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Chae JS, Kim WJ, Choi SH. Effects of Local Anesthetics With or Without Steroids in High-Volume Transforaminal Epidural Blocks for Lumbar Disc Herniation: A Randomized, Double-Blind, Controlled Trial. J Korean Med Sci 2022; 37:e137. [PMID: 35502503 PMCID: PMC9062275 DOI: 10.3346/jkms.2022.37.e137] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/04/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Lumbar transforaminal epidural block (TFEB) is an effective treatment modality for radicular pain due to lumbar disc herniation (LDH). The addition of steroids is more effective than local anesthetic alone in TFEBs for patients with LDH. Moreover, the efficacy of TFEBs has been reported to be positively correlated with the volume of injectate. We hypothesized that high-volume TFEBs without steroids effectively alleviate axial back and radicular pain associated with LDH. This study compared the efficacy of high-volume TFEBs with vs. without steroids for the management of the axial and radicular pain caused by LDH. METHODS A total of 54 patients were randomly assigned to either group L or group D. Patients in group L received 8-mL injections of 0.33% lidocaine only. Patients in group D received 8-mL injections of 0.33% lidocaine with 5 mg of dexamethasone. The primary outcomes were pain intensity at baseline and 4 weeks after the procedure. The secondary outcomes included the change of functional disability between baseline and 4 weeks after the procedure, pain scores during injection, and adverse effects. RESULTS Both groups showed a significant reduction in axial and radicular pain and improvement in the functional status at the outpatient visit 4 weeks after TFEB. However, there were no significant differences between the groups in terms of changes in back pain (10.00 [20.00] vs. 10.00 [22.50]; P = 0.896) or radicular pain (5.00 [20.00] vs. 10.00 [12.50]; P = 0.871). CONCLUSION High-volume TFEBs with and without steroid administration yielded similar significant pain reductions and functional improvements among LDH patients 4 weeks after the procedure.
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Affiliation(s)
- Ji Seon Chae
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Won-Joong Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, Korea.
| | - Se Hee Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Ewha Womans University Mokdong Hospital, Seoul, Korea
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Kwak DG, Lee DG. Sequential Activation of AMPA Receptors and Glial Cells in a Pain Model of Lumbar Spine Disc Herniation. Ann Rehabil Med 2020; 44:343-352. [PMID: 32986944 PMCID: PMC7655227 DOI: 10.5535/arm.19202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/11/2020] [Indexed: 12/01/2022] Open
Abstract
Objective To investigate the glial cell and AMPA (alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) receptor activity after surgery for disc herniation pain model. Methods In total, 83 Sprague-Dawley rats were randomly assigned to the following groups: control (n=16), sham-operated (n=4), rats for pain behavior evaluation (n=3), nucleus pulposus-exposed groups for AMPA receptors (n=30), and glial cell (n=30). The rats were tested for mechanical allodynia; immunohistochemical staining for AMPA receptors (GluA1 and GluA2) and glial cells (OX-42 and glial fibrillary acid protein [GFAP]) in the spinal dorsal horn was performed on postoperative days 3, 7, and 14. Results Mechanical withdrawal thresholds decreased after surgery, and this effect was maintained for up to 14 days. Immunohistochemical expression of GluA1 and GluA2 in the spinal dorsal horn had increased quantitatively on postoperative days 3 and 7 (p<0.05) to levels similar to that of the controls on postoperative day 14. Moreover, immunohistochemical expression of OX-42 and GFAP showed similar changes to AMPA receptors after surgery. Although the activity of AMPA receptors and glial cells achieved normalcy, the mechanical withdrawal threshold of the hind paw remained decreased 38 days after surgery. Conclusion The rat model of lumbar disc herniation showed increased expression of AMPA receptor and glial cell activity in the spinal dorsal horn 3 and 7 days after surgery, which deceased to control levels at 14 days. The AMPA receptors and glial cell activations showed similar patterns after disc herniation surgery.
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Affiliation(s)
- Dong Gyu Kwak
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea
| | - Dong Gyu Lee
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea
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Abstract
PURPOSE OF REVIEW Myofascial pain syndrome (MPS) is a musculoskeletal pain condition that stems from localized, taut regions of skeletal muscle and fascia, termed trigger points. The purpose of this comprehensive review is to provide updated information on prevalence, pathophysiology, and treatment modalities with a focus on interventional modalities in managing MPS. RECENT FINDINGS Though MPS can present acutely, it frequently presents as a chronic condition, affecting up to 85% of adults during their lifetime. MPS is an often-overlooked component of pain with overarching effects on society, including patient quality of life, physical and social functioning, emotional well-being, energy, and costs on health care. The prevalence of MPS is generally increased among patients with other chronic pain disorders and has been associated with various other conditions such as bladder pain syndrome, endometriosis, and anxiety. MPS is poorly understood and remains a challenging condition to treat. Non-pharmacologic treatment modalities such as acupuncture, massage, transcutaneous electrical stimulation, and interferential current therapy may offer relief to some patients with MPS. Additional studies are warranted to get a better understanding of managing myofascial pain.
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Does Epidural Bupivacaine with or Without Steroids Provide Long-Term Relief? A Systematic Review and Meta-analysis. Curr Pain Headache Rep 2020; 24:26. [DOI: 10.1007/s11916-020-00859-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Urits I, Hasegawa M, Orhurhu V, Peck J, Kelly AC, Kaye RJ, Orhurhu MS, Brinkman J, Giacomazzi S, Foster L, Manchikanti L, Kaye AD, Viswanath O. Minimally Invasive Treatment of Chronic Ankle Instability: a Comprehensive Review. Curr Pain Headache Rep 2020; 24:8. [PMID: 32020393 DOI: 10.1007/s11916-020-0840-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Chronic ankle pain is a prevalent and significant cause of chronic pain. While the definition of chronic ankle pain is heterogeneous and poorly defined in the literature, systematic reviews and meta-analyses have estimated this condition to be a prevalent and debilitating source of chronic pain. The most identifiable and prominent cause of chronic ankle pain is chronic ankle instability (CAI), a condition defined by instability of the ankle-joint complex. It is a common consequence of lateral ankle sprains or ligamentous injuries and can be described as a failure of the lateral ankle joint complex after an acute, or recurring, ankle injury. The objective of this manuscript is to provide a comprehensive review of CAI diagnosis and our current understanding of minimally invasive treatment options. RECENT FINDINGS First-line treatment is conservative management, some of which includes neuromuscular rehabilitation, balance training, nonsteroidal anti-inflammatory drugs (NSAIDs), manual mobilization, ice therapy, and compression. While conservative management is effective, additional treatments for those who fail conservative management, or who seek alternative options also have been explored. Recent advances and modern techniques have expanded available treatment options, many of which are becoming less invasive, and have shown improving functionality, recovery, and patient satisfaction. Minimally invasive treatments highlighted in this review include: arthroscopic surgery, steroid injections, plasma-rich plasma injections, hyaluronic acid (HA) injections, medicinal signaling cell injections, radiofrequency therapies, and shockwave therapies. This review will discuss some of these current treatments for minimally invasive treatment of CAI, as well as suggest novel treatments for clinical trials and further investigation.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Morgan Hasegawa
- Creighton University School of Medicine at Regional Campus St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Vwaire Orhurhu
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Jacquelin Peck
- Mount Sinai Medical Center of Florida, Department of Anesthesiology, Miami Beach, FL, USA
| | - Angele C Kelly
- Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, USA
| | - Rachel J Kaye
- Medical University of South Carolina, Charleston, SC, USA
| | - Mariam Salisu Orhurhu
- Department of Anesthesia, Critical Care, and Pain Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Joseph Brinkman
- Creighton University School of Medicine at Regional Campus St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Stephen Giacomazzi
- Creighton University School of Medicine at Regional Campus St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Lukas Foster
- Creighton University School of Medicine at Regional Campus St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | | | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Phoenix, AZ, USA.,Department of Anesthesiology, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
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Cho JH, Lee DG. Translocation of AMPA Receptors in the Dorsal Horn of the Spinal Cord Corresponding to Long-term Depression Following Pulsed Radiofrequency Stimulation at the Dorsal Root Ganglion. PAIN MEDICINE 2019; 21:1913-1920. [DOI: 10.1093/pm/pnz307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Objective
Pulsed radiofrequency stimulation at the dorsal root ganglion is used for treatment of radicular pain; however, its mechanism for neuropathic pain treatment has not been fully elucidated. Here, we investigated whether pulsed radiofrequency stimulation affects the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors, which play a critical role in synaptic plasticity.
Methods
Neuropathic pain was studied using a radicular neuropathic pain model (43 female Sprague-Dawley rats; 200–250 g). In total, 28 rats were assigned to the following groups for fraction analysis: a control group, a control + pulsed radiofrequency stimulation group, a disc pain group, and a disc pain + pulsed radiofrequency stimulation group. For nonfraction analysis of Glutamate A1 (GluA1) and GluA2 subunits, a total of 15 female Sprague-Dawley rats were assigned to a control group, a disc pain group, and a disc pain + pulsed radiofrequency stimulation group. Pulsed radiofrequency stimulation and subsequent analysis were conducted three days after surgery.
Results
AMPA receptor subunits, GluA1 and GluA2, in the radicular neuropathic pain model were upregulated compared with those in the control group three days after surgery. Pulsed radiofrequency stimulation induced the translocation of GluA1 and GluA2 subunits from the synaptosome to cytosol without a change in the total amount of AMPA receptors in the dorsal horn.
Conclusions
Our results demonstrated that pulsed radiofrequency stimulation affected the synaptic plasticity corresponding to long-term depression. Thus, we show that long-term depression from pulsed radiofrequency stimulation is associated with analgesic effects in the radicular neuropathic pain model following peripheral inflammation.
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Affiliation(s)
- Jang Hyuk Cho
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Dong Gyu Lee
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, Republic of Korea
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Manchikanti L, Malla Y, Cash KA, Pampati V, Hirsch JA. Comparison of effectiveness for fluoroscopic cervical interlaminar epidural injections with or without steroid in cervical post-surgery syndrome. Korean J Pain 2018; 31:277-288. [PMID: 30310553 PMCID: PMC6177539 DOI: 10.3344/kjp.2018.31.4.277] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 09/16/2018] [Indexed: 12/12/2022] Open
Abstract
Background Neck and back pain are leading sources of disability placing substantial burden on health care systems. Surgical interventions in managing chronic neck pain secondary to various disorders continue to increase. Even though surgical interventions are effective, a significant proportion of patients continue to have symptomatology and develop cervical post-surgery syndrome. This study was performed to know the effectiveness of cervical interlaminar epidural injections with or without steroids. Methods The effectiveness of fluoroscopic cervical interlaminar epidural injections in post-surgery syndrome was evaluated in a randomized, active controlled trial. The study population included 116 patients assigned to 2 groups. Group 1 received cervical interlaminar epidural injections with local anesthetic alone and Group 2 received injection with local anesthetic and steroids. The main outcomes were defined as significant improvement (greater than 50%) of pain relief using the numeric rating scale and/or functional status improvement using the Neck Disability Index (NDI). Results Both groups had similar results with significant improvement (≥ 50% pain relief and functional status improvement) in 69% of the patients in Group I, whereas, in Group II, 71% of the patients showed significant improvement at the end of 2 years. During a 2-year period, the average number of procedures was 5 to 6, with an average of approximately 12 weeks of significant improvement per procedure. Conclusions Fluoroscopic cervical interlaminar epidural injections administered in cervical post-surgery syndrome using local anesthetic, regardless of the use of steroids, may be effective in approximately 70% of the patients at 2-year follow-up.
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Affiliation(s)
| | - Yogesh Malla
- Pain Management Center of Paducah, Paducah, Kentucky, USA
| | - Kimberly A Cash
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Vidyasagar Pampati
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Sencan S, Ozcan-Eksi EE, Cil H, Tay B, Berven S, Burch S, Deviren V, Demir-Deviren S. The effect of transforaminal epidural steroid injections in patients with spondylolisthesis. J Back Musculoskelet Rehabil 2018; 30:841-846. [PMID: 28372316 DOI: 10.3233/bmr-160543] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Transforaminal epidural steroid injection (TFE) is a widely accepted non-surgical treatment for pain in patients with spondylolisthesis. However, the effectiveness of TFE has not been compared in patients with degenerative (DS) and isthmic spondylolisthesis (IS). OBJECTIVE To compare the effectiveness of bilateral TFEs in DS and IS. METHODS Patients who underwent bilateral TFEs for spondylolisthesis at University of California San Francisco Orthopaedic Institute from 2009 to 2014 were evaluated retrospectively. RESULTS DS patients (120 female, 51 male) were significantly older and had higher comorbidity than those with IS (18 female, 14 male). They had better pain relief after TFE than patients with IS (72.11 ± 27.46% vs 54.39 ± 34.31%; p = 0.009). The number of TFEs, the mean duration of pain relief after TFE, follow-up periods, translation and facet joint widening were similar in DS and IS groups (p > 0.05). DS group had higher successful treatment rate (66.1% vs 46.9%, p = 0.009) and longer duration of pain relief (181.29 ± 241.37 vs 140.07 ± 183.62 days, p = 0.065) compared to IS group. CONCLUSIONS Bilateral TFEs at the level of spondylolisthesis effectively decreased pain in patients. TFEs provided better pain relief for longer duration in patients with DS than for those with IS.
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Affiliation(s)
- Savas Sencan
- Department of Physical Medicine and Rehabilitation, Marmara University, Pain Management, Istanbul, Turkey
| | - Emel E Ozcan-Eksi
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Hemra Cil
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Bobby Tay
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Sigurd Berven
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Shane Burch
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Sibel Demir-Deviren
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
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9
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Epidural Injection With or Without Steroid in Managing Chronic Low-Back and Lower Extremity Pain: A Meta-Analysis of 10 Randomized Controlled Trials. Am J Ther 2017; 24:e259-e269. [DOI: 10.1097/mjt.0000000000000265] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Sharma AK, Vorobeychik Y, Wasserman R, Jameson J, Moradian M, Duszynski B, Kennedy DJ. The Effectiveness and Risks of Fluoroscopically Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data. PAIN MEDICINE 2017; 18:239-251. [PMID: 28204730 DOI: 10.1093/pm/pnw131] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective To determine the effectiveness and risks of fluoroscopically guided lumbar interlaminar epidural steroid injections. Design Systematic review of the literature with comprehensive analysis of the published data. Interventions Three reviewers with formal training in evidence-based medicine searched the literature on fluoroscopically guided lumbar interlaminar epidural steroid injections. A larger team consisting of five reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented. Outcome Measures The primary outcome assessed was pain relief. Other outcomes such as functional improvement, reduction in surgery rate, decreased use of opioids/medications, and complications were noted, if reported. The evidence on each outcome was appraised in accordance with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system of evaluating evidence. Results The search yielded 71 primary publications addressing fluoroscopically guided lumbar interlaminar epidural steroid injections. There were no explanatory studies and all pragmatic studies identified were of low quality, yielding evidence comparable to observational studies. Conclusions The body of evidence regarding effectiveness of fluoroscopically guided interlaminar epidural steroid injection is of low quality according to GRADE. Studies suggest a lack of effectiveness of fluoroscopically guided lumbar interlaminar epidural steroid injections in treating primarily axial pain regardless of etiology. Most studies on radicular pain due to lumbar disc herniation and stenosis do, however, report statistically significant short-term improvement in pain.
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Affiliation(s)
- Anil K Sharma
- Spine and Pain Centers, Shrewsbury, New Jersey, NJ, USA
| | - Yakov Vorobeychik
- Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Ronald Wasserman
- Back and Pain Center, University of Michigan, Ann Arbor, Michigan, MI, USA
| | | | | | | | - David J Kennedy
- Department of Orthopedics, Stanford University, Redwood City, California, USA
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11
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Vorobeychik Y, Sharma A, Smith CC, Miller DC, Stojanovic MP, Lobel SM, Valley MA, Duszynski B, Kennedy DJ. The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data. PAIN MEDICINE 2016; 17:2185-2202. [PMID: 28025354 DOI: 10.1093/pm/pnw091] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the effectiveness and risks of non-image-guided lumbar interlaminar epidural steroid injections. DESIGN Systematic review. INTERVENTIONS Three reviewers with formal training and certification in evidence-based medicine searched the literature on non-image-guided lumbar interlaminar epidural steroid injections. A larger team of seven reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented. OUTCOME MEASURES The primary outcome assessed was pain relief. Other outcomes such as functional improvement, reduction in surgery rate, decreased use of opioids, and complications were noted, if reported. The evidence was appraised in accordance with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system of evaluating evidence. RESULTS The searches yielded 92 primary publications addressing non-image-guided lumbar interlaminar epidural steroid injections. The evidence supporting the effectiveness of these injections for pain relief and functional improvement in patients with lumbar radicular pain due to disc herniation or neurogenic claudication secondary to lumbar spinal stenosis is limited. This procedure may provide short-term benefit in the first 3-6 weeks. The small number of case reports on significant risks suggests these injections are relatively safe. In accordance with GRADE, the quality of evidence is very low. CONCLUSIONS In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, non-image-guided lumbar interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical practice, these procedures should be restricted to the rare settings where fluoroscopy is not available.
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Affiliation(s)
- Yakov Vorobeychik
- *Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
| | - Anil Sharma
- Spine and Pain Centers, New Jersey and New York
| | - Clark C Smith
- Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Milan P Stojanovic
- Anesthesiology, Critical Care and Pain Medicine Service, VA Boston Healthcare System, Boston, Massachusetts
| | - Steve M Lobel
- Medical Associates of North Georgia, Canton, Georgia
| | | | | | - David J Kennedy
- Department of Orthopedics, Stanford University, Redwood City, California, USA
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Liu J, Zhou H, Lu L, Li X, Jia J, Shi Z, Yao X, Wu Q, Feng S. The Effectiveness of Transforaminal Versus Caudal Routes for Epidural Steroid Injections in Managing Lumbosacral Radicular Pain: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2016; 95:e3373. [PMID: 27149443 PMCID: PMC4863760 DOI: 10.1097/md.0000000000003373] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Epidural steroid injection (ESI) is one of the most commonly used treatments for radiculopathy. Previous studies have described the effectiveness of ESI in the management of radiculopathy. However, controversy exists regarding the route that is most beneficial and effective with respect to the administration of epidural steroids, as both transforaminal (TF) and caudal (C) routes are commonly used.This analysis reviewed studies comparing the effectiveness of TF-ESIs with that of C-ESIs in the treatment of radiculopathy as a means of providing pain relief and improving functionality. This meta-analysis was performed to guide clinical decision-making.The study was a systematic review of comparative studies.A systematic literature search was performed using the PubMed, EMBASE, and Cochrane Library databases for trials written in English. The randomized trials and observational studies that met our inclusion criteria were subsequently included. Two reviewers, respectively, extracted data and estimated the risk of bias. All statistical analyses were performed using Review Manager 5.3.Six prospective and 2 retrospective studies involving 664 patients were included. Statistical analysis was performed utilizing only the 6 prospective studies. Although slight pain and functional improvements were noted in the TF-ESI groups compared with the C-ESI groups, these improvements were neither clinically nor statistically significant.The limitations of this meta-analysis resulted primarily from the weaknesses of the comparative studies and the relative paucity of patients included in each study.Both the TF and C approaches are effective in reducing pain and improving functional scores, and they demonstrated similar efficacies in the management of lumbosacral radicular pain.
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Affiliation(s)
- Jun Liu
- From the Department of Orthopedics (JL, HZ, LL, JJ, ZS, XY, QW, SF), Tianjin Medical University General Hospital, No. 154 Anshan Road; Key Laboratory of Immuno Microenvironment and Disease of the Educational Ministry of China (XL), Department of Immunology, Tianjin Medical University, No. 22 Qixiangtai Road, Heping District; and Department of Orthopedic Trauma (JJ), Tianjin Hospital, No. 406 Jiefangnan Road, Hexi District, Tianjin, PR China
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Boswell MV, Manchikanti L. Appropriate design, methodological quality assessment, and clinically relevant outcomes are essential to determine the therapeutic role of epidural injections for low back pain and radiculopathy. ACTA ACUST UNITED AC 2016; 21:89. [PMID: 26887421 DOI: 10.1136/eb-2015-110310] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Mark V Boswell
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, Kentucky, USA; University of Louisville, Louisville, Kentucky, USA
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Grava ALDS, Ferrari LF, Parada CA, Defino HLA. EVALUATION OF HYPERALGESIA AND HISTOLOGICAL CHANGES OF DORSAL ROOT GANGLION INDUCED BY NUCLEUS PULPOSUS. Rev Bras Ortop 2015; 45:460-7. [PMID: 27022595 PMCID: PMC4799083 DOI: 10.1016/s2255-4971(15)30436-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
To evaluate the hyperalgesia and histological abnormalities induced by contact between the dorsal root ganglion and the nucleus pulposus. Methods: Twenty Wistar rats were used, divided into two experimental groups. In one of the groups, a fragment of autologous nucleus pulposus was removed from the sacrococcygeal region and deposited on the L5 dorsal root ganglia. In the other group (control), a fragment of adipose tissue was deposited on the L5 dorsal root ganglia. Mechanical and thermal hyperalgesia was evaluated on the third day and the first, third, fifth and seventh weeks after the operation. A L5 dorsal root ganglion was removed in the first, third, fifth and seventh weeks after the operation for histological study using HE staining and histochemical study using specific labeling for iNOS. Results: Higher intensity of mechanical and thermal hyperalgesia was observed in the group of animals in which the nucleus pulposus was placed in contact with the dorsal root ganglion. In this group, the histological study showed abnormalities of the dorsal root ganglion tissue, characterized by an inflammatory process and axonal degeneration. The histopathological abnormalities of the dorsal root ganglion tissue presented increasing intensity with increasing length of observation, and there was a correlation with maintenance of the hyperalgesia observed in the behavioral assessment. Immunohistochemistry using specific labeling for iNOS in the group of animals in which the nucleus pulposus was placed in contact with the dorsal root ganglion showed higher expression of this enzyme in the nuclei of the inflammatory cells (glial cells) surrounding the neurons. Conclusion: Contact between the nucleus pulposus and the dorsal root ganglion induced mechanical and thermal hyperalgesia and caused histological abnormalities in the dorsal root ganglion components. These abnormalities were characterized by an inflammatory and degenerative process in the structures of the dorsal root ganglion, and they presented increasing intensity with longer periods of observation.
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Affiliation(s)
- André Luiz de Souza Grava
- Postgraduate student in the Department of Biomechanics, Medicine and Rehabilitation of the Locomotor Apparatus, Ribeirão Preto School of Medicine, University of São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Luiz Fernando Ferrari
- Postgraduate student in the Department of Pharmacology, Ribeirão Preto School of Medicine, University of São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Carlos Amílcar Parada
- Supervising Professor in the Department of Pharmacology, Ribeirão Preto School of Medicine, University of São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Helton Luiz Aparecido Defino
- Titular Professor of the Department of Biomechanics, Medicine and Rehabilitation of the Locomotor Apparatus, Ribeirão Preto School of Medicine, University of São Paulo (USP), Ribeirão Preto, SP, Brazil
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Manchikanti L, Hirsch JA, Kaye AD, Boswell MV. Cervical zygapophysial (facet) joint pain: effectiveness of interventional management strategies. Postgrad Med 2015; 128:54-68. [PMID: 26653406 DOI: 10.1080/00325481.2016.1105092] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diagnostic facet joint nerve blocks have been utilized in the diagnosis of cervical facet joint pain in patients without disk herniation or radicular pain due to a lack of reliable noninvasive diagnostic measures. Therapeutic interventions include intra-articular injections, facet joint nerve blocks and radiofrequency neurotomy. The diagnostic accuracy and effectiveness of facet joint interventions have been assessed in multiple diagnostic accuracy studies, randomized controlled trials (RCTs), and systematic reviews in managing chronic neck pain. This assessment shows there is Level II evidence based on a total of 11 controlled diagnostic accuracy studies for diagnosing cervical facet joint pain in patients without disk herniation or radicular pain utilizing controlled diagnostic blocks. Due to significant variability and internal inconsistency regarding prevalence in a heterogenous population; despite 11 studies, evidence is determined as Level II. Prevalence ranged from 36% to 67% with at least 80% pain relief as the criterion standard with a false-positive rate ranging from 27% to 63%. The evidence is Level II for the long-term effectiveness of radiofrequency neurotomy and facet joint nerve blocks in managing cervical facet joint pain. There is Level III evidence for cervical intra-articular injections.
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Affiliation(s)
- Laxmaiah Manchikanti
- a Pain Management Center of Paducah , Paducah , KY , USA.,b Department of Anesthesiology and Perioperative Medicine , University of Louisville , Louisville , KY , USA
| | - Joshua A Hirsch
- c Neuroendovascular Program , Massachusetts General Hospital , Boston , MA , USA
| | - Alan D Kaye
- d Department of Anesthesia , LSU Health Science Center , New Orleans , LA , USA
| | - Mark V Boswell
- b Department of Anesthesiology and Perioperative Medicine , University of Louisville , Louisville , KY , USA
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Zanon IDB, Jacob Júnior C, Cardoso IM, Batista Júnior JL, Maia TC, Brazolino MAN, Debom TG. COMPARISON OF THE EFFECTIVENESS OF RADICULAR BLOCKING TECHNIQUES IN THE TREATMENT OF LUMBAR DISK HERNIA. COLUNA/COLUMNA 2015. [DOI: 10.1590/s1808-185120151404152856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective : Compare the interlaminar blocking technique with the transforaminal blocking, with regard to pain and the presence or absence of complications. Methods : Prospective, descriptive and comparative, double-blind, randomized study, with 40 patients of both sex suffering from sciatic pain due to central-lateral or foraminal disc herniation, who did not respond to 20 physiotherapy sessions and had no instability diagnosed on examination of dynamic radiography. The type of blocking, transforaminal or interlaminar, to be performed was determined by draw. Results : We evaluated 40 patients, 17 males, mean age 49 years, average VAS pre-blocking of 8.85, average values in transforaminal technique in 24 hours, 7, 21, and 90 days of 0.71, 1.04, 2.33 and 3.84, respectively; the average VAS post-blocking for interlaminar technique was 0.89, 1.52, 3.63 and 4.88. The techniques differ only in the post-blocking period of 21 days and overall post-blocking, with significance of p=0.022 and p=0.027, respectively. Conclusion : Both techniques are effective in relieving pain and present low complication rate, and the transforaminal technique proved to be the most effective.
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Thalidomide represses inflammatory response and reduces radiculopathic pain by inhibiting IRAK-1 and NF-κB/p38/JNK signaling. J Neuroimmunol 2015; 290:1-8. [PMID: 26711561 DOI: 10.1016/j.jneuroim.2015.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 11/10/2015] [Accepted: 11/12/2015] [Indexed: 01/07/2023]
Abstract
Intervertebral disc (IVD) disease, the most common cause of disc failure and low back pain, is characterized by age-related changes in the adult disc. In this study we aimed to analyze the potential of thalidomide for the treatment of IVD disease, through identifying and explaining its anti-inflammatory and anti-catabolic activity in both in vitro IVD cell culture and in vivo animal model. Inflammatory response was induced by IL-1β, then the activity and expression of inflammatory mediators and pathways were assessed in the presence or absence of thalidomide. The p38 inhibitor SB203580 was also used to investigate the involvement of the MAPK pathway in the observed effects. Moreover the analgesic properties of thalidomide were analyzed by the von Frey filament test in Sprague-Dawley rats. Our results indicated that thalidomide significantly inhibited the expression of pro-inflammatory mediators and matrix metalloproteinases in vitro, as well as radiculopathic pain in vivo, most probably by modulation of the activity of IRAK-1 and its downstream effectors p38, JNK and NF-κB. Our current study strongly supports the potential of thalidomide for the treatment of pain and inflammation in degenerative disc disease.
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Handa J, Sekiguchi M, Krupkova O, Konno SI. The effect of serotonin–noradrenaline reuptake inhibitor duloxetine on the intervertebral disk-related radiculopathy in rats. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:877-87. [DOI: 10.1007/s00586-015-4239-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 08/17/2015] [Accepted: 09/10/2015] [Indexed: 01/23/2023]
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Tanshinone IIA represses inflammatory response and reduces radiculopathic pain by inhibiting IRAK-1 and NF-κB/p38/JNK signaling. Int Immunopharmacol 2015; 28:382-9. [PMID: 26163178 DOI: 10.1016/j.intimp.2015.06.032] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 06/11/2015] [Accepted: 06/29/2015] [Indexed: 11/23/2022]
Abstract
Intervertebral disc (IVD) disease, a most common cause of disc failure and low back pain, is characterized by age-related changes in the adult disc. In this study we aimed to investigate the potential of Tanshinone IIA (TSA) for the treatment of IVD disease, through exploring its anti-inflammatory and anti-catabolic activities in both in vitro IVD cell culture and in vivo animal models. After the inflammatory response was induced in IVD cells by IL-1β, the activity and expression of inflammatory mediators, and potentially involved pathways were investigated in the presence or absence of TSA. The p38-MAPK inhibitor, SB239063, was also used to investigate the involvement of the MAPK signaling pathway in the observed effects. Meanwhile, the analgesic properties of TSA were analyzed by the von Frey filament test in Sprague-Dawley rats. Our results indicated that TSA significantly inhibited the expression of pro-inflammatory mediators and matrix metalloproteinases in vitro, as well as radiculopathic pain in vivo, probably by modulation of the activity of interleukin-1 receptor-associated kinase 1 (IRAK-1) and its downstream effectors p38, JNK and NF-κB. Our current study strongly demonstrates the potential of TSA for the treatment of inflammation and followed pain in degenerative disc disease.
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Manchikanti L, Benyamin RM, Falco FJE, Kaye AD, Hirsch JA. Do Epidural Injections Provide Short- and Long-term Relief for Lumbar Disc Herniation? A Systematic Review. Clin Orthop Relat Res 2015; 473:1940-56. [PMID: 24515404 PMCID: PMC4419020 DOI: 10.1007/s11999-014-3490-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Laxmaiah Manchikanti
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA,
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Manchikanti L, Nampiaparampil DE, Manchikanti KN, Falco FJ, Singh V, Benyamin RM, Kaye AD, Sehgal N, Soin A, Simopoulos TT, Bakshi S, Gharibo CG, Gilligan CJ, Hirsch JA. 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. Surg Neurol Int 2015; 6:S194-235. [PMID: 26005584 PMCID: PMC4431057 DOI: 10.4103/2152-7806.156598] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 12/14/2015] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Laxmaiah Manchikanti
- Medical Director of the Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, KY, 42003, and Clinical Professor, Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | | | - Kavita N. Manchikanti
- Fourth Year Resident in Department of Physical Medicine and Rehabilitation at the University of Kentucky, Lexington, KY, USA
| | - Frank J.E. Falco
- Medical Director of Mid Atlantic Spine and Pain Physicians, Newark, DE, Pain Medicine Fellowship Program, Temple University Hospital, Philadelphia, PA, Department of PM and R, Temple University Medical School, Philadelphia, PA, USA
| | - Vijay Singh
- Medical Director, Spine Pain Diagnostics Associates, Niagara, WI, USA
| | - Ramsin M. Benyamin
- Medical Director, Millennium Pain Center, Bloomington, IL, and Clinical Assistant Professor of Surgery, College of Medicine, University of Illinois, Urbana-Champaign, IL, USA
| | - Alan D. Kaye
- Department of Anesthesia, LSU Health Science Center, New Orleans, LA, USA
| | - Nalini Sehgal
- Interventional Pain Program, Professor and Director Pain Fellowship, Department of Orthopedics and Rehabilitation Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Amol Soin
- Ohio Pain Clinic, Centerville, OH, USA
| | - Thomas T. Simopoulos
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA., USA
| | - Sanjay Bakshi
- President of Manhattan Spine and Pain Medicine, Department of Anesthesiology, NYU Langone-Hospital for Joint Diseases, NYU School of Medicine, New York, NY, USA
| | - Christopher G. Gharibo
- Medical Director of Pain Medicine and Associate Professor of Anesthesiology and Orthopedics, Department of Anesthesiology, NYU Langone-Hospital for Joint Diseases, NYU School of Medicine, New York, NY, USA
| | - Christopher J. Gilligan
- Department of Anesthesia, Critical Care, and Pain Medicine at Beth Israel Deaconess Medical Center, Boston, MA, and Assistant Professor of Anesthesiology at Harvard Medical School, Harvard Medical School, Boston, MA, USA
| | - Joshua A. Hirsch
- Vice Chief of Interventional Care, Chief of Minimally Invasive Spine Surgery, Service Line Chief of Interventional Radiology, Director of Endovascular Neurosurgery and Neuroendovascular Program, Massachusetts General Hospital; and Associate Professor, Department of Radiology, Harvard Medical School, Boston, MA, USA
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Comparison of the efficacy of transforaminal and interlaminar radicular block techniques for treating lumbar disk hernia. Rev Bras Ortop 2015; 50:220-5. [PMID: 26229920 PMCID: PMC4519619 DOI: 10.1016/j.rboe.2015.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 12/05/2013] [Indexed: 12/29/2022] Open
Abstract
Objective To compare the interlaminar and transforaminal block techniques with regard to the state of pain and presence or absence of complications. Method This was a randomized double-blind prospective study of descriptive and comparative nature, on 40 patients of both sexes who presented lumbar sciatic pain due to central-lateral or foraminal disk hernias. The patients had failed to respond to 20 physiotherapy sessions, but did not present instability, as diagnosed in dynamic radiographic examinations. The type of block to be used was determined by means of a draw: transforaminal (group 1; 20 patients) or interlaminar (group 2; 20 patients). Results Forty patients were evaluated (17 males), with a mean age of 49 years. There was a significant improvement in the state of pain in all patients who underwent radicular block using both techniques, although the transforaminal technique presented better results than the interlaminar technique. Conclusion Both techniques were effective for pain relief and presented low complication rates, but the transforaminal technique was more effective than the interlaminar technique.
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Comparação da eficácia das técnicas transforaminal e interlaminar de bloqueio radicular feito no tratamento de hérnia de disco lombar. Rev Bras Ortop 2015. [DOI: 10.1016/j.rbo.2013.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Manchikanti L, Pampati V, Benyamin RM, Boswell MV. Analysis of efficacy differences between caudal and lumbar interlaminar epidural injections in chronic lumbar axial discogenic pain: local anesthetic alone vs. local combined with steroids. Int J Med Sci 2015; 12:214-22. [PMID: 25678838 PMCID: PMC4323359 DOI: 10.7150/ijms.10870] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 12/30/2014] [Indexed: 12/13/2022] Open
Abstract
STUDY DESIGN Comparative assessment of randomized controlled trials of caudal and lumbar interlaminar epidural injections in chronic lumbar discogenic pain. OBJECTIVE To assess the comparative efficacy of caudal and lumbar interlaminar approaches of epidural injections in managing axial or discogenic low back pain. SUMMARY OF BACKGROUND DATA Epidural injections are commonly performed utilizing either a caudal or lumbar interlaminar approach to treat chronic lumbar axial or discogenic pain, which is pain exclusive of that associated with a herniated intervertebral disc, or that is due to degeneration of the zygapophyseal joints, or due to dysfunction of the sacroiliac joints, respectively. The literature on the efficacy of epidural injections in managing chronic axial lumbar pain of presumed discogenic origin is limited. METHODS The present analysis is based on 2 randomized controlled trials of chronic axial low back pain not caused by disc herniation, radiculitis, or facet joint pain, utilizing either a caudal or lumbar interlaminar approach, with a total of 240 patients studied, and a 24-month follow-up. Patients were assigned to receive either local anesthetic only or local anesthetic with a steroid in each 60 patient group. RESULTS The primary outcome measure was significant improvement, defined as pain relief and functional status improvement of at least 50% from baseline, which was reported at 24-month follow-ups in 72% who received local anesthetic only with a lumbar interlaminar approach and 54% who received local anesthetic only with a caudal approach. In patients receiving local anesthetic with a steroid, the response rate was 67% for those who had a lumbar interlaminar approach and 68% for those who had a caudal approach at 12 months. The response was significantly better in the lumbar interlaminar group who received local anesthetic only, 77% versus 56% at 12 months and 72% versus 54% at 24 months. CONCLUSION This assessment shows that in patients with axial or discogenic pain in the lumbar spine after excluding facet joint and SI Joint pain, epidural injections of local anesthetic by the caudal or lumbar interlaminar approach may be effective in managing chronic low back pain with a potential superiority for a lumbar interlaminar approach over a caudal approach.
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Affiliation(s)
| | | | - Ramsin M Benyamin
- 2. Millennium Pain Center, Bloomington, College of Medicine, University of Illinois, Urbana-Champaign, IL, USA
| | - Mark V Boswell
- 1. The Pain Management Center of Paducah, Paducah, KY, USA. ; 3. Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
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Manchikanti L, Cash KA, Pampati V, Malla Y. Two-year follow-up results of fluoroscopic cervical epidural injections in chronic axial or discogenic neck pain: a randomized, double-blind, controlled trial. Int J Med Sci 2014; 11:309-20. [PMID: 24578607 PMCID: PMC3936024 DOI: 10.7150/ijms.8069] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 01/01/2014] [Indexed: 02/07/2023] Open
Abstract
STUDY DESIGN A randomized, double-blind, active-controlled trial. OBJECTIVE To assess the effectiveness of cervical interlaminar epidural injections of local anesthetic with or without steroids for the management of axial or discogenic pain in patients without disc herniation, radiculitis, or facet joint pain. SUMMARY OF BACKGROUND DATA Cervical discogenic pain without disc herniation is a common cause of suffering and disability in the adult population. Once conservative management has failed and facet joint pain has been excluded, cervical epidural injections may be considered as a management tool. Despite a paucity of evidence, cervical epidural injections are one of the most commonly performed nonsurgical interventions in the management of chronic axial or disc-related neck pain. METHODS One hundred and twenty patients without disc herniation or radiculitis and negative for facet joint pain as determined by means of controlled diagnostic medial branch blocks were randomly assigned to one of the 2 treatment groups. Group I patients received cervical interlaminar epidural injections of local anesthetic (lidocaine 0.5%, 5 mL), whereas Group II patients received 0.5% lidocaine, 4 mL, mixed with 1 mL or 6 mg of nonparticulate betamethasone. The primary outcome measure was ≥ 50% improvement in pain and function. Outcome assessments included numeric rating scale (NRS), Neck Disability Index (NDI), opioid intake, employment, and changes in weight. RESULTS Significant pain relief and functional improvement (≥ 50%) was present at the end of 2 years in 73% of patients receiving local anesthetic only and 70% receiving local anesthetic with steroids. In the successful group of patients, however, defined as consistent relief with 2 initial injections of at least 3 weeks, significant improvement was illustrated in 78% in the local anesthetic group and 75% in the local anesthetic with steroid group at the end of 2 years. The results reported at the one-year follow-up were sustained at the 2-year follow-up. CONCLUSIONS Cervical interlaminar epidural injections with or without steroids may provide significant improvement in pain and functioning in patients with chronic discogenic or axial pain that is function-limiting and not related to facet joint pain.
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Affiliation(s)
- Laxmaiah Manchikanti
- 1. Pain Management Center of Paducah, Paducah, KY, USA; ; 2. Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | | | | | - Yogesh Malla
- 1. Pain Management Center of Paducah, Paducah, KY, USA
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Strong JA, Xie W, Bataille FJ, Zhang JM. Preclinical studies of low back pain. Mol Pain 2013; 9:17. [PMID: 23537369 PMCID: PMC3617092 DOI: 10.1186/1744-8069-9-17] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 03/18/2013] [Indexed: 12/12/2022] Open
Abstract
Chronic low back pain is a major cause of disability and health care costs. Current treatments are inadequate for many patients. A number of preclinical models have been developed that attempt to mimic aspects of clinical conditions that contribute to low back pain. These involve application of nucleus pulposus material near the lumbar dorsal root ganglia (DRG), chronic compression of the DRG, or localized inflammation of the DRG. These models, which are primarily implemented in rats, have many common features including behavioral hypersensitivity of the hindpaw, enhanced excitability and spontaneous activity of sensory neurons, and locally elevated levels of inflammatory mediators including cytokines. Clinically, epidural injection of steroids (glucocorticoids) is commonly used when more conservative treatments fail, but clinical trials evaluating these treatments have yielded mixed results. There are relatively few preclinical studies of steroid effects in low back pain models. One preclinical study suggests that the mineralocorticoid receptor, also present in the DRG, may have pro-inflammatory effects that oppose the activation of the glucocorticoid receptor. Although the glucocorticoid receptor is the target of anti-inflammatory steroids, many clinically used steroids activate both receptors. This could be one explanation for the limited effects of epidural steroids in some patients. Additional preclinical research is needed to address other possible reasons for limited efficacy of steroids, such as central sensitization or presence of an ongoing inflammatory stimulus in some forms of low back pain.
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Affiliation(s)
- Judith A Strong
- Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0531, USA
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Bartynski WS, Jennings RB, Rothfus WE, Agarwal V. Immediate pain response to interlaminar lumbar epidural steroid administration: response characteristics and effects of anesthetic concentration. AJNR Am J Neuroradiol 2013; 34:239-46. [PMID: 22766680 DOI: 10.3174/ajnr.a3170] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Interlaminar LESIs are commonly used to treat LBP or radiculopathy. Most studies focus on the long-term outcomes of LESI. The purpose of this study is to evaluate the immediate effects of fluoroscopically guided LESI on LBP/radiculopathy including low- or high-strength anesthetic response. MATERIALS AND METHODS The procedure notes, post-procedure records, and imaging records dedicated spine nurse assessments, and imaging records were retrospectively evaluated in 392 fluoroscopically guided LESIs performed in 276 patients (nonrandomized, nonblinded; 131 males, 145 females; average age, 56 years) with LBP/radiculopathy using either low- or high-strength anesthetic (80 mg of methylprednisilone mixed with bupivacaine [0.25% or 0.5%]). Post-procedure documentation of the patient's pre- and postprocedure VAS pain-scale level were tabulated. RESULTS Single LESI was performed in 199 patients, with multiple LESIs in 77 (193 injections). Low-strength bupivacaine (0.25%) was used in 237 injections, with high-strength (0.5%) in 155. Complete to near-complete immediate pain relief (<20% residual pain) was reported after 197 of 392 (50.3%) injections. No pain relief was reported after 60 (15.4%) injections (>80% residual), with partial relief in the remainder. No statistical difference was noted between low- and high-anesthetic strength or between single- and multiple-injection patients. In multiple-LESI patients, consistent pain relief response was noted in 39 of 77 (50.6%) patients, with improving LESI response in 20.8%, deteriorating LESI response in 19.5%, and variable response in 9.1%. CONCLUSIONS An immediate pain-extinction response is identified after LESI, which appears independent of anesthetic strength. This observation may relate to pain origin and/or pain nociceptor afferent pathway in an individual patient and potentially relate to treatment response.
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Affiliation(s)
- W S Bartynski
- Department of Radiology, Division of Neuroradiology, Presbyterian University Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
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Manchikanti L, Singh V, Cash KA, Pampati V, Falco FJE. The role of fluoroscopic interlaminar epidural injections in managing chronic pain of lumbar disc herniation or radiculitis: a randomized, double-blind trial. Pain Pract 2012; 13:547-58. [PMID: 23279452 DOI: 10.1111/papr.12023] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 11/06/2012] [Indexed: 01/03/2023]
Abstract
BACKGROUND There is continued debate on the effectiveness, indications, and medical necessity of epidural injections in managing pain and disability from lumbar disc herniation, despite extensive utilization. There is paucity of literature on interlaminar epidural injections in managing lumbar disc herniation or radiculitis in contemporary interventional pain management settings utilizing fluoroscopy. METHODS A randomized, double-blind, active-control trial was undertaken to assess the effectiveness of lumbar interlaminar epidural injections with or without steroids for disc herniation and radiculitis. The primary outcome was defined as pain relief and functional status improvement of ≥ 50%. One hundred twenty patients were randomly assigned to 1 of the 2 groups. Group I patients received lumbar interlaminar injections containing a local anesthetic (lidocaine 0.5%, 6 mL), whereas Group II patients received lumbar interlaminar epidural injections of 0.5% lidocaine, 5 mL, mixed with 1 mL of non-particulate betamethasone. RESULTS In the patients who responded with initial 2 procedures with at least 3 weeks of relief, significant improvement was seen in 80% of the patients in the local anesthetic group and 86% of the patients in the local anesthetic and steroid group. The overall average procedures per year were 3.6 in the local anesthetic group and 4.1 in the local anesthetic and steroid group, with an average relief of 33.7 ± 18.1 weeks in the local anesthetic group and 39.1 ± 12.2 weeks in the local anesthetic and steroid group over a period of 52 weeks in the overall population. CONCLUSIONS Lumbar interlaminar epidural injections of local anesthetic with or without steroids might be effective in patients with disc herniation or radiculitis, with potential superiority of steroids compared with local anesthetic alone at 1 year follow-up.
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Manchikanti L, Singh V, Cash KA, Pampati V. Assessment of effectiveness of percutaneous adhesiolysis and caudal epidural injections in managing post lumbar surgery syndrome: 2-year follow-up of a randomized, controlled trial. J Pain Res 2012; 5:597-608. [PMID: 23293536 PMCID: PMC3533727 DOI: 10.2147/jpr.s38999] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background The literature is replete with evaluations of failed surgery, illustrating a 9.5%–25% reoperation rate. Speculated causes of post lumbar surgery syndrome include epidural fibrosis, acquired stenosis, recurrent disc herniation, sacroiliac joint pain, and facet joint pain among other causes. Methods Patients (n = 120) were randomly assigned to two groups with a 2-year follow-up. Group I (control group, n = 60) received caudal epidural injections with catheterization up to S3 with local anesthetic (lidocaine 2%, 5 mL), nonparticulate betamethasone (6 mg, 1 mL), and 6 mL of 0.9% sodium chloride solution. Group II (intervention group, n = 60) received percutaneous adhesiolysis of the targeted area, with targeted delivery of lidocaine 2% (5 mL), 10% hypertonic sodium chloride solution (6 mL), and nonparticulate betamethasone (6 mg). The multiple outcome measures included the Numeric Rating Scale, the Oswestry Disability Index 2.0, employment status, and opioid intake with assessments at 3, 6, 12, 18, and 24 months posttreatment. Primary outcome was defined as 50% improvement in pain and Oswestry Disability Index scores. Results Significant improvement with at least 50% relief with pain and improvement in functional status was illustrated in 82% of patients at the 2-year follow-up in the intervention group compared to 5% in the control group receiving caudal epidural injections. The average number of procedures over a period of 2 years in Group II was 6.4 ± 2.35 with overall total relief of approximately 78 weeks out of 104 weeks. Conclusion The results of this study show significant improvement in 82% of patients over a period of 2 years with an average of six to seven procedures of 1-day percutaneous adhesiolysis in patients with failed back surgery syndrome.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, KY ; Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY
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Manchikanti L, Cash KA, McManus CD, Pampati V. Assessment of effectiveness of percutaneous adhesiolysis in managing chronic low back pain secondary to lumbar central spinal canal stenosis. Int J Med Sci 2012; 10:50-9. [PMID: 23289005 PMCID: PMC3534877 DOI: 10.7150/ijms.5303] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 11/13/2012] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Chronic persistent low back and lower extremity pain secondary to central spinal stenosis is common and disabling. Lumbar surgical interventions with decompression or fusion are most commonly performed to manage severe spinal stenosis. However, epidural injections are also frequently performed in managing central spinal stenosis. After failure of epidural steroid injections, the next sequential step is percutaneous adhesiolysis and hypertonic saline neurolysis with a targeted delivery. The literature on the effectiveness of percutaneous adhesiolysis in managing central spinal stenosis after failure of epidural injections has not been widely studied. STUDY DESIGN A prospective evaluation. SETTING An interventional pain management practice, a specialty referral center, a private practice setting in the United States. OBJECTIVE To evaluate the effectiveness of percutaneous epidural adhesiolysis in patients with chronic low back and lower extremity pain with lumbar central spinal stenosis. METHODS Seventy patients were recruited. The initial phase of the study was randomized, double-blind with a comparison of percutaneous adhesiolysis with caudal epidural injections. The 25 patients from the adhesiolysis group continued with follow-up, along with 45 additional patients, leading to a total of 70 patients. All patients received percutaneous adhesiolysis and appropriate placement of the Racz catheter, followed by an injection of 5 mL of 2% preservative-free lidocaine with subsequent monitoring in the recovery room. In the recovery room, each patient also received 6 mL of 10% hypertonic sodium chloride solution, and 6 mg of non-particulate betamethasone, followed by an injection of 1 mL of sodium chloride solution and removal of the catheter. OUTCOMES ASSESSMENT Multiple outcome measures were utilized including the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3, 6, and 12, 18 and 24 months post treatment. The primary outcome measure was 50% or more improvement in pain scores and ODI scores. RESULTS Overall, a primary outcome or significant pain relief and functional status improvement of 50% or more was seen in 71% of patients at the end of 2 years. The overall number of procedures over a period of 2 years were 5.7 ± 2.73. LIMITATIONS The lack of a control group and a prospective design. CONCLUSIONS Significant relief and functional status improvement as seen in 71% of the 70 patients with percutaneous adhesiolysis utilizing local anesthetic steroids and hypertonic sodium chloride solution may be an effective management strategy in patients with chronic function limiting low back and lower extremity pain with central spinal stenosis after failure of conservatie management and fluoroscopically directed epidural injections.
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Affiliation(s)
- Laxmaiah Manchikanti
- 1. Pain Management Center of Paducah, Paducah, Kentucky, USA
- 2. University of Louisville, Louisville, Kentucky, USA
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Manchikanti L, Cash KA, McManus CD, Pampati V. Fluoroscopic caudal epidural injections in managing chronic axial low back pain without disc herniation, radiculitis, or facet joint pain. J Pain Res 2012; 5:381-90. [PMID: 23091395 PMCID: PMC3474158 DOI: 10.2147/jpr.s35924] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background Chronic low back pain without disc herniation is common. Various modalities of treatments are utilized in managing this condition, including epidural injections. However, there is continued debate on the effectiveness, indications, and medical necessity of any treatment modality utilized for managing axial or discogenic pain, including epidural injections. Methods A randomized, double-blind, actively controlled trial was conducted. The objective was to evaluate the ability to assess the effectiveness of caudal epidural injections of local anesthetic with or without steroids for managing chronic low back pain not caused by disc herniation, radiculitis, facet joints, or sacroiliac joints. A total of 120 patients were randomized to two groups; one group did not receive steroids (group 1) and the other group did (group 2). There were 60 patients in each group. The primary outcome measure was at least 50% improvement in Numeric Rating Scale and Oswestry Disability Index. Secondary outcome measures were employment status and opioid intake. These measures were assessed at 3, 6, 12, 18, and 24 months after treatment. Results Significant pain relief and functional status improvement (primary outcome) defined as a 50% or more reduction in scores from baseline, were observed in 54% of patients in group 1 and 60% of patients in group 2 at 24 months. In contrast, 84% of patients in group 1 and 73% in group 2 saw significant pain relief and functional status improvement in the successful groups at 24 months. Conclusion Caudal epidural injections of local anesthetic with or without steroids are effective in patients with chronic axial low back pain of discogenic origin without facet joint pain, disc herniation, and/or radiculitis.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah ; Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
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Buchmann J, Arens U, Harke G, Smolenski U, Kayser R. Manualmedizinische Syndrome bei unteren Rückenschmerzen: Teil I. MANUELLE MEDIZIN 2012. [DOI: 10.1007/s00337-012-0965-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Manchikanti L, Cash KA, McManus CD, Pampati V, Benyamin R. Fluoroscopic lumbar interlaminar epidural injections in managing chronic lumbar axial or discogenic pain. J Pain Res 2012; 5:301-11. [PMID: 23055773 PMCID: PMC3442746 DOI: 10.2147/jpr.s32699] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Among the multiple causes of chronic low back pain, axial and discogenic pain are common. Various modalities of treatments are utilized in managing discogenic and axial low back pain including epidural injections. However, there is a paucity of evidence regarding the effectiveness, indications, and medical necessity of any treatment modality utilized for managing axial or discogenic pain, including epidural injections. In an interventional pain management practice in the US, a randomized, double-blind, active control trial was conducted. The objective was to assess the effectiveness of lumbar interlaminar epidural injections of local anesthetic with or without steroids for managing chronic low back pain of discogenic origin. However, disc herniation, radiculitis, facet joint pain, or sacroiliac joint pain were excluded. Two groups of patients were studied, with 60 patients in each group receiving either local anesthetic only or local anesthetic mixed with non-particulate betamethasone. Primary outcome measures included the pain relief-assessed by numeric rating scale of pain and functional status assessed by the, Oswestry Disability Index, Secondary outcome measurements included employment status, and opioid intake. Significant improvement or success was defined as at least a 50% decrease in pain and disability. Significant improvement was seen in 77% of the patients in Group I and 67% of the patients in Group II. In the successful groups (those with at least 3 weeks of relief with the first two procedures), the improvement was 84% in Group I and 71% in Group II. For those with chronic function-limiting low back pain refractory to conservative management, it is concluded that lumbar interlaminar epidural injections of local anesthetic with or without steroids may be an effective modality for managing chronic axial or discogenic pain. This treatment appears to be effective for those who have had facet joints as well as sacroiliac joints eliminated as the pain source.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, KY ; University of Louisville, Louisville, KY
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The role of thoracic medial branch blocks in managing chronic mid and upper back pain: a randomized, double-blind, active-control trial with a 2-year followup. Anesthesiol Res Pract 2012; 2012:585806. [PMID: 22851967 PMCID: PMC3407605 DOI: 10.1155/2012/585806] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 05/27/2012] [Indexed: 01/12/2023] Open
Abstract
Study Design. A randomized, double-blind, active-control trial. Objective. To determine the clinical effectiveness of therapeutic thoracic facet joint nerve blocks with or without steroids in managing chronic mid back and upper back pain. Summary of Background Data. The prevalence of thoracic facet joint pain has been established as 34% to 42%. Multiple therapeutic techniques utilized in managing chronic thoracic pain of facet joint origin include medial branch blocks, radiofrequency neurotomy, and intraarticular injections.
Methods. This randomized double-blind active controlled trial was performed in 100 patients with 50 patients in each group who received medial branch blocks with local anesthetic alone or local anesthetic and steroids.
Outcome measures included the numeric rating scale (NRS), Oswestry Disability Index (ODI), opioid intake, and work status, at baseline, 3, 6, 12, 18, and 24 months.
Results. Significant improvement with significant pain relief and functional status improvement of 50% or more were observed in 80% of the patients in Group I and 84% of the patients in Group II at 2-year followup.
Conclusions. Therapeutic medial branch blocks of thoracic facets with or without steroids may provide a management option for chronic function-limiting thoracic pain of facet joint origin.
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Manchikanti L, Cash KA, Pampati V, Malla Y. Fluoroscopic cervical epidural injections in chronic axial or disc-related neck pain without disc herniation, facet joint pain, or radiculitis. J Pain Res 2012; 5:227-36. [PMID: 22826642 PMCID: PMC3401988 DOI: 10.2147/jpr.s32692] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background While chronic neck pain is a common problem in the adult population, with a typical 12-month prevalence of 30%–50%, there is a lack of consensus regarding its causes and treatment. Despite limited evidence, cervical epidural injections are one of the commonly performed nonsurgical interventions in the management of chronic neck pain. Methods A randomized, double-blind, active, controlled trial was conducted to evaluate the effectiveness of cervical interlaminar epidural injections of local anesthetic with or without steroids for the management of chronic neck pain with or without upper extremity pain in patients without disc herniation, radiculitis, or facet joint pain. Results One hundred and twenty patients without disc herniation or radiculitis and negative for facet joint pain by means of controlled diagnostic medial branch blocks were randomly assigned to one of two treatment groups, ie, injection of local anesthetic only (group 1) or local anesthetic mixed with nonparticulate betamethasone (group 2). The primary outcome of significant pain relief and improvement in functional status (≥50%) was demonstrated in 72% of group 1 and 68% of group 2. The overall average number of procedures per year was 3.6 in both groups with an average total relief per year of 37–39 weeks in the successful group over a period of 52 weeks. Conclusion Cervical interlaminar epidural injections of local anesthetic with or without steroids may be effective in patients with chronic function-limiting discogenic or axial pain.
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Manchikanti L, Cash KA, Pampati V, Wargo BW, Malla Y. Management of chronic pain of cervical disc herniation and radiculitis with fluoroscopic cervical interlaminar epidural injections. Int J Med Sci 2012; 9:424-34. [PMID: 22859902 PMCID: PMC3410361 DOI: 10.7150/ijms.4444] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 07/16/2012] [Indexed: 11/05/2022] Open
Abstract
STUDY DESIGN A randomized, double-blind, active controlled trial. OBJECTIVE To evaluate the effectiveness of cervical interlaminar epidural injections of local anesthetic with or without steroids in the management of chronic neck pain and upper extremity pain in patients with disc herniation and radiculitis. SUMMARY OF BACKGROUND DATA Epidural injections in managing chronic neck and upper extremity pain are commonly employed interventions. However, their long-term effectiveness, indications, and medical necessity, of their use and their role in various pathologies responsible for persistent neck and upper extremity pain continue to be debated, even though, neck and upper extremity pain secondary to disc herniation and radiculitis, is described as the common indication. There is also paucity of high quality literature. METHODS One-hundred twenty patients were randomly assigned to one of 2 groups: Group I patients received cervical interlaminar epidural injections of local anesthetic (lidocaine 0.5%, 5 mL); Group II patients received 0.5% lidocaine, 4 mL, mixed with 1 mL of nonparticulate betamethasone. Primary outcome measure was ≥ 50 improvement in pain and function. Outcome assessments included Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), opioid intake, employment, and changes in weight. RESULTS Significant pain relief and functional status improvement (≥ 50%) was demonstrated in 72% of patients who received local anesthetic only and 68% who received local anesthetic and steroids. In the successful group of participants, significant improvement was illustrated in 77% in local anesthetic group and 82% in local anesthetic with steroid group. CONCLUSIONS Cervical interlaminar epidural injections with or without steroids may provide significant improvement in pain and function for patients with cervical disc herniation and radiculitis.
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Manchikanti L, Singh V, Cash KA, Pampati V, Datta S. Fluoroscopic caudal epidural injections in managing post lumbar surgery syndrome: two-year results of a randomized, double-blind, active-control trial. Int J Med Sci 2012; 9:582-91. [PMID: 23028241 PMCID: PMC3461763 DOI: 10.7150/ijms.4672] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 09/04/2012] [Indexed: 12/25/2022] Open
Abstract
STUDY DESIGN A randomized, active control, double-blind trial. OBJECTIVE To evaluate the effectiveness of fluoroscopically directed caudal epidural injections with or without steroids in managing chronic low back and lower extremity pain secondary to post lumbar surgery syndrome. SUMMARY OF BACKGROUND DATA There is a paucity of evidence concerning caudal epidural injections for managing chronic persistent low back pain with or without lower extremity pain caused by post lumbar surgery syndrome. METHODS This active control randomized study included 140 patients with 70 patients in each group. Group I received 0.5% lidocaine, 10 mL; Group II received 9 mL of 0.5% lidocaine mixed with 1 mL of 6 mg of nonparticulate betamethasone. The multiple outcome measures included the numeric rating scale, the Oswestry Disability Index 2.0, employment status, and opioid intake with assessments at 3, 6, 12, 18, and 24 months posttreatment. Primary outcome was defined as at least 50% improvement in pain and Oswestry Disability Index scores. Patients with a positive response to the first 2 procedures with at least 3 weeks of relief were considered to be successful. All others were considered as failures. RESULTS Overall in Group I, 53% and 47% of the patients and in Group II, 59% and 58% of the patients, showed significant improvement with reduction in pain scores and disability index at 12 months and 24 months. In contrast, in the successful groups, significant pain relief and improvement in function were observed in 70% and 62% of Group I at one and 2 years; in 75% and 69% of Group II at one and 2 years. The results in the successful group showed that at the end of the first year patients experienced approximately 38 weeks of relief and at the end of 2 years Group I had 62 weeks and Group II had 68 weeks of relief. Overall total relief for 2 years was 48 weeks in Group I and 54 weeks in Group II. The average procedures in the successful groups were at 4 in one year and 6 at the end of 2 years. CONCLUSION Caudal epidural injections of local anesthetic with or without steroid might be effective in patients with chronic persistent low back and/or lower extremity pain in patients with post lumbar surgery syndrome.
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A randomized, controlled, double-blind trial of fluoroscopic caudal epidural injections in the treatment of lumbar disc herniation and radiculitis. Spine (Phila Pa 1976) 2011; 36:1897-905. [PMID: 21897343 DOI: 10.1097/brs.0b013e31823294f2] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A randomized, controlled, double-blind trial. OBJECTIVE To assess the effectiveness of fluoroscopically directed caudal epidural injections in managing chronic low back and lower extremity pain in patients with disc herniation and radiculitis with local anesthetic with or without steroids. SUMMARY OF BACKGROUND DATA The available literature on the effectiveness of epidural injections in managing chronic low back pain secondary to disc herniation is highly variable. METHODS One hundred twenty patients suffering with low back and lower extremity pain with disc herniation and radiculitis were randomized to one of the two groups: group I received caudal epidural injections with an injection of local anesthetic, lidocaine 0.5%, 10 mL; group II patients received caudal epidural injections with 0.5% lidocaine, 9 mL, mixed with 1 mL of steroid. The Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake were utilized with assessment at 3, 6, and 12 months posttreatment. RESULTS The percentage of patients with significant pain relief of 50% or greater and/or improvement in functional status with 50% or more reduction in ODI scores was seen in 70% and 67% in group I and 77% and 75% in group II with average procedures per year of 3.8 ± 1.4 in group I and 3.6 + 1.1 in group II. However, the relief with first and second procedures was significantly higher in the steroid group. The number of injections performed was also higher in local anesthetic group even though overall relief was without any significant difference among the groups. There was no difference among the patients receiving steroids. CONCLUSION Caudal epidural injection with local anesthetic with or without steroids might be effective in patients with disc herniation or radiculitis. The present evidence illustrates potential superiority of steroids compared with local anesthetic at 1-year follow-up.
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Analgesic effects of prostaglandin E2 receptor subtype EP1 receptor antagonist: experimental study of application of nucleus pulposus. Spine (Phila Pa 1976) 2011; 36:1829-34. [PMID: 21270690 DOI: 10.1097/brs.0b013e3181fa1fca] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN The effect of an EP1 receptor antagonist on pain-related behavior induced by nucleus pulposus (NP) applied to the dorsal root ganglion (DRG) in rats was investigated. OBJECTIVE We investigated pain-related behavior, the amount of prostaglandin E2 (PGE2), and neural damage to the DRG after application of NP to the DRG after administration of an EP1 receptor antagonist. SUMMARY OF BACKGROUND DATA PGE2 induces mechanical allodynia and hyperalgesia, which are mediated by PGE2 receptors. EP1 is one of the PGE2 receptor subtypes. An EP1 antagonist reduces hyperalgesia, allodynia, and c-fos expression in the rat chronic nerve constriction model. METHODS Sprague-Dawley rats (n = 103) were used. Animals receiving NP were divided into three experimental groups (n = 12 in each group): saline, high-dose (5 mg/kg) EP1 receptor antagonist (RA), and low-dose (2.5 mg/kg) EP1-RA (orally once daily for 5 days). Animals in the sham group did not receive NP. Von Frey tests were used for pain-behavior testing. The amount of PGE2 in DRG and the number of activating transcription factor-3 (ATF3) immunoreactive positive cells were compared among groups. RESULTS The mechanical thresholds in the three groups decreased 7 days after surgery (just before treatment). The threshold in both the high- and low-dose EP1-RA groups increased at 11 days (5 days after treatment) and continued for 14 days. The thresholds in both the low- and high-dose EP1-RA groups increased significantly compared with the saline group (P < 0.05). The amount of PGE2 was significantly increased in the NP group compared with the sham and naïve animals after application of NP. ATF3 expression was increased by NP but was not increased after administration of the EP1-RA. CONCLUSION An EP1 receptor antagonist improves pain-related behavior in the rat model and might be a potential agent to improve pain-related behavior in patients with lumbar disc herniation.
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Quraishi NA. Transforaminal injection of corticosteroids for lumbar radiculopathy: systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 21:214-9. [PMID: 21892774 DOI: 10.1007/s00586-011-2008-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 08/05/2011] [Accepted: 08/23/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transforaminal epidural injection of steroids is used to treat lumbar radicular pain. However, there are only a few well-designed randomized, controlled studies on the effectiveness of steroid injection. STUDY DESIGN Hence, this study aims to assess the effectiveness of steroid injection to treat lumbar radicular pain using a meta-analysis of transforaminal epidural injection therapy for low back and lumbar radicular pain. The comparison was based on the mean difference in the Visual Analogue Score (VAS) and Oswestry Disability Index (ODI) from baseline to the specified followed up. METHODS The available literature of lumbar transforaminal epidural injections in managing low back and radicular pain was reviewed. Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to 2009, and manual searches of the bibliographies of known primary and review articles. Finally, the search included the Current Controlled Trials Register and the Cochrane Database of Controlled Trials. RESULTS The initial search identified 126 papers. After screening, five randomised controlled trials (RCTs) were studied for analysis and only three of these had followed-up patients systematically with pain and disability outcome scores to 3 months and of these, only one had follow up to 12 months. A total of 187 patients ('treatment group' receiving local anaesthetic/steroid injection) were compared with 181 patients ('control' group, receiving local anaesthetic only or saline injection). Improvement in pain (standardised mean difference in VAS 0.2 in favour of 'treatment'; 95%CI: -0.41 to 0.00, p = 0.05, I squared 0%) but not disability (standardised mean difference in ODI 0; 95%CI: -0.21 to 0.20, p = 0.99, I squared 0%) was observed between 'treatment' and 'control' groups; these differences were not significant. Additionally, the one study following patients to 12 months did not find any significant difference in VAS and ODI between treatment and control groups. CONCLUSION The current meta-analysis shows that transforaminal epidural steroid injections, when appropriately performed, should result in an improvement in pain, but not disability. The three RCTs that followed patients to 3 months (and the single study to 12 months) have found no benefit by the addition of steroids. The limitations of this study include the paucity of the available literature.
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Affiliation(s)
- Nasir A Quraishi
- Centre for Spine Studies and Surgery, Queens Medical Centre, West Block, D Floor, Derby Road, Nottingham, NG7 2UH, UK.
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Uesugi K, Sekiguchi M, Kikuchi SI, Konno SI. The effect of repeated restraint stress in pain-related behavior induced by nucleus pulposus applied on the nerve root in rats. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 20:1885-91. [PMID: 21698480 DOI: 10.1007/s00586-011-1877-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Revised: 05/25/2011] [Accepted: 06/04/2011] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Chronic pain has an impact on psychological and social factors. It is known that stress influences physiological and behavioral changes and affects several neurotransmitter and hormonal systems. It is also known that corticosterone is increased by stress. The role of chronic stress in sciatica in lumbar disc herniation (LDH) in rats has not been investigated. The aim of this study was to investigate the effect of the restraint stress (RS) on pain-related behavior induced by application of nucleus pulposus (NP) in rats. MATERIALS AND METHODS Adult female Sprague-Dawley rats were divided into six experimental groups (naive group; naive + RS; sham group; sham + RS; autologous nucleus pulposus [NP] applied on the left L5 nerve root [NP group]; and NP + RS group). Von Frey tests were used to test pain-related behavior. Concentrations of plasma corticosterone were measured to assess changes in levels of endogenous corticosterone caused by RS. Expression of ATF-3 in the left L5 DRG was examined by immunohistochemical analyses in each group. RESULTS Mechanical withdrawal thresholds of the NP and NP + RS groups were significantly decreased after surgery compared with the naive group. Although the thresholds in the NP group recovered after 28 days, the thresholds in the NP + RS group were significantly decreased during the 42 days after surgery. RS increased the concentration of plasma corticosterone at 21 and 42 days after surgery. In the NP and the NP + RS groups, the expression of ATF-3 was significantly increased at 7 days after surgery. The expression of ATF-3 was sustained for 21 days by RS. CONCLUSION Concentrations of plasma corticosterone were increased in three groups that underwent RS. The pain-related behavior persisted for the long term in the LDH model. The expression of ATF-3 in DRG neurons increased for 21 days by RS. These results suggest that RS plays a role in the chronicity of pain-related behavior in the LDH rats.
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Affiliation(s)
- Kazuhide Uesugi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, 1-Hikarigaoka, Fukushima City, Fukushima 960-1295, Japan
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Watanabe K, Yabuki S, Sekiguchi M, Kikuchi SI, Konno SI. Etanercept attenuates pain-related behavior following compression of the dorsal root ganglion in the rat. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 20:1877-84. [PMID: 21633793 DOI: 10.1007/s00586-011-1854-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 04/25/2011] [Accepted: 05/18/2011] [Indexed: 12/20/2022]
Abstract
PURPOSE TNFα is an inflammatory mediator related to neuropathic pain including sciatica. Much basic research suggests that anti-TNFα therapy may be useful for the treatment of sciatica. The purpose of this study was to clarify the effects of etanercept in a dorsal root ganglion (DRG) compression model. METHODS Adult male Sprague-Dawley rats (200-250 g, n = 60) were used. An L-shaped stainless rod was used to compress the left L5 DRG in the saline and etanercept groups. No rod was used in the sham group. In the etanercept group, 1 mg of etanercept was applied locally onto the DRG at the end of surgery. Saline was applied in the saline and sham groups. On day 3 and day 7 after surgery, the number of ED1-immunoreactive (IR) cells (macrophages) in the DRG was calculated by immunohistochemical methods (n = 6). In addition, double-immunofluorescence labeling for ED1 and TNFα was performed. Behavioral testing with von Frey filaments and a heat stimulator was performed (n = 12). RESULTS ED1-IR cells in the DRG significantly increased in the control group compared with the sham group (p < 0.05). Some ED1-IR cells were co-labeled for TNFα. In the etanercept group, decrease in mechanical threshold was significantly inhibited compared with the saline group (p < 0.05). Thermal hyperalgesia was observed in the control group, but in neither the sham nor etanercept group (p < 0.05). CONCLUSION Etanercept attenuated the pain-related behavior induced by DRG compression. These findings suggest that mechanical effects on the DRG might be reduced by etanercept in addition to the effects on nucleus pulposus in lumbar disc herniation.
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Affiliation(s)
- Kazuyuki Watanabe
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Fukushima 960-1295, Japan.
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Effects of asialo-erythropoietin on pain-related behavior and expression of phosphorylated-p38 map kinase and tumor necrosis factor-alpha induced by application of autologous nucleus pulposus on nerve root in rat. Spine (Phila Pa 1976) 2011; 36:E86-94. [PMID: 21228694 DOI: 10.1097/brs.0b013e3181f137a8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN this study was designed to examine the neuroprotective effects of asialo-erythropoietin (A-EPO) in a rat model of lumbar disc herniation. OBJECTIVE to investigate the effects of A-EPO on pain-related behavior, the expression of phosphorylated-p38 (p-p38) mitogen activated kinase, and the expression of tumor necrosis factor alpha (TNF-α) induced by nucleus pulposus (NP) application on the nerve root. SUMMARY OF BACKGROUND DATA erythropoietin (EPO) has neuroprotective effects in a variety of models of central and peripheral nerve injuries. However, EPO is a hematopoietic growth factor and can therefore cause significant side effects such as thicker blood and promotion of blood clotting. A-EPO is a neuroprotective derivative of EPO that is not hematopoietic. METHODS female Sprague-Dawley rats (n = 149) were used in this study. NP harvested from the tail was applied to the left L5 nerve root and the rats were then divided into four groups: NP + nontreatment group, no further treatment; NP + A-EPO group, 13.4 microg/kg A-EPO; NP + EPO group, 13.4 microg/kg EPO; and NP + vehicle group, received vehicle. The substances were administered subcutaneously 1 day before surgery and daily for 2 weeks. In the sham group of animals, the L5 nerve root was exposed and NP was not applied. Withdrawal thresholds were determined by the von-Frey test 28 days after surgery. The expressions of p-p38 and TNF-α were assessed by immunohistochemical and immunoblotting analysis. Data were analyzed by unpaired Student t test and Dunnett t test (significance level, P < 0.05). RESULTS in the NP + nontreatment and NP + vehicle groups, withdrawal thresholds were decreased significantly for 28 days compared with the sham group (P < 0.05). In the NP + A-EPO group, the thresholds were significantly increased on day 28, and in the NP + EPO group, the thresholds were significantly increased on days 21 and 28 (P < 0.05) compared with the NP + nontreatment and NP + vehicle groups. The expression of p-p38 in the NP + A-EPO group was significantly lower than that in the NP + vehicle group on day 1 (P < 0.05). The expression of TNF in the NP + A-EPO and NP + EPO groups was significantly lower than that in the NP + vehicle group on days 1 and 7 (P < 0.05). CONCLUSIONS A-EPO improved pain-related behavior and reduced the expression of p-p38 and TNF-α. The effect of A-EPO may be related to the inhibitory action of p-p38 and TNF-α in the dorsal root ganglion.
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Gelalis I, Arnaoutoglou E, Pakos E, Politis A, Rapti M, Xenakis T, Papadopoulos G. Effect of interlaminar epidural steroid injection in acute and subacute pain due to lumbar disk herniation: a randomized comparison of 2 different protocols. Open Orthop J 2009; 3:121-4. [PMID: 20111695 PMCID: PMC2812872 DOI: 10.2174/1874325000903010121] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 10/26/2009] [Accepted: 11/11/2009] [Indexed: 11/22/2022] Open
Abstract
In order to assess the efficacy of epidural steroid injections (ESI) in acute and subacute pain due to lumbar spine disk herniation, we conducted a randomized trial, comparing 2 different protocols. Fourty patients with radicular pain due to L4-L5 and L5-S1 disc herniation were assigned to receive either 3 consecutive ESI every 24 hours through a spinal catheter (group A) or 3 consecutive ESI every 10 days with an epidural needle (group B). All patients had improved Oswestry Disabilty Index (ODI) and the Visual Analog Scale (VAS) for pain scores at 1 month of follow-up compared to baseline, while no significant differences were observed between the 2 groups. The scores for group B were statistically significant lower at 2 months of follow-up compared to those of group A. The improvement in the scores of group B was continuous since the mean scores at 2 months of follow up were lower compared to the respective scores at 1 month. Protocol B (3 consecutive ESI every 10 days) was found more effective in the treatment of subacute pain compared to Protocol A (3 consecutive ESI every 24 hours) with statistically significant differences in the ODI and VAS scores at 2 months of follow-up.
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Affiliation(s)
- I.D Gelalis
- Department of Orthopaedic Surgery, University Hospital of Ioannina, University of Ioannina, School of Medicine, Ioannina, Greece
| | - E Arnaoutoglou
- Department of Anesthesiology, University Hospital of Ioannina, University of Ioannina, School of Medicine, Ioannina, Greece
| | - E.E Pakos
- Department of Orthopaedic Surgery, University Hospital of Ioannina, University of Ioannina, School of Medicine, Ioannina, Greece
| | - A.N Politis
- Department of Orthopaedic Surgery, University Hospital of Ioannina, University of Ioannina, School of Medicine, Ioannina, Greece
| | - M Rapti
- Department of Anesthesiology, University Hospital of Ioannina, University of Ioannina, School of Medicine, Ioannina, Greece
| | - T.A Xenakis
- Department of Orthopaedic Surgery, University Hospital of Ioannina, University of Ioannina, School of Medicine, Ioannina, Greece
| | - G Papadopoulos
- Department of Anesthesiology, University Hospital of Ioannina, University of Ioannina, School of Medicine, Ioannina, Greece
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Manchikanti L, Shah RV, Datta S, Singh V. Critical evaluation of interventional pain management literature provides inaccurate conclusions. Spine J 2009; 9:706-8; author reply 708-9. [PMID: 19442587 DOI: 10.1016/j.spinee.2009.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2008] [Revised: 03/03/2009] [Accepted: 03/27/2009] [Indexed: 02/03/2023]
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Levin JH. Prospective, double-blind, randomized placebo-controlled trials in interventional spine: what the highest quality literature tells us. Spine J 2009; 9:690-703. [PMID: 18789773 DOI: 10.1016/j.spinee.2008.06.447] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 04/16/2008] [Accepted: 06/28/2008] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The prospective, double-blind, randomized, placebo-controlled study design is essential in the interventional spine literature to truly evaluate whether or not a procedure is effective. PURPOSE This article will critically evaluate the highest quality interventional spine literature with strict interpretation of the results of these trials. STUDY DESIGN Review article. METHODS Extensive Medline/Pubmed searches and searches of the large review articles on the major interventional spine topics were performed to find all prospective, double-blind, randomized placebo-controlled trials in the English language interventional spine literature. RESULTS Fluoroscopically-guided lumbosacral transforaminal epidural corticosteroid injections are effective in the treatment of acute/subacute lumbosacral radicular pain, and in preventing future surgeries. Injection of corticosteroid or Sarapin on the cervical or lumbar medical branch nerves is not effective. When done with proper technique, percutaneous radiofrequency lumbar and cervical medial branch neurotomy are both effective. Intraarticular sacroiliac joint corticosteroid injections are effective in patients with spondyloarthropathy. IDET is modestly effective in the treatment of lumbosacral discogenic pain in carefully selected patients. Percutaneous radio frequency neurotomy of the ramus communicans is effective in the treatment of lumbosacral discogenic pain. No firm conclusions can be drawn about cervical epidural corticosteroid injections, lumbosacral epidural corticosteroid injections for the treatment of chronic radicular pain, cervical or lumbosacral intraarticular zygapophysial joint corticosteroid injections for the treatment of degenerative zygapophysial joint pain, or intradiscal corticosteroid injections. CONCLUSIONS The prospective, double-blind, randomized placebo-controlled trials in the interventional spine literature demonstrate efficacy from several different procedures when properly performed on appropriate patients. Other procedures have been shown to lack efficacy, while inconclusive evidence exists from multiple other interventional spine procedures. Further details are discussed in the text.
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Affiliation(s)
- Joshua H Levin
- Aurora Advanced Healthcare, Physical Medicine and Rehabilitation, 3003 W. Good Hope Road, Milwaukee, WI 53209, USA.
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Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976) 2009; 34:1078-93. [PMID: 19363456 DOI: 10.1097/brs.0b013e3181a103b1] [Citation(s) in RCA: 234] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To systematically assess benefits and harms of nonsurgical interventional therapies for low back and radicular pain. SUMMARY OF BACKGROUND DATA Although use of certain interventional therapies is common or increasing, there is also uncertainty or controversy about their efficacy. METHODS Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of local injections, botulinum toxin injection, prolotherapy, epidural steroid injection, facet joint injection, therapeutic medial branch block, sacroiliac joint injection, intradiscal steroid injection, chemonucleolysis, radiofrequency denervation, intradiscal electrothermal therapy, percutaneous intradiscal radiofrequency thermocoagulation, Coblation nucleoplasty, and spinal cord stimulation. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and by Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force. RESULTS For sciatica or prolapsed lumbar disc with radiculopathy, we found good evidence that chemonucleolysis is moderately superior to placebo injection but inferior to surgery, and fair evidence that epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. We found fair evidence that spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. We found good or fair evidence that prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. Insufficient evidence exists to reliably evaluate other interventional therapies. CONCLUSION Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.
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Pseudoradicular and radicular low-back pain – A disease continuum rather than different entities? Rebuttal: Reply to the letter “Cheese and Chalk? Missing the real anatomy” by Breck McKay. Pain 2008. [DOI: 10.1016/j.pain.2008.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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