Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial

Causal association between circulating inflammatory markers and sciatica development: a Mendelian randomization study

Background

This research explores the causal association between circulating inflammatory markers and the development of sciatica, a common and debilitating condition. While previous studies have indicated that inflammation may be a factor in sciatica, but a thorough genetic investigation to determine a cause-and-effect relationship has not yet been carried out. Gaining insight into these interactions may uncover novel treatment targets.

Methods

We utilized data from the OpenGWAS database, incorporating a large European cohort of 484,598 individuals, including 4,549 sciatica patients. Our study focused on 91 distinct circulating inflammatory markers. Genetic variations were employed as instrumental variables (IVs) for these markers. The analysis was conducted using inverse variance weighting (IVW) as the primary method, supplemented by weighted median-based estimation. Validation of the findings was conducted by sensitivity studies, utilizing the R software for statistical computations.

Results

The analysis revealed that 52 out of the 91 inflammatory markers studied showed a significant causal association with the risk of developing sciatica. Key markers like CCL2, monocyte chemotactic protein-4, and protein S100-A12 demonstrated a positive correlation. In addition, there was no heterogeneity or horizontal pleiotropy in these results. Interestingly, a reverse Mendelian randomization analysis also indicated potential causative effects of sciatica on certain inflammatory markers, notably Fms-related tyrosine kinase 3 ligands.

Discussion

The study provides robust evidence linking specific circulating inflammatory markers with the risk of sciatica, highlighting the role of inflammation in its pathogenesis. These findings could inform future research into targeted treatments and enhance our understanding of the biological mechanisms underlying sciatica.

[Injection treatment for cervical and lumbar syndromes : Special infiltration techniques]

Minimally invasive injection treatment is indicated particularly in cases of treatment-resistant, painful degenerative alterations of the cervical and lumbar spine, intervertebral disc displacement and radicular syndrome. Through the injections and the supplementation with further conservative, e.g., physical therapy and activating measures, the vicious circle of neural irritation and muscle tension and sympathetic nerve reactions can be interrupted.

Percutaneous Spinal Interventions for Chronic Pain Management

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.

The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain

Introduction

Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety.

Objective

The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders.

Methods

The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented.

Results

After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain.

Conclusion

The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

Association of a Clinician's Antibiotic-Prescribing Rate With Patients' Future Likelihood of Seeking Care and Receipt of Antibiotics

Background

One underexplored driver of inappropriate antibiotic prescribing for acute respiratory illnesses (ARI) is patients’ prior care experiences. When patients receive antibiotics for an ARI, patients may attribute their clinical improvement to the antibiotics, regardless of their true benefit. These experiences, and experiences of family members, may drive whether patients seek care or request antibiotics for subsequent ARIs.

Methods

Using encounter data from a national United States insurer, we identified patients <65 years old with an index ARI urgent care center (UCC) visit. We categorized clinicians within each UCC into quartiles based on their ARI antibiotic prescribing rate. Exploiting the quasi-random assignment of patients to a clinician within an UCC, we examined the association between the clinician’s antibiotic prescribing rate to the patients’ and their spouses’ rates of ARI antibiotic receipt in the subsequent year.

Results

Across 232,256 visits at 736 UCCs, ARI antibiotic prescribing rates were 42.1% and 80.2% in the lowest and highest quartile of clinicians, respectively. Patient characteristics were similar across the four quartiles. In the year after the index ARI visit, patients seen by the highest-prescribing clinicians received more ARI antibiotics (+3.0 fills/100 patients (a 14.6% difference), 95% CI 2.2–3.8, P < 0.001,) versus those seen by the lowest-prescribing clinicians. The increase in antibiotics was also observed among the patients’ spouses. The increase in patient ARI antibiotic prescriptions was largely driven by an increased number of ARI visits (+5.6 ARI visits/100 patients, 95% CI 3.6–7.7, P < 0.001), rather than a higher antibiotic prescribing rate during those subsequent ARI visits.

Conclusions

Receipt of antibiotics for an ARI increases the likelihood that patients and their spouses will receive antibiotics for future ARIs.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

Epidural steroid compared to placebo injection in sciatica: a systematic review and meta-analysis

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.

Role of Epidural Steroid Injection in Lumbar Spinal Stenosis—A Randomized Controlled Trial

Background Degenerative lumbar spinal stenosis (DLSS) is an important cause of pain and disability among the elderly and common indication for spinal surgery. However, due to age-related comorbidities, it becomes difficult for elderly patients of DLSS to immediately go for operative treatment. Caudal epidural steroid injection (CESI) can be an effective procedure for a selected group of patients who have chronic function-limiting lower back and lower extremity pain secondary to DLSS. The aim of this study was to compare the effects of CESI with physical therapy in patients afflicted with DLSS.

Materials and Methods It is a single center, open-label randomized controlled trial conducted in department of Physical Medicine and Rehabilitation at a tertiary care center of northern India from January 2016 to August 2017 among DLSS patients. Trial was registered under the clinical trial registry of India. Patients were randomized in two groups–32 in intervention group A (CESI with local anesthetic and physical therapy) and 32 in control group B (physical therapy alone). Outcome measures were numerical pain rating scale (NPRS), Oswestry disability index (ODI), and mean claudication distance (MCD) at 3, 6, 12, and 24 weeks.

Results NPRS and ODI showed significant improvement at 3, 6, 12, and 24 weeks (group A >> group B). Improvement in MCD was seen at each follow-up from baseline (group A >> group B).

Conclusion Caudal epidural steroid administration can ameliorate pain, disability and claudication distance in DLSS patients, which provides them a window period for further definitive management.

Epidural Corticosteroid Injections for Sciatica: An Abridged Cochrane Systematic Review and Meta-Analysis

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.

Epidural corticosteroid injections for lumbosacral radicular pain

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

AAPT Diagnostic Criteria for Chronic Low Back Pain

Chronic low back pain (CLBP) conditions are highly prevalent and constitute the leading cause of disability worldwide. The Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks (ACTTION) public-private partnership with the US Food and Drug Administration and the American Pain Society (APS), have combined to create the ACTTION-APS Pain Taxonomy (AAPT). The AAPT initiative convened a working group to develop diagnostic criteria for CLBP. The working group identified 3 distinct low back pain conditions which result in a vast public health burden across the lifespan. This article focuses on: 1) the axial predominant syndrome of chronic musculoskeletal low back pain, 2) the lateralized, distally-radiating syndrome of chronic lumbosacral radicular pain 3) and neurogenic claudication associated with lumbar spinal stenosis. This classification of CLBP is organized according to the AAPT multidimensional framework, specifically 1) core diagnostic criteria; 2) common features; 3) common medical and psychiatric comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors. PERSPECTIVE: An evidence-based classification of CLBP conditions was constructed for the AAPT initiative. This multidimensional diagnostic framework includes: 1) core diagnostic criteria; 2) common features; 3) medical and psychiatric comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors.

Heterogeneity Among Hospitals in the Percentages of All Lumbosacral Epidural Steroid Injections Where the Patient Had Received 4 or More in the Previous Year

BACKGROUND

Current guidelines for the administration of therapeutic epidural injections suggest that these be limited to a maximum of 4 per year. We sought to gain an understanding of the proportion of lumbosacral epidural injections administered to patients who had received ≥4 such injections during the preceding 364 days, and whether these proportions varied among hospitals.

METHODS

This observational cohort study included data from all facilities owned by the 121 nonfederal hospitals in the State of Iowa, July 2012 through September 2017. One end point was the percentage of all lumbar or sacral transforaminal or interlaminar epidural injections where the patient had received ≥4 such injections during the preceding 364 days. Comparisons also were made among hospitals' percentages of injections that were the fifth or greater (ie, patient had already received ≥4 during preceding 364 days) using Bonferroni-adjusted conservative 95% confidence intervals.

RESULTS

There were 48,270 unique patients who underwent at least 1 lumbosacral epidural steroid injection. The patients received care at 112 hospitals' facilities. Most patients received no additional steroid injections within 364 subsequent calendar days after the first steroid injection (54.1%). There were ≥5 steroid injections for 1.27% of patients (ie, the injection was the fifth or greater). Among the 39 hospitals in Iowa that performed overall at least 1 steroid injection every 4 days, there were 6 hospitals at which the percentages of injections that were the fifth or greater significantly exceeded the overall prevalence of 1.91% (range: 3.0%-6.4%). There were 14 of the 39 hospitals with prevalences significantly less.

CONCLUSIONS

Although most patients received only 1 lumbosacral steroid injection within 1 year, 1.27% of patients received 5 or more, and 1.91% of injections were the fifth or greater. Several hospitals had significantly greater than the overall average percent of steroid injections which were fifth or more. This heterogeneity warrants study of whether annual steroid injections per patient should be a clinical quality measure for the care received by patients with lower back pain or whether payment should be greater when injections are in accordance with guidelines.

Kambin's Triangle Approach versus Traditional Safe Triangle Approach for Percutaneous Transforaminal Epidural Adhesiolysis Using an Inflatable Balloon Catheter: A Pilot Study

Spinal stenosis is a common condition in elderly individuals. Many patients are unresponsive to the conventional treatment. If the transforaminal epidural block does not exert a sufficient treatment effect, percutaneous transforaminal epidural adhesiolysis (PTFA) through the safe-triangle approach using an inflatable balloon catheter can reduce the patients’ pain and improve their functional capacity. We aimed to evaluate the safety and efficacy of the Kambin’s-triangle approach for PTFA using an inflatable balloon catheter and compare this approach to the traditional safe-triangle approach. Thirty patients with chronic unilateral L5 radiculopathy were divided into two groups: the safe-triangle-approach and Kambin’s-triangle-approach groups, with 15 patients each. The success rate of the procedure was assessed. Pain and dysfunction were assessed using the Numerical Rating Scale and Oswestry Disability Index, respectively, before the procedure and at 1 and 3 months after the procedure. The success rate of the procedure was high in both the groups, with no significant difference between the groups. The Numerical Rating Scale and Oswestry Disability Index scores significantly decreased 3 months after the procedure in both the groups, with no significant difference between the groups. For patients in whom the safe-triangle approach for PTFA is difficult, the Kambin’s-triangle approach could be an alternative.

Efficacy of Caudal Epidural Steroid Injection with Targeted Indwelling Catheter and Manipulation in Managing Patients with Lumbar Disk Herniation and Radiculopathy: A Prospective, Randomized, Single-Blind Controlled Trial

BACKGROUND

Lumbar disk herniation (LDH) is considered a common cause of lumbosacral radiculopathy. Epidural steroid injection is a common method to treat inflammation associated with low back-related leg pain. Spinal manipulations are widely used, and systematic reviews have also shown that these manipulations are more effective than placebos.

OBJECTIVE

Due to the absence of clinical evidence, we designed a prospective, randomized, single-blind controlled trial in patients with LDH with radiculopathy, aiming to detect the safety and clinical efficacy of targeted indwelling catheter combined with "4-step" manipulative therapy in patients with LDH.

METHODS

Patient visits were performed at baseline and days 1, 3, 7, and 28 after treatment. Clinical outcomes were measured using visual analog scale for back and leg pain, Oswestry Disability Index (ODI), and clinical symptom scores of the Japanese Orthopedic Association (JAO).

RESULTS

The study included 85 eligible patients. They were categorized with a randomization schedule into a Catheter Group (N = 43) and No-Catheter Group (N = 42). Between the measurement points, there was a statistically significant difference in the visual analog scale (back) at days 1, 3, and 7 of follow-up after treatment between the 2 groups. The change was statistically different at days 1 and 3, and a higher change was observed in the Catheter Group compared with the No-Catheter Group. There was a statistically significant difference in change of JOA and ODI scores at day 1 of follow-up after treatment between the 2 groups, and a greater change was seen in the Catheter Group at days 1 and 3 compared with the No-Catheter Group.

LIMITATIONS

The small sample size was small, and the follow-up time was short. The study also lacked documents of adjuvant therapies, like individual patient exercise routines and analgesic drug therapy.

CONCLUSION

Both methods were effective in reducing pain intensity and functional disability compared with pretreatment. The Catheter Group showed a more significant decrease in visual analog scale and greater changes in JOA and ODI scores of short/term follow-up, compared with the No-Catheter Group. The therapy project was safe.

Cost-effectiveness of Lumbar Epidural Steroid Injections

STUDY DESIGN

Longitudinal cohort.

OBJECTIVE

To determine the cost per quality-adjusted life-year for lumbar epidural steroid injections (LESI).

SUMMARY OF BACKGROUND DATA

Despite being a widely performed procedure, there are few studies evaluating the cost-effectiveness of LESIs.

METHODS

Patients who had received LESI between June 2012 and July 2013 with EuroQOL-5D (EQ-5D) scores available before and after LESIs but before any surgical intervention were identified. Costs were calculated on the basis of the Medicare Fee Schedule multiplied by the number of LESIs received between the 2 clinic visits. Quality-adjusted life-years (QALYs) were calculated using the EQ-5D.

RESULTS

Of 421 patients who had pre-LESI EQ-5D data, 323 (77%) had post-LESI data available; 200 females, 123 males, mean age: 59.2 ± 14.2 years. Cost per LESI was $608, with most patients receiving 3 LESIs for more than 1 year (range: 1-6 yr). Mean QALY gained was 0.005. One hundred forty-five patients (45%) had a QALY gain (mean = 0.117) at a cost of $62,175 per QALY gained; 127 patients (40%) had a loss in QALY (mean = -0.120) and 51 patients (15%) had no change in QALY. Fourteen of the 145 patients who improved, and 29 of the 178 patients who did not, have medical comorbidities that precluded surgery. Thirty-two (22%) of 131 patients without medical comorbidities who improved and 57 (32%) of 149 patients without medical comorbidities who did not improve subsequently had undergone surgery (P = 0.015).

CONCLUSION

LESI may not be cost-effective in patients with lumbar degenerative disorders. For the 145 patients who improved, cost per QALY gained was acceptable at $62,175. However, for the 178 patients with no gain or a loss in QALY, the economics are not reportable with a cost per QALY gained being theoretically infinite. Further studies are needed to identify specific patient populations who will benefit from LESI because the economic viability of LESI requires improved patient selection.

LEVEL OF EVIDENCE

2.

Opioid Reduction Following Interventional Procedures for Chronic Pain: A Synthesis of the Evidence

The past decade has witnessed the tremendous growth of procedures to treat chronic pain, which has resulted in increased third-party scrutiny. Although most of these procedures appear to be associated with significant pain relief, at least in the short and intermediate term, their ability to improve secondary outcome measures, including function and work status is less clear-cut. One of these secondary outcome measures that has garnered substantial interest in the pain and general medical communities is whether interventions can reduce opioid intake, which is associated with significant risks that in most cases outweigh the benefits in the long term. In the article, we examine whether procedural interventions for chronic pain can reduce opioid intake. Most studies that have examined analgesic reduction as a secondary outcome measure have not separated opioid and nonopioid analgesics, and, among those studies that have, few have demonstrated between-group differences. Reasons for failure to demonstrate opioid reduction can be broadly classified into procedural, design-related, clinical, psychosocial, biological, and pharmacological categories, all of which are discussed. In the future, clinical trials in which this outcome is examined should be designed to evaluate this, at least on a preliminary basis.

A Comparison of the Efficacy and Tolerability of the Treatments for Sciatica: A Network Meta-Analysis

Background: There remains a lack of a systematic summary of the efficacy and safety of various medicines for sciatica, and discrepancies among these exist. Objective: The aim of this study is to comprehensively assess the efficacy of and tolerance to several medical options for the treatment of sciatica. Methods: We performed a network meta-analysis and illustrated the results by the mean difference or odds ratio. The surface under the cumulative ranking curve (SUCRA) was used for indicating the preferable treatments. All data analyses and graphs were achieved via R 3.3.2 and Stata 13.0. Results: The subcutaneous anti–tumor necrosis factor–α (anti-TNF-α) was superior to the epidural steroid + anesthetic in reducing lumbar pain in both acute + chronic sciatica patients and acute sciatica patients. The epidural steroid demonstrated a better ability regarding the Oswestry disability score (ODI) compared to the subcutaneous anti-TNF-α. In addition, for total pain relief, the use of nonsteroidal antiinflammatory drugs was inferior to the epidural steroid + anesthetic. The epidural anesthetic and epidural steroid + anesthetic both demonstrated superiority over the epidural steroid and intramuscular steroid. The intravenous anti-TNF-α ranked first in leg pain relief, while the subcutaneous anti-TNF-α ranked first in lumbar pain relief, and the epidural steroid ranked first in the ODI on the basis of SUCRA. In addition, their safety outcome (withdrawal) rankings were all medium to high. Conclusions: Intravenous and subcutaneous anti-TNF-α were identified as the optimal treatments for both acute + chronic sciatica patients and acute sciatica patients. In addition, the epidural steroid was also recommended as a good intervention due to its superiority in reducing ODI.

Predictive Factors of the Effectiveness of Caudal Epidural Steroid Injections in Managing Patients With Chronic Low Back Pain and Radiculopathy

STUDY DESIGN

Retrospective clinical outcome analysis.

OBJECTIVE

To evaluate and determine whether demographic, comorbid factors, or physical examination findings may predict the outcome of caudal epidural steroid injections in managing patients with chronic low back pain and radiculopathy SUMMARY OF BACKGROUND DATA:: The caudal epidural approach is commonly utilized with patients who are on anticoagulation or who have had prior lumbar surgery to treat L5 or S1 radiculopathies.

METHODS

A retrospective review of 136 patients undergoing an initial caudal epidural steroid injection for radiculopathy from January 1, 2006 to August 30, 2013. The patients were assessed before their injections for their pain levels: visual analog scale, presence of lumbar paraspinal and sciatic notch sensitivity, pain with provocative maneuvers, motor weakness, and sensory loss. The patients were then reassessed following their injection for their visual analog scale pain levels, percentage improvement, and duration of pain relief.

RESULTS

Stepwise regression was used to determine whether demographic, comorbid factors, or physical examination signs were predictive of percentage improvement or length of relief following an injection. Among these variables, duration of symptoms was found to be negatively significantly related with a P-value of 0.032 for percentage of improvement. For each week of the duration of symptoms, the percentage of improvement decreased by 0.07%. Regarding physical examination findings, presence of pain with lumbar extension was negatively and significantly related to length of relief duration with a P-value of 0.0124. The mean length of relief duration is 38.37 weeks for individuals without painful lumbar extension and 14.68 weeks for individuals with painful lumbar extension CONCLUSIONS:: The mean length of relief following a caudal injection is reduced by 62% in patients who exhibit pain with lumbar extension.

The effectiveness of transforaminal epidural steroid injections on radicular pain, functionality, psychological status and sleep quality in patients with lumbar disc herniation

BACKGROUND

The significance of fluoroscopy-guided transforaminal epidural steroid injections (TFESI) in the treatment of lumbar disc herniation (LDH) is well known. The aim of our study is to investigate the effectiveness of TFESI on radicular pain, functionality, psychological status, and sleep quality in patients with LDH.

METHODS

Seventy-five LDH patients (36 males, 39 females) were enrolled in the study. All patients received a fluoroscopically guided TFESI (betamethasone 40 mg, lidocaine 2%). Also all patients were evaluated according to (with the visual analogue scale) radicular pain, Oswestry disability index (ODI), hospital axiety and depression scale, and Pittsburgh sleep quality index (PSQI) at baseline, at two weeks, and 12 months post injections.

RESULTS

Mean age was 46.4 ± 12.5. When compared to baseline measurements there were significant improvements in radicular pain, ODI, modified schober, Laseque angle, finger to floor distance, depressive symptoms and PSQI scores at two weeks and 12 months after injection. Improvement of at least 50% in radicular pain relief, ODI score and sleep quality index was detected at two weeks 83%, 71%, 69% respectively. This rate showed regression at 12 months of 73%, 65% and 62% respectively. Duration of symptoms was significantly negatively correlated with changes in scores of radicular pain, ODI, depressive symptoms, and PSQI. There were no significant correlations with symptom duration and anxious symptoms.

CONCLUSION

Fluoroscopy guided TFESI had positive effects on radicular pain, functionality, depressive symptoms and sleep quality in management of LDH.

Non-operative treatment of lumbar spinal stenosis

BACKGROUND AND OBJECTIVE

Non-operative treatment is widely accepted for early stages of lumbar spinal stenosis. In general, a trial of conservative treatment is recommended prior to surgery. However, there is an ongoing debate regarding benefits from non-operative treatment and their duration.

METHODS

Thirty-eight patients were included in this prospective study. All patients received repeated epidural injections and facet joint injections as well as physiotherapy during a one week hospitalization. Patient characteristics, VAS scores, COMI and ODI scores and SF-36 were assessed prior to and immediately after treatment as well as after six, twelve, and 26 weeks. For six weeks after treatment, patients were asked to record a pain diary.

RESULTS

Back and leg pain scores improved significantly on VAS up to three months follow-up. COMI score improved significantly over the entire follow-up. Regarding quality of life, mental sub-scores showed no improvement. Physical component summary scores improved for the first three months.

CONCLUSIONS

Non-operative treatment offers pain relief and improves physical function for three months. COMI scores improve up to six months follow-up. Spine Tango registry offers standardized instruments for outcome evaluation of non-operative treatment.

[Injection therapy for cervical and lumbar syndromes]

In cervical and lumbar pain syndromes special injections are key for effective pain therapy. Depending on the origin of pain injections are placed at the nerve root or the joints. Thus, the vicious cycle can be stopped. A correct technical procedure is of enormous importance. Because pharmacological effects and special complications are possible, monitoring and precautions are mandatory.

Fluoroscopically Guided Epidural Injections of the Cervical and Lumbar Spine

Advances in imaging and the development of injection techniques have enabled spinal intervention to become an important tool in managing chronic spinal pain. Epidural steroid injection (ESI) is one of the most widely used spinal interventions; it directly delivers drugs into the epidural space to relieve pain originating from degenerative spine disorders-central canal stenoses and neural foraminal stenoses-or disk herniations. Knowledge of the normal anatomy of the epidural space is essential to perform an effective and safe ESI and to recognize possible complications. Although computed tomographic (CT) or combined CT-fluoroscopic guidance has been increasingly used in ESI, conventional fluoroscopic guidance is generally performed. In ESI, drugs are delivered into the epidural space by interlaminar or transforaminal routes in the cervical spine or by interlaminar, transforaminal, or caudal routes in the lumbar spine. Epidurography is usually performed before drug delivery to verify the proper position of the needle in the epidural space. A small amount of contrast agent is injected with fluoroscopic guidance. Familiarity with the findings on a typical "true" epidurogram (demonstrating correct needle placement in the epidural space) permits proper performance of ESI. Findings on "false" epidurograms (demonstrating incorrect needle placement) include muscular staining and evidence of intravascular injection, inadvertent facet joint injection, dural puncture, subdural injection, and intraneural or intradiscal injection. ^©RSNA, 2016 An earlier incorrect version of this article appeared online. This article was corrected on December 22, 2016.

Comparative effectiveness of percutaneous epidural adhesiolysis for different sacrum types in patients with chronic pain due to lumbar disc herniation: A propensity score matching analysis

For percutaneous epidural adhesiolysis (PEA) in patients with chronic low back and/or leg pain, comparative efficacy of lumbar PEA between the sacral types has not yet been investigated. This study aimed to determine the comparative efficacy of lumbar PEA between the sacral types in chronic pain with lumbosacral herniated intervertebral disc (L-HIVD).A total of 1158 chronic low back and/or leg pain patients who diagnosed with L-HIVD and underwent PEA between February 2011 and March 2015 were retrospectively examined. All enrolled patients were divided into 2 types: dome-sacral type and flat type. To avoid confounding bias, propensity score analysis was used. Numeric rating scales (NRS) and Patients' Global Impression of Change (PGIC) were compared between the 2 types at baseline and at 3 months post-PEA.After conducting a propensity score matching analysis, 114 patients were included in each type. The mean sacral angle significantly differed between the flat-sacral and dome-sacral types (P < 0.001). A linear mixed effect model analysis showed that the adjusted NRS score at baseline was 7.58 [95% confidence interval (CI): 7.40-7.76] for the flat-sacral type and 7.47 (95% CI: 7.29-7.64) for the dome-sacral type. The adjusted NRS score after 3 months post-PEA was 4.27 (95% CI: 3.77-4.77) for the flat-sacral type and 3.71 (95% CI: 3.21-4.21) for the dome-sacral type. We detected no significant differences in NRS at baseline (P = 0.371) and after 3 months (P = 0.121) between the 2 groups. No significant differences were observed in terms of the NRS score between the 2 groups during the 3 months follow-up (omnibus P = 0.223). There were no significant differences in PGIC between flat-sacral and dome-sacral types at 3 months after the follow-up period (4.40 ± 2.17 and 4.67 ± 1.88, respectively, P = 0.431).PEA provides sufficient pain relief for chronic pain due to L-HIVD at 3 months postprocedure. The sacral type might not affect the outcome of lumbar PEA in chronic pain associated lumbar HIVD.

Transforaminal epidural steroid injection in lumbar spinal stenosis: an observational study with two-year follow-up

BACKGROUND CONTEXT

Transforaminal epidural steroid injection (TFESI) is recognised as a treatment for symptomatic lumbar disc herniation, whilst surgical decompression is generally thought to be the most effective treatment option for lumbar spinal stenosis. There is little available literature examining the effect of TFESI on symptomatic lumbar spinal stenosis.

PURPOSE

To evaluate the use of TFESI as an alternative to surgery in patients with symptomatic stenosis.

STUDY DESIGN/SETTING

An observational study which took place between May 2010 and July 2013. All patients were seen by the Extended Scope Physiotherapist (ESP) injection service.

PATIENT SAMPLE

A total of 68 consecutive patients were included. Thirty-one were male and 37 were female. The average age was 75 years.

OUTCOME MEASURES

The primary outcome measure was the avoidance of decompressive surgery.

METHODS

Patients with radicular leg pain were seen by an ESP in an Outpatient setting. Concordant clinical examination and magnetic resonance imaging were required for diagnosis. Peri-radicular bupivacaine hydrochloride 0.25% (3 ml) and triamcinolone (40 mg) were then injected. Outcome measures were recorded at 6 weeks, 1 year and 2 years.

RESULTS

Of 68 patients with spinal stenosis, 22 (32%) had opted for surgery at two year follow-up. Thirty (44%) patients were satisfied with non-surgical management at 2 years, required no further treatment, and were discharged. Of the remaining 24%, nine patients were referred for further injection, four declined surgery but were referred to the Pain Relief Clinic, two still had a similar level of pain but declined surgery and one had died.

CONCLUSIONS

Our study reports a considerably lower percentage patients opting for surgery than previously demonstrated by the available literature. TFESI is a reasonable treatment for lumbar spinal stenosis and can result in long-term relief from symptoms in a high proportion of patients.

Surgical and nonsurgical treatments for lumbar spinal stenosis

Lumbar spinal stenosis (LSS) is the most common indication for spinal surgery in older adults; however, the efficacy of surgery for LSS as compared to nonsurgical treatments remains unclear. Here, we reviewed numerous studies, including randomized control trails (RCTs), to compare nonsurgical and surgical treatments for LSS. The nonsurgical management of LSS includes medication, epidural injections, physiotherapy, lifestyle modification, and multidisciplinary rehabilitative approaches. Patients with LSS who do not improve after nonsurgical treatments are typically treated surgically using decompressive surgery, which has the strongest evidence base. Although decompressive surgical treatment is associated with modestly successful outcomes, it remains unclear whether decompression combined with fusion surgery results in clinical outcomes that are superior to those following decompression surgery alone. Future RCTs assessing the effectiveness of specific treatments based on high-quality scientific evidence are expected to aid clinical decision-making and improve treatment outcomes for LSS.

Ultrasound versus fluoroscopy-guided caudal epidural steroid injection for the treatment of chronic low back pain with radiculopathy: A randomised, controlled clinical trial

Background and Aims:

Caudal epidural steroid administration is an effective treatment for chronic low back pain (LBP). Fluoroscopy guidance is the gold standard for pain procedures. Ultrasound guidance is recently being used in pain clinic procedures. We compared the fluoroscopy guidance and ultrasound guidance for caudal epidural steroid injection with respect to the time needed for correct placement of the needle and clinical effectiveness in patients with chronic LBP.

Methods:

Fifty patients with chronic LBP with radiculopathy, not responding to conventional medical management, were randomly allocated to receive injection depot methyl prednisolone (40 mg) through caudal route either using ultrasound guidance (Group U, n = 25) or fluoroscopy guidance (Group F, n = 25). Pre-procedural visual analogue scale (VAS) score and Oswestry Disability Index (ODI) were noted. During the procedure, the time needed for correct placement of needle was observed. Adverse events, if any, were also noted. All patients were followed up for next 2 months to evaluate Visual Analogue Scale (VAS) score and ODI at the 2^nd week and again at the end of 1^st and 2^nd month.

Results:

The needle-placement time was less using ultrasound guidance as compared to fluoroscopy guidance (119 ± 7.66 vs. 222.28 ± 29.65 s, respectively, P < 0.001). Significant reduction in VAS score and ODI (clinical improvement) was noted in the follow-up time points and comparable between the groups at all time points.

Conclusion:

Ultrasound guidance can be a safe alternative tool for achieving faster needle placement in caudal epidural space. Clinical effectiveness (reduction of VAS and ODI scores) remains comparable between both the techniques.

Neurological complications associated with epidural steroid injections

Multiple case reports of neurological complications resulting from intraarterial injection of corticosteroids have led the Food and Drug Administration (FDA) to issue a warning, requiring label changes, warning of serious neurological events, some resulting in death. The FDA has identified 131 cases of neurological adverse events, including 41 cases of arachnoiditis. A review of the literature reveals an overwhelming proportion of the complications are related to transforaminal epidural injections, of which cervical transforaminal epidural injections constituted the majority of neurological complications. Utilization data of epidural injections in the Medicare population revealed that cervical transforaminal epidural injections constitute only 2.4 % of total epidural injections and <5 % of all transforaminal epidural injections. Multiple theories have been proposed as the cause of neurological injury including particulate steroid, arterial intimal flaps, arterial dissection, dislodgement of plaque causing embolism, arterial muscle spasm, and embolism of a fresh thrombus following disruption of the intima.

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

BACKGROUND

Use of epidural corticosteroid injections is increasing.

PURPOSE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

LIMITATIONS

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

CONCLUSION

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

Epidural injection with or without steroid in managing chronic low back and lower extremity pain: ameta-analysis of ten randomized controlled trials

BACKGROUND

Chronic low back and lower extremity pain is mainly caused by lumbar disc herniation (LDH) and radiculitis. Various surgery and nonsurgical modalities, including epidural injections, have been used to treat LDH or radiculitis. Therefore, we conducted this meta-analysis to assess the effects of the two interventions in managing various chronic low and lower extremity pain.

METHODS

A systematic literature search was conducted to identify randomized controlled trials (RCTs) which compared the effect of local anesthetic with or without steroids. The outcomes included pain relief, functional improvement, opioid intake, and therapeutic procedural characteristics. Pooled estimates were calculated using a random-effects or fixed-effects model, depending on the heterogeneity between the included studies.

RESULTS

10 RCTs (involving 1111 patients) were included in this meta-analysis. The pooled results showed that 41.7% of patients who received local anesthetic with steroid (group 1) and 40.2% of patients who received local anesthetic alone (group 2) had significant improvement in pain relief. And the Numeric Rating Scale pain scales were significantly reduced by 4.09 scores (95% CI: -4.26, -3.91), and 4.12 (95% CI: -4.35, -3.89) scores, respectively. Similarly, 39.8% of patients in group 1 and 40.7% of patients in group 2 achieved significantly improved functional status. The Oswestry Disability Index in the two groups were reduced by 14.5 (95% CI: -15.24, -13.75) and 12.37 (95% CI: -16.13, -8.62), respectively. The average procedures per year in group 1 was 3.68 ± 1.17 and 3.68 ± 1.26 in group 2 with an average total relief per year of 31.67 ± 13.17 weeks and 32.64 ± 13.92 weeks, respectively. The opioid intake decreased from baseline by 8.81 mg (95% CI: -12.24, -5.38) and 16.92 mg (95% CI: -22.71, -11.12) in the two groups, respectively.

CONCLUSION

This meta-analysis confirms that epidural injections of local anesthetic with or without steroids have beneficial but similar effects in the treatment of patients with chronic low back and lower extremity pain.

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study

OBJECTIVE

To evaluate whether an epidural steroid injection or gabapentin is a better treatment for lumbosacral radiculopathy.

DESIGN

A multicenter randomized study conducted between 2011 and 2014. Computer generated randomization was stratified by site. Patients and evaluating physicians were blinded to treatment outcomes.

SETTINGS

Eight military, Veterans Administration, and civilian hospitals.

PARTICIPANTS

145 people with lumbosacral radicular pain secondary to herniated disc or spinal stenosis for less than four years in duration and in whom leg pain is as severe or more severe than back pain.

INTERVENTIONS

Participants received either epidural steroid injection plus placebo pills or sham injection plus gabapentin.

MAIN OUTCOME MEASURES

Average leg pain one and three months after the injection on a 0-10 numerical rating scale. A positive outcome was defined as a ≥ 2 point decrease in leg pain coupled with a positive global perceived effect. All patients had one month follow-up visits; patients whose condition improved remained blinded for their three month visit.

RESULTS

There were no significant differences for the primary outcome measure at one month (mean pain score 3.3 (SD 2.6) and mean change from baseline -2.2 (SD 2.4) in epidural steroid injection group versus 3.7 (SD 2.6) and -1.7 (SD 2.6) in gabapentin group; adjusted difference 0.4, 95% confidence interval -0.3 to 1.2; P=0.25) and three months (mean pain score 3.4 (SD 2.7) and mean change from baseline -2.0 (SD 2.6) versus 3.7 (SD 2.8) and -1.6 (SD 2.7), respectively; adjusted difference 0.3, -0.5 to 1.2; P=0.43). Among secondary outcomes, one month after treatment those who received epidural steroid injection had greater reductions in worst leg pain (-3.0, SD 2.8) than those treated with gabapentin (-2.0, SD 2.9; P=0.04) and were more likely to experience a positive successful outcome (66% v 46%; number needed to treat=5.0, 95% confidence interval 2.8 to 27.0; P=0.02). At three months, there were no significant differences between treatments.

CONCLUSIONS

Although epidural steroid injection might provide greater benefit than gabapentin for some outcome measures, the differences are modest and are transient for most people.Trial registration ClinicalTrials.gov Identifier: NCT01495923.

Outcome prediction in chronic unilateral lumbar radiculopathy: prospective cohort study

Background

Identification of prognostic factors for persistent pain and disability are important for better understanding of the clinical course of chronic unilateral lumbar radiculopathy and to assist clinical decision-making. There is a lack of scientific evidence concerning prognostic factors. The aim of this study was to identify clinically relevant predictors for outcome at 52 weeks.

Methods

116 patients were included in a sham controlled clinical trial on epidural injection of glucocorticoids in patients with chronic unilateral lumbar radiculopathy. Success at follow-up was ≤17.5 for visual analogue scale (VAS) leg pain, ≤22.5 for VAS back pain and ≤20 for Oswestry Disability Index (ODI). Fifteen clinically relevant variables included demographic, psychosocial, clinical and radiological data and were analysed using a logistic multivariable regression analysis.

Results

At follow-up, 75 (64.7%) patients had reached a successful outcome with an ODI score ≤20, 54 (46.6%) with a VAS leg pain score ≤17.5, and 47 (40.5%) with a VAS back pain score ≤22.5.

Lower age (OR 0.94 (CI 0.89–0.99) for each year decrease in age) and FABQ Work ≥34 (OR 0.16 (CI 0.04-0.61)) were independent variables predicting a successful outcome on the ODI.

Higher education (OR 5.77 (CI 1.46–22.87)) and working full-time (OR 2.70 (CI 1.02–7.18)) were statistically significant (P <0.05) independent predictors for successful outcome (VAS score ≤17.5) on the measure of leg pain. Lower age predicted success on ODI (OR 0.94 (95% CI 0.89 to 0.99) for each year) and less back pain (OR 0.94 (0.90 to 0.99)), while higher education (OR 5.77 (1.46 to 22.87)), working full-time (OR 2.70 (1.02 to 7.18)) and muscle weakness at baseline (OR 4.11 (1.24 to 13.61) predicted less leg pain, and reflex impairment at baseline predicted the contrary (OR 0.39 (0.15 to 0.97)).

Conclusions

Lower age, higher education, working full-time and low fear avoidance beliefs each predict a better outcome of chronic unilateral lumbar radiculopathy. Specifically, lower age and low fear avoidance predict a better functional outcome and less back pain, while higher education and working full-time predict less leg pain. These results should be validated in further studies before being used to inform patients.

Trial registration

Current Controlled Trials ISRCTN12574253. Registered 18 May 2005.

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

BACKGROUND CONTEXT

Low back pain is debilitating and costly, especially for patients not responding to conservative therapy and requiring surgery.

PURPOSE

Our objective was to determine whether epidural steroid injections (ESI) have a surgery-sparing effect in patients with spinal pain.

STUDY DESIGN/SETTING

The study design was based on a systematic review and meta-analysis.

METHODS

Databases searched included Cochrane, PubMed, and EMBASE. The primary analysis evaluated randomized controlled trials (RCTs) in which treatment groups received ESI and control groups underwent control injections. Secondary analyses involved RCTs comparing surgery with ESI, and subgroup analyses of trials comparing surgery with conservative treatment in which the operative disposition of subjects who received ESI were evaluated.

RESULTS

Of the 26 total studies included, only those evaluating the effect of ESI on the need for surgery as a primary outcome examined the same patient cohort, providing moderate evidence that patients who received ESI were less likely to undergo surgery than those who received control treatment. For studies examining surgery as a secondary outcome, ESI demonstrated a trend to reduce the need for surgery for short-term (<1 year) outcomes (risk ratio, 0.68; 95% confidence interval, 0.41-1.13; p=.14) but not long-term (≥1 year) outcomes (0.95, 0.77-1.19, p=.68). Secondary analyses provided low-level evidence suggesting that between one-third and half of patients considering surgery who undergo ESI can avoid surgery.

CONCLUSIONS

Epidural steroid injections may provide a small surgery-sparing effect in the short term compared with control injections and reduce the need for surgery in some patients who would otherwise proceed to surgery.

Placebo effects in trials evaluating 12 selected minimally invasive interventions: a systematic review and meta-analysis

OBJECTIVES

To analyse the impact of placebo effects on outcome in trials of selected minimally invasive procedures and to assess reported adverse events in both trial arms.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES AND STUDY SELECTION

We searched MEDLINE and Cochrane library to identify systematic reviews of musculoskeletal, neurological and cardiac conditions published between January 2009 and January 2014 comparing selected minimally invasive with placebo (sham) procedures. We searched MEDLINE for additional randomised controlled trials published between January 2000 and January 2014.

DATA SYNTHESIS

Effect sizes (ES) in the active and placebo arms in the trials' primary and pooled secondary end points were calculated. Linear regression was used to analyse the association between end points in the active and sham groups. Reported adverse events in both trial arms were registered.

RESULTS

We included 21 trials involving 2519 adult participants. For primary end points, there was a large clinical effect (ES≥0.8) after active treatment in 12 trials and after sham procedures in 11 trials. For secondary end points, 7 and 5 trials showed a large clinical effect. Three trials showed a moderate difference in ES between active treatment and sham on primary end points (ES ≥0.5) but no trials reported a large difference. No trials showed large or moderate differences in ES on pooled secondary end points. Regression analysis of end points in active treatment and sham arms estimated an R(2) of 0.78 for primary and 0.84 for secondary end points. Adverse events after sham were in most cases minor and of short duration.

CONCLUSIONS

The generally small differences in ES between active treatment and sham suggest that non-specific mechanisms, including placebo, are major predictors of the observed effects. Adverse events related to sham procedures were mainly minor and short-lived. Ethical arguments frequently raised against sham-controlled trials were generally not substantiated.

Comparison of the efficacy of caudal, interlaminar, and transforaminal epidural injections in managing lumbar disc herniation: is one method superior to the other?

Background

Epidural injections are performed utilizing 3 approaches in the lumbar spine: caudal, interlaminar, and transforaminal. The literature on the efficacy of epidural injections has been sporadic. There are few high-quality randomized trials performed under fluoroscopy in managing disc herniation that have a long-term follow-up and appropriate outcome parameters. There is also a lack of literature comparing the efficacy of these 3 approaches.

Methods

This manuscript analyzes data from 3 randomized controlled trials that assessed a total of 360 patients with lumbar disc herniation. There were 120 patients per trial either receiving local anesthetic alone (60 patients) or local anesthetic with steroids (60 patients).

Results

Analysis showed similar efficacy for caudal, interlaminar, and transforaminal approaches in managing chronic pain and disability from disc herniation. The analysis of caudal epidural injections showed the potential superiority of steroids compared with local anesthetic alone a 2-year follow-up, based on the average relief per procedure. In the interlaminar group, results were somewhat superior for pain relief in the steroid group at 6 months and functional status at 12 months. Interlaminar epidurals provided improvement in a significantly higher proportion of patients. The proportion of patients nonresponsive to initial injections was also lower in the group for local anesthetic with steroid in the interlaminar trial.

Conclusions

The results of this assessment show significant improvement in patients suffering from chronic lumbar disc herniation with 3 lumbar epidural approaches with local anesthetic alone, or using steroids with long-term follow-up of up to 2 years, in a contemporary interventional pain management setting.

Analysis of efficacy differences between caudal and lumbar interlaminar epidural injections in chronic lumbar axial discogenic pain: local anesthetic alone vs. local combined with steroids

STUDY DESIGN

Comparative assessment of randomized controlled trials of caudal and lumbar interlaminar epidural injections in chronic lumbar discogenic pain.

OBJECTIVE

To assess the comparative efficacy of caudal and lumbar interlaminar approaches of epidural injections in managing axial or discogenic low back pain.

SUMMARY OF BACKGROUND DATA

Epidural injections are commonly performed utilizing either a caudal or lumbar interlaminar approach to treat chronic lumbar axial or discogenic pain, which is pain exclusive of that associated with a herniated intervertebral disc, or that is due to degeneration of the zygapophyseal joints, or due to dysfunction of the sacroiliac joints, respectively. The literature on the efficacy of epidural injections in managing chronic axial lumbar pain of presumed discogenic origin is limited.

METHODS

The present analysis is based on 2 randomized controlled trials of chronic axial low back pain not caused by disc herniation, radiculitis, or facet joint pain, utilizing either a caudal or lumbar interlaminar approach, with a total of 240 patients studied, and a 24-month follow-up. Patients were assigned to receive either local anesthetic only or local anesthetic with a steroid in each 60 patient group.

RESULTS

The primary outcome measure was significant improvement, defined as pain relief and functional status improvement of at least 50% from baseline, which was reported at 24-month follow-ups in 72% who received local anesthetic only with a lumbar interlaminar approach and 54% who received local anesthetic only with a caudal approach. In patients receiving local anesthetic with a steroid, the response rate was 67% for those who had a lumbar interlaminar approach and 68% for those who had a caudal approach at 12 months. The response was significantly better in the lumbar interlaminar group who received local anesthetic only, 77% versus 56% at 12 months and 72% versus 54% at 24 months.

CONCLUSION

This assessment shows that in patients with axial or discogenic pain in the lumbar spine after excluding facet joint and SI Joint pain, epidural injections of local anesthetic by the caudal or lumbar interlaminar approach may be effective in managing chronic low back pain with a potential superiority for a lumbar interlaminar approach over a caudal approach.

Prevalence of the fibromyalgia phenotype in patients with spine pain presenting to a tertiary care pain clinic and the potential treatment implications

OBJECTIVE

Injections for spinal pain have high failure rates, emphasizing the importance of patient selection. It is possible that detecting the presence of a fibromyalgia (FM)-like phenotype could aid in prediction, because in these individuals a peripheral injection would not address pain due to alterations in central neurotransmission. We undertook this study to test the hypothesis that patients who have spine pain meeting survey criteria for FM would be phenotypically distinct from those who do not.

METHODS

We studied 548 patients diagnosed as having primary spine pain. All patients completed validated self-report questionnaires, including the Brief Pain Inventory, the PainDETECT questionnaire, the Hospital Anxiety and Depression Scale, measures of physical function, and the FM criteria and severity scales.

RESULTS

Forty-two percent of the patients were FM positive according to the FM criteria and severity scales. Compared with FM-negative patients, FM-positive patients were more likely to be younger, unemployed, and receiving compensation for pain and to have greater pain severity and pain interference and more neuropathic pain descriptors as well as higher levels of depression and anxiety and a lower level of physical function (P < 0.002 for each comparison). Female sex, neuropathic pain, pain interference, and anxiety were independently predictive of FM status in a multivariate analysis (P < 0.01 for all variables). Receiver operating characteristic curve analysis showed a strength of association of 0.80 as measured by the cross-validated C statistic.

CONCLUSION

Using the FM criteria and severity scales, we demonstrated profound phenotypic differences in a population of patients with spine pain. Although centralized pain cannot be confirmed with a self-report instrument alone, the pathophysiology of FM may help explain a portion of the variability of responses to spine interventions.

Two-year follow-up results of fluoroscopic cervical epidural injections in chronic axial or discogenic neck pain: a randomized, double-blind, controlled trial

STUDY DESIGN

A randomized, double-blind, active-controlled trial.

OBJECTIVE

To assess the effectiveness of cervical interlaminar epidural injections of local anesthetic with or without steroids for the management of axial or discogenic pain in patients without disc herniation, radiculitis, or facet joint pain.

SUMMARY OF BACKGROUND DATA

Cervical discogenic pain without disc herniation is a common cause of suffering and disability in the adult population. Once conservative management has failed and facet joint pain has been excluded, cervical epidural injections may be considered as a management tool. Despite a paucity of evidence, cervical epidural injections are one of the most commonly performed nonsurgical interventions in the management of chronic axial or disc-related neck pain.

METHODS

One hundred and twenty patients without disc herniation or radiculitis and negative for facet joint pain as determined by means of controlled diagnostic medial branch blocks were randomly assigned to one of the 2 treatment groups. Group I patients received cervical interlaminar epidural injections of local anesthetic (lidocaine 0.5%, 5 mL), whereas Group II patients received 0.5% lidocaine, 4 mL, mixed with 1 mL or 6 mg of nonparticulate betamethasone. The primary outcome measure was ≥ 50% improvement in pain and function. Outcome assessments included numeric rating scale (NRS), Neck Disability Index (NDI), opioid intake, employment, and changes in weight.

RESULTS

Significant pain relief and functional improvement (≥ 50%) was present at the end of 2 years in 73% of patients receiving local anesthetic only and 70% receiving local anesthetic with steroids. In the successful group of patients, however, defined as consistent relief with 2 initial injections of at least 3 weeks, significant improvement was illustrated in 78% in the local anesthetic group and 75% in the local anesthetic with steroid group at the end of 2 years. The results reported at the one-year follow-up were sustained at the 2-year follow-up.

CONCLUSIONS

Cervical interlaminar epidural injections with or without steroids may provide significant improvement in pain and functioning in patients with chronic discogenic or axial pain that is function-limiting and not related to facet joint pain.