Epidural injections in prevention of surgery for spinal pain: systematic review and meta-analysis of randomized controlled trials

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.

Chronic pain for rheumatological disorders: Pathophysiology, therapeutics and evidence

Pain is the leading reason people seek orthopedic and rheumatological care. By definition, most pain can be classified as nociceptive, or pain resulting from non-neural tissue injury or potential injury, with between 15% and 50% of individuals suffering from concomitant neuropathic pain or the newest category of pain, nociplastic pain, defined as "pain arising from altered nociception despite no clear evidence of actual or threatened tissue damage, or of a disease or lesion affecting the somatosensory system." Pain classification is important because it affects treatment decisions at all levels of care. Although several instruments can assist with classifying treatment, physician designation is the reference standard. The appropriate treatment of pain should ideally involve multidisciplinary care including physical therapy, psychotherapy and integrative therapies when appropriate, and pharmacotherapy with non-steroidal anti-inflammatory drugs for acute, mechanical pain, membrane stabilizers for neuropathic and nociplastic pain, and serotonin-norepinephrine reuptake inhibitors and tricyclic antidepressants for all types of pain. For nonsurgical interventions, there is evidence to support a small effect for epidural steroid injections for an intermediate-term duration, and conflicting evidence for radiofrequency ablation to provide at least 6months of benefit for facet joint pain, knee osteoarthritis, and sacroiliac joint pain. Since pain and disability represent the top reason for elective surgery, it should be reserved for patients who fail conservative interventions. Risk factors for procedural failure are the same as risk factors for conservative treatment failure and include greater disease burden, psychopathology, opioid use, central sensitization and multiple comorbid pain conditions, poorly controlled preoperative and postoperative pain, and secondary gain.

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.

Characteristics of patients with meningitis after lumbar epidural steroid injection

To investigate the clinical, laboratory, and radiological features of meningitis after lumbar epidural steroid injection (M-ESI) without accompanying spinal infection, data of patients with meningitis admitted between January 2014 and December 2021 in a single center were retrospectively reviewed. Among them, patients with a recent history of lumbar ESI were identified, and their medical records were collected. Patients with concomitant infections other than meningitis, including spinal epidural abscess, were excluded. Seven patients with M-ESI were identified. All patients presented with headache and fever without focal neurological deficits, and headache developed shortly after a procedure (median, 4 hours). Cerebrospinal fluid (CSF) analysis showed neutrophilic pleocytosis (median, 6729/μL), elevated protein level (median, 379.1 mg/dL), decreased ratio of CSF glucose to serum glucose (median, 0.29), and elevated lactate level (median, 8.64 mmol/L). Serum level of C-reactive protein was elevated in 6, but serum procalcitonin level was within normal range. No causative pathogen was identified in the microbiological studies. The most frequent radiologic feature was sulcal hyperintensity on fluid-attenuated inversion recovery images (57%), followed by pneumocephalus (43%). Symptoms subsided in a short period (median, 1 day) after initiating treatment with antibiotics and adjuvant intravenous corticosteroids. None of the patients experienced neurological sequelae. Though the cardinal symptoms and CSF findings of M-ESI were comparable to those of bacterial meningitis, M-ESI seems to have distinctive characteristics regarding the clinical course, laboratory parameters, and pneumocephalus.

Intradiscal oxygen-ozone chemonucleolysis versus microdiscectomy for lumbar disc herniation radiculopathy: a non-inferiority randomized control trial

BACKGROUND CONTEXT

Low back pain with or without radicular leg pain is an extremely common health condition significantly impacting patient's activities and quality of life. When conservative management fails, epidural injections providing only temporary relief, are frequently utilized. Intradiscal oxygen-ozone may offer an alternative to epidural injections and further reduce the need for microdiscectomy.

PURPOSE

To compare the non-inferiority treatment status and clinical outcomes of intradiscal oxygen-ozone with microdiscectomy in patients with refractory radicular leg pain due to single-level contained lumbar disc herniations.

STUDY DESIGN / SETTING

Multicenter pilot prospective non-inferiority blocked randomized control trial conducted in three European hospital spine centers.

PATIENT SAMPLE

Forty-nine patients (mean 40 years of age, 17 females/32 males) with a single-level contained lumbar disc herniation, radicular leg pain for more than six weeks, and resistant to medical management were randomized, 25 to intradiscal oxygen-ozone and 24 to microdiscectomy. 88% (43 of 49) received their assigned treatment and constituted the AS-Treated (AT) population.

OUTCOME MEASURES

Primary outcome was overall 6-month improvement over baseline in leg pain. Other validated clinical outcomes, including back numerical rating pain scores (NRS), Roland Morris Disability Index (RMDI) and EQ-5D, were collected at baseline, 1 week, 1-, 3-, and 6-months. Procedural technical outcomes were recorded and adverse events were evaluated at all follow-up intervals.

METHODS

Oxygen-ozone treatment performed as outpatient day surgeries, included a one-time intradiscal injection delivered at a concentration of 35±3 μg/cc of oxygen-ozone by a calibrated delivery system. Discectomies performed as open microdiscectomy inpatient surgeries, were without spinal instrumentation, and not as subtotal microdiscectomies. Primary analyses with a non-inferiority margin of -1.94-point difference in 6-month cumulative weighted mean leg pain NRS scores were conducted using As-Treated (AT) and Intent-to-Treat (ITT) populations. In post hoc analyses, differences between treatment groups in improvement over baseline were compared at each follow-up visit, using baseline leg pain as a covariate.

RESULTS

In the primary analysis, the overall 6-month difference between treatment groups in leg pain improvement using the AT population was -0.31 (SE, 0.84) points in favor of microdiscectomy and using the ITT population, the difference was 0.32 (SE, 0.88) points in favor of oxygen-ozone. The difference between oxygen-ozone and microdiscectomy did not exceed the non-inferiority 95% confidence lower limit of treatment difference in either the AT (95% lower limit, -1.72) or ITT (95% lower limit, -1.13) populations. Both treatments resulted in rapid and statistically significant improvements over baseline in leg pain, back pain, RMDI, and EQ-5D that persisted in follow-up. Between group differences were not significant for any outcomes. During 6-month follow-up, 71% (17 of 24) of patients receiving oxygen-ozone, avoided microdiscectomy. The mean procedure time for oxygen-ozone was significantly faster than microdiscectomy by 58 minutes (p<.0010) and the mean discharge time from procedure was significantly shorter for the oxygen-ozone procedure (4.3±2.9 hours vs. 44.2±29.9 hours, p<.001). No major adverse events occurred in either treatment group.

CONCLUSIONS

Intradiscal oxygen-ozone chemonucleolysis for single-level lumbar disc herniations unresponsive to medical management, met the non-inferiority criteria to microdiscectomy on 6-month mean leg pain improvement. Both treatment groups achieved similar rapid significant clinical improvements that persisted and overall, 71% undergoing intradiscal oxygen-ozone were able to avoid surgery.

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

»

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.

»

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

»

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.

Low back pain

Low back pain covers a spectrum of different types of pain (eg, nociceptive, neuropathic and nociplastic, or non-specific) that frequently overlap. The elements comprising the lumbar spine (eg, soft tissue, vertebrae, zygapophyseal and sacroiliac joints, intervertebral discs, and neurovascular structures) are prone to different stressors, and each of these, alone or in combination, can contribute to low back pain. Due to numerous factors related to low back pain, and the low specificity of imaging and diagnostic injections, diagnostic methods for this condition continue to be a subject of controversy. The biopsychosocial model posits low back pain to be a dynamic interaction between social, psychological, and biological factors that can both predispose to and result from injury, and should be considered when devising interdisciplinary treatment plans. Prevention of low back pain is recognised as a pivotal challenge in high-risk populations to help tackle high health-care costs related to therapy and rehabilitation. To a large extent, therapy depends on pain classification, and usually starts with self-care and pharmacotherapy in combination with non-pharmacological methods, such as physical therapies and psychological treatments in appropriate patients. For refractory low back pain, a wide range of non-surgical (eg, epidural steroid injections and spinal cord stimulation for neuropathic pain, and radiofrequency ablation and intra-articular steroid injections for mechanical pain) and surgical (eg, decompression for neuropathic pain, disc replacement, and fusion for mechanical causes) treatment options are available in carefully selected patients. Most treatment options address only single, solitary causes and given the complex nature of low back pain, a multimodal interdisciplinary approach is necessary. Although globally recognised as an important health and socioeconomic challenge with an expected increase in prevalence, low back pain continues to have tremendous potential for improvement in both diagnostic and therapeutic aspects. Future research on low back pain should focus on improving the accuracy and objectivity of diagnostic assessments, and devising treatment algorithms that consider unique biological, psychological, and social factors. High-quality comparative-effectiveness and randomised controlled trials with longer follow-up periods that aim to establish the efficacy and cost-effectiveness of low back pain management are warranted.

Platelet-Rich Plasma Versus Corticosteroid Injection for Lumbar Spondylosis and Sacroiliac Arthropathy: A Systematic Review of Comparative Studies

This systematic review compares clinical outcomes between platelet-rich plasma (PRP) and corticosteroid injections for the treatment of lumbar spondylosis and sacroiliac arthropathy. A systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Pubmed, SCOPUS, and Ovid MEDLINE databases. All level I-III evidence comparative studies published in the English language investigating the clinical outcomes between PRP and corticosteroid injections for the treatment of lumbar spondylosis and sacroiliac arthropathy were included. Five studies (242 patients, 114 PRP, 128 corticosteroid) were analyzed. One randomized study was level I evidence, two randomized studies were level II, and two non-randomized studies were level III. Final follow-up ranged from six weeks to six months. Four studies found that both PRP and corticosteroid treatment led to a statistically significant reduction in the visual analog scale (VAS). One found that only the PRP group led to a statistically significant reduction in VAS. Three studies found more significant improvements in one or more clinical outcome scores among PRP patients as compared with corticosteroid patients at the three- to six-month follow-up. Two studies found no difference in outcome score improvements between the two groups at six- to 12-week follow-up. There were no reports of major complications. There were no significant differences in minor complication rates between the two groups. In conclusion, both PRP and corticosteroid injections are safe and effective options for the treatment of lumbar spondylosis and sacroiliac arthropathy. There is some evidence that PRP injection is a more effective option at long-term follow-up compared with corticosteroid injection. Further randomized controlled trials with longer-term follow-up are necessary to compare its long-term efficacy.

Safety of epidural steroids: a review

Spine disease is one of the most common musculoskeletal diseases, especially in an aging society. An epidural steroid injection (ESI) is a highly effective treatment that can be used to bridge the gap between physical therapy and surgery. Recently, it has been increasingly used clinically. The purpose of this article is to review the complications of corticosteroids administered epidurally. Common complications include: hypothalamic-pituitary-adrenal (HPA) axis suppression, adrenal insufficiency, iatrogenic Cushing's syndrome, hyperglycemia, osteoporosis, and immunological or infectious diseases. Other less common complications include psychiatric problems and ocular ailments. However, the incidence of complications related to epidural steroids is not high, and most of them are not serious. The use of nonparticulate steroids is recommended to minimize the complications associated with epidural steroids. The appropriate interval and dosage of ESI are disputed. We recommend that the selection of appropriate ESI protocol should be based on the suppression of HPA axis, which reflects the systemic absorption of the corticosteroid.

Caudal epidural steroid injection ultrasound-guided versus fluoroscopy-guided in treatment of refractory lumbar disc prolapse with radiculopathy

Background

Lumbar disc prolapse is a localized herniation of disc beyond intervertebral disc space and is the most common cause of sciatica; the aim of this study is to investigate the efficacy of ultrasound (US)-guided caudal epidural steroid injection (CESI) compared with fluoroscopy (FL)-guided CESI in treatment of patients with refractory lumbar disc prolapse (LDP) with radiculopathy.

Results

At the beginning of the study, there was no significant difference between both groups in all parameters. (a) Group 1 had significantly improved the straight leg raising and modified Schober tests, VAS, and ODI at 1-month and 3-month post-injection evaluation in comparison to baseline recordings (p< 0.001); (b) Group 2 had significantly improved the straight leg raising and modified Schober tests, VAS, and ODI at 1-month and 3-month post-injection evaluation in comparison to baseline recordings (p< 0.001); and (c) US-guided CESI was not statistically different from the FL-guided CESI in the improvement of the straight leg raising (p= 0.87, 0.82) and modified Schober tests (p= 0.87, 0.82) as well as VAS (p= 0.40, 0.43) and ODI (p= 0.7, 0.2) at 1-month and 3-month post-injection evaluation. In a multivariate analysis using CI = 95%, the significant predictors for a successful outcome were duration<6 months (p= 0.03, OR = 2.25), target level not L2-3/L3-4 (p< 0.001, OR = 4.13), and LDP other than foraminal type (p= 0.002, OR = 3.78). However, age < 40 years was found to be non-significant in predicting a successful outcome (p= 0.38, OR = 0.98).

Conclusion

US is excellent in guiding CESI with similar treatment outcomes as compared with FL-guided CESI.

Trial registration

ClinicalTrials.gov Identifier:NCT03933150.

Cervical epidural steroid injections: incidence and determinants of subsequent surgery

BACKGROUND CONTEXT

Cervical epidural steroid injections (CESIs) are sometimes used in the management of cervical radicular pain in order to delay or avoid surgery. However, the rate and determinants of surgery following CESIs remain uncertain.

PURPOSE

This study sought to determine: (1) the proportion of patients having surgery following CESI, and (2) the timing of and factors associated with subsequent surgery.

STUDY DESIGN

Retrospective analysis of a large, national administrative claims database.

PATIENT SAMPLE

The study included 192,777 CESI patients (age 50.9±11.3 years, 55.2% female) who underwent CESI for imaging-based diagnoses of cervical disc herniation or stenosis, a clinical diagnosis of radiculopathy, or a combination thereof.

OUTCOME MEASURES

The primary outcome was the time from index CESI to surgery.

METHODS

Inclusion criteria were CESI for cervical disc herniation, stenosis, or radiculopathy, age ≥18, and active enrollment for 1 year before CESI to screen for exclusions. Patients were followed until they underwent cervical surgery, or their enrollment lapsed. Rates of surgery were assessed with Kaplan-Meier survival curves and 99% confidence intervals. Factors associated with subsequent surgery were assessed with multivariable Cox proportional hazard models.

RESULTS

Within 6 months of CESI, 11.2% of patients underwent surgery, increasing to 14.5% by 1 year and 22.3% by 5 years. Male patients and those aged 35 to 54 had an increased likelihood of subsequent surgery. Patients with radiculopathy were less likely to undergo surgery following CESI than those with stenosis or herniation, while patients with multiple diagnoses were more likely. Patients with comorbidities including CHF, other cardiac comorbidities or chronic pain were less likely to undergo surgery, as were patients in the northeast US region. Some 33.5% of patients underwent >1 CESI, with 84.6% of these occurring within 1 year. Additional injections were associated with reduced rates of subsequent surgery.

CONCLUSIONS

Following CESI, over one in five patients underwent surgery within 5 years. Multiple patient-specific risk factors for subsequent surgery were identified, and patients undergoing repeated injections were at lower risk. Determining which patients may progress to surgery can be used to improve resource utilization and to inform shared decision-making.

Epidural steroid injection versus conservative treatment for patients with lumbosacral radicular pain: A meta-analysis of randomized controlled trials

BACKGROUND

Previous systemic reviews have examined the efficacy of individual therapeutic agents, but which type of treatment is superior to another has not been pooled or analyzed. The objective of the current study was to compare the clinical effectiveness of epidural steroid injection (ESI) versus conservative treatment for patients with lumbosacral radicular pain.

METHODS

A systematic search was conducted with MEDLINE, EMBASE, and CENTRAL databases with a double-extraction technique for relevant studies published between 2000 and January 10, 2019. The randomized controlled trials which directly compared the efficacy of ESI with conservative treatment in patients with lumbosacral radicular pain were included. Outcomes included visual analog scale, numeric rating scale, Oswetry disability index, or successful events. Two reviewers extracted data and evaluated the methodological quality of papers using the Cochrane Collaboration Handbook. A meta-analysis was performed using Revman 5.2 software. The heterogeneity of the meta-analysis was also assessed.

RESULTS

Of 1071 titles initially identified, 6 randomized controlled trials (249 patients with ESI and 241 patients with conservative treatment) were identified and included in this meta-analysis. The outcome of the pooled analysis showed that ESI was beneficial for pain relief at short-term and intermediate-term follow-up when compared with conservative treatment, but this effect was not maintained at long-term follow-up. Successful event rates were significantly higher in patients who received ESI than in patients who received conservative treatment. There were no statistically significant differences in functional improvement after ESI and conservative treatment at short-term and intermediate-term follow-up. The limitations of this meta-analysis resulted from the variation in types of interventions and small sample size.

CONCLUSIONS

According to the results of this meta-analysis, the use of ESI is more effective for alleviating lumbosacral radicular pain than conservative treatments in terms of short-term and intermediate-term. Patients also reported more successful outcomes after receiving ESI when compared to conservative treatment. However, this effect was not maintained at long-term follow-up. This meta-analysis will help guide clinicians in making decisions for the treatment of patients with lumbosacral radicular pain, including the use of ESI, particularly in the management of pain at short-term.

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.

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.

Preganglionic Epidural Steroid Injection through Translateral Recess Approach

The approach we suggest was developed for cases in which the fourth and fifth lumbar and first sacral spinal nerves were affected in lumbar degenerative disc disease. Retrodiscal transforaminal epidural injection is known to be very effective for lumbar radiculopathy because of excellent access to primary pathology; however, access below L5 is often restricted by the anatomic characteristics of the L5-S1. In the translateral recess approach (TLR), proper final needle placement (i.e., in the axillary portion between the exiting and traversing nerve roots) can be achieved by setting the direction of the needle laterally and superiorly from the distal tip of the infra-adjacent spinous process toward the medial wall of the pedicle and neural foramen of the given level without neural injury. This approach is possible because of the wide interlaminar space in the L5-S1. Preganglionic epidural injection through TLR is an effective and safe spinal intervention for lumbosacral radiculopathy.

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.

Non-Specific Low Back Pain

BACKGROUND

For many years, low back pain has been both the leading cause of days lost from work and the leading indication for medical rehabilitation. The goal of the German Disease Management Guideline (NDMG) on nonspecific low back pain is to improve the treatment of patients with this condition.

METHODS

The current update of the NDMG on non-specific low back pain is based on articles retrieved by a systematic search of the literature for systematic reviews. Its recommendations for diagnosis and treatment were developed by a collaborative effort of 29 scientific medical societies and organizations and approved in a formal consensus process.

RESULTS

If the history and physical examination do not arouse any suspicion of a dangerous underlying cause, no further diagnostic evaluation is indicated for the time being. Passive, reactive measures should be taken only in combination with activating measures, or not at all. When drugs are used for symptomatic treatment, patients should be treated with the most suitable drug in the lowest possible dose and for as short a time as possible.

CONCLUSION

A physician should be in charge of the overall care process. The patient should be kept well informed over the entire course of his or her illness and should be encouraged to adopt a healthful lifestyle, including regular physical exercise.

Effect of Drugs Associated With Bleeding Tendency on the Complications and Outcomes of Transforaminal Epidural Steroid Injection

STUDY DESIGN

This is a retrospective case-control study.

OBJECTIVE

To evaluate the influence of medication-related bleeding tendency on the clinical outcomes and complications of transforaminal epidural steroid injection (TFESI).

SUMMARY OF BACKGROUND DATA

TFESI may result in serious complications such as epidural hematoma or adhesions in patients with medication-related bleeding tendency. However, little is known about the true relationship between medication-related bleeding tendency and postprocedural complications.

METHODS

Retrospective review of the medical records of patients who had TFESI from 2010 to 2014 was done. Commonly used medications such as warfarin, heparin, aspirin, clopidogrel, and Opalmon (limaprost alfadex) were included as medications associated with bleeding tendency. Patients were divided into 3 groups and the treatment outcomes for each group were compared: The first group used medications associated with bleeding tendency, but discontinued them in due time before the procedure (discontinued group). The second group used medications associated with bleeding tendency and continued receiving medication (continuing group). The third group did not use any medications associated with a bleeding tendency (nonmedicated group).

RESULTS

Among 2,469 patients, 1,234 were in the discontinued group, 408 patients in the continuing group, and 827 patients in the nonmedicated group. There were no statistically significant differences between groups for the treatment outcomes such as the degree of pain relief, duration of improvement, and complication rates including symptomatic epidural hematoma. Moreover, for the discontinued group and continuing group, the treatment outcomes were compared among patients with same medication, and revealed no differences.

CONCLUSIONS

This study demonstrated that continued use of medications associated with bleeding tendency does not increase epidural hematoma or symptomatic exacerbation, and thus should not be considered as a contraindication for TFESI.

LEVEL OF EVIDENCE

Level 3.

Failed back surgery syndrome: current perspectives

The treatment of failed back surgery syndrome (FBSS) can be equally challenging to surgeons, pain specialists, and primary care providers alike. The onset of FBSS occurs when surgery fails to treat the patient's lumbar spinal pain. Minimizing the likelihood of FBSS is dependent on determining a clear etiology of the patient's pain, recognizing those who are at high risk, and exhausting conservative measures before deciding to go into a revision surgery. The workup of FBSS includes a thorough history and physical examination, diagnostic imaging, and procedures. After determining the cause of FBSS, a multidisciplinary approach is preferred. This includes pharmacologic management of pain, physical therapy, and behavioral modification and may include therapeutic procedures such as injections, radiofrequency ablation, lysis of adhesions, spinal cord stimulation, and even reoperations.

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.

Evaluation and Treatment of Low Back Pain: A Clinically Focused Review for Primary Care Specialists

Low back pain (LBP) is a leading cause of disability worldwide. In the absence of a classification system for pain syndromes, classification of LBP on the basis of the distribution of pain as axial (pain generally localized to the low back) or radicular neuropathic (pain radiating to the lower extremities) is relevant to clinical practice because the distribution of pain is often a corollary of frequently occurring disease processes involving the lumbar spine. Common sources of axial LBP include the intervertebral disc, facet joint, sacroiliac joint, and paraspinal musculature, whereas common sources of radicular pain include a herniated intervertebral disc and spinal stenosis. The accuracy of historical and physical examination findings has been established for sacroiliac joint pain, radiculopathy, and lumbar spinal stenosis. However, the accuracy of similar data, so-called red flags, for identifying the underlying medical sources of LBP has been overstated. Diagnostic imaging studies can be useful, and adherence to established guidelines can protect against overuse. Multiple pharmacological trials exist for the management of LBP; however, the long-term outcomes of commonly used drugs are mixed. For carefully selected patients with axial LBP, radiofrequency denervation techniques can provide sustained pain relief. In patients with radicular pain, transforaminal epidural steroid injections may provide short-term pain relief, but neurostimulation may confer more enduring benefits of refractory symptoms. Pain-related indications for commonly performed operations include spinal decompression for radicular symptoms as well as spinal fusion or disc prosthesis for discogenic LBP. Physical modalities and psychological treatments can improve pain and functioning, but patient preferences may influence treatment adherence.

Unnecessary multiple epidural steroid injections delay surgery for massive lumbar disc: Case discussion and review

Background:

Epidural steroid injections (ESI) in the lumbar spine are not effective over the long-term for resolving “surgical” lesions. Here, we present a patient with a massive L2–L3 lumbar disk herniation whose surgery was delayed for 4 months by multiple unnecessary ESI, resulting in a cauda equina syndrome.

Methods:

A 54-year-old male acutely developed increased low back and radiating left leg pain in October of 2014. In December of 2014, a magnetic resonance imaging (MRI) scan showed a massive central/left sided disk herniation at the L2–L3 level resulting in marked thecal sac and left L2 foraminal and L3 lateral recess root compression. Despite the marked degree of neural compression, pain management treated him with 3 ESI over the next 3 months.

Results:

At the end of April of 2015, he presented to spine surgeon with a cauda equina syndrome. When the new MRI scan confirmed the previously documented massive central-left sided L2–L3 disk herniation, the patient emergently underwent an L1–L3 laminectomy with central-left sided L2–L3 lateral/foraminal diskectomy. Postoperatively, the patient was neurologically intact.

Conclusions:

Pain specialists performed multiple unnecessary lumbar ESI critically delaying spinal surgery for 4 months in this patient with a massive lumbar disk herniation who ultimately developed a cauda equina syndrome. Unfortunately, pain specialists (e.g., radiologists, anesthesiologists, and physiatrists), not specifically trained to perform neurological examinations or spinal surgery, are increasingly mismanaging spinal disease with ESI/variants. It is time for spine surgeons to speak out against this, and “take back” the care of patients with spinal surgical disease.