlaminar steroid injections for treatment of chronic low back and radicular pain caused sufficient improvement and significant reduction of medication especially in younger patients.

Adverse events associated with fluoroscopically guided lumbosacral transforaminal epidural steroid injections

BACKGROUND CONTEXT

Although the types and incidence of adverse events (AEs) associated with transforaminal epidural steroid injection (TFESI) have been described, no study has used a systematic standardized questionnaire to solicit AEs from patients to capture an accurate range and incidence of complications.

PURPOSE

The aim was to systematically identify the types and incidence of AEs associated with TFESI. Additionally, this study evaluated demographic and clinical factors that may predict a higher risk of an AE.

STUDY DESIGN/SETTING

This was a retrospective cohort study from a multiphysician academic PM&R clinic.

PATIENT SAMPLE

Patients, aged 19 to 89, who underwent a fluoroscopically guided TFESI for lumbosacral radicular pain between 2004 and 2007 were included.

OUTCOME MEASURES

The relationship of AEs with gender, age, trainee presence, steroid type, preprocedure visual analog scale (VAS) pain score, systolic blood pressure, fluoroscopy time, and corticosteroid injectate volume was analyzed.

METHODS

Adverse event data were collected using a survey both immediately and at 24 to 72 hours after TFESI. Statistical analysis was performed using the chi-square, Fisher exact, or Wilcoxon rank sum two-sided tests. Logistic regression analysis was also performed. C.P. is the owner of Rehabilitation Institute of Chicago Physiatric Log & Analysis System computer software.

RESULTS

In 1,295 consecutive patients undergoing 2,025 TFESI procedures, immediate AEs and delayed AEs occurred after 182 (9.2%) and 305 (20.0%) injections, respectively. The most common immediate AEs were: vasovagal reaction (4.2%) and interrupted procedure from intravascular flow (1.7%). Common delayed AEs included: pain exacerbation (5.0%), injection site soreness (3.9%), headache (3.9%), facial flushing/sweating (1.8%), and insomnia (1.6%). Significant associations were identified between AEs and gender, age, preprocedure VAS, steroid type, and fluoroscopy time. Trainee involvement in the procedure did not impact the complication rate.

CONCLUSIONS

Fluoroscopically guided lumbosacral TFESI is associated with a similar rate of minor AEs both immediately and 24 to 72 hours after procedure that are typical of other axial corticosteroid injections. Permanent AEs were not found in this sample. The most common AEs associated with TFESI include vasovagal episodes, procedure interruption from intravascular flow, pain exacerbation, injection site soreness, headache, and insomnia.

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.

Do Epidural Injections Provide Short- and Long-term Relief for Lumbar Disc Herniation? A Systematic Review

BACKGROUND

As part of a comprehensive nonsurgical approach, epidural injections often are used in the management of lumbar disc herniation. Recent guidelines and systematic reviews have reached different conclusions about the efficacy of epidural injections in managing lumbar disc herniation.

QUESTIONS/PURPOSES

In this systematic review, we determined the efficacy (pain relief and functional improvement) of the three anatomic approaches (caudal, lumbar interlaminar, and transforaminal) for epidural injections in the treatment of disc herniation.

METHODS

We performed a literature search from 1966 to June 2013 in PubMed, Cochrane library, US National Guideline Clearinghouse, previous systematic reviews, and cross-references for trials studying all types of epidural injections in managing chronic or chronic and subacute lumbar disc herniation. We wanted only randomized controlled trials (RCTs) (either placebo or active controlled) to be included in our analysis, and 66 studies found in our search fulfilled these criteria. We then assessed the methodologic quality of these 66 studies using the Cochrane review criteria for RCTs. Thirty-nine studies were excluded, leaving 23 RCTs of high and moderate methodologic quality for analysis. Evidence for the efficacy of all three approaches for epidural injection under fluoroscopy was strong for short-term (< 6 months) and moderate for long-term (≥ 6 months) based on the Cochrane rating system with five levels of evidence (best evidence synthesis), with strong evidence denoting consistent findings among multiple high-quality RCTs and moderate evidence denoting consistent findings among multiple low-quality RCTs or one high-quality RCT. The primary outcome measure was pain relief, defined as at least 50% improvement in pain or 3-point improvement in pain scores in at least 50% of the patients. The secondary outcome measure was functional improvement, defined as 50% reduction in disability or 30% reduction in the disability scores.

RESULTS

Based on strong evidence for short-term efficacy from multiple high-quality trials and moderate evidence for long-term efficacy from at least one high quality trial, we found that fluoroscopic caudal, lumbar interlaminar, and transforaminal epidural injections were efficacious at managing lumbar disc herniation in terms of pain relief and functional improvement.

CONCLUSIONS

The available evidence suggests that epidural injections performed under fluoroscopy by trained physicians offer improvement in pain and function in well-selected patients with lumbar disc herniation.

The Impact of Lumbosacral Transitional Vertebrae on Therapeutic Outcomes of Transforaminal Epidural Injection in Patients with Lumbar Disc Herniation

BACKGROUND

Although some studies have evaluated the clinical impact of lumbosacral transitional vertebrae (LSTV), few have attempted to determine an effective conservative treatment method for lumbar disc herniation (LDH) presenting concurrently with LSTV.

METHODS

We prospectively enrolled 291 consecutive patients who were followed-up for at least one year after transforaminal epidural injection (TFEI) for LDH. We confirmed the presence of LSTV with Paik et al.'s method, the Castellvi classification, and the Southworth and Bersack method. Clinical outcomes were evaluated with a visual analogue scale (VAS) for pain intensity and the Oswestry Disability Index (ODI) for functional status.

RESULTS

Of the 291 patients, 47 (16.2%) had LSTV, including 33 with sacralization and 14 with lumbarization, while 244 (83.8%) did not have LSTV. Patients in both groups improved significantly after TFEI in terms of the VAS (P < 0.001) and ODI (P < 0.001) scores. However, LDH patients with LSTV had a worse clinical outcome after six months of TFEI than did those without LSTV, with a significant difference between groups for both the VAS (P < 0.01) and ODI (P = 0.01) scores. LDH patients with sacralization had worse post-treatment clinical outcomes than LDH patients with lumbarization (P < 0.001) or LDH patients without LSTV (P < 0.001).

CONCLUSIONS

Sacralization can reduce the improvement after TFEI among LDH patients, while lumbarization appears to have no direct effect on TFEI outcomes. The presence of sacralization should be identified before TFEI, and if present, patients should be informed that the outcomes of TFEI may not be as good as they would be if sacralization was not present.

Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: A systematic review of randomized controlled trials

BACKGROUND

The efficacy of epidural and facet joint injections has been assessed utilizing multiple solutions including saline, local anesthetic, steroids, and others. The responses to these various solutions have been variable and have not been systematically assessed with long-term follow-ups.

METHODS

Randomized trials utilizing a true active control design were included. The primary outcome measure was pain relief and the secondary outcome measure was functional improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the criteria developed by the American Society of Interventional Pain Physicians (ASIPP) for assessing interventional techniques. An evidence analysis was conducted based on the qualitative level of evidence (Level I to IV).

RESULTS

A total of 31 trials met the inclusion criteria. There was Level I evidence that local anesthetic with steroids was effective in managing chronic spinal pain based on multiple high-quality randomized controlled trials. The evidence also showed that local anesthetic with steroids and local anesthetic alone were equally effective except in disc herniation, where the superiority of local anesthetic with steroids was demonstrated over local anesthetic alone.

CONCLUSION

This systematic review showed equal efficacy for local anesthetic with steroids and local anesthetic alone in multiple spinal conditions except for disc herniation where the superiority of local anesthetic with steroids was seen over local anesthetic alone.