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Zhang J, Zhang R, Wang Y, Dang X. Efficacy of epidural steroid injection in the treatment of sciatica secondary to lumbar disc herniation: a systematic review and meta-analysis. Front Neurol 2024; 15:1406504. [PMID: 38841695 PMCID: PMC11150834 DOI: 10.3389/fneur.2024.1406504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 05/06/2024] [Indexed: 06/07/2024] Open
Abstract
Epidural steroid injection for the treatment of sciatica caused by disc herniation is increasingly used worldwide, but its effectiveness remains controversial. The review aiming to analyze the efficacy of epidural steroid injection on sciatica caused by lumbar disc herniation. Randomized controlled trials (RCTs) investigating the use of epidural steroid injections in the management of sciatica induced by lumbar disc herniation were collected from PubMed and other databases from January, 2008 to December, 2023, with epidural steroid injection in the test group and epidural local anesthetic and/or placebo in the control group. Pain relief rate, assessed by numerical rating scale (NRS) and visual analogue scale (VAS) scores, and function recovery, evaluated by Roland Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI) scores, were recorded and compared. Meta-analysis was performed by Review Manager. In comparison to the control group, epidural steroid injections have been shown to be effective for providing short- (within 3 months) [MD = 0.44, 95%CI (0.20, 0.68), p = 0.0003] and medium-term (within 6 months) [MD = 0.66, 95%CI (0.09,1.22), p = 0.02] pain relief for sciatica caused by lumbar disc herniation, while its long-term pain-relief effect were limited. However, the administration of epidural steroid injections did not lead to a significant improvement on sciatic nerve function in short- [MD = 0.79, 95%CI = (0.39, 1.98), p = 0.19] and long-term [MD = 0.47, 95% CI = (-0.86, 1.80), p = 0.49] assessed by IOD. Furthermore, the analysis revealed that administering epidural steroid injections resulted in a reduction in opioid usage among patients with lumbar disc herniation [MD = -14.45, 95% CI = (-24.61, -4.29), p = 0.005]. The incidence of epidural steroid injection was low. Epidural steroid injection has demonstrated notable efficacy in relieving sciatica caused by lumbar disc herniation in short to medium-term. Therefore, it is recommended as a viable treatment option for individuals suffering from sciatica.
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Affiliation(s)
- Jianan Zhang
- Zonglian College, Xi’an Jiaotong University, Xi’an, China
| | - Ruimeng Zhang
- Zonglian College, Xi’an Jiaotong University, Xi’an, China
| | - Yue Wang
- Zonglian College, Xi’an Jiaotong University, Xi’an, China
| | - Xiaoqian Dang
- The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
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Di Z, Zhenni C, Zifeng Z, Bei J, Yong C, Yixuan L, Yuwei P, Li G, Jiaxu C, Guoping Z. Danggui Sini Decoction normalizes the intestinal microbiota and serum metabolite levels to treat sciatica. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2024; 132:155740. [PMID: 39059091 DOI: 10.1016/j.phymed.2024.155740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 04/15/2024] [Accepted: 05/14/2024] [Indexed: 07/28/2024]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Danggui Sini Decoction (DGSD), which is commonly used to treat sciatica, has been shown to have an analgesic effect, but the underlying mechanisms are unclear. Here, Danggui Sini Decoction was shown to normalize the intestinal microbiota and serum metabolite levels to exert an analgesic effect. AIM OF THE STUDY This study aimed to elucidate the therapeutic effects of DGSD on sciatica and the underlying mechanisms involved. METHODS In this study, we conducted chronic constriction injury (CCI) model. Mecobalamin and DGSD were administered to CCI rats. Behavioural tests were used to examine the therapeutic effects of the drugs. UHPLC was used to identify DGSD components. 16S rRNA gene sequencing analysis of the intestinal flora was used to analyse the effect of DGSD on the intestinal microbiota. UHPLC‒MS/MS was used to identify blood metabolites. KEGG pathway analysis of differentially abundant metabolites was subsequently conducted. ELISA was used to measure the serum inflammatory factor levels, and correlation analysis between the serum inflammatory factor levels and intestinal microbe abundance was conducted. PCR, western blotting, and immunohistochemical staining were used to validate the results of the KEGG pathway analysis. RESULTS After CCI, the rats exhibited obvious thermal hyperalgesia; disruption of sciatic nerve structure; increased IL1α, SP, CCL5, and PGE2 levels; decreased IL10 levels in the blood; increased IL1β, IL6, COX2, MMP9, nNOS, and p-NF-κB levels; and decreased IL4 levels in the sciatic nerve. In addition, CCI led to increased abundances of Peptostreptococcaceae, Leuconostocaceae, Christensenellaceae, Akkermansiaceae, Staphylococcaceae, Romboutsia, Marvinbryantia, Turicibacter, Weissella, UCG-005, Christensenellaceae_R-7_group, Akkermansia, Staphylococcus, Romboutsia_ilealis, Weissella_paramesenteroides, and Akkermansia_muciniphila and decreased abundances of Lactobacillaceae, Lactobacillus, Lactobacillus_murinus, and Lactobacillus_johnsonii. Correlation analysis indicated that Turicibacter abundance was most strongly related to IL1α, PGE2, IL10, and CCL5 levels, while norank_o_Coriobacteriales abundance had the weakest relationship with SP levels. KEGG pathway analysis of the differentially abundant metabolites revealed that the 'NF-kappa B signalling pathway' was involved in sciatica. DGSD reduced the levels of inflammatory factors, including IL1α, SP, CCL5, PGE2, IL6, COX2, and MMP9, in the blood and sciatic nerve and inhibited nNOS and NF-κB phosphorylation. DGSD improved the abundance of probiotics, including Lactobacillus and Blautia, and lowered the abundance of harmful bacteria, including Romboutsia, Turicibacter, and Weissella. DGSD promoted the repair of the injured sciatic nerve. CONCLUSIONS DGSD can treat sciatica by inhibiting intestinal microbiota disorders induced by CCI in rats, normalizing inflammatory factor levels, and promoting nerve repair.
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Affiliation(s)
- Zhang Di
- College of Traditional Chinese Medicine, Jinan University, Guangzhou, China
| | - Chen Zhenni
- College of Traditional Chinese Medicine, Jinan University, Guangzhou, China
| | - Zhuang Zifeng
- College of Traditional Chinese Medicine, Jinan University, Guangzhou, China
| | - Jing Bei
- College of Traditional Chinese Medicine, Jinan University, Guangzhou, China
| | - Cao Yong
- College of Traditional Chinese Medicine, Jinan University, Guangzhou, China
| | - Li Yixuan
- Guangzhou Medical University Affiliated Traditional Chinese Medicine Hospital, China
| | - Pan Yuwei
- Guangzhou Medical University Affiliated Traditional Chinese Medicine Hospital, China
| | - Gao Li
- College of Traditional Chinese Medicine, Jinan University, Guangzhou, China.
| | - Chen Jiaxu
- College of Traditional Chinese Medicine, Jinan University, Guangzhou, China.
| | - Zhao Guoping
- College of Traditional Chinese Medicine, Jinan University, Guangzhou, China.
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Ter Meulen BC, Maas ET, van der Vegt R, Haumann J, Weinstein HC, Ostelo RWJG, van Dongen JM. Cost-effectiveness of Transforaminal epidural steroid injections for patients with ACUTE sciatica: a randomized controlled trial. BMC Musculoskelet Disord 2024; 25:247. [PMID: 38561748 PMCID: PMC10983727 DOI: 10.1186/s12891-024-07366-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/20/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Transforaminal epidural injections with steroids (TESI) are increasingly being used in patients sciatica. The STAR (steroids against radiculopathy)-trial aimed to evaluate the (cost-) effectiveness of TESI in patients with acute sciatica (< 8 weeks). This article contains the economic evaluation of the STAR-trial. METHODS Participants were randomized to one of three study arms: Usual Care (UC), that is oral pain medication with or without physiotherapy, n = 45); intervention group 1: UC and transforaminal epidural steroid injection (TESI) 1 ml of 0.5% Levobupivacaine and 1 ml of 40 mg/ml Methylprednisolone and intervention group 2: UC and transforaminal epidural injection (TEI) with 1 ml of 0,5% Levobupivacaine and 1 ml of 0.9% NaCl (n = 50). The primary effect measure was health-related quality of life. Secondary outcomes were pain, functioning, and recovery. Costs were measured from a societal perspective, meaning that all costs were included, irrespective of who paid or benefited. Missing data were imputed using multiple imputation, and bootstrapping was used to estimate statistical uncertainty. RESULTS None of the between-group differences in effects were statistically significant for any of the outcomes (QALY, back pain, leg pain, functioning, and global perceived effect) at the 26-weeks follow-up. The adjusted mean difference in total societal costs was €1718 (95% confidence interval [CI]: - 3020 to 6052) for comparison 1 (intervention group 1 versus usual care), €1640 (95%CI: - 3354 to 6106) for comparison 2 (intervention group 1 versus intervention group 2), and €770 (95%CI: - 3758 to 5702) for comparison 3 (intervention group 2 versus usual care). Except for the intervention costs, none of the aggregate and disaggregate cost differences were statistically significant. The maximum probability of all interventions being cost-effective compared to the control was low (< 0.7) for all effect measures. CONCLUSION These results suggest that adding TESI (or TEI) to usual care is not cost-effective compared to usual care in patients with acute sciatica (< 8 weeks) from a societal perspective in a Dutch healthcare setting. TRIAL REGISTRATION Dutch National trial register: NTR4457 (March, 6th, 2014).
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Affiliation(s)
- Bastiaan C Ter Meulen
- Department of Neurology at OLVG Teaching Hospital, Amsterdam, The Netherlands.
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands.
| | - Esther T Maas
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands
| | - Rien van der Vegt
- Department of Pain Medicine and Anesthesiology Zaans MC, Zaandam, The Netherlands
| | - Johan Haumann
- Department of Pain Medicine and Anesthesiology, OLVG, Amsterdam, The Netherlands
| | - Henry C Weinstein
- Department of Neurology at OLVG Teaching Hospital, Amsterdam, The Netherlands
| | - Raymond W J G Ostelo
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam and the Amsterdam Movement Sciences Research Institute, De Boelelaan 1085, 1081, HV, Amsterdam, The Netherlands
| | - Johanna M van Dongen
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands
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Ter Meulen BC, van Dongen JM, Maas E, van de Vegt MH, Haumann J, Weinstein HC, Ostelo R. Author's Reply to the Letter of Van Boxem, Van Gaag, Van Zundert, and Kallewaard, Entitled 'Response to Ter Meulen et al. Effect of Transforaminal Epidural Corticosteroid Injections in Acute Sciatica'. Clin J Pain 2024; 40:197-198. [PMID: 38126421 DOI: 10.1097/ajp.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/15/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Bastiaan C Ter Meulen
- Department of Neurology at OLVG Teaching Hospital
- Department of Epidemiology and Data Sciences, Amsterdam UMC location Vrije Universiteit, and the Amsterdam Movement Sciences Research Institute Amsterdam
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
| | - Johanna M van Dongen
- Department of Epidemiology and Data Sciences, Amsterdam UMC location Vrije Universiteit, and the Amsterdam Movement Sciences Research Institute Amsterdam
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
| | - Esther Maas
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
| | | | - Johan Haumann
- Department of Anesthesiology and Pain Medicine, OLVG, Amsterdam The Netherlands
| | | | - Raymond Ostelo
- Department of Epidemiology and Data Sciences, Amsterdam UMC location Vrije Universiteit, and the Amsterdam Movement Sciences Research Institute Amsterdam
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
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Ter Meulen BC, van Dongen JM, Maas E, van de Vegt MH, Haumann J, Weinstein HC, Ostelo R. Effect of Transforaminal Epidural Corticosteroid Injections in Acute Sciatica: A Randomized Controlled Trial. Clin J Pain 2023; 39:654-662. [PMID: 37712323 DOI: 10.1097/ajp.0000000000001155] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 08/01/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE Transforaminal epidural steroid injections (TESIs) are widely administered for sciatica. The aim of this trial was to evaluate the effectiveness of TESIs in patients with acute sciatica (<8 wk). METHODS This study was conducted in 2 Dutch hospitals. Participants (n=141) were randomly assigned to (1) usual care and TESI of 1 ml of 40 mg/ml Methylprednisolone plus 1 ml of 0.5% Levobupivacaine (intervention 1); (2) usual care and transforaminal epidural injection with 1 ml of 0.5% Levobupivacaine and 1 ml NaCl 0.9% (intervention 2); (3) usual care consisting of oral pain medication with or without physiotherapy (control). Co-primary outcomes were back pain and leg pain intensity, physical functioning, and recovery measured during 6-month follow-up. RESULTS There were no statistically significant mean differences in co-primary outcomes between groups during follow-up, except for leg pain when comparing intervention group 1 with control (-0.96 95%CI:-1.83 to -0.09). For secondary outcomes, some statistical significant between-group differences were found for treatment satisfaction and surgery, but only when comparing intervention group 2 to control. Post hoc analyses showed a statistically significant difference in response [50% improvement of leg pain (yes/no)] between intervention 1 and the control group at 3 months and that both intervention groups used less opioids. DISCUSSION Except for a statistically significant effect of TESI on leg pain for patients with acute sciatica compared with usual care, there were no differences in co-primary outcomes. Nonetheless, transforaminal epidural injections seem to be associated with less opioid use, which warrants further exploration.
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Affiliation(s)
- Bastiaan C Ter Meulen
- Department of Neurology at OLVG Teaching Hospital
- Department of Epidemiology and Data Sciences, Amsterdam UMC
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
| | - Johanna M van Dongen
- Department of Epidemiology and Data Sciences, Amsterdam UMC
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
| | - Esther Maas
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
| | | | - Johan Haumann
- Department of Anesthesiology and Pain Medicine, OLVG, Amsterdam, The Netherlands
| | | | - Raymond Ostelo
- Department of Epidemiology and Data Sciences, Amsterdam UMC
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
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van Dijk W, Tanke MAC, Meinders MJ, Verkerk EW, Jeurissen PPT, Westert GP. Cascade of decisions meet personal preferences in sciatica treatment decisions. BMJ Open Qual 2022; 11:bmjoq-2021-001694. [PMID: 36319028 PMCID: PMC9628667 DOI: 10.1136/bmjoq-2021-001694] [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] [Received: 04/14/2022] [Accepted: 09/20/2022] [Indexed: 11/05/2022] Open
Abstract
STUDY DESIGN An in-depth interview study including patients, general practitioners, neurologists and neurosurgeons. OBJECTIVE To gain insight in decision-making in sciatica care, by identifying patients' and physicians' preferences for treatment options, and the differences between and within both groups. SUMMARY OF BACKGROUND DATA Sciatica is a self-limiting condition, which can be treated both conservatively and surgically. The value of both options has been disputed, and the care pathway is known for a substantial amount of practice variation. Most Dutch patients are taken care of by general practitioners before they are referred to hospital-based neurologists, who might refer to a neurosurgeon, who can perform a surgical intervention. Dutch sciatica care thus follows the principles of stepped care, and a cascade of decisions precedes surgery. Better understanding of the decision-making within this cascade might reveal opportunities to improve shared decision-making and to reduce unwarranted practice variation. METHODS Interviews with 10 patients and 22 physicians were analysed thematically. RESULTS While physicians were confident of their clinical diagnosis, patients preferred confirmation trough imaging to exclude other possible explanations. Furthermore, many patients showed reluctance towards the use of (strong) opioids, while all physicians favoured this and underlined the benefits of opioids in the management of sciatica complaints, to buy time and to allow patients to recover naturally. Finally, individual physicians differed strongly in their opinion on benefits and optimal timing of surgical treatment and epidural injections. CONCLUSIONS Dutch sciatica care is characterised by a cascade of decisions preceding surgery. Preferences differ within and between patients and physicians, which adds to the practice variation. To improve decision-making, physicians and patients should invest not necessarily more in the exchange of options or preferences, but in making sure the other understands the rationale behind them.
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Affiliation(s)
- Wieteke van Dijk
- Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ healthcare), Radboudumc, Nijmegen, The Netherlands
| | - Marit A C Tanke
- Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ healthcare), Radboudumc, Nijmegen, The Netherlands
| | - Marjan J Meinders
- Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ healthcare), Radboudumc, Nijmegen, The Netherlands
| | - Eva W Verkerk
- Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ healthcare), Radboudumc, Nijmegen, The Netherlands
| | - Patrick P T Jeurissen
- Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ healthcare), Radboudumc, Nijmegen, The Netherlands
| | - Gert P Westert
- Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ healthcare), Radboudumc, Nijmegen, The Netherlands
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Asagai Y, Minamikawa S, Ueshima E, Aida Y, Nakagishi Y. Sciatic neuropathy caused by forced stretching exercise. Pediatr Int 2022; 64:e15387. [PMID: 36239001 DOI: 10.1111/ped.15387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 10/01/2022] [Accepted: 10/12/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Yoshitaka Asagai
- Department of General Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Shogo Minamikawa
- Department of General Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan.,Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Eri Ueshima
- Department of Anesthesiology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Yukari Aida
- Department of General Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Yasuo Nakagishi
- Department of General Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
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