1
|
Raymaekers V, Roosen G, Put E, Vanvolsem S, Achahbar SE, Meeuws S, Wissels M, Bamps S, Ridder DD, Menovsky T, Plazier M. Transforaminal epidural steroid injection for radiculopathy and the evolution to surgical treatment: a pragmatic prospective observational multicenter study. Pain Manag 2024; 14:173-182. [PMID: 38440806 PMCID: PMC11229444 DOI: 10.2217/pmt-2023-0121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/07/2023] [Indexed: 03/06/2024] Open
Abstract
Aim: The aim of this study is to analyze the real-world outcomes of transforaminal epidural steroid injections (TFESIs) in all patients with radiculopathy and their long-term outcomes. Methods: Patients with radiculopathy and failure of conservative treatment were included in a prospective, multicenter, observational cohort study. Results: In total, 117 patients were treated with one or two TFESIs. The mean duration of follow-up was 116 (±14) weeks. In total 19,6% (95% CI: 12.9-28.0%) patients were treated with surgery after insufficient symptom improvement. The evolution to surgery was not associated with etiology, symptom duration or previous spine surgery. Conclusion: Real-world data confirms that TFESIs is an effective treatment with satisfactory results in about 80% of patients for a period of 2 years.
Collapse
Affiliation(s)
- Vincent Raymaekers
- Department of Neurosurgery, Antwerp University Hospital, Antwerp, Belgium
- Faculty of Medicine & Health Sciences, University of Antwerp, Antwerp, 2650, Belgium
- Faculty of Medicine & Life Science, Hasselt University, Hasselt, 3500, Belgium
| | - Gert Roosen
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, 3500, Belgium
- Department of Neurosurgery Jessa Hospital, Hasselt, 3500, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, 3800, Belgium
- Department of Neurosurgery St. Franciscus Hospital, Heusden-Zolder, 3550, Belgium
| | - Eric Put
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, 3500, Belgium
- Department of Neurosurgery Jessa Hospital, Hasselt, 3500, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, 3800, Belgium
- Department of Neurosurgery St. Franciscus Hospital, Heusden-Zolder, 3550, Belgium
| | - Steven Vanvolsem
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, 3500, Belgium
- Department of Neurosurgery Jessa Hospital, Hasselt, 3500, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, 3800, Belgium
- Department of Neurosurgery St. Franciscus Hospital, Heusden-Zolder, 3550, Belgium
| | - Salah-Eddine Achahbar
- Department of Neurosurgery Jessa Hospital, Hasselt, 3500, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, 3800, Belgium
- Department of Neurosurgery St. Franciscus Hospital, Heusden-Zolder, 3550, Belgium
| | - Sacha Meeuws
- Department of Neurosurgery Jessa Hospital, Hasselt, 3500, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, 3800, Belgium
- Department of Neurosurgery St. Franciscus Hospital, Heusden-Zolder, 3550, Belgium
| | - Maarten Wissels
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, 3500, Belgium
- Department of Neurosurgery Jessa Hospital, Hasselt, 3500, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, 3800, Belgium
- Department of Neurosurgery St. Franciscus Hospital, Heusden-Zolder, 3550, Belgium
| | - Sven Bamps
- Faculty of Medicine & Life Science, Hasselt University, Hasselt, 3500, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, 3500, Belgium
- Department of Neurosurgery Jessa Hospital, Hasselt, 3500, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, 3800, Belgium
- Department of Neurosurgery St. Franciscus Hospital, Heusden-Zolder, 3550, Belgium
| | - Dirk De Ridder
- Department of Surgical Sciences, Section of Neurosurgery, Dunedin School of Medicine, University of Otago, Dunedin, 9016, New Zealand
| | - Tomas Menovsky
- Department of Neurosurgery, Antwerp University Hospital, Antwerp, Belgium
- Faculty of Medicine & Health Sciences, University of Antwerp, Antwerp, 2650, Belgium
| | - Mark Plazier
- Faculty of Medicine & Life Science, Hasselt University, Hasselt, 3500, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, 3500, Belgium
- Department of Neurosurgery Jessa Hospital, Hasselt, 3500, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, 3800, Belgium
- Department of Neurosurgery St. Franciscus Hospital, Heusden-Zolder, 3550, Belgium
| |
Collapse
|
2
|
Maus T. The Anatomy, Technique, Safety, and Efficacy of Image-Guided Epidural Access. Radiol Clin North Am 2024; 62:199-215. [PMID: 38272615 DOI: 10.1016/j.rcl.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Epidural steroid injections have demonstrable efficacy and safety in treatment of radicular pain syndromes; transforaminal access has greater evidence of efficacy than interlaminar approaches. The interventionalist must understand epidural and foraminal anatomy and imaging to insure delivery of medication to the target, the ventral epidural space at the site of neural compression. This obligates pre-procedural planning. When performed with appropriate risk mitigation strategies, epidural injections by either access are safe. For transforaminal access, the use of dexamethasone as the injectate, and infraneural approaches, provides safety advantages.
Collapse
|
3
|
Le VT, Nguyen CH, Do PT, Nguyen AM, Vo KH. Guidance of Nerve Stimulator and Ultrasound for Transforaminal Epidural Steroid Injection in Lumbosacral Radicular Pain : A Single Institution Experience in Vietnam. J Korean Neurosurg Soc 2024; 67:194-201. [PMID: 37661090 PMCID: PMC10924910 DOI: 10.3340/jkns.2023.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/15/2023] [Accepted: 08/23/2023] [Indexed: 09/05/2023] Open
Abstract
OBJECTIVE This study aimed to evaluate the clinical feasibility of the combination of ultrasound and nerve stimulator guidance in transforaminal epidural steroid injections (TESIs) to manage lumbosacral chronic radicular pain. METHODS Using the combination of nerve stimulator and ultrasound guidance, TESIs were performed in 125 segments of 78 patients who presented with chronic lumbar radicular pain. Demographic characteristics and surgical outcomes were recorded on admission, pre-procedural and post-procedural for 1-week, 1-month, 3-month, and 6-month follow-ups. The result was measured using the Numeric rating scale (NRS) and Oswestry disability index (ODI). RESULTS Patients who received TESIs showed significant improvements on two evaluation tools (NRS, ODI), compared to that before procedure (p<0.001). No significant complications were observed for 6 months' follow-up. CONCLUSION The result suggests that a combination of ultrasound and nerve stimulator guidance in transforaminal epidural injections is safe, reliable and effective for short-term management of lumbar disc herniation. It is a promising technique and has shown good results in providing intermediate pain relief.
Collapse
Affiliation(s)
- Viet-Thang Le
- Faculty of Medicine, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
- Pain Management Unit, Department of Neurosurgery, University Medical Center, Ho Chi Minh City, Vietnam
| | - Chi Hue Nguyen
- Department of Anesthesia, Intensive Care and Pain Management, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Phuoc Trong Do
- Faculty of Medicine, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
- Pain Management Unit, Department of Neurosurgery, University Medical Center, Ho Chi Minh City, Vietnam
| | - Anh Minh Nguyen
- Faculty of Medicine, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
- Pain Management Unit, Department of Neurosurgery, University Medical Center, Ho Chi Minh City, Vietnam
| | - Khoi Hong Vo
- Department of Neurology, Hanoi Medical University, Hanoi, Vietnam
| |
Collapse
|
4
|
Miller S, Caragea M, Carson D, McFarland MM, Teramoto M, Cushman DM, Cooper AN, Burnham T, McCormick ZL, Conger A. The effectiveness of intradiscal corticosteroid injection for the treatment of chronic discovertebral low back pain: a systematic review. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:33-46. [PMID: 37740319 DOI: 10.1093/pm/pnad127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 09/24/2023]
Abstract
OBJECTIVE Determine the effectiveness of intradiscal corticosteroid injection (IDCI) for the treatment of discovertebral low back pain. DESIGN Systematic review. POPULATION Adults with chronic low back pain attributed to disc or vertebral end plate pain, as evidenced by positive provocation discography or Modic 1 or 2 changes on magnetic resonance imaging. INTERVENTION Fluoroscopically guided or computed tomography-guided IDCI. COMPARISON Sham/placebo procedure including intradiscal saline, anesthetic, discography alone, or other active treatment. OUTCOMES Reduction in chronic low back pain reported on a visual analog scale or numeric rating scale and reduction in disability reported by a validated scale such as the Oswestry Disability Index. METHODS Four reviewers independently assessed articles published before January 31, 2023, in Medline, Embase, CENTRAL, and CINAHL. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The risk of bias in randomized trials was evaluated with the Cochrane Risk of Bias tool (version 2). RESULTS Of the 7806 unique records screened, 6 randomized controlled trials featuring 603 total participants ultimately met the inclusion criteria. In multiple randomized controlled trials, IDCI was found to reduce pain and disability for 1-6 months in those with Modic 1 and 2 changes but not in those selected by provocation discography. CONCLUSION According to GRADE, there is low-quality evidence that IDCI reduces pain and disability for up to 6 months in individuals with chronic discovertebral low back pain as evidenced by Modic 1 and 2 changes but not in individuals selected by provocation discography. STUDY REGISTRATION PROSPERO (CRD42021287421).
Collapse
Affiliation(s)
- Scott Miller
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Marc Caragea
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Dan Carson
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Mary M McFarland
- Eccles Health Sciences Library, University of Utah, Salt Lake City, UT 84112, United States
| | - Masaru Teramoto
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Daniel M Cushman
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Amanda N Cooper
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Taylor Burnham
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| |
Collapse
|
5
|
Pholsawatchai W, Manakul P, Lertcheewanan W, Siribumrungwoung K, Suntharapa T, Arunakul R. Comparison of Efficacy between Transforaminal Epidural Steroid Injection Technique without Contrast versus with Contrast in Lumbar Radiculopathy: A Prospective Longitudinal Cohort Study. Asian Spine J 2023; 17:1108-1116. [PMID: 37946336 PMCID: PMC10764127 DOI: 10.31616/asj.2023.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/27/2023] [Accepted: 05/24/2023] [Indexed: 11/12/2023] Open
Abstract
STUDY DESIGN A prospective longitudinal cohort study. PURPOSE To evaluate the efficacy of two different techniques of transforaminal epidural steroid injection (TFESI) with contrast and without contrast in treating lumbar radiculopathy. OVERVIEW OF LITERATURE Epidural injections are one of the most frequently used nonsurgical treatment options for managing lumbar radiculopathy. This study aims to simplify the TFESI technique, which is effective and requires less effort to replicate. METHODS We collected data on 118 patients who underwent TFESI without contrast versus TFESI with contrast for lumbar radiculopathy. The pain was evaluated using a Numerical Rating Scale (NRS) for pain at 5 minutes, 2 hours, 2 weeks, and 2 months. The functional status was assessed using the Oswestry Disability Index (ODI) score. The operation time and fluoroscopic dosage were also measured using this score. RESULTS Two groups of patients with radiculopathy were studied, comprising of 56 patients in the non-contrast group (NC group) and 62 patients in the contrast group (C group). There was a significant decrease in pain, as evaluated by NRS, in the C group compared to the NC group at 5 minutes post-procedure (3.39±1.54 vs. 3.86±0.72, with a p-value of 0.039). There was no significant difference in NRS scores at 2 hours, 2 weeks, and 2 months, as well as in ODI scores. The operation time and fluoroscopic dosage were lower in the group without contrast compared to the contrast group, with 12.58±3.30 minutes per level vs. 16.70±5.94 minutes per level (p <0.001) and 3.62±1.66 mGy vs. 5.32±2.74 mGy per level (p =0.014), respectively. No complications were reported in either group. CONCLUSIONS There is no difference in pain and functional outcome when treating lumbar radiculopathy with or without contrast using TFESI. The TFESI without contract technique has a shorter operation time and lower intra-operative fluoroscopic dosage without complications.
Collapse
Affiliation(s)
- Waroot Pholsawatchai
- Chulabhorn International College of Medicine, Thammasat University, Pathumthani,
Thailand
| | - Park Manakul
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathumthani,
Thailand
| | - Warisara Lertcheewanan
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathumthani,
Thailand
| | | | - Thongchai Suntharapa
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathumthani,
Thailand
| | - Rattalerk Arunakul
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathumthani,
Thailand
| |
Collapse
|
6
|
Khan N, Drolet CE, Farrokhi F, Nemani V, Leveque JCA, Krause K, Friedman AS, Bansal A, Louie PK. Clinical Guidelines for the Evaluation and Treatment of Lumbar Disc Herniations: How Accurate is the Internet? World Neurosurg 2023; 178:e682-e691. [PMID: 37544595 DOI: 10.1016/j.wneu.2023.07.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/31/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE To compare information online regarding lumbar disc herniation (LDH) on commonly searched websites and compare those findings with the evidence-based recommendations listed in the North American Spine Society (NASS) clinical practice guidelines. METHODS NASS Clinical Practice Guidelines, Internet searches were performed utilizing three common search engines (Google, Bing, Yahoo) and keywords associated with LDH. The top 20 websites from each search were selected. The content regarding diagnosis and treatment of LDH was compared to the NASS clinical practice guidelines. RESULTS On average, websites mentioned only 59% of recommendations supported by Level I evidence. Websites included an average of 3 recommendations not discussed in the NASS guidelines out of an average of 12 total recommendations. Muscle and sensory testing and physical therapy were the most frequent recommendations, appearing on over 80% of websites. Websites were equally likely to contain recommendations backed by high-quality evidence as recommendations not included in NASS guidelines. CONCLUSIONS This study demonstrates that websites regarding LDH contain a mix of information, with only a fraction of recommendations aligning with NASS clinical guidelines. Patients who use these websites are presented with unsubstantiated information, conceivably impacting their understanding, expectations and decision-making in physician offices.
Collapse
Affiliation(s)
- Nadia Khan
- Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle, Washington, USA; School of Medicine, University of Washington, Seattle, Washington, USA
| | - Caroline E Drolet
- Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Farrokh Farrokhi
- Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Venu Nemani
- Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | | | - Katie Krause
- Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Andrew S Friedman
- Physcial Medicine and Rehabilitation, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Aiyush Bansal
- Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Philip K Louie
- Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle, Washington, USA.
| |
Collapse
|
7
|
Shin DA, Choo YJ, Chang MC. Spinal Injections: A Narrative Review from a Surgeon's Perspective. Healthcare (Basel) 2023; 11:2355. [PMID: 37628553 PMCID: PMC10454431 DOI: 10.3390/healthcare11162355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/03/2023] [Accepted: 08/19/2023] [Indexed: 08/27/2023] Open
Abstract
Spinal pain is one of most frequent complaints of the general population, which can cause decreased activities of daily living and absence from work. Among numerous therapeutic methods, spinal injection is one of the most effective treatments for spinal pain and is currently widely applied in the clinical field. In this review, spinal injection is discussed from a surgeon's perspective. Recently, although the number of spinal surgeries has been increasing, questions are arising as to whether they are necessary. The failure rate after spinal surgery is high, and its long-term outcome was reported to be similar to spinal injection. Thus, spinal surgeries should be performed conservatively. Spinal injection is largely divided into diagnostic and therapeutic blocks. Using diagnostic blocks, such as the diagnostic selective nerve root block, disc stimulation test, and diagnostic medial branch block (MBB), the precise location causing the pain can be confirmed. For therapeutic blocks, transforaminal nerve root injection, therapeutic MBB, and percutaneous epidural neuroplasty are used. When unbearable spinal pain persists despite therapeutic spinal injections, spinal surgeries can be considered. Spinal injection is usefully used to identify the precise location prior to a patient undergoing injection treatment or surgery and can reduce pain and improve quality of life, and help to avoid spinal surgery. Pain physicians should treat patients with spinal pain by properly utilizing spinal injection.
Collapse
Affiliation(s)
- Dong Ah Shin
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea;
| | - Yoo Jin Choo
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Nam-gu, Daegu 42415, Republic of Korea;
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Nam-gu, Daegu 42415, Republic of Korea;
| |
Collapse
|
8
|
Manakul P, Siribumrungwong K, Dhanachanvisith N. A Change in Global Sagittal Alignment after Transforaminal Epidural Steroid Injections in Lumbar Spinal Stenosis. J Clin Med 2023; 12:4727. [PMID: 37510841 PMCID: PMC10380783 DOI: 10.3390/jcm12144727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
Patients' functional adaptation to pain can affect global sagittal alignment. This study evaluated the short-term spinal sagittal alignment change after transforaminal epidural steroid injection (TFESI) in lumbar spinal stenosis patients. Patients with lumbar spinal stenosis who underwent TFESI were retrospectively examined. Clinical outcomes were assessed using the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). Before and two weeks after the intervention, whole-spine lateral standing view radiographs were taken. Radiographic parameters including the Sagittal Vertical Axis (SVA), C2C7 Cobb, Thoracic Kyphosis (TK), Lumbar Lordosis (LL), Pelvic Incidence (PI), Pelvic Tilt (PT), Sacral Slope (SS), and Lumbopelvic Mismatch (PI-LL) were measured. Ninety-nine patients (mean age 64.3 ± 9.2 years) were included in this study. Both VAS and ODI outcomes were statistically improved after two weeks of intervention. Radiographic parameters showed that SVA, PT, and PI-LL mismatch were significantly decreased, while C2C7 Cobb, TK, SS, and LL were significantly increased after the intervention. SVA was improved by 29.81% (52.76 ± 52.22 mm to 37.03 ± 41.07 mm, p < 0.001). PT also decreased significantly from 28.71° ± 10.22° to 23.84° ± 9.96° (p < 0.001). Transforaminal epidural steroid injection (TFESI) significantly improves VAS, ODI, and global sagittal parameters in lumbar spinal stenosis patients.
Collapse
Affiliation(s)
- Park Manakul
- Department of Orthopedics, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
| | - Koopong Siribumrungwong
- Chulabhorn International College of Medicine, Thammasat University, Pathum Thani 12120, Thailand
| | | |
Collapse
|
9
|
Veljanovski D, Panev SD, Kostova M, Ristikj-Stomnaroska D, Stoshevska TD, Janevski P, Kocev SB, Prgova B. Clinical Effectiveness of Single Lumbar Periradicular Infiltration in Patients with Sciatica. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2023; 44:149-156. [PMID: 37453127 DOI: 10.2478/prilozi-2023-0034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Periradicular therapy (PRT) is a minimally invasive radiological procedurein patients with chronic lumbar pain.The aim of the study is to identify clinical and radiological predictive factors for treatment success after a single PRT treatment in patients with sciatica.The study includes a prospective follow-up of 166 patients treated with PRT. The pain intensity is determined according to the VAS scale and the degree of improvement is presented as excellent (over 75%), good (50-70%), moderate (25-49%), and weak (less than 25%). The follow up of the treated patients was done at 2 weeks, 3 and 6 months. In patients with pain duration up to 3 months, the improvement was excellent in n=32 (58.18%) after 2 weeks, after 3 months n=41 (74.55%) and after 6 months n=41 (74.55%). This stands in contrast to patients with pain over 1 year. The percentage of improvement after 6 months, post-intervention, was highest in patients without nerve root compression (86.25±19.2),and the highest improvement after 6 months was in patients with localization of pain at the L4-L5 level (69.69±29.7), the greatest improvement after six months was in patients with extraforaminal hernia (62.82±34.3), and the lowest in patients with central stenosis (40.21±30.7).Our study results suggest that the shorter a pain duration, low-grade root compression, injection level and type of herniation area predictor the more favourable response patients have to transforaminal epidural steroid injection in patients with sciatica.
Collapse
Affiliation(s)
- Dimitar Veljanovski
- 1Department of Radiology, General City Hospital "8-mi Septemvri" Skopje, RN Macedonia
| | - Sandra Dejanova Panev
- 1Department of Radiology, General City Hospital "8-mi Septemvri" Skopje, RN Macedonia
| | - Masha Kostova
- 1Department of Radiology, General City Hospital "8-mi Septemvri" Skopje, RN Macedonia
| | | | | | - Petar Janevski
- 3Department of Radiology, University Clinic "Mother Theresa", Skopje, RN Macedonia
| | | | - Biljana Prgova
- 1Department of Radiology, General City Hospital "8-mi Septemvri" Skopje, RN Macedonia
| |
Collapse
|
10
|
Abstract
Chronic neck and back pain are two of the most common and disabling complaints seen in primary care and neurology practices. Most commonly these come in the form of cervical and lumbar radiculopathy, lumbar spinal stenosis, and cervical and lumbar facet arthropathy. Treatment options are widespread and include nonpharmacological, pharmacological, surgical, and interventional options. The focus of this review will be to discuss the most common interventional procedures performed for chronic cervical and lumbar back pain, common indications for performing these interventions, as well as associated benefits and risks. These interventions alone may not suffice to improve the quality of life in those suffering from chronic pain. However, an understanding of the interventional pain options available and the evidence behind performing these interventions can help providers incorporate these into a multimodal approach to provide effective pain management that may allow patients an improved quality of life.
Collapse
Affiliation(s)
- Robert McCormick
- Department of Neurology, Boston Medical Center, Boston, Massachusetts
| | - Sunali Shah
- Department of Neurology, Boston Medical Center, Boston, Massachusetts
| |
Collapse
|
11
|
Nourbakhsh A, Harrison K. Use of Steroids in Spine Surgery. J Am Acad Orthop Surg 2023:00124635-990000000-00692. [PMID: 37184471 DOI: 10.5435/jaaos-d-22-00971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/01/2023] [Indexed: 05/16/2023] Open
Abstract
Steroids are commonly used in spine pathologies. A broad range of providers from different specialties such as primary care, emergency medicine, and spine surgeons use steroids. The indications and controversies of steroid use are discussed in this article. A literature review was conducted on the use of steroids in spine pathologies. Steroids have been successfully used in anterior cervical discectomy and fusion (ACDF) to prevent dysphagia, in spinal cord injuries to improve neurological function, in acute back and neck pain for pain control, and in spinal metastasis. Steroid injections have been used for axial as well as radicular pain. Techniques and complications are further discussed. Local and systemic steroids have been successful in preventing dysphagia after anterior cervical diskectomy and fusion. Steroids failed to improve the neurologic outcomes after spinal cord injuries, and they were associated with multiple complications. Systemic steroids have not been proven to provide better clinical outcomes for acute low back pain. Steroid injections are more effective in radicular pain rather than axial pain. There are not enough high-quality studies on the use of steroids for metastatic spinal cord compression.
Collapse
|
12
|
Whitaker CD, Stone BK, Gregorczyk JA, Alsoof D, Hardacker K, Diebo BG, Daniels A, Basques B. Nonsurgical Interventional Spine Pain Procedures: Outcomes and Complications. JBJS Rev 2023; 11:01874474-202304000-00003. [PMID: 37058581 DOI: 10.2106/jbjs.rvw.22.00235] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
» Nonsurgical interventional spine pain procedures provide an additional treatment option for lower back pain at the traditional bifurcation of conversative vs. operative management. » Transforaminal epidural steroid injections, radiofrequency ablations, intrathecal drug delivery, and spinal cord stimulation were found to be effective and safe techniques when applied to their specific indication. » Thermal annuloplasty and minimally invasive lumbar decompression showed mixed support. » Discography, sacroiliac joint injections, and spinous process spacers lacked sufficient evidence to support efficacy. » Medial branch blocks and facet joint injections were found to be useful diagnostic tools.
Collapse
Affiliation(s)
- Colin D Whitaker
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Benjamin K Stone
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | | | - Daniel Alsoof
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Kyle Hardacker
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Bassel G Diebo
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Alan Daniels
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Bryce Basques
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| |
Collapse
|
13
|
Um MK, Lee E, Lee JW, Kang Y, Ahn JM, Kang HS. Fluoroscopic lumbar transforaminal epidural steroid injections for recurrent herniated intervertebral disc after discectomy: Effectiveness and outcome predictors. PLoS One 2022; 17:e0271054. [PMID: 35797391 PMCID: PMC9262237 DOI: 10.1371/journal.pone.0271054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 06/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background Despite transforaminal epidural steroid injection (ESI) being the first choice in patient with recurrent herniated intervertebral disc (HIVD), efficacy of ESI in those patients are not well established. Herein, we evaluate the effectiveness and outcome predictors of fluoroscopic transforaminal ESI for recurrent HIVD. Methods Seventy-seven patients (48 male; mean age, 51.3 years) with recurrent lumbar HIVD were included and divided into three groups according to initial treatment: conservative treatment, transforaminal ESI, and immediate surgery. ESI effectiveness was evaluated by operation rates, injection numbers in 6 months, and pain reduction (visual analog scale (VAS) scores). Clinical and MRI variables were analyzed as possible outcome predictors. Each subject in the transforaminal ESI group was individually matched to two patients with initial HIVD (control group). Results In the transforaminal ESI group (n = 37), 20 patients (54.1%) did not undergo reoperation. The initial and follow-up VAS scores were significantly higher in the reoperation group (p = 0.014, p = 0.019, respectively). Patients with either paresthesia or motor weakness (12/19, 63.2%) had a significantly higher reoperation rate than patients with only pain (5/18, 27.8%; p = 0.031). Extruded disc ratios ≥2.0 were significantly higher in the reoperation group (10/17, 58.8%; p = 0.048). The reoperation rate in the transforaminal ESI group (17/37, 45.9%) was higher than the operation rate in the control group (6/73, 8.2%; p<0.001). Conclusion Transforaminal ESI was effective in reducing radicular pain in patients with recurrent HIVD. Approximately 54% of patients did not undergo reoperation. An extruded disc ratio ≥2.0 and paresthesia or motor weakness were poor outcome predictors.
Collapse
Affiliation(s)
- Mi-Kyung Um
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
- Department of Radiology, Kangwon National University School of Medicine, Chuncheon-si, Republic of Korea
| | - Eugene Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
- * E-mail:
| | - Joon Woo Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Yusuhn Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Joong Mo Ahn
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Heung Sik Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| |
Collapse
|
14
|
Sayeed Y, Chang RG, Chhatre A, Vallabh J, Soin A, Mauck WD, Duszynski BS, Kreiner DS. Response to: Reply to Sayeed et al. J Occup Environ Med 2022; 64:e389-e390. [PMID: 35761428 DOI: 10.1097/jom.0000000000002547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
|
15
|
Carragee EJ, Andersson GBJ, Belcourt RM, Eskay-Auerbach M, Goertz M, Haldeman S, Hegmann KT, Lessenger JE, Mayer T, Mueller KL, Murphy DR, Tellin WG, Thiese MS, Travis R, Weiss MS, Harris JS. Reply to Sayeed et al's Reply to Reply. J Occup Environ Med 2022; 64:e391-e392. [PMID: 35761429 DOI: 10.1097/jom.0000000000002548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
William J, Roehmer C, Mansy L, Kennedy DJ. Epidural Steroid Injections. Phys Med Rehabil Clin N Am 2022; 33:215-231. [DOI: 10.1016/j.pmr.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
18
|
Ko S, Nam J, Lee J. Usefulness of the additional contrast agents to identify offending nerve root in selective nerve root block. Medicine (Baltimore) 2022; 101:e25131. [PMID: 35118998 PMCID: PMC8812628 DOI: 10.1097/md.0000000000025131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 02/14/2021] [Indexed: 01/04/2023] Open
Abstract
It is hypothesized that if it is confirmed that the pain caused by the injection needle coincides with the lower leg radiating pain(LLRP) that the patient mainly complains of, then the contrast agents may be used less. This study aims to understand if the identification of lancinating identical pain in the procedure could replace the use of contrast agents that causes additional pain provocation using control arm of randomized clinical trial.This retrospective study included 165 patients who met exclusion criteria from among patients who underwent Selective nerve root block for the treatment of LLRP. With the identical and lancinating pain confirmed in the same site of the patient, consistent with that of the original symptom, the subjects were divided into 2 groups: 1 without contrast injection (Non-Dye [ND] group; 57 patients) and the other with contrast injection (Dye [D] group; 108 patients). The degree of LLRP in the 2 groups was evaluated using visual analog scale (VAS) before injection, 2, 6, and 12 weeks after injection. Functional outcomes were measured using Owestry Disability Index and Rolland-Morris Disability Questionnair, whereas quality of life was measured using Physical component score and Mental component score of Short Form 36 (SF-36) before injection and 3 months after injection.There was no statistically significant difference in the LLRP severity in both groups at all times and no statistical difference in the degree of VAS improvement relative to the before-injection VAS value between the 2 groups at 2 and 6 weeks after injection (all P > .05). At 12 weeks after injection, there was a statistically significant difference, but they were below Minimum Clinical Important Difference, bearing little clinical implications. There was no statistically significant difference between the 2 groups in Owestry Disability Index, Rolland-Morris Disability Questionnair, SF-36 Physical component score, and SF-36 Mental component score at every interval (all P > .05).Instead of contrast agent injections that have been used for accurate nerve root identification during Selective Nerve Root Block, the method of merely checking if the needle-induced pain under fluoroscopic imaging is consistent with the LLRP that the patient predominantly experiences shows the same effect in the patient's pain control and functional outcome.
Collapse
|
19
|
Travis R, Andersson GBJ, Belcourt RM, Carragee EJ, Eskay-Auerbach M, Goertz M, Haldeman S, Hegmann KT, Lessenger JE, Mayer T, Mueller KL, Murphy DR, Tellin WG, Thiese MS, Weiss MS, Harris JS. Reply to Sayeed et al. J Occup Environ Med 2022; 64:e84-e86. [PMID: 34873136 DOI: 10.1097/jom.0000000000002453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Russell Travis
- RACOEM Evidence-based Practice Spine Panel University of Utah Salt Lake City, Utah
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Alqroom R, Rakan A, Aldurgham R, Al Abdallat A, Haddad S, Ibrahim J, Nowar H, Odeh A. The lead of direct adjuvant intraoperative foraminal steroids' infiltration. Anesth Essays Res 2022; 16:187-190. [DOI: 10.4103/aer.aer_88_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/11/2022] [Accepted: 07/25/2022] [Indexed: 11/04/2022] Open
|
21
|
Turakhiya J, Parmar H, Zala K, Maru N, Prajapati A. A series of transforaminal epidural steroid injections in acute lumbar disc herniation with unilateral radiculopathy. JOURNAL OF ORTHOPAEDIC DISEASES AND TRAUMATOLOGY 2022. [DOI: 10.4103/jodp.jodp_18_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
22
|
de Bruijn TM, Miedema HS, de Groot IB, Haumann J, Ostelo RWJG. Clinical Relevance of Epidural Steroid Injections on Lumbosacral Radicular Syndrome-related Symptoms: Systematic Review and Meta-Analysis. Clin J Pain 2021; 38:149-150. [PMID: 34723863 DOI: 10.1097/ajp.0000000000000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Thomas M de Bruijn
- Department Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam
- National Health Care Institute, Diemen
| | - Harald S Miedema
- National Health Care Institute, Diemen
- Rotterdam University of Applied Sciences Rotterdam, The Netherlands
| | | | - Johan Haumann
- Department of Anesthesiology and Chronic Pain, OLVG, Amsterdam
| | - Raymond W J G Ostelo
- Department Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam
- Department of Epidemiology and Biostatistics, Amsterdam UMC (Location VUmc) and Amsterdam Movement Sciences
| |
Collapse
|
23
|
McCormick ZL, Schneider BJ, Smith CC, Duszynski BS, Stojanovic MP. Clinical Relevance of Epidural Steroid Injections on Lumbosacral Radicular Syndrome-related Symptoms: Systematic Review and Meta-analysis. Clin J Pain 2021; 37:865-866. [PMID: 34475339 DOI: 10.1097/ajp.0000000000000978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT
| | - Byron J Schneider
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Nashville, TN
| | - Clark C Smith
- Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | | | - Milan P Stojanovic
- Anesthesiology, Critical Care, and Pain Medicine Service, VA Boston Healthcare System, Harvard Medical School Boston, MA
| |
Collapse
|
24
|
Yazici Sacaklidir G, Sencan S, Sacaklidir R, Gunduz OH. The effect of spinopelvic parameters on transforaminal epidural steroid injection treatment success in lumbar disc herniation. Int J Clin Pract 2021; 75:e14708. [PMID: 34370361 DOI: 10.1111/ijcp.14708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/06/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Spinopelvic parameters (SPP) is closely associated with diseases such as lumbar disc herniation (LDH), disc degeneration and spondylolisthesis. Although there exist many known clinical and radiological factors affecting the success of the transforaminal epidural steroid injection (TFESI) treatment, the effect of SPP has not yet been investigated. This study aims to examine the effects of SPP on treatment success in patients who undergo TFESI because of lumbar disc herniation and to investigate the correlation among multifidus cross-sectional area (MFCSA). METHODS This was a prospective, observational study. Patients with low back and/or leg pain, unilateral nerve root compression were applied TFESI. Outcome measures included the numerical rating scale (NRS), Oswestry Disability Index (ODI) and Beck Depression Inventory (BDI). The patients were evaluated at the first hour, third week and third month. The SPP and MFCSA measurements were made on direct radiographs and MRIs. RESULTS A total of 58 patients, 24 women and 34 men, with an average age of 42.0 ± 9.5 were included. NRS, ODI and BDI scores improved significantly up to three months follow-up (P < .001). Moderately positive correlations were found between leg NRS and PT/PI scores immediately after treatment (r: 0.307 and r: 0.334) and a weak positive correlation was found between BDI and PT at third week (r: 0.269). The MFCSA/vertebral sectional area (VSA) and MFCSA/total multifidus cross-sectional area (TMFCSA) of the affected side was found to be significantly low (P < .001). CONCLUSIONS Subjects with high PI and PT reported less improvement in leg pain immediately after treatment and patients with high PT had fewer BDI improvements. MFCSA had no correlations with SPPs in patients who underwent TFESI.
Collapse
Affiliation(s)
- Gonca Yazici Sacaklidir
- Department of Physical Medicine and Rehabilitation, Sureyyapasa Chest Diseases and Thoracic Surgery Training Hospital, İstanbul, Turkey
| | - Savas Sencan
- Division of Pain Medicine, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Rekib Sacaklidir
- Division of Pain Medicine, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Osman Hakan Gunduz
- Division of Pain Medicine, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, İstanbul, Turkey
| |
Collapse
|
25
|
Van Boxem K, Cohen SP, van Kuijk SMJ, Hollmann MW, Zuidema X, Kallewaard JW, Benzon HT, Van Zundert J. Systematic Review on Epidural Steroid Injections: Quo Vadis? Clin J Pain 2021; 37:863-865. [PMID: 34419976 DOI: 10.1097/ajp.0000000000000973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Koen Van Boxem
- Department of Anesthesiology, Critical Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Bessemerstraat, Lanaken Belgium
- Department of Anesthesiology and Pain Medicine
| | - Steven P Cohen
- Departments of Anesthesiology and Critical Care Medicine, Neurology, Physical Medicine and Rehabilitation and Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore
- Departments of Physical Medicine and Rehabilitation and Anesthesiology Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Sander M J van Kuijk
- Department Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht
| | - Marcus W Hollmann
- Department of Anesthesiology Amsterdam University Medical Center, location AMC Amsterdam
| | - Xander Zuidema
- Department of Anesthesiology and Pain Medicine
- Department of Anesthesiology and Pain Medicine, Diakonessenziekenhuis, Utrecht/Zeist
| | - Jan W Kallewaard
- Department of Anesthesiology Amsterdam University Medical Center, location AMC Amsterdam
- Department of Anesthesiology, Rijnstate Hospital, AZ Velp, The Netherlands
| | - Honorio T Benzon
- Department of Anesthesiology Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jan Van Zundert
- Department of Anesthesiology, Critical Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Bessemerstraat, Lanaken Belgium
- Department of Anesthesiology and Pain Medicine
| |
Collapse
|
26
|
Azharuddin A, Aryandono T, Magetsari R, Dwiprahasto I. Predictors of the conservative management outcomes in patients with lumbar herniated nucleus pulposus: A prospective study in Indonesia. Asian J Surg 2021; 45:277-283. [PMID: 34384675 DOI: 10.1016/j.asjsur.2021.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/30/2021] [Accepted: 05/17/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The objective of this study was to identify the predictors of the conservative management outcomes in patients with lumbar herniated nucleus pulposus (HNP). METHODS A prospective study was conducted between June 2010 and April 2012 in Banda Aceh, Indonesia. Clinical and baseline neurologic examinations such as passive straight leg raising test (SLRT), cross SLRT, and patellar and Achilles reflexes were assessed prior to the conservative management. The patients were evaluated at 2nd, 4th, 8th, 12th and 24th week following commencement of the conservative management. RESULTS We recruited and followed 171 HNP patients of which 35.7% of them had good outcome. At univariate analysis, patients with more than 12 months duration of complaint, those with dominant radicular pain, severe pain intensity (visual analogue scale 7-10), positive SLRT, positive cross SLRT, and reduced motor power of knee extensors (muscle strength grade 1-4), were associated with poor outcome. Multivariate analysis suggested that patients with dominant radicular type of pain were likely to had poor outcome compared to those with dominant back pain (odd ratio (OR) 10.57 with 95% confidence interval (CI) 1.15-96.93). Patients with reduced motor power of knee extensors also had a higher chance to have poor outcome compared to those who were normal (OR: 10.57; 95% CI: 1.15-96.93). CONCLUSION Type of pain and the strength of lower extremities could be able to predict the failure of conservative management in patients with lumbar disc herniation. However, further studies with the bigger sample size are warrant to validate our results.
Collapse
Affiliation(s)
- Azharuddin Azharuddin
- Department of Orthopaedic and Traumatology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Department of Orthopaedic and Traumatology, Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia.
| | - Teguh Aryandono
- Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia.
| | - Rahadyan Magetsari
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia.
| | - Iwan Dwiprahasto
- Department of Clinical Pharamacology, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia.
| |
Collapse
|
27
|
de Bruijn TM, de Groot IB, Miedema HS, Haumann J, Ostelo RW. Clinical Relevance of Epidural Steroid Injections on Lumbosacral Radicular Syndrome-related Synptoms: Systematic Review and Meta-Analysis. Clin J Pain 2021; 37:524-537. [PMID: 33859113 PMCID: PMC8162229 DOI: 10.1097/ajp.0000000000000943] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Epidural steroid injections (ESIs) can be used to reduce lumbosacral radicular syndrome (LRS) related pain. The clinical relevance of ESIs are currently unknown. This systematic review and meta-analyses aims to assess whether ESIs are clinically relevant for patients with LRS. MATERIALS AND METHODS Comprehensive literature searches for randomized controlled trials regarding steroid injections for LRS were conducted in PudMed, EMBASE, CINAHL, and CENTRAL from their inception to September 2018 (December 2019 for PubMed). For each homogenous comparison, the outcomes function, pain intensity and health-related quality of life at different follow-up intervals were pooled separately. The GRADE approach was used to determine the overall certainty of the evidence. RESULTS Seventeen studies were included. Two different homogenous comparisons were identified for which the randomized controlled trials could be pooled. In 36 of the 40 analyses no clinically relevant effect was found. The certainty of evidence varied between very low to high. Four analyses found a clinically relevant effect, all on pain intensity and health-related quality of life, but the certainty of the evidence was either low or very low. Two of the 33 subgroup analyses showed a clinically relevant effect. However, according to the GRADE approach the certainty of these findings are low to very low. DISCUSSION On the basis of the analyses we conclude there is insufficient evidence that ESIs for patients with LRS are clinically relevant at any follow-up moment. High-quality studies utilizing a predefined clinical success are necessary to identify potential clinically relevant effects of ESIs. Until the results of these studies are available, there is reason to consider whether the current daily practice of ESIs for patients with LRS should continue.
Collapse
Affiliation(s)
- Thomas M. de Bruijn
- Department Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam
- National Health Care Institute, Diemen
| | | | - Harald S. Miedema
- National Health Care Institute, Diemen
- Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | | | - Raymond W.J.G. Ostelo
- Department Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam
- Department of Epidemiology and Biostatistics, Amsterdam UMC (Location VUmc) and Amsterdam Movement Sciences, Amsterdam
| |
Collapse
|
28
|
Verheijen EJA, Bonke CA, Amorij EMJ, Vleggeert-Lankamp CLA. Epidural steroid compared to placebo injection in sciatica: a 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 2021; 30:3255-3264. [PMID: 33974132 DOI: 10.1007/s00586-021-06854-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/18/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE The purpose of this systematic review and meta-analysis was to determine whether epidural steroid injections (ESI) are superior to epidural or non-epidural placebo injections in sciatica patients. METHODS The PubMed, Embase, Cochrane Library, and Web of science databases were searched for trials comparing ESI to epidural or non-epidural placebo. Risk of bias was assessed using the Cochrane RoB 2 tool. The primary outcome measures were pooled using a random-effects model for 6-week, 3-month, and 6-month follow-up. Secondary outcomes were described qualitatively. Quality of evidence was graded using GRADE classification. RESULTS Seventeen out of 732 articles were included. ESI was superior compared to epidural placebo at 6 weeks (- 8.6 [- 13.4; - 3.9]) and 3 months (- 5.2 [- 10.1; - 0.2]) for leg pain and at 6 weeks for functional status (- 4.1 [- 6.5; - 1.6]), though the minimally clinical important difference (MCID) was not met. There was no difference in ESI and placebo for back pain, except for non-epidural placebo at 3 months (6.9 [1.3; 12.5]). Proportions of treatment success were not different. ESI reduced analgesic intake in some studies and complication rates are low. CONCLUSION The literature indicates that ESI induces larger improvements in pain and disability on the short term compared to epidural placebo, though evidence is of low to moderate quality and MCID is not met. Strong conclusions for longer follow-up or for comparisons with non-epidural placebo cannot be drawn due to general low quality of evidence and limited number of studies. Epidural injections can be considered a safe therapy.
Collapse
Affiliation(s)
- E J A Verheijen
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands. .,Department of Neurosurgery, Spaarne Gasthuis Hospital, Haarlem/Hoofddorp, The Netherlands.
| | - C A Bonke
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - E M J Amorij
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - C L A Vleggeert-Lankamp
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Department of Neurosurgery, Spaarne Gasthuis Hospital, Haarlem/Hoofddorp, The Netherlands
| |
Collapse
|
29
|
Hegmann KT, Travis R, Andersson GBJ, Belcourt RM, Carragee EJ, Eskay-Auerbach M, Galper J, Goertz M, Haldeman S, Hooper PD, Lessenger JE, Mayer T, Mueller KL, Murphy DR, Tellin WG, Thiese MS, Weiss MS, Harris JS. Invasive Treatments for Low Back Disorders. J Occup Environ Med 2021; 63:e215-e241. [PMID: 33769405 DOI: 10.1097/jom.0000000000001983] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders. METHODS Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders. RESULTS Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations. CONCLUSION Quality evidence should guide invasive treatment for all phases of managing low back disorders.
Collapse
Affiliation(s)
- Kurt T Hegmann
- American College of Occupational and Environmental Medicine, Elk Grove Village, Illinois
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Wilby MJ, Best A, Wood E, Burnside G, Bedson E, Short H, Wheatley D, Hill-McManus D, Sharma M, Clark S, Bostock J, Hay S, Baranidharan G, Price C, Mannion R, Hutchinson PJ, Hughes DA, Marson A, Williamson PR. Microdiscectomy compared with transforaminal epidural steroid injection for persistent radicular pain caused by prolapsed intervertebral disc: the NERVES RCT. Health Technol Assess 2021; 25:1-86. [PMID: 33845941 DOI: 10.3310/hta25240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Sciatica is a common condition reported to affect > 3% of the UK population at any time and is most often caused by a prolapsed intervertebral disc. Currently, there is no uniformly adopted treatment strategy. Invasive treatments, such as surgery (i.e. microdiscectomy) and transforaminal epidural steroid injection, are often reserved for failed conservative treatment. OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of microdiscectomy with transforaminal epidural steroid injection for the management of radicular pain secondary to lumbar prolapsed intervertebral disc for non-emergency presentation of sciatica of < 12 months' duration. INTERVENTIONS Patients were randomised to either (1) microdiscectomy or (2) transforaminal epidural steroid injection. DESIGN A pragmatic, multicentre, randomised prospective trial comparing microdiscectomy with transforaminal epidural steroid injection for sciatica due to prolapsed intervertebral disc with < 1 year symptom duration. SETTING NHS services providing secondary spinal surgical care within the UK. PARTICIPANTS A total of 163 participants (aged 16-65 years) were recruited from 11 UK NHS outpatient clinics. MAIN OUTCOME MEASURES The primary outcome was participant-completed Oswestry Disability Questionnaire score at 18 weeks post randomisation. Secondary outcomes were visual analogue scores for leg pain and back pain; modified Roland-Morris score (for sciatica), Core Outcome Measures Index score and participant satisfaction at 12-weekly intervals. Cost-effectiveness and quality of life were assessed using the EuroQol-5 Dimensions, five-level version; Hospital Episode Statistics data; medication usage; and self-reported cost data at 12-weekly intervals. Adverse event data were collected. The economic outcome was incremental cost per quality-adjusted life-year gained from the perspective of the NHS in England. RESULTS Eighty-three participants were allocated to transforaminal epidural steroid injection and 80 participants were allocated to microdiscectomy, using an online randomisation system. At week 18, Oswestry Disability Questionnaire scores had decreased, relative to baseline, by 26.7 points in the microdiscectomy group and by 24.5 points in the transforaminal epidural steroid injection. The difference between the treatments was not statistically significant (estimated treatment effect -4.25 points, 95% confidence interval -11.09 to 2.59 points). Nor were there significant differences between treatments in any of the secondary outcomes: Oswestry Disability Questionnaire scores, visual analogue scores for leg pain and back pain, modified Roland-Morris score and Core Outcome Measures Index score up to 54 weeks. There were four (3.8%) serious adverse events in the microdiscectomy group, including one nerve palsy (foot drop), and none in the transforaminal epidural steroid injection group. Compared with transforaminal epidural steroid injection, microdiscectomy had an incremental cost-effectiveness ratio of £38,737 per quality-adjusted life-year gained and a probability of 0.17 of being cost-effective at a willingness to pay threshold of £20,000 per quality-adjusted life-year. LIMITATIONS Primary outcome data was invalid or incomplete for 24% of participants. Sensitivity analyses demonstrated robustness to assumptions made regarding missing data. Eighteen per cent of participants in the transforaminal epidural steroid injection group subsequently received microdiscectomy prior to their primary outcome assessment. CONCLUSIONS To the best of our knowledge, the NErve Root Block VErsus Surgery trial is the first trial to evaluate the comparative clinical effectiveness and cost-effectiveness of microdiscectomy and transforaminal epidural steroid injection. No statistically significant difference was found between the two treatments for the primary outcome. It is unlikely that microdiscectomy is cost-effective compared with transforaminal epidural steroid injection at a threshold of £20,000 per quality-adjusted life-year for sciatica secondary to prolapsed intervertebral disc. FUTURE WORK These results will lead to further studies in the streamlining and earlier management of discogenic sciatica. TRIAL REGISTRATION Current Controlled Trials ISRCTN04820368 and EudraCT 2014-002751-25. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 24. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Martin J Wilby
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust (member of Liverpool Health Partners), Liverpool, UK
| | - Ashley Best
- Liverpool Clinical Trials Centre, University of Liverpool (member of Liverpool Health Partners), Liverpool, UK
| | - Eifiona Wood
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Girvan Burnside
- Liverpool Clinical Trials Centre, University of Liverpool (member of Liverpool Health Partners), Liverpool, UK
| | - Emma Bedson
- Liverpool Clinical Trials Centre, University of Liverpool (member of Liverpool Health Partners), Liverpool, UK
| | - Hannah Short
- Liverpool Clinical Trials Centre, University of Liverpool (member of Liverpool Health Partners), Liverpool, UK
| | - Dianne Wheatley
- Liverpool Clinical Trials Centre, University of Liverpool (member of Liverpool Health Partners), Liverpool, UK
| | - Daniel Hill-McManus
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Manohar Sharma
- Department of Pain Medicine, The Walton Centre NHS Foundation Trust, Liverpool, Liverpool, UK
| | - Simon Clark
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust (member of Liverpool Health Partners), Liverpool, UK
| | | | - Sally Hay
- Patient and public involvement representative, Norfolk, UK
| | | | - Cathy Price
- Pain Clinic, Solent NHS Trust, Southampton, UK
| | | | - Peter J Hutchinson
- Academic Division of Neurosurgery, University of Cambridge, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Anthony Marson
- Department of Pharmacology and Therapeutics, University of Liverpool and The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Paula R Williamson
- Liverpool Clinical Trials Centre, University of Liverpool (member of Liverpool Health Partners), Liverpool, UK
| |
Collapse
|
31
|
Krishnan R, Kurup V, Vadivelu N, Dai F, Zhou B, Rajput K. Does Choice of Steroid Matter for Treatment of Chronic Low Back Pain with Sacroiliac Joint Injections: a Retrospective Study. Curr Pain Headache Rep 2021; 25:34. [PMID: 33760993 DOI: 10.1007/s11916-021-00942-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Prevalence of chronic low back pain (cLBP) is increasing. Sacroiliac joint (SIJ) is a common source of cLBP, but data behind its diagnosis and treatment is controversial. There is moderate quality evidence for effectiveness of therapeutic SIJ injections. However, there are no studies comparing the two most common steroid preparations, methylprednisolone (MTP) and triamcinolone (TAC) in SIJ injections. RECENT FINDINGS After institutional IRB approval, a retrospective chart review was conducted to evaluate the effectiveness of SIJ injections in terms of pain relief at 1-month follow-up and compare MTP versus TAC. All injections were performed by a single pain physician with fluoroscopic guidance. RESULTS Sixty-five percent of patients in the MTP group and 57% patients in the TAC group had >50% pain relief at 1-month follow-up, with no statistical difference between the two groups. Patients in the TAC group had significantly greater BMI and consisted of higher proportion of smokers (72% patients in TAC group versus 39% patients in the MTP group, p-value 0.004). Other sources of pain such as facet joints were unmasked post-procedurally after SIJ injections, with this unmasking being significant for the TAC group. Opiate use decreased in the MTP group from 35% pre-procedurally to 20% post-procedurally, and this difference did not reach statistical significance. Both MTP and TAC are effective in providing pain relief for SIJ pain at 1-month follow-up, with no statistical difference between the two types of steroids. Although not statistically significant, there is a modest reduction in opiate use in the MTP group.
Collapse
Affiliation(s)
- Ramya Krishnan
- Department of Anesthesia, Yale University School of Medicine, New Haven, CT, USA
| | - Viji Kurup
- Department of Anesthesia, Yale University School of Medicine, New Haven, CT, USA
| | - Nalini Vadivelu
- Department of Anesthesia, Yale University School of Medicine, New Haven, CT, USA
| | - Feng Dai
- Department of Anesthesia, Yale University School of Medicine, New Haven, CT, USA
| | - Bin Zhou
- Department of Anesthesia, Yale University School of Medicine, New Haven, CT, USA
| | - Kanishka Rajput
- Department of Anesthesia, Yale University School of Medicine, New Haven, CT, USA.
| |
Collapse
|
32
|
Verheijen EJA, Munts AG, van Haagen OBHAM, de Vries D, Vleggeert-Lankamp CLA. The Outcome of Epidural Injections in Lumbar Radiculopathy Is Not Dependent on the Presence of Disc Herniation on Magnetic Resonance Imaging: Assessment of Short-Term and Long-Term Efficacy. World Neurosurg 2021; 148:e643-e649. [PMID: 33497827 DOI: 10.1016/j.wneu.2021.01.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Lumbar radiculopathy is a condition with major physical, social, and economic consequences. Despite its favorable prognosis, the burden can be significant. In this study, we aimed to determine the value of magnetic resonance imaging (MRI) and the efficacy of transforaminal epidural injections (TEIs) in patients with lumbar radiculopathy secondary to lumbar disc herniation (LDH) and other causes (non-LDH). METHODS Patients with lumbar radiculopathy were reviewed for radiologic diagnosis based on MRI. For patients receiving TEI therapy, response after 6-8 weeks (short-term) and 16 weeks (long-term), number of injections, subsequent surgery, and patient outcome were evaluated. Treatment response was assessed by patient-reported symptom relief and numeric rating scale pain scores. RESULTS Overall, 66% of MRI examinations showed a clinically relevant LDH. A total of 486 of 1824 patients received TEI, of whom one third did not show LDH. Of patients, 70% reported a short-term effect with significant pain reduction and 44% reported a long-term effect. No significant differences were observed between the LDH and non-LDH groups. Of patients, 59% required multiple injections and reported similar efficacy compared with patients treated with a single injection. CONCLUSIONS A considerable part of MRI examinations in patients with lumbar radiculopathy do not show a clinically relevant LDH. Regardless of the radiologic diagnosis, most patients treated with TEI benefit in both the short-term and the long-term after a single-injection or multiple-injection regime. Subsequent injections are advisable if the effect from the first injection is unsatisfactory or wears off. MRI examination before TEI therapy may be redundant, which allows for expedition of this treatment.
Collapse
Affiliation(s)
- Eduard J A Verheijen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.
| | | | | | - Dirk de Vries
- Department of Anaesthesiology, Spaarne Gasthuis, Haarlem, The Netherlands
| | | |
Collapse
|
33
|
Oliveira CB, Maher CG, Ferreira ML, Hancock MJ, Oliveira VC, McLachlan AJ, Koes BW, Ferreira PH, Cohen SP, Pinto RZ. Epidural Corticosteroid Injections for Sciatica: An Abridged Cochrane Systematic Review and Meta-Analysis. Spine (Phila Pa 1976) 2020; 45:E1405-E1415. [PMID: 32890301 DOI: 10.1097/brs.0000000000003651] [Citation(s) in RCA: 14] [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 Systematic with meta-analysis OBJECTIVES.: The aim of this study was to investigate the efficacy and safety of epidural corticosteroid injections compared with placebo injection in reducing leg pain and disability in patients with sciatica. SUMMARY OF BACKGROUND DATA Conservative treatments, including pharmacological and nonpharmacological treatments, are typically the first treatment options for sciatica but the evidence to support their use is limited. The overall quality of evidence found by previous systematic reviews varies between moderate and high, which suggests that future trials may change the conclusions. New placebo-controlled randomized trials have been published recently which highlights the importance of an updated systematic review. METHODS The searches were performed without language restrictions in the following databases from 2012 to 25 September 2019: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PubMed, Embase, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and trial registers. We included placebo-controlled randomized trials investigating epidural corticosteroid injections in patients with sciatica. The primary outcomes were leg pain intensity and disability. The secondary outcomes were adverse events, overall pain, and back pain intensity. We grouped similar trials according to outcome measures and their respective follow-up time points. Short-term follow-up (>2 weeks but ≤3 months) was considered the primary follow-up time point due to the expected mechanism of action of epidural corticosteroid injection. Weighted mean differences (MDs) and risk ratios (RRs) with their respective 95% confidence intervals (CIs) were estimated. We assessed the overall quality of evidence using the GRADE approach and conducted the analyses using random effects. RESULTS We included 25 clinical trials (from 29 publications) providing data for a total of 2470 participants with sciatica, an increase of six trials when compared to the previous review. Epidural corticosteroid injections were probably more effective than placebo in reducing short-term leg pain (MD -4.93, 95% CI -8.77 to -1.09 on a 0-100 scale), short-term disability (MD -4.18, 95% CI: -6.04 to -2.17 on a 0-100 scale) and may be slightly more effective in reducing short-term overall pain (MD -9.35, 95% CI -14.05 to -4.65 on a 0-100 scale). There were mostly minor adverse events (i.e., without hospitalization) after epidural corticosteroid injections and placebo injections without difference between groups (RR 1.14, 95% CI: 0.91-1.42). The quality of evidence was at best moderate mostly due to problems with trial design and inconsistency. CONCLUSION A review of 25 placebo-controlled trials provides moderate-quality evidence that epidural corticosteroid injections are effective, although the effects are small and short-term. There is uncertainty on safety due to very low-quality evidence. LEVEL OF EVIDENCE 1.
Collapse
Affiliation(s)
- Crystian B Oliveira
- Department of Physiotherapy, São Paulo State University, Presidente Prudente, Brazil
| | | | - Manuela L Ferreira
- Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Mark J Hancock
- Discipline of Physiotherapy, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Vinicius Cunha Oliveira
- Department of Physiotherapy, Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Diamantina, Brazil
| | | | - Bart W Koes
- Department of General Practice, Erasmus Medical Center, Rotterdam, Netherlands.,Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
| | - Paulo H Ferreira
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Steven P Cohen
- Blaustein Pain Treatment Center, Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rafael Z Pinto
- Department of Physiotherapy, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| |
Collapse
|
34
|
Abdul Jalil MF, Dower A, Tawfik S, Brooks M, Davies MA, Ghahreman A. MRI predictors of revision surgery after primary lumbar discectomy. J Clin Neurosci 2020; 81:442-446. [PMID: 33222960 DOI: 10.1016/j.jocn.2020.09.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 08/10/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
The prognostic significance of preoperative MRI findings in patients undergoing discectomy is incompletely understood. Identifying the radiological predictors of revision surgery on pre-operative MRI can guide management decisions and potentially prevent multiple surgeries. We included 181 patients who underwent primary lumbar discectomy between 2010 and 2014. All patients were contacted via a short telephone interview to determine if they had revision surgery within 5 years of their index surgery. Preoperative MRI of the lumbosacral spine was evaluated for various radiological factors including type of disc herniation, anatomical location of herniation, direction of herniation, degree of disc degeneration, end plate changes and presence of listhesis. Other potential confounders including age, gender, smoking status and index level of surgery were also recorded. Multivariate model of all radiological predictors and confounders were developed and a step-wise approach was used to remove insignificant variables in order to develop final significant multivariate model. P value of <0.05 was considered statistically significant. Patients with retrolisthesis were found to be 2.7 times more likely than the patients without listhesis to require revision surgery (p = 0.019). Patients with foraminal disc herniation were 3.45 times more likely than the patients with paramedian disc herniation to require revision surgery (p = 0.026). Other MRI predictors failed to achieve statistical significance. Based on the data presented patients with retrolisthesis and/or foraminal disc herniation should be counselled on the relatively higher risk of revision surgery when proceeding with discectomy, or alternative options should be considered.
Collapse
Affiliation(s)
| | - Ashraf Dower
- Department of Neurosurgery, St. George Hospital, Kogarah, New South Wales, Australia; Faculty of Medicine, University of Sydney, Camperdown, New South Wales, Australia
| | - Samuel Tawfik
- Department of Neurosurgery, St. George Hospital, Kogarah, New South Wales, Australia
| | - Michael Brooks
- School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Mark Andrew Davies
- Department of Neurosurgery, St. George Hospital, Kogarah, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Ali Ghahreman
- Department of Neurosurgery, St. George Hospital, Kogarah, New South Wales, Australia
| |
Collapse
|
35
|
Kennedy DJ, Schneider B. Lies, Damn Lies, and Statistic: A Commentary. PAIN MEDICINE 2020; 21:2052-2054. [PMID: 32918475 DOI: 10.1093/pm/pnaa287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- David J Kennedy
- Vanderbilt University Medical Center, Physical Medicine and Rehabilitation, Nashville, Tennessee, USA
| | - Byron Schneider
- Vanderbilt University Medical Center, Physical Medicine and Rehabilitation, Nashville, Tennessee, USA
| |
Collapse
|
36
|
Scipione R, Alfieri G, De Maio A, Panella E, Napoli S, Bianchi L, Pandaloro N, Bazzocchi A, Facchini G, Albisinni U, Spinnato P, Catalano C, Napoli A. STUDY PROTOCOL - pulsed radiofrequency in addition to transforaminal epidural steroid injection in patients with acute and subacute sciatica due to lumbosacral disc herniation: rationale and design of a phase III, multicenter, randomized, controlled trial. Expert Rev Med Devices 2020; 17:945-949. [PMID: 32880493 DOI: 10.1080/17434440.2020.1815529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Lumbosacral disc herniation (LDH) represents the most common cause of sciatica. Currently, there is limited evidence about minimally invasive interventional therapies for the treatment of this condition. This paper presents the protocol for a multicenter, prospective, randomized, controlled, phase III trial evaluating if PRF in addition to TFESI leads to better outcomes in patients with sciatica due to LDH, compared to TFESI alone, during the first year after treatment (Pulsed Radiofrequency in Addition to TFESI for Sciatica [PRATS]). Eligible patients are between 18 and 75 years of age, suffer from sciatica of less than 12-week duration with pain intensity >4 on the Visual Analogue Scale (VAS) and have unilateral LDH compatible with symptoms at MRI. The Medical Ethics Committee of participating hospitals approved the study protocol. Patients will be randomized to receive either combined treatment (PRF and TFESI) or TFESI alone. The primary outcome will be the assessment of pain intensity with VAS at different timepoints from week-1 to 52 after treatment; secondary outcomes will include Roland Disability Questionnaire for sciatica and Oswestry Disability Index, evaluated at 4, 12 and 52 weeks. The follow-up will last 52 weeks for each patient. Statistical analysis will be performed on a per-protocol basis.
Collapse
Affiliation(s)
- Roberto Scipione
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I - Sapienza University of Rome , Rome, Italy
| | - Giulia Alfieri
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I - Sapienza University of Rome , Rome, Italy
| | - Alessandro De Maio
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I - Sapienza University of Rome , Rome, Italy
| | | | - Simone Napoli
- Spine Unit, Centro SaNa Servizi Sanitari , Aprilia, Italy
| | - Luca Bianchi
- Spine Unit, Centro SaNa Servizi Sanitari , Aprilia, Italy
| | | | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli , Bologna, Italy
| | - Giancarlo Facchini
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli , Bologna, Italy
| | - Ugo Albisinni
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli , Bologna, Italy
| | - Paolo Spinnato
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli , Bologna, Italy
| | - Carlo Catalano
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I - Sapienza University of Rome , Rome, Italy
| | - Alessandro Napoli
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I - Sapienza University of Rome , Rome, Italy.,Spine Unit, Centro SaNa Servizi Sanitari , Aprilia, Italy
| |
Collapse
|
37
|
Koltsov JCB, Smuck MW, Alamin TF, Wood KB, Cheng I, Hu SS. Preoperative epidural steroid injections are not associated with increased rates of infection and dural tear in lumbar spine surgery. 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 2020; 30:870-877. [PMID: 32789696 DOI: 10.1007/s00586-020-06566-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/12/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The study objectives were to use a large national claims data resource to examine rates of preoperative epidural steroid injections (ESI) in lumbar spine surgery and determine whether preoperative ESI or the timing of preoperative ESI is associated with rates of postoperative complications and reoperations. METHODS A retrospective longitudinal analysis of patients undergoing lumbar spine surgery for disc herniation and/or spinal stenosis was undertaken using the MarketScan® databases from 2007-2015. Propensity-score matched cohorts were constructed to compare rates of complications and reoperations in patients with and without preoperative ESI. RESULTS Within the year prior to surgery, 120,898 (46.4%) patients had a lumber ESI. The median time between ESI and surgery was 10 weeks. 23.1% of patients having preoperative ESI had more than one level injected, and 66.5% had more than one preoperative ESI treatment. Patients with chronic pain were considerably more likely to have an ESI prior to their surgery [OR 1.62 (1.54, 1.69), p < 0.001]. Patients having preoperative ESI within in close proximity to surgery did not have increased rates of infection, dural tear, neurological complications, or surgical complications; however, they did experience higher rates of reoperations and readmissions than those with no preoperative ESI (p < 0.001). CONCLUSION Half of patients undergoing lumbar spine surgery for stenosis and/or herniation had a preoperative ESI. These were not associated with an increased risk for postoperative complications, even when the ESI was given in close proximity to surgery. Patients with preoperative ESI were more likely to have readmissions and reoperations following surgery.
Collapse
Affiliation(s)
- Jayme C B Koltsov
- Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA, 94063, USA.
| | - Matthew W Smuck
- Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA, 94063, USA
| | - Todd F Alamin
- Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA, 94063, USA
| | - Kirkham B Wood
- Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA, 94063, USA
| | - Ivan Cheng
- Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA, 94063, USA
| | - Serena S Hu
- Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA, 94063, USA
| |
Collapse
|
38
|
Dillingham TR, Annaswamy TM, Plastaras CT. Evaluation of persons with suspected lumbosacral and cervical radiculopathy: Electrodiagnostic assessment and implications for treatment and outcomes (Part II). Muscle Nerve 2020; 62:474-484. [PMID: 32564381 DOI: 10.1002/mus.27008] [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] [Received: 06/18/2020] [Accepted: 06/18/2020] [Indexed: 11/06/2022]
Abstract
The electrodiagnostic (EDX) examination with needle electromyography (EMG) is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity and complements imaging of the spine. In this second of a two-part review, the implications of electrodiagnostic findings for diagnosis and clinical management of persons with radiculopathy are reviewed. An EMG confirmed lumbosacral radiculopathy is associated with better clinical outcomes for persons undergoing aggressive conservative management. A positive EMG test portends a better clinical response to epidural corticosteroid injections. If a person undergoes spine surgery, a positive pre-operative EMG for radiculopathy is also associated with better outcomes.
Collapse
Affiliation(s)
- Timothy R Dillingham
- Department of Physical Medicine and Rehabilitation, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thiru M Annaswamy
- Electrodiagnostic and Spine Sections, VA North Texas Health Care System, Dallas VA Medical Center, Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Christopher T Plastaras
- Musculoskeletal Spine & Sports Rehabilitation Medicine, MossRehab, Einstein Spine Institute, Co-Chair, Albert Einstein Healthcare Network, Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| |
Collapse
|
39
|
Oliveira CB, Maher CG, Ferreira ML, Hancock MJ, Oliveira VC, McLachlan AJ, Koes BW, Ferreira PH, Cohen SP, Pinto RZ. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev 2020; 4:CD013577. [PMID: 32271952 PMCID: PMC7145384 DOI: 10.1002/14651858.cd013577] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Lumbosacral radicular pain (commonly called sciatica) is a syndrome involving patients who report radiating leg pain. Epidural corticosteroid injections deliver a corticosteroid dose into the epidural space, with the aim of reducing the local inflammatory process and, consequently, relieving the symptoms of lumbosacral radicular pain. This Cochrane Review is an update of a review published in Annals of Internal Medicine in 2012. Some placebo-controlled trials have been published recently, which highlights the importance of updating the previous review. OBJECTIVES To investigate the efficacy and safety of epidural corticosteroid injections compared with placebo injection on pain and disability in patients with lumbosacral radicular pain. SEARCH METHODS We searched the following databases without language limitations up to 25 September 2019: Cochrane Back and Neck group trial register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and two trial registers. We also performed citation tracking of included studies and relevant systematic reviews in the field. SELECTION CRITERIA We included studies that compared epidural corticosteroid injections of any corticosteroid drug to placebo injections in patients with lumbosacral radicular pain. We accepted all three anatomical approaches (caudal, interlaminar, and transforaminal) to delivering corticosteroids into the epidural space. We considered trials that included a placebo treatment as delivery of an inert substance (i.e. one with no pharmacologic activity), an innocuous substance (e.g. normal saline solution), or a pharmacologically active substance but not one considered to provide sustained benefit (e.g. local anaesthetic), either into the epidural space (i.e. to mimic epidural corticosteroid injection) or adjacent spinal tissue (i.e. subcutaneous, intramuscular, or interspinous tissue). We also included trials in which a local anaesthetic with a short duration of action was used as a placebo and injected together with corticosteroid in the intervention group. DATA COLLECTION AND ANALYSIS Two authors independently performed the screening, data extraction, and 'Risk of bias' assessments. In case of insufficient information, we contacted the authors of the original studies or estimated the data. We grouped the outcome data into four time points of assessment: immediate (≤ 2 weeks), short term (> 2 weeks but ≤ 3 months), intermediate term (> 3 months but < 12 months), and long term (≥ 12 months). We assessed the overall quality of evidence for each outcome and time point using the GRADE approach. MAIN RESULTS We included 25 clinical trials (from 29 publications) investigating the effects of epidural corticosteroid injections compared to placebo in patients with lumbosacral radicular pain. The included studies provided data for a total of 2470 participants with a mean age ranging from 37.3 to 52.8 years. Seventeen studies included participants with lumbosacral radicular pain with a diagnosis based on clinical assessment and 15 studies included participants with mixed duration of symptoms. The included studies were conducted mainly in North America and Europe. Fifteen studies did not report funding sources, five studies reported not receiving funding, and five reported receiving funding from a non-profit or government source. Eight trials reported data on pain intensity, 12 reported data on disability, and eight studies reported data on adverse events. The duration of the follow-up assessments ranged from 12 hours to 1 year. We considered eight trials to be of high quality because we judged them as having low risk of bias in four out of the five bias domains. We identified one ongoing trial in a trial registry. Epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing leg pain at short-term follow-up (mean difference (MD) -4.93, 95% confidence interval (CI) -8.77 to -1.09 on a 0 to 100 scale; 8 trials, n = 949; moderate-quality evidence (downgraded for risk of bias)). For disability, epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing disability at short-term follow-up (MD -4.18, 95% CI -6.04 to -2.17, on a 0 to 100 scale; 12 trials, n = 1367; moderate-quality evidence (downgraded for risk of bias)). The treatment effects are small, however, and may not be considered clinically important by patients and clinicians (i.e. MD lower than 10%). Most trials provided insufficient information on how or when adverse events were assessed (immediate or short-term follow-up) and only reported adverse drug reactions - that is, adverse events that the trialists attributed to the study treatment. We are very uncertain that epidural corticosteroid injections make no difference compared to placebo injection in the frequency of minor adverse events (risk ratio (RR) 1.14, 95% CI 0.91 to 1.42; 8 trials, n = 877; very low quality evidence (downgraded for risk of bias, inconsistency and imprecision)). Minor adverse events included increased pain during or after the injection, non-specific headache, post-dural puncture headache, irregular periods, accidental dural puncture, thoracic pain, non-local rash, sinusitis, vasovagal response, hypotension, nausea, and tinnitus. One study reported a major drug reaction for one patient on anticoagulant therapy who had a retroperitoneal haematoma as a complication of the corticosteroid injection. AUTHORS' CONCLUSIONS This study found that epidural corticosteroid injections probably slightly reduced leg pain and disability at short-term follow-up in people with lumbosacral radicular pain. In addition, no minor or major adverse events were reported at short-term follow-up after epidural corticosteroid injections or placebo injection. Although the current review identified additional clinical trials, the available evidence still provides only limited support for the use of epidural corticosteroid injections in people with lumbosacral radicular pain as the treatment effects are small, mainly evident at short-term follow-up and may not be considered clinically important by patients and clinicians (i.e. mean difference lower than 10%). According to GRADE, the quality of the evidence ranged from very low to moderate, suggesting that further studies are likely to play an important role in clarifying the efficacy and tolerability of this treatment. We recommend that further trials should attend to methodological features such as appropriate allocation concealment and blinding of care providers to minimise the potential for biased estimates of treatment and harmful effects.
Collapse
Affiliation(s)
- Crystian B Oliveira
- São Paulo State UniversityDepartment of PhysiotherapyRua Roberto Simonsen, 305Presidente PrudenteSão PauloBrazilCEP 19060‐900
| | - Christopher G Maher
- University of SydneySydney School of Public HealthLevel 10 North, King George V Building, Missenden Road, CamperdownSydneyNSWAustralia2050
| | - Manuela L Ferreira
- Sydney Medical School, The University of SydneyInstitute of Bone and Joint Research, The Kolling InstituteSydneyNSWAustralia
| | - Mark J Hancock
- Macquarie UniversityDiscipline of Physiotherapy, Faculty of Medicine and Health SciencesSydneyAustralia
| | - Vinicius Cunha Oliveira
- Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM)Departamento de FisioterapiaCampus JK ‐ Rodovia MGT 367‐ Km 583, nº 5000 ‐ Alto da JacubaDiamantinaMinas GeraisBrazil39100‐000
| | - Andrew J McLachlan
- University of SydneyFaculty of PharmacyA15 ‐ PharmacyRoom N405SydneyNSWAustralia2006
| | - Bart W Koes
- University of Southern DenmarkCenter for Muscle and HealthOdenseDenmark
| | - Paulo H Ferreira
- The University of SydneyDiscipline of Physiotherapy, Faculty of Health Sciences75 East StreetSydneyLidcombe NSWAustralia1825
| | - Steven P Cohen
- Johns Hopkins University School of MedicineBlaustein Pain Treatment Center, Department of AnesthesiologyBaltimoreMarylandUSA
| | - Rafael Zambelli Pinto
- Universidade Federal de Minas Gerais (UFMG)Department of PhysiotherapyAv. Pres. Antônio Carlos, 6627Belo Horizonte ‐ MGBelo Horizonte, Minas GeraisMinas Gerais(MG)BrazilCEP 31270‐901
| | | |
Collapse
|
40
|
Evidenzbasierte interventionelle Schmerztherapie. Schmerz 2020; 34:123-126. [DOI: 10.1007/s00482-019-00440-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
41
|
Donohue NK, Tarima SS, Durand MJ, Wu H. Comparing pain relief and functional improvement between methylprednisolone and dexamethasone lumbosacral transforaminal epidural steroid injections: a self-controlled study. Korean J Pain 2020; 33:192-198. [PMID: 32235020 PMCID: PMC7136301 DOI: 10.3344/kjp.2020.33.2.192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 11/25/2022] Open
Abstract
Background Previous studies have shown varying results between lumbosacral transforaminal epidural steroid injections (TFESIs) performed with particulate versus non-particulate corticosteroids. The purpose of this study was to investigate the difference in pain relief and functional improvement between particulate and non-particulate lumbosacral TFESIs in patients who had undergone both injections, sequentially. Methods This was a self-controlled, retrospective study of 20 patients who underwent both a methylprednisolone and a dexamethasone TFESI to the same vertebral level and side. Primary outcomes included pain relief according to the visual analogue scale (VAS) and functional improvement determined by a yes/no answer to questions regarding mobility and the activities of daily living. Post-injection data was recorded at 2, 3, and 6 months. Results A decrease in VAS scores of –3.4 ± 3.0 (mean ± standard deviation), –3.1 ± 3.1, and –2.8 ± 3.4 was seen for the methylprednisolone group at 2, 3, and 6 months, respectively. Similar decreases of –3.9 ± 3.5, –3.4 ± 2.8, and –2.3 ± 3.4 were seen in the dexamethasone group. There was no significant difference in pain relief at any point between the two medications. The percentage of subjects who reported improved function at 2, 3, and 6 months was 65%, 51%, and 41%, respectively, for the methylprednisolone group and 75%, 53%, and 42% for the dexamethasone group. Conclusions These findings support the use of non-particulate corticosteroids for lumbosacral TFESIs in the context of documented safety concerns with particulate corticosteroids.
Collapse
Affiliation(s)
- Nicholas K Donohue
- Department of Physical Medicine & Rehabilitation, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sergey S Tarima
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Matthew J Durand
- Department of Physical Medicine & Rehabilitation, Medical College of Wisconsin, Milwaukee, WI, USA.,Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Hong Wu
- Department of Physical Medicine & Rehabilitation, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
42
|
Abdel Shaheed C, Maher CG, Buchbinder R, Ng B, Enke O, Guzowski R, McLachlan AJ, Day RO, Richards B, Latimer J, Lin CWC. Efficacy and harms of orally, intramuscularly or intravenously administered glucocorticoids for sciatica: A systematic review and meta-analysis. Eur J Pain 2020; 24:518-535. [PMID: 31715647 DOI: 10.1002/ejp.1505] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/03/2019] [Accepted: 11/05/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Sciatica can be a debilitating condition and there is limited guidance on the use of glucocorticoids administered via the oral, intramuscular or intravenous route for this condition. These represent viable treatment options in the primary care setting. OBJECTIVE To evaluate the evidence on efficacy and harms of oral, IM and IV glucocorticoid administration for sciatica. DATABASES AND DATA TREATMENT MEDLINE, EMBASE, CENTRAL, CINAHL, PsycINFO (inception to October 2018) were searched for randomised placebo-controlled trials evaluating oral, IV or IM glucocorticoid administration for sciatica. Two authors extracted outcomes data. Continuous pain and disability outcomes were converted to a 0 (no pain/disability) to 100 (worst pain/disability) scale. Data were pooled using a random effects model. Overall quality of evidence was assessed using GRADE. Primary outcomes were leg pain and disability. Primary follow-up period was the immediate-term (<2 weeks from administration). We also considered adverse events. RESULTS Nine trials were eligible. One study [n = 27] provided low quality evidence of a small reduction in disability with early administration of oral prednisone (within 1 week); MD -13.4 [-23.3, -3.5] but not for pain MD -2.5 [-16.9, 11.9]. There was low quality evidence from one study [n = 78] of moderate reduction in disability and small reduction in pain with early (within 72 hr of symptom onset) single intramuscular administration of methylprednisolone acetate; MD -24.5 [-38.8, -10.2] and -14.0 [-27.4, -0.6], respectively. There were no immediate-term benefits with IV administration. CONCLUSION The effects of glucocorticoids on immediate-term leg pain or disability are uncertain. Future large high quality trials are needed to resolve this uncertainty.
Collapse
Affiliation(s)
| | - Chris G Maher
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Sydney Local Health District, Institute for Musculoskeletal Health, Sydney, NSW, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne Victoria, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Beverly Ng
- Department of Rheumatology, St George Hospital Kogarah, Sydney, NSW, Australia
| | - Oliver Enke
- Department of Orthopaedics, Nepean Hospital, Kingswood, NSW, Australia
| | - Robert Guzowski
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Andrew J McLachlan
- Faculty of Pharmacy, University of Sydney, Sydney, NSW, Australia.,Centre for Research Excellence in Medicines and Ageing, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Ric O Day
- St Vincent's Hospital Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.,Department of Pharmacology, University of New South Wales, Sydney, NSW, Australia
| | - Bethan Richards
- Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jane Latimer
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | | |
Collapse
|
43
|
Comparing the short-term cost-effectiveness of epidural steroid injections and medical management alone for discogenic lumbar radiculopathy. Clin Neurol Neurosurg 2020; 191:105675. [PMID: 31954364 DOI: 10.1016/j.clineuro.2020.105675] [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] [Received: 04/14/2019] [Revised: 10/19/2019] [Accepted: 01/11/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Epidural steroid injections (ESIs) are a commonly used treatment strategy for low back pain and lumbar radiculopathy. However, their cost-effectiveness and ability to mediate long-term quality of life (QOL) improvements is debated. We sought to analyze the cost-effectiveness of lumbar epidural steroid injections (ESIs) compared to medical management alone for patients with lumbar radiculopathy and low back pain. PATIENTS AND METHODS QOL outcomes were prospectively collected at 3- and 6-months following initial consultation. Metrics included the EuroQol-5 Dimensions (EQ-5D) questionnaire, the Pain Disability Questionnaire (PDQ), the Patient Health Questionnaire (PHQ-9) and the Visual Analogue Scale (VAS). Cost estimations were based on Medicare national payment amounts, median income, and missed workdays. A cost-utility analysis was performed based upon cost estimations and a cost-effectiveness threshold of $100,000/Quality-adjusted life year (QALY). RESULTS One hundred forty-one patients met our inclusion/exclusion criteria; 89 received ESI and 52 were treated with medical management alone. Both cohorts showed improved EQ-5D scores at 3 months but were similar to one another: ESI (ΔEQ-5D = 0.06; p = 0.03) and medical-alone (ΔEQ-5D = 0.07; p = 0.03). No significant difference was seen between groups for total costs ($2,190 vs. $1,772; p = 0.18) or cost-utility ratios ($38,710/QALY vs. $27,313/QALY; p = 0.73). At both the 3-month and 6-month endpoints, absolute differences in cost-utility was driven by overall costs as opposed to QALY gains. Medical management alone was more cost effective at both points owing to lower expenditures, however these differences were not significant. No benefits were seen in either group on the EQ-5D or any of the patient reported outcomes at the 6-month time point. CONCLUSION ESIs were not cost-effective at either the 3-month or 6-month follow-up period. At 3 months, ESIs provide similar improvements in QOL outcomes relative to medical management and at similar costs. At 6 months, neither ESIs nor conservative management provide significant improvements in QOL outcomes.
Collapse
|
44
|
Vigneri S, Sindaco G, La Grua M, Zanella M, Lo Bianco G, Paci V, Vinci FM, Sciacca C, Ravaioli L, Pari G. Electrocatheter-mediated High-voltage Pulsed Radiofrequency of the Dorsal Root Ganglion in the Treatment of Chronic Lumbosacral Neuropathic Pain: A Randomized Controlled Study. Clin J Pain 2020; 36:25-33. [PMID: 31577546 PMCID: PMC6903354 DOI: 10.1097/ajp.0000000000000766] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 08/21/2019] [Accepted: 09/08/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Despite the interest in scientific community, there is still poor evidence about pulsed radiofrequency (PRF) efficacy in the treatment of neuropathic pain. In order to determine whether high-voltage PRF and epidural adhesiolysis (PRF-EA) showed better results than epidural adhesiolysis alone (EA), a randomized, double-blind, comparative-effectiveness study was conducted in patients with chronic lumbosacral radiating pain and neuropathic features. MATERIALS AND METHODS A total of 41 patients were randomly allocated to 2 groups. Twenty-one patients were randomized to receive 2 cycles of 240 seconds high-voltage PRF followed by the injection of local anesthetics, hyaluronidase, and betamethasone, whereas 20 patients underwent sham stimulation followed by adhesiolysis. The treatment was delivered at the affected lumbosacral roots and patients, treating physicians and assessors were blinded to intervention. RESULTS A significant reduction of radiating pain was observed in mean Numeric Rating Scale score at follow-up. A change of -3.43 versus -1.75 (P=0.031) after 1 month and -3.34 versus -0.80 (P=0.005) after 6 months was reported in patients undergoing PRF-EA in comparison with EA, respectively. After 1 month, 57% of patients in the PRF-EA group experienced a pain reduction of ≥50% versus only 25% of patients allocated to EA (P=0.037). Improvement decreased to 48% in the PRF-EA group whereas only 10% of EA reported significant pain relief after 6 months (P=0.008). DISCUSSION High-voltage PRF of dorsal root ganglion delivered through multifunctional electrode provided significant pain relief and may be considered a valuable treatment in chronic lumbosacral radicular pain with neuropathic features.
Collapse
Affiliation(s)
- Simone Vigneri
- Santa Maria Maddalena Hospital, Pain Medicine Unit, Occhiobello
- Department of Experimental Biomedicine and Clinical Neurosciences (BioNeC), University of Palermo, Palermo
| | | | - Marco La Grua
- Santa Maria Maddalena Hospital, Pain Medicine Unit, Occhiobello
| | - Matteo Zanella
- Santa Maria Maddalena Hospital, Pain Medicine Unit, Occhiobello
| | - Giuliano Lo Bianco
- I.R.C.C.S. Centro Regionale Oncologico, Pain Medicine Unit, Rionero in Vulture, Italy
| | - Valentina Paci
- Santa Maria Maddalena Hospital, Pain Medicine Unit, Occhiobello
| | | | - Chiara Sciacca
- Santa Maria Maddalena Hospital, Pain Medicine Unit, Occhiobello
| | - Laura Ravaioli
- Santa Maria Maddalena Hospital, Pain Medicine Unit, Occhiobello
| | - Gilberto Pari
- Santa Maria Maddalena Hospital, Pain Medicine Unit, Occhiobello
| |
Collapse
|
45
|
Karunakaran J, Parasuraman M, Duvvuru A, Shanmugam N. Role of transforaminal epidural steroid injection in chronic disc pain. JOURNAL OF ORTHOPAEDICS AND SPINE 2020. [DOI: 10.4103/joas.joas_49_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
46
|
Viswanathan VK, Kanna RM, Farhadi HF. Role of transforaminal epidural injections or selective nerve root blocks in the management of lumbar radicular syndrome - A narrative, evidence-based review. J Clin Orthop Trauma 2020; 11:802-809. [PMID: 32904233 PMCID: PMC7452348 DOI: 10.1016/j.jcot.2020.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/01/2020] [Accepted: 06/05/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Lumbar radicular Syndrome (LRS) is a common spinal pathology and is attributed to complex interplay of mechanical, inflammatory and immunological processes. Epidural injection of steroids has a significant therapeutic role in mitigating the inflammatory component of LRS. Trans-foraminal approach under image guidance enables a targeted drug delivery. The current narrative review discusses the various aspects related to lumbar trans-foraminal epidural injection of steroid (LTFIS). METHODS An elaborate search on PubMed, Google and Medline databases was made using keywords "lumbar selective nerve root block", "lumbar trans-foraminal epidural steroid injection", "selective nerve root block in lumbar disc prolapse", "trans-foraminal epidural steroid injection in lumbar prolapse", "selective nerve root block in lumbar radiculopathy", and "trans-foraminal epidural steroid injection in lumbar radiculopathy" The articles were selected based on specific inclusion criteria. RESULTS Our search identified 539 articles. All articles discussing alternate procedures, LTFIS in other pathologies, diagnostic roles of LTFIS, not pertaining to concerned questions, in non-English language and duplicate articles were excluded. Review articles, randomised controlled trials or level 1 studies were given preference. Overall, 108 articles were included. Being a focussed narrative review, further screening [Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) or Methodological Index for non-randomized studies (MINORS) criteria] was not performed to select articles. Based on the evidence, LTFIS is an effective and useful treatment modality. It is offered to patients with lumbar disc herniation (LDH) presenting with persistent, unilateral, radiculopathy after a course of conservative measures for around 6 weeks' duration. It has been reported to yield better results than caudal or inter-laminar epidural injections. The anti-inflammatory and nociceptive signal stabilization actions of steroids, as well as mechanical effects of washout of inflammatory mediators and neural lysis contribute to its efficacy. The three different approaches include sub-pedicular, retro-neural and retro-discal. The procedure is performed under image guidance using a water-soluble contrast under fluoroscopy. The four described radiculogram patterns include "arm", "arrow", "linear" and "splash". Computerised tomography, ultrasonography and magnetic resonance imaging are other modalities, which may be helpful in performing LTFIS. The use of particulate versus non-particulate steroids is controversial. CONCLUSION The overall success rate of SNRB is reported to be 76-88%. The majority of benefits are observed during immediate and early post-injection period. Clinical factors including duration and severity of symptoms, and radiological factors like presence of osteophytes, location, size and type of disc prolapse influence outcomes. The radiculogram "splash" pattern is associated with poor outcomes.
Collapse
Affiliation(s)
| | - Rishi Mugesh Kanna
- Department of Spine Surgery, Ganga Medical Center and Hospitals, Coimbatore, India,Corresponding author. Ganga Center and Hospitals, Sai Baba Colony, Coimbatore, India.
| | - H. Francis Farhadi
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| |
Collapse
|
47
|
Gürbüz MS. Lomber Disk Hernisine Bağlı Radikülopatili Hastalarda Floroskopi Eşlikli LomberTransforaminalEpidural Enjeksiyonun Etkinliği. DICLE MEDICAL JOURNAL 2019. [DOI: 10.5798/dicletip.620333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
48
|
Tate Q, Conger A, Burnham T, Cushman DM, Kendall R, Schneider B, McCormick ZL. The Effectiveness and Safety of Genicular Nerve Radiofrequency Ablation for the Treatment of Recalcitrant Knee Pain Due to Osteoarthritis: a Comprehensive Literature Review. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00246-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
49
|
Dower A, Davies MA, Ghahreman A. Pathologic Basis of Lumbar Radicular Pain. World Neurosurg 2019; 128:114-121. [DOI: 10.1016/j.wneu.2019.04.147] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 04/16/2019] [Indexed: 12/26/2022]
|
50
|
Smith CC, McCormick ZL, Mattie R, MacVicar J, Duszynski B, Stojanovic MP. The Effectiveness of Lumbar Transforaminal Injection of Steroid for the Treatment of Radicular Pain: A Comprehensive Review of the Published Data. PAIN MEDICINE 2019; 21:472-487. [DOI: 10.1093/pm/pnz160] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Abstract
Objective
To determine the effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain.
Design
Comprehensive systematic review.
Outcome Measures
The primary outcome of interest was the proportion of individuals with reduction of pain by ≥50%. Additional outcomes of interest were a more-than-two-point reduction in pain score, patient satisfaction, functional improvement, decreased use of pain medication, and avoidance of spinal surgery.
Results
For patients with disc herniations, using the criterion of ≥50% reduction in pain, success rates across included studies (range) were 63% (58–68%) at one month, 74% (68–80%) at three months, 64% (59–69%) at six months, and 64% (57–71%) at one year. For patients with lumbar spinal stenosis, success rates across included studies (range) were 49% (43–55%) at one month, 48% (35–61%) at three months, 43% (33–53%) at six months, and 59% (45–73%) at one year, but there was a lack of corroboration from appropriately controlled studies.
Conclusions
There is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. There is a lack of high-quality evidence demonstrating their effectiveness for the treatment of radicular pain due to spinal stenosis, though small studies suggest a possible benefit. Lumbar transforaminal injection of nonparticulate steroids is as effective as injections with particulate steroids.
Collapse
Affiliation(s)
- Clark C Smith
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ryan Mattie
- Providence Cedars-Sinai Tarzana Hospital, Providence Specialty Medical Group, Comprehensive Spine & Interventional Pain Management, Tarzana, California
| | | | | | - Milan P Stojanovic
- Anesthesiology, Critical Care and Pain Medicine Service, VA Boston Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|