Methylprednisolone Following Minimally Invasive Lumbar Decompression: A Large Prospective Single-Institution Study

STUDY DESIGN

Prospective randomized.

OBJECTIVE

Intraoperative methylprednisolone is a common adjunct following microscopic laminectomy/microdiscectomy. The goal of epidural instillation is a rapid symptomatic reduction in irritation of neural elements. There is inconsistent data supporting its use intraoperatively. To understand whether this maneuver results in any clinical effect, we performed a multiyear prospective study.

SUMMARY OF BACKGROUND DATA

Previous work has demonstrated equivocal effects on pain with a suggestion of an increased risk of complication. These studies tend to suffer from small sample sizes and short follow-ups.

MATERIALS AND METHODS

Study obtained IRB approval. During the study period from 2013 to 2019, nearly equivalent numbers of patients who had received steroids during MIS decompressions were followed. Primary outcomes included pain (visual analog scale) and disability [Oswestry Disability Index (ODI)] at 2 weeks and 4 months. Secondary outcomes included complications, readmissions, and reoperation rates during the study period.

RESULTS

Four hundred eighty-six patients were followed for a mean follow-up of 5.17 years. The index case was more likely to be a revision surgery in the steroid group. Across all patients, there was no difference in pain at 2 weeks or 4 months. Disability was reduced at 2 weeks in the steroid group (ODI: 16.71 vs . 21.02, P = 0.04) but not at 4 months. By subgroup analysis, this is largely explained by ODI reduction in patients with high preoperative ODI (13.00 vs . 43.43, P = 0.03). Patients in the steroid cohort were more likely to undergo subsequent spinal surgery during the study period.

CONCLUSION

Methylprednisolone instillation is associated with a large, transient reduction in ODI for patients with high preoperative ODI; there is no measurable effect on pain. There is equivocal effect on risk of subsequent reoperation. This issue was clarified in peer review but changes did not make it to the abstract. Therefore, the technique is likely best reserved for patients with significant preoperative disability.

Intraoperative epidural analgesia for pain relief after lumbar decompressive spine surgery: A systematic review and meta-analysis

Introduction

During lumbar decompressive spine surgery, the epidural space is easily accessible. This intraoperative situation allows surgeons to apply an epidural bolus of analgesia at the end of the surgical procedure. In literature, several papers about the methods and effectiveness of delivering local analgesia during lumbar decompressive spine surgery have been published.

Research question

This systematic review and meta-analysis aims to summaries the current literature on the effectiveness and safety of intraoperative epidural analgesia in lumbar decompressive surgery, delivered as a bolus.

Material and method

A systematic search was conducted according to the PRISMA guidelines. Inclusion criteria were randomized controlled trials or comparative cohort studies of patients aged 18 years or older who underwent decompressive lumbar spine surgery. Nonsteroidal epidural analgesia had to be administered as a bolus, intraoperatively, as an adjunct to standard analgesia therapy. Primary outcome measures were reduction in postoperative pain scores, analgesics consumption and length of hospital stay. Secondary outcomes were adverse events.

Results

Eight studies evaluating the effectiveness of intraoperative epidural analgesia were included. Seven studies reported statistically significant reductions in postoperative VAS-pain scores. Six studies reported a statistically significant decrease in postoperative analgesics consumption. Four studies reported on the length of hospital stay, with no statistically significant difference between study groups.

Discussion and conclusion

This systematic review and meta-analysis suggests that additional intraoperative epidural nonsteroidal analgesia, delivered as a bolus, can reduce postoperative pain and postoperative analgesics consumption in patients undergoing decompressive spinal surgery. Further well-powered research is needed to bolster the evidence.

Epidural steroids following percutaneous endoscopic interlaminar discectomy: A protocol for systematic review and meta-analysis

BACKGROUND

Percutaneous endoscopic interlaminar discectomy (PEID) has been widely used in the treatment of lumbar disc herniation and spinal stenosis, epidural steroids following PEID in an effort to reduce the incidence and duration of postoperative pain. Although steroids are widely thought to reduce the effect of surgical trauma, the observation index is not uniform, so the issue is still controversial. Therefore, the purpose of this paper is to systematically evaluate the efficacy and safety of local epidural steroids application following PEID.

METHODS

We will search the following databases from their inception to August 2020, PubMed, Embase, Medline, Chinese National Knowledge Infrastructure, Chinese Biomedical Literature Database, Web of Science, Wan Fang Database, Cochrane Library. The search strategy includes the MeSH terms. Meta-analysis will be performed using Rev Man V.5.3.5 statistical software.

RESULTS

This study will provide a high-quality synthesis to evaluate the efficacy and safety of local epidural steroids following PEID.

CONCLUSION

This systematic review will provide evidence to judge whether local epidural steroids application following PEID is an effective and safe intervention for patients. It will provide reliable evidence for its extensive application.

REGISTRATION NUMBER

INPLASY2020100085.

Intraoperative epidural application of steroid and local anaesthetic agent following lumbar discectomy: A prospective double blinded randomized controlled trial

BACKGROUND

Postoperative pain management following lumbar discectomy is a key part of the procedure and various postoperative pain protocols including a wide range of agents are being used in daily practice worldwide. The aim of this study is to investigate the effect of intraoperative epidural infiltration of local anaesthetic and steroid compared with placebo (normal saline) following microscopic lumbar discectomy.

METHODS

Sixty patients undergoing lumbar discectomy were randomized to intraoperative infiltration of 3 mg betamethoasone acetate and 18 mg ropivacaine (Group A) or normal saline (Group B). Infiltration was performed after discectomy and decompression and immediately prior to incision closure. Postoperatively a standard protocol of intravenous acetaminophen administration and physiotherapy was followed. Additional analgesia with tramadol was given only in patients who required further pain management. Postoperative pain was evaluated using VAS score. Opioid consumption was recorded. Primary outcome measures included immediate postoperative back pain VAS score, opioid consumption and infection rate. Patients were reviewed in clinic at 6 weeks, 6 months and 1 year postoperatively.

RESULTS

None of the patients in Group A required further analgesia while 12 Group B patients required further treatment with tramadol (p = 0.01). At 3 h postoperatively the VAS score was significantly lower in Group A compared to Group B (p < 0.05). Fifty-seven patients completed the 1 year follow up (95%) and 2 patients (1 from each group) suffered a complication of postoperative radiculopathy.

CONCLUSION

Intraoperative application of steroid and local anaesthetic agent is effective on pain reduction for only a short period after surgery, while there is no effect on infection rate or any other long-term outcome compared with placebo. Hence although it is a safe technique, its benefits are limited from the duration of action.

Epidural versus intravenous steroids application following percutaneous endoscopic lumbar discectomy

Retrospectively study.The purpose of this study was to compare the effects of intraoperative epidural steroids and single dose intravenous steroids following a percutaneous endoscopic lumbar discectomy (PELD).Inflammatory irritation of dorsal root ganglia or sensory nerve roots may cause postoperative pain. Epidural steroids have been applied after a lumbar discectomy for more than 20 years. Epidural steroid application after a PELD is easier to perform and safer because the operations are under observation of the scope.We retrospectively reviewed the medical records of patients with lumbar intervertebral disc herniation who had undergone transforaminal PELD at our department. There are 60 patients in epidural steroid group, intravenous steroid group, and control group, respectively. Visual analog scores (VAS) and the Oswestry Disability Index (ODI) were collected. Successful pain control is defined as 50% or more reduction in back and leg pain (VAS scores).VAS scores (back and leg) and ODI showed a significant decrease in all groups when comparing pre- and postoperatively. Epidural steroid group had a significant improvement in successful pain control compared with the control group at 2 weeks of follow-up. VAS scores (leg) in the epidural steroid group showed a significant decrease compared with the intravenous steroids group at 1, 3, and 7 days after the surgery, but this difference had no statistical significance at 1, 6, and 12 months of follow-up. All groups did not show a significant difference in ODI at 1, 6, and 12 months follow-up.Epidural application of steroid has a better effect on controlling the postoperative pain of PELD in the short term. The epidural application of steroid did not show a tendency to cause infection.

Epidural Steroids at Closure After Microdiscectomy/Laminectomy for Reduction of Postoperative Analgesia: Systematic Review and Meta-Analysis

BACKGROUND

This review assessed the efficacy of epidural steroid administration on the reduction of pain, hospital stay time, and use of opioid analgesics postoperatively.

METHODS

We searched Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews for studies using epidural steroids through any route after lumbar surgery. The primary study outcomes included preoperative and postoperative pain as assessed with a visual analogue scale (VAS), length of hospital stay (LOS), and postoperative use of opioid analgesics. The data were extracted and stratified according to the steroid administered. Data were then assessed for heterogeneity, subgroup differences, and ultimately tabulated in a Forest plot.

RESULTS

A total of 17 randomized controlled trials were included in this review, with 16 undergoing quantitative analysis. Steroids were shown to be superior in terms of VAS outcome at 24 hours, with triamcinolone and dexamethasone performing similarly. Methylprednisolone paradoxically performed worse at the 24-hour mark. At 1 month, all steroids illustrated superiority in terms of VAS outcome. Steroids also proved superior in reducing LOS and postoperative use of opioid analgesia.

CONCLUSIONS

Intraoperative or perioperative epidural administration of steroids offers significant benefits in terms of pain control, reduction in LOS, and use of postoperative opioid analgesia. Before steroids are routinely used by spinal surgeons, however, significantly more research is required. A particular emphasis should be placed on quality study protocols and data recording, to allow for more thorough analyses in the future.

Perioperative steroids for lumbar disc surgery: A meta-analysis of randomized controlled trials

BACKGROUND

Our review question was "Does perioperative steroids administration, in comparison with other treatments or placebo, improve either postoperative pain control, length of hospital stay, or return to work in patients undergoing lumbar disc surgery?"

METHODS

We searched PubMed, CINAHL PLUS, and Cochrane databases for randomized control trials (RCTs) studying the role of steroids for lumbar disc surgery. Studies that compared perioperative steroids with other treatments or placebo were included. Study outcomes included postoperative back pain, leg pain, length of hospital stay, and return to work. Data was extracted through a proforma. Means and mean differences were calculated for continuous data, whereas odds ratios were calculated for dichotomous data. Data were analyzed with the help of Rev Man 5.

RESULTS

Twenty RCTs were included in the review. Quantitative analysis could be performed on 19 RCTs. Intraoperative steroids improve control of back pain at 24-48 hours. Although there was some benefit of steroid administration in controlling postoperative leg pain, it disappeared at 1 year and in the overall pooled analysis. The length of hospital stay was much shorter in the steroid group. The frequency of adverse events and complications also favored steroid administration.

CONCLUSION

Intraoperative epidural steroid administration offers some benefit in pain control with a significant reduction in the length of hospital stay. However, there is insufficient evidence to support the routine use of oral and intravenous steroids in the perioperative period.

The Role of Multimodal Analgesia in Spine Surgery

Optimal postoperative pain control allows for faster recovery, reduced complications, and improved patient satisfaction. Historically, pain management after spine surgery relied heavily on opioid medications. Multimodal regimens were developed to reduce opioid consumption and associated adverse effects. Multimodal approaches used in orthopaedic surgery of the lower extremity, especially joint arthroplasty, have been well described and studies have shown reduced opioid consumption, improved pain and function, and decreased length of stay. A growing body of evidence supports multimodal analgesia in spine surgery. Methods include the use of preemptive analgesia, NSAIDs, the neuromodulatory agents gabapentin and pregabalin, acetaminophen, and extended-action local anesthesia. The development of a standard approach to multimodal analgesia in spine surgery requires extensive assessment of the literature. Because a substantial number of spine surgeries are performed annually, a standardized approach to multimodal analgesia may provide considerable benefits, particularly in the context of the increased emphasis on accountability within the healthcare system.

Surgical Site Infections in Posterior Lumbar Surgery: A Controlled-Cohort Study of Epidural Steroid Paste

STUDY DESIGN

A retrospective, single-center cohort study of consecutive patients undergoing posterior lumbar decompression between 2007 and 2013 was conducted.

OBJECTIVE

To compare rates of surgical site infection between matched cohorts of patients undergoing lumbar surgery with and without intraoperative application of epidural steroid pastes.

SUMMARY OF BACKGROUND DATA

Epidural steroid agents reduce postoperative pain and inflammation following lumbar surgery, reducing the use of postoperative narcotics and improving McGill pain scores. Preliminary studies have, however, suggested an increase in surgical site infections following the use of these steroid-containing pastes.

METHODS

We reviewed 758 patients undergoing decompression performed at a single center by surgeons who either routinely used or never used an analgesic steroid paste. Patients undergoing instrumentation or revision surgery were excluded, and surgical and postoperative protocols were uniform. Two hundred eighty-three patients met specific inclusion and exclusion criteria. Demographic, clinical, and surgical data were assessed and correlated to the incidence of postoperative infections. Multivariate logistic regression controlled for confounding characteristics and identified independent predictors of postoperative surgical-site infections.

RESULTS

Patient demographics, comorbidities, and perioperative protocols were similar between groups. There were six acute infections among 103 patients receiving steroid paste (5.83%), and two infections among 180 patients not receiving paste (1.11%), a statistically significant difference which remained after controlling for confounding characteristics (odds ratio 6.74, P = 0.01). All but one infection occurred among patients with identifiable preoperative risk factors for infection.

CONCLUSION

The observed increase in infection among patients receiving pain paste is clinically significant, but infection was primarily observed among at-risk patients. The present study confirms suspicions raised in preliminary studies, and we recommend caution when treating patients with identifiable, comorbid risk factors.

LEVEL OF EVIDENCE

3.

Complications of intraoperative epidural steroid use in lumbar discectomy: a systematic review and meta-analysis

OBJECT The authors' aim in this paper was to review the intraoperative use of epidural steroids in lumbar discectomy surgery with a focus on surgical complications. METHODS A comprehensive literature search was done using PubMed, MEDLINE, and the Cochrane Central Registry of Controlled Trials. Relevant papers were retrieved and analyzed. The authors performed a meta-analysis of all available data. Search terms included epidural, steroids, discectomy, lumbar disc surgery, herniated lumbar disc, methylprednisolone, and perioperative.The primary outcome was surgical complications such as wound infection or need for reoperation. Secondary outcomes were pain and postoperative narcotic usage. RESULTS Sixteen trials and 1 retrospective study (a total of 1933 patients) were eligible for inclusion in this study. In all studies, steroids were added epidurally over the nerve root before closure in cases, and control patients underwent discectomy alone. The mean age (42.7 years vs 42.4 years; RR 0.30 [95% CI -0.30 to 0.90], p = 0.32), overall complication rates (2.69% vs 1.18%; RR 1.94 [95% CI 0.72-5.26], p = 0.19), and infectious complication rates (0.94% vs 0.08%; RR 4.58 [95% CI 0.75-27.95], p = 0.10) were similar between the steroid group and control group, respectively. CONCLUSIONS There is good evidence that epidural steroids can decrease pain in the short term and decrease the usage of postoperative narcotics after lumbar spinal surgery for degenerative spinal disease. The authors' results demonstrate a trend toward increased infection with epidural steroid use, but there was not a statistically significant difference. More studies are needed to validate the long-term risk/benefit ratio of epidural steroids in lumbar discectomy.

Endogenous opiates and behavior: 2013

This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.

Efficacy of intraoperative epidural steroids in lumbar discectomy: a systematic review

BACKGROUND

This study is a descriptive review of the literature aimed at examining the efficacy of the use of intraoperative epidural steroids in lumbar disc surgery, a matter that remains controversial.

METHODS

The relevant clinical trials were selected from databases and reviewed. The methodological quality of each included study was assessed and graded for perceived risk of bias. All the documented significant and non-significant findings were collected. Our outcome targets were reduction in postoperative pain scores, consumption of analgesia, duration of hospital stay and no increase in complication rates. The variation in the timing of postoperative pain assessments necessitated grouping the outcome into three postoperative stages; early: 0 to 2 weeks, intermediate: more than 2 weeks to 2 months and late: more than 2 months to 1 year.

RESULTS

Sixteen trials that were published from 1990 to 2012 were eligible. At least one significant reduction in pain score was reported in nine of the eleven trials that examined pain in the early stage, in four of the seven trials that examined pain in the intermediate stage and in two of the eight trials that examined pain in the late stage. Seven of the nine trials that looked at consumption of postoperative analgesia reported significant reduction while six of the ten trails that examined the duration of hospital stay reported significant reduction. None of the trials reported a significant increase of steroid-related complications.

CONCLUSIONS

There is relatively strong evidence that intraoperative epidural steroids are effective in reducing pain in the early stage and reducing consumption of analgesia. There is also relatively strong evidence that they are ineffective in reducing pain in the late stage and in reducing duration of hospital stay. The evidence for their effectiveness in reducing pain in the intermediate stage is considered relatively weak. The heterogeneity between the trials makes it difficult to make undisputed conclusions and it indicates the need for a large multicenter trial with validated outcome measures that are recorded at fixed time intervals.