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Kale S, Vatkar A. Beyond the Back: The Science of Lumbar Epidural Steroid Injections. J Orthop Case Rep 2024; 14:6-10. [PMID: 39035395 PMCID: PMC11258721 DOI: 10.13107/jocr.2024.v14.i07.4554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 05/11/2024] [Indexed: 07/23/2024] Open
Abstract
Chronic low back pain causes significant morbidity and increases the global burden of disability. It has been shown to increase psychological, physical, and monetary load on the world population, In the USA alone, it causes an economic burden of 100 billion dollars/year [1]. Low back pain has been referred to as sciatica pain, lumbar radiculopathy, lumbar nerve entrapment, and neurogenic claudication. It is basically pain arising from the lower back region and radiating like a current to the lower limbs. The two prime causes of this low back pain with radiculopathy are intervertebral disc disease and facet joint arthritis [2]. The pathological aging changes happening in intervertebral disk cause disk herniation and other degenerative diseases such as lumbar canal stenosis and chronic instability. Lumbar radiculopathy or sciatica is mainly caused by compression of the nerve by protruded nucleus pulposus, which is the jelly like material of intervertebral disk [3,4]. Most of the patients with intervertebral disk disease and sciatica can be managed with conservative measures. These include anti-inflammatory analgesics, neuropathic medications such as pregabalin and gabapentin, regular exercises, and epidural steroid injections [5-7]. These measures help to prevent surgery. Significant compression of nerves with no relief from conservative measures qualifies to surgical intervention [2]. ESI, which has been used since 1952, is mainly used for lumbar and neck pain with radicular pain. It has shown excellent and quick results with minimal adverse effects. The ESI consists of injecting the steroids with or without local anesthetic medication in the epidural space to decrease the discogenic source of pain [8-11]. LSEI can be divided according to the needle route (interlaminar, transforaminal, or caudal). In this article, we will go over the various approaches for intralaminar (between the 2 adjacent laminae of lumbar vertebrae), transforaminal (through the intervertebral foramen), and caudal (through the sacral hiatus) epidural steroid injections [12-14].
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Affiliation(s)
- Sachin Kale
- Department of Orthopedics, D Y Patil Hospital and Medical College, Navi Mumbai, Maharashtra, India
| | - Arvind Vatkar
- Department of Orthopedic, Spine Surgery Unit, Fortis Hiranandani Hospital, Navi Mumbai, Maharashtra, India
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2
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Huo L, Liu G, Deng B, Xu L, Mo Y, Jiang S, Tao J, Bai H, Wang L, Yang X, Yang J, Mu X. Effect of use of NSAIDs or steroids during the acute phase of pain on the incidence of chronic pain: a systematic review and meta-analysis of randomised trials. Inflammopharmacology 2024; 32:1039-1058. [PMID: 38153536 PMCID: PMC11006744 DOI: 10.1007/s10787-023-01405-8] [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: 11/11/2023] [Accepted: 11/27/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND This study is the first to summarize the evidence on how the use of anti-inflammatory drugs during acute pain has an impact on the development of chronic pain. METHODS Randomized controlled trials retrieved from nine databases included anti-inflammatory drugs (NSAIDs or steroids) versus non-anti-inflammatory drugs in patients with acute pain and reported the incidence of chronic pain. No specified date, age, sex, or language restrictions. Subgroup analyses were performed according to pain classification, follow-up time, and medication. The GRADE method was used to evaluate quality of evidence. RESULTS A total of 29 trials (5220 patients) were included. Steroids or NSAIDs did not reduce the incidence of chronic nociceptive pain. Steroid use in acute phase significantly reduced the incidence of chronic neuropathic pain. In subgroup analysis, benefits were observed for methylprednisolone and dexamethasone, with some adverse effects. Steroids or NSAIDs were statistically significant in reducing pain intensity over 1 year, but the effect size was too small, and whether the long-term effect is clinically relevant needs to be further studied. CONCLUSION Quality of the evidence was low to moderate. No drug can be recommended to prevent chronic nociceptive pain. Injections of steroids (methylprednisolone or dexamethasone) during the acute phase reduce the incidence of chronic neuropathic pain, but most included studies also used local anesthetics. The results are indirect and need to be interpreted with caution. The pooled data effect sizes for pain intensity were small, so the clinical relevance was unclear. Study registration PROSPERO (CRD42022367030).
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Affiliation(s)
- Luyao Huo
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Gang Liu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Bowen Deng
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Division of Intelligent and Biomechanical System, State Key Laboratory of Tribology, Department of Mechanical Engineering, Tsinghua University, Haidian, Beijing, China
| | - Lin Xu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yanjun Mo
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Shengyuan Jiang
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jingwei Tao
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Huizhong Bai
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Li Wang
- Beijing An Yuan Quan Lv Medical Research Institute, Beijing, China
| | | | - Jizhou Yang
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaohong Mu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China.
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Alqroom R, Rakan A, Aldurgham R, Al Abdallat A, Haddad S, Ibrahim J, Nowar H, Odeh A. The lead of direct adjuvant intraoperative foraminal steroids' infiltration. Anesth Essays Res 2022; 16:187-190. [DOI: 10.4103/aer.aer_88_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/11/2022] [Accepted: 07/25/2022] [Indexed: 11/04/2022] Open
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Carassiti M, Pascarella G, Strumia A, Russo F, Papalia GF, Cataldo R, Gargano F, Costa F, Pierri M, De Tommasi F, Massaroni C, Schena E, Agrò FE. Epidural Steroid Injections for Low Back Pain: A Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:ijerph19010231. [PMID: 35010492 PMCID: PMC8744824 DOI: 10.3390/ijerph19010231] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/19/2021] [Accepted: 12/22/2021] [Indexed: 05/03/2023]
Abstract
Low back pain represents a significant socioeconomic burden. Several nonsurgical medical treatments have been proposed for the treatment of this disabling condition. Epidural steroid injections (ESIs) are commonly used to treat lumbosacral radicular pain and to avoid surgery. Even though it is still not clear which type of conservative intervention is superior, several studies have proved that ESIs are able to increase patients' quality of life, relieve lumbosacral radicular pain and finally, reduce or delay more invasive interventions, such as spinal surgery. The aim of this narrative review is to analyze the mechanism of action of ESIs in patients affected by low back pain and investigate their current application in treating this widespread pathology.
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Affiliation(s)
- Massimiliano Carassiti
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
- Correspondence:
| | - Giuseppe Pascarella
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Alessandro Strumia
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Fabrizio Russo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.R.); (G.F.P.)
| | - Giuseppe Francesco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.R.); (G.F.P.)
| | - Rita Cataldo
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Francesca Gargano
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Fabio Costa
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Michelangelo Pierri
- Integrated Sleep Surgery Team UCBM, Unit of Otolaryngology, Integrated Therapies in Otolaryngology, Campus Bio-Medico University of Rome, 00128 Rome, Italy;
| | - Francesca De Tommasi
- Unit of Measurements and Biomedical Instrumentation, Department of Engineering, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.D.T.); (C.M.); (E.S.)
| | - Carlo Massaroni
- Unit of Measurements and Biomedical Instrumentation, Department of Engineering, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.D.T.); (C.M.); (E.S.)
| | - Emiliano Schena
- Unit of Measurements and Biomedical Instrumentation, Department of Engineering, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.D.T.); (C.M.); (E.S.)
| | - Felice Eugenio Agrò
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
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de Bruijn TM, de Groot IB, Miedema HS, Haumann J, Ostelo RW. Clinical Relevance of Epidural Steroid Injections on Lumbosacral Radicular Syndrome-related Synptoms: Systematic Review and Meta-Analysis. Clin J Pain 2021; 37:524-537. [PMID: 33859113 PMCID: PMC8162229 DOI: 10.1097/ajp.0000000000000943] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Epidural steroid injections (ESIs) can be used to reduce lumbosacral radicular syndrome (LRS) related pain. The clinical relevance of ESIs are currently unknown. This systematic review and meta-analyses aims to assess whether ESIs are clinically relevant for patients with LRS. MATERIALS AND METHODS Comprehensive literature searches for randomized controlled trials regarding steroid injections for LRS were conducted in PudMed, EMBASE, CINAHL, and CENTRAL from their inception to September 2018 (December 2019 for PubMed). For each homogenous comparison, the outcomes function, pain intensity and health-related quality of life at different follow-up intervals were pooled separately. The GRADE approach was used to determine the overall certainty of the evidence. RESULTS Seventeen studies were included. Two different homogenous comparisons were identified for which the randomized controlled trials could be pooled. In 36 of the 40 analyses no clinically relevant effect was found. The certainty of evidence varied between very low to high. Four analyses found a clinically relevant effect, all on pain intensity and health-related quality of life, but the certainty of the evidence was either low or very low. Two of the 33 subgroup analyses showed a clinically relevant effect. However, according to the GRADE approach the certainty of these findings are low to very low. DISCUSSION On the basis of the analyses we conclude there is insufficient evidence that ESIs for patients with LRS are clinically relevant at any follow-up moment. High-quality studies utilizing a predefined clinical success are necessary to identify potential clinically relevant effects of ESIs. Until the results of these studies are available, there is reason to consider whether the current daily practice of ESIs for patients with LRS should continue.
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Affiliation(s)
- Thomas M. de Bruijn
- Department Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam
- National Health Care Institute, Diemen
| | | | - Harald S. Miedema
- National Health Care Institute, Diemen
- Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | | | - Raymond W.J.G. Ostelo
- Department Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam
- Department of Epidemiology and Biostatistics, Amsterdam UMC (Location VUmc) and Amsterdam Movement Sciences, Amsterdam
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Ter Meulen BC, van Dongen JM, van der Vegt M, Weinstein HC, Ostelo RWJG. STeroids Against Radiculopathy (STAR) trial: a statistical analysis plan. Trials 2021; 22:80. [PMID: 33482888 PMCID: PMC7821662 DOI: 10.1186/s13063-020-05018-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 12/31/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transforaminal epidural injections with steroids (TESI) are used increasingly for patients with sciatica. However, their safety, effectiveness, and cost-effectiveness are still a matter of debate. This a priori statistical analysis plan describes the methodology of the analysis for the STAR trial that assesses the (cost-)effectiveness of TESI during the acute stage of sciatica (< 8 weeks). METHODS The STAR trial is a multicentre, randomized controlled, prospective trial (RCT) investigating the (cost-)effectiveness of TESI by making a three-group comparison among patients with acute sciatica due to a herniated lumbar disc (< 8 weeks): (1) TESI combined with levobupivacaine added to oral pain medication (intervention group 1) versus oral pain medication alone (control group), (2) intervention group 1 versus transforaminal epidural injection with levobupivacaine and saline solution added to oral pain medication (intervention group 2), and (3) intervention group 2 versus control group. Co-primary outcomes were physical functioning (Roland Morris Disability Questionnaire), pain intensity (10-point numerical rating scale), and global perceived recovery (7-point Likert scale, dichotomized into 'recovered' and 'not recovered'). For all three comparisons, we defined the following minimal clinically relevant between-group differences: two points for pain intensity (range 0-10), four points for physical functioning (range 0-24) and a 20% difference in recovery rate. Secondary outcomes are health-related quality of life (EQ-5D-5L) and patient satisfaction (7-point Likert scale) and surgery rate. We also collected resource use data to perform an economic evaluation. Analyses will be conducted by intention-to-treat with p < 0.05 (two-tailed) for all three comparisons. Effects will be estimated using mixed models by maximum likelihood. For each comparison, mean differences, or difference in proportions, between groups will be tested per time point and an overall mean difference, or difference in proportions, between groups during the complete duration of follow-up (6 months) will be estimated. In the economic evaluation, Multivariate Imputation by Chained Equations will be used to handle missing data. Cost and effect differences will be estimated using seemingly unrelated regression, and uncertainty will be estimated using bootstrapping techniques. DISCUSSION This statistical analysis plan provides detailed information on the intended analysis of the STAR trial, which aims to deliver evidence about the (cost-)effectiveness of TESI during the acute phase of sciatica (< 8 weeks). TRIAL REGISTRATION Dutch National trial register NTR4457 (6 March 2014).
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Affiliation(s)
- Bastiaan C Ter Meulen
- Department of Neurology, OLVG Amsterdam, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands. .,Department of Epidemiology and Biostatistics Amsterdam Movement Sciences Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelenlaan 1089a, 1081 HV, Amsterdam, The Netherlands.
| | - Johanna M van Dongen
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, de Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
| | | | - Henry C Weinstein
- Department of Neurology, OLVG Amsterdam, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands
| | - Raymond W J G Ostelo
- Department of Epidemiology and Biostatistics Amsterdam Movement Sciences Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelenlaan 1089a, 1081 HV, Amsterdam, The Netherlands.,Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, de Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
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7
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Verheijen E, Munts AG, van Haagen O, de Vries D, Dekkers O, van den Hout W, Vleggeert-Lankamp C. Transforaminal epidural injection versus continued conservative care in acute sciatica (TEIAS trial): study protocol for a randomized controlled trial. BMC Neurol 2019; 19:216. [PMID: 31481010 PMCID: PMC6719366 DOI: 10.1186/s12883-019-1445-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 08/25/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Sciatica is a condition that is characterised by radicular pain in the leg and primarily caused by a herniated lumbar intervertebral disk. In addition to leg pain, patients can experience back pain, leg numbness and leg weakness resulting in decreased productivity and social activity. The majority of sciatica cases recovers spontaneously and therefore patients are initially treated conservatively with oral pain medication. However, some patients experience intractable pain that severely impedes them and no consensus exists on the optimal conservative treatment to reduce this discomfort in the acute phase of sciatica. The aim of the TEIAS trial is to assess the effectiveness, cost-effectiveness and predictive capability on patient outcome of transforaminal epidural injection (TEI) compared to treatment with standard pain medication. METHODS This study is designed as a prospective, open-label, mono-centered, randomized controlled trial. Patients that visit their general practitioner with complaints of radicular leg pain and meet the selection criteria are asked to participate in this study. Eligible patients will be randomized to treatment with TEI or to treatment with standard oral pain medication. Treatment of TEI will comprise lidocaine with methylprednisolone acetate for L3 and below and lidocaine with dexamethasone above L3. A total of 142 patients will be recruited and follow-up will occur after 1, 2, 4, 10 and 21 weeks for assessment of pain, functionality, patient received recovery and cost-effectiveness. The primary outcome will be the average score for leg pain at 2 weeks. For this outcome we defined a clinically relevant difference as 1.5 on the 11-point NRS scale. DISCUSSION Adequate conservative treatment in the acute phase of sciatica is lacking, particularly for patients with severe symptoms. Focusing on effectiveness, cost-effectiveness and predictive capability on patient outcome of TEI will produce useful information allowing for more lucid decision making in the conservative treatment of sciatica in the acute phase. TRIAL REGISTRATION This trial is registered in the ClinicalTrials.gov database under registry number NCT03924791 on April 23, 2019.
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Affiliation(s)
- Eduard Verheijen
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, PO Box 9600. 2300, RC Leiden, The Netherlands
| | - Alexander G. Munts
- Department of Neurology, Spaarne Gasthuis, Haarlem, /Hoofddorp, The Netherlands
| | - Oscar van Haagen
- Department of Anaesthesiology, Spaarne Gasthuis, Haarlem, /Hoofddorp, The Netherlands
| | - Dirk de Vries
- Department of Anaesthesiology, Spaarne Gasthuis, Haarlem, /Hoofddorp, The Netherlands
| | - Olaf Dekkers
- Department of Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert van den Hout
- Department of Biomedical Data Science, Leiden University Medical Center, Leiden, The Netherlands
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Knezevic NN, Jovanovic F, Voronov D, Candido KD. Do Corticosteroids Still Have a Place in the Treatment of Chronic Pain? Front Pharmacol 2018; 9:1229. [PMID: 30443214 PMCID: PMC6221932 DOI: 10.3389/fphar.2018.01229] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 10/08/2018] [Indexed: 12/31/2022] Open
Abstract
Corticosteroids have played a standard role in the multimodal pain management in the treatment of chronic spinal pain (cervical and lumbar) and osteoarthritis pain over the past three decades. In this review we discuss different types of injectable steroids that are mainly used for injection into the epidural space (for the treatment of radicular back and neck pain), and as intra-articular injections for different types of osteoarthritis related pain conditions. Furthermore, we discuss different approaches taken for epidural corticosteroid injections and spinal surgical rates when injections fail to resolve painful conditions, as well as the possibility of using local anesthetics alone for neuraxial injections, instead of in combination with corticosteroids. While we present some beneficial effects of newly available treatment options for low back pain and osteoarthritis pain, such as use of PRP and hyaluronic acid, corticosteroids remain important considerations in the management of these chronic pain conditions.
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Affiliation(s)
- Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States.,Department of Anesthesiology, University of Illinois, Chicago, IL, United States.,Department of Surgery, University of Illinois, Chicago, IL, United States
| | - Filip Jovanovic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States
| | - Dimitry Voronov
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States.,Department of Anesthesiology, University of Illinois, Chicago, IL, United States
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Ter Meulen BC, Maas ET, Vyas A, van der Vegt M, de Priester K, de Boer MR, van Tulder MW, Weinstein HC, Ostelo RWJG. Treatment of acute sciatica with transforaminal epidural corticosteroids and local anesthetic: design of a randomized controlled trial. BMC Musculoskelet Disord 2017; 18:215. [PMID: 28545491 PMCID: PMC5445356 DOI: 10.1186/s12891-017-1571-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 05/11/2017] [Indexed: 12/28/2022] Open
Abstract
Background Transforaminal epidural injections with steroids (TESI) are used increasingly for patients with sciatica. However there is much debate about their safety and effectiveness. It is important to identify patients that benefit most from TESI and only few trials have yet evaluated the effects in patients with acute sciatica. Methods We describe a prospective, randomized controlled trial (RCT), with the aim to evaluate the hypothesis that TESI plus Levobupivacaine (TESI-plus) added to oral pain medication is more effective compared to pain medication alone or compared to transforaminal injection with a local anesthetic of short duration among patients with acute sciatica. We will recruit a total of 264 patients with sciatica (<8 weeks) caused by a herniated disc, from two clinical sites. Participants are randomly assigned one of three study groups: 1) oral pain medication (control group), 2) oral pain medication and TESI-plus (intervention group one), 3) oral pain medication and transforaminal epidural injection (TEI) with Levobupivaine and saline solution (intervention group two). Primary outcomes are functional status (Roland-Morris Disability Questionnaire), pain intensity for both leg and back, (100 mm visual analogous scale (VAS)), and global perceived recovery (GPR, reported on a 7-point Likert scale, dichotomized into ‘recovered’ and ‘not recovered’). The secondary outcomes are health-related quality of life (EQ5D-5 L) and patient satisfaction (7-point Likert scale). We will also collect information on healthcare utilization and costs, to perform an economic evaluation. All outcomes are measured at three and six weeks, three and six months after randomization. We defined a minimal clinically relevant difference between groups as a difference between both intervention groups and the control group of 20 points for pain (100-point VAS), four points for functional status (24-point RDQ) and a 20% difference on dichotomized GPR (recovered versus not recovered). Discussion A clinically relevant outcome in favor of TESI-plus implies that future patients with acute sciatica should be recommended TESI-plus within the first few weeks rather than being treated with pain medication alone in order to relieve pain and improve their functioning. In case of a negative result (no relevant differences in outcome between the three study arms), pain medication will remain the mainstay of treatment in the acute stages of sciatica. Trial registration Dutch National trial register: NTR4457 (March, 6th, 2014)
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Affiliation(s)
- Bastiaan C Ter Meulen
- Department of Neurology, Zaans Medisch Centrum, Zaandam and Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
| | - Esther T Maas
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Amrita Vyas
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | - Koo de Priester
- Department of Radiology Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Michiel R de Boer
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands.,Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Henry C Weinstein
- Department of Neurology, Zaans Medisch Centrum, Zaandam and Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Raymond W J G Ostelo
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands.,Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
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Mohamed AA, Salama AK, Essam Salem A, El Gallad A. Management for failed back surgery syndrome: three-in-one procedure versus percutaneous spinal fixation alone. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2017. [DOI: 10.1080/22201181.2017.1287835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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11
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Bhatti AB, Kim S. Role of Epidural Injections to Prevent Surgical Intervention in Patients with Chronic Sciatica: A Systematic Review and Meta-Analysis. Cureus 2016; 8:e723. [PMID: 27625909 PMCID: PMC5010373 DOI: 10.7759/cureus.723] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Objective: The aim of this study is to evaluate the efficacy of the different types of epidural injections (EI) to prevent surgical intervention in patients suffering from chronic sciatica due to lumbar disc herniation (LDH). Material and Methods: Studies were identified by searching PubMed, MEDLINE, and Google Scholar to retrieve all available relevant articles. Lists of references of several systematic reviews were also used for scanning further references. Publications from the past ten years (2006-2016) were considered, and all studies selected were in the English language only. The studies employed specified the use of EI to treat sciatica caused by LDH. A total of 19 papers meeting the eligibility criteria (mentioned below) were included in this study. The pain scores, functional disability scores, and surgical rates from these studies were considered, and meta-analysis was performed. Outcome measures: Pain scores, functional disability scores, and surgical rates were assessed from the included studies. The Numeric Rating Scale (NRS) and Visual Analogue Scale (VAS) have been the most commonly used baseline scales for pain evaluation followed by the Verbal Numerical Rating Scale (VNRS) and Japanese Orthopedic Association (JOA). The Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ) scales were used for the functional disability scoring system in the literature. Results: Significant improvement in the pain scores and functional disability scores were observed. Additionally, greater than 80% of the patients suffering from chronic sciatica caused by LDH could successfully prevent surgical intervention after EI treatment with or without steroids. Conclusion: The management of sciatica with EI treatment results in significant improvements in the pain score, functional disability score, and surgical rate. We concluded that EI provides new hope to prevent surgical intervention in patients suffering from sciatica caused by LDH.
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Affiliation(s)
- Adnan Bashir Bhatti
- Medical Director of Clinical Research, Spine Surgery, Tristate Brain and Spine Institute
| | - Sunny Kim
- Spine Surgery, Tristate Brain and Spine Institute
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