The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation: a subgroup analysis of the SPORT trial

Comparing Quality of Life: Discectomy Surgery versus Epidural Corticosteroid Injection for Lumbar Disc Herniation

BACKGROUND

Selecting an efficient treatment for patients with radiculopathy caused by lumbar disc herniation (LDH) unresponsive to conservative management remains a challenging task under investigation, yielding varying results. This study aims to compare the outcomes of the 2 most prevalent invasive treatments.

METHODS

In this retrospective longitudinal study, we enrolled patients with confirmed refractory symptomatic LDH who sought treatment at Valiasr Hospital and underwent either discectomy surgery or epidural steroid injection (ESI) between 2019 and 2022. The outcome measures included pain intensity using the Visual Analog Scale (VAS) and quality of life (QoL) using the SF-36 questionnaire.

RESULTS

A total of 202 individuals (112 in the discectomy group and 90 in the ESI group) consisting of 90 males and 112 females, with a mean age of 50.9 ± 13.5 years, underwent analysis. In the univariate analysis, QoL scores were significantly higher in the discectomy group (57.4 ± 2.4) compared to the ESI group (44.2 ± 2.4) (P < 0.01). Furthermore, the surgery group exhibited a significantly greater reduction in the Leg VAS score after treatment compared to the ESI group (mean difference: -2.59, 95% confidence interval (CI): -3.45 to -1.70, P < 0.01). After adjusting for the most important confounding variables using multiple linear regression analysis, the association between surgery and higher QoL scores remained statistically significant (Unstandardized Coefficients B = 7.65, 95% CI: 0.55, 14.76, P = 0.03).

CONCLUSIONS

Our findings indicate that discectomy surgery has a more pronounced effect on patient outcomes and is a preferable treatment option for LDH patients.

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.

Immune exposure: how macrophages interact with the nucleus pulposus

Intervertebral disc degeneration (IDD) is a primary contributor to low back pain. Immune cells play an extremely important role in modulating the progression of IDD by interacting with disc nucleus pulposus (NP) cells and extracellular matrix (ECM). Encased within the annulus fibrosus, healthy NP is an avascular and immune-privileged tissue that does not normally interact with macrophages. However, under pathological conditions in which neovascularization is established in the damaged disc, NP establishes extensive crosstalk with macrophages, leading to different outcomes depending on the different microenvironmental stimuli. M1 macrophages are a class of immune cells that are predominantly pro-inflammatory and promote inflammation and ECM degradation in the NP, creating a vicious cycle of matrix catabolism that drives IDD. In contrast, NP cells interacting with M2 macrophages promote disc tissue ECM remodeling and repair as M2 macrophages are primarily involved in anti-inflammatory cellular responses. Hence, depending on the crosstalk between NP and the type of immune cells (M1 vs. M2), the overall effects on IDD could be detrimental or regenerative. Drug or surgical treatment of IDD can modulate this crosstalk and hence the different treatment outcomes. This review comprehensively summarizes the interaction between macrophages and NP, aiming to highlight the important role of immunology in disc degeneration.

The Impact of Corticosteroid Injection Timing on Infection Rates Following Spine Surgery: A Systematic Review and Meta-Analysis

STUDY DESIGN/SETTING

Systematic review/meta-analysis.

OBJECTIVES

The objective of this review was to assess how the risk of infection following lumbar spine surgery varies as a function of the timing of preoperative corticosteroid spinal injections (CSIs).

METHODS

A systematic review and meta-analysis was performed in accordance with the PRISMA guidelines. PubMed and EMBASE databases were searched and data was pooled for meta-analysis.

RESULTS

Six studies were identified for inclusion. Two (33.3%) demonstrated a significant relationship between the timing of preoperative CSIs and the risk of postoperative infection, while 4 (66.7%) demonstrated no impact. A total of 2.5% (110/4,448) of patients who underwent CSI <1 month before surgery experienced a postoperative infection, as compared to 1.2% (1,466/120, 943) of controls, which was statistically significant (RR = 1.986 95% CI 1.202-3.282 P = 0.007). A total of 1.6% (25/1,600) of patients who underwent CSI 0-3 months before surgery experienced a postoperative infection, as compared to 1.6% (201/12, 845) of controls (RR = 0.887 95% CI 0.586-1.341, P = 0.569). A total of 1.1% (199/17 870) of patients who underwent CSI 3-6 months before surgery experienced a postoperative infection, as compared to 1.3% (1,382/102, 572) of controls (RR = 1.053 95% CI 0.704-1.575, P = 0.802). Differences in infection risk for 0-3 months and 3-6 months were not statistically significant.

CONCLUSIONS

CSIs <1 month prior to lumbar spine surgery are a significant risk factor for infection, while CSIs beyond that point showed no such association. Surgeons should consider avoiding CSIs <1 month of the use of CSIs of the spine.

Preoperative Duration of Symptoms Does Not Affect Outcomes of Anterior Lumbar Interbody Fusion

BACKGROUND

Previous studies have examined the impact of preoperative duration of symptoms (DOS) on lumbar spinal surgery outcomes although this has not been explored for anterior lumbar interbody fusion (ALIF).

OBJECTIVE

To assess the impact of preoperative DOS on patient-reported outcome measures (PROMs) of ALIF with posterior instrumentation.

METHODS

A database was retrospectively reviewed for ALIFs with posterior instrumentation. PROMs recorded at preoperative, 6-wk, 12-wk, 6-mo, and 1-yr postoperative timepoints included Visual Analog Scale back and leg, Oswestry Disability Index, 12-Item Short-Form Physical Component Score (SF-12 PCS), and PROM Information System physical function. Achievement of minimum clinically important difference (MCID) was determined by comparing differences in postoperative PROMs from baseline to established values. Patients were grouped based on preoperative DOS into <1-yr and ≥1-yr groups. Differences in PROMs were compared using a t-test, whereas MCID achievement used a χ2 test.

RESULTS

Fifty-three patients were included, with 20 in the <1-yr group and 33 in the ≥1-yr group. The most common diagnosis was isthmic spondylolisthesis. No significant preoperative differences were observed in any PROM. DOS groups demonstrated significantly different scores for SF-12 PCS at 6 wk (P = .049). No significant differences in MCID achievement were observed between groups for any PROM.

CONCLUSION

ALIF patients demonstrated similar levels of pain, disability, and physical function regardless of preoperative DOS, except for back pain and physical function at intermittent timepoints. MCID achievement did not differ based on DOS for all outcome measures.

Epidural Steroid Injections for Low Back Pain: A Narrative Review

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.

Safety of Epidural Steroid Injections for Lumbosacral Radicular Pain: Unmet Medical Need

OBJECTIVE

Epidural steroid injections (ESIs) are a commonly utilized treatment for lumbosacral radicular pain caused by intervertebral disc herniation or stenosis. Although effective in certain patient populations, ESIs have been associated with serious complications, including paralysis and death. In 2014, the US Food and Drug Administration (FDA) issued a safety warning on the risk of injecting corticosteroids into the epidural space. The aims of this article were to review the neurological complications associated with ESIs and to compare the formulations, safety, and effectiveness of commercially available corticosteroids given by transforaminal, interlaminar, or caudal injection.

METHODS

Serious adverse events associated with ESIs were identified by a search of the FDA Adverse Event Reporting System (FAERS) database. A MEDLINE search of the literature was conducted to identify clinical trials comparing the safety and effectiveness of nonparticulate and particulate corticosteroid formulations.

RESULTS

Neurological complications with ESIs were rare and more often associated with the use of particulate corticosteroids administered by transforaminal injection. Among the 10 comparative-effectiveness studies reviewed, 7 found nonparticulate steroids had comparable efficacy to particulate steroids, and 3 studies suggested reduced efficacy or shorter duration of effect for nonparticulate steroids.

DISCUSSION

The risk of complications for transforaminal ESI is greater with particulate corticosteroids. Nonparticulate corticosteroids, which are often recommended as first-line therapy, may have a short duration of effect, and many commercial formulations contain neurotoxic preservatives. The safety profile of ESIs may continue to improve with the development of safer, sterile formulations that reduce the risk of complications while maintaining efficacy.

Artificial intelligence predicts disk re-herniation following lumbar microdiscectomy: development of the "RAD" risk profile

PURPOSE

Surgical treatment of herniated lumbar intervertebral disks is a common procedure worldwide. However, recurrent herniated nucleus pulposus (re-HNP) may develop, complicating outcomes and patient management. The purpose of this study was to utilize machine-learning (ML) analytics to predict lumbar re-HNP, whereby a personalized risk prediction can be developed as a clinical tool.

METHODS

A retrospective, single center study was conducted of 2630 consecutive patients that underwent lumbar microdiscectomy (mean follow-up: 22-months). Various preoperative patient pain/disability/functional profiles, imaging parameters, and anthropomorphic/demographic metrics were noted. An Extreme Gradient Boost (XGBoost) classifier was implemented to develop a predictive model identifying patients at risk for re-HNP. The model was exported to a web application software for clinical utility.

RESULTS

There were 1608 males and 1022 females, 114 of whom experienced re-HNP. Primary herniations were central (65.8%), paracentral (17.6%), and far lateral (17.1%). The XGBoost algorithm identified multiple re-HNP predictors and was incorporated into an open-access web application software, identifying patients at low or high risk for re-HNP. Preoperative VAS leg, disability, alignment parameters, elevated body mass index, symptom duration, and age were the strongest predictors.

CONCLUSIONS

Our predictive modeling via an ML approach of our large-scale cohort is the first study, to our knowledge, that has identified significant risk factors for the development of re-HNP after initial lumbar decompression. We developed the re-herniation after decompression (RAD) profile index that has been translated into an online screening tool to identify low-high risk patients for re-HNP. Additional validation is needed for potential global implementation.

Lumbar Disk Herniations and Radiculopathy in Athletes

Lumbar disk herniation is the most common surgical condition of the spine. High-level athletes participate in activities that place extreme loads on the intervertebral disks. These repetitive loads may lead to an elevated risk for degenerative disk disease, which in turn predisposes to disk herniations. Treatment algorithms for athletes with disk herniations are similar to those in the nonathletic population; however, success in the athletic population is often measured in the ability to return to play. Both nonoperative and operative treatment show a high success rate in return to play in athletes treated for disk herniations.

Cervical epidural steroid injections: incidence and determinants of subsequent surgery

BACKGROUND CONTEXT

Cervical epidural steroid injections (CESIs) are sometimes used in the management of cervical radicular pain in order to delay or avoid surgery. However, the rate and determinants of surgery following CESIs remain uncertain.

PURPOSE

This study sought to determine: (1) the proportion of patients having surgery following CESI, and (2) the timing of and factors associated with subsequent surgery.

STUDY DESIGN

Retrospective analysis of a large, national administrative claims database.

PATIENT SAMPLE

The study included 192,777 CESI patients (age 50.9±11.3 years, 55.2% female) who underwent CESI for imaging-based diagnoses of cervical disc herniation or stenosis, a clinical diagnosis of radiculopathy, or a combination thereof.

OUTCOME MEASURES

The primary outcome was the time from index CESI to surgery.

METHODS

Inclusion criteria were CESI for cervical disc herniation, stenosis, or radiculopathy, age ≥18, and active enrollment for 1 year before CESI to screen for exclusions. Patients were followed until they underwent cervical surgery, or their enrollment lapsed. Rates of surgery were assessed with Kaplan-Meier survival curves and 99% confidence intervals. Factors associated with subsequent surgery were assessed with multivariable Cox proportional hazard models.

RESULTS

Within 6 months of CESI, 11.2% of patients underwent surgery, increasing to 14.5% by 1 year and 22.3% by 5 years. Male patients and those aged 35 to 54 had an increased likelihood of subsequent surgery. Patients with radiculopathy were less likely to undergo surgery following CESI than those with stenosis or herniation, while patients with multiple diagnoses were more likely. Patients with comorbidities including CHF, other cardiac comorbidities or chronic pain were less likely to undergo surgery, as were patients in the northeast US region. Some 33.5% of patients underwent >1 CESI, with 84.6% of these occurring within 1 year. Additional injections were associated with reduced rates of subsequent surgery.

CONCLUSIONS

Following CESI, over one in five patients underwent surgery within 5 years. Multiple patient-specific risk factors for subsequent surgery were identified, and patients undergoing repeated injections were at lower risk. Determining which patients may progress to surgery can be used to improve resource utilization and to inform shared decision-making.

Preoperative epidural steroid injections are not associated with increased rates of infection and dural tear in lumbar spine surgery

PURPOSE

The study objectives were to use a large national claims data resource to examine rates of preoperative epidural steroid injections (ESI) in lumbar spine surgery and determine whether preoperative ESI or the timing of preoperative ESI is associated with rates of postoperative complications and reoperations.

METHODS

A retrospective longitudinal analysis of patients undergoing lumbar spine surgery for disc herniation and/or spinal stenosis was undertaken using the MarketScan® databases from 2007-2015. Propensity-score matched cohorts were constructed to compare rates of complications and reoperations in patients with and without preoperative ESI.

RESULTS

Within the year prior to surgery, 120,898 (46.4%) patients had a lumber ESI. The median time between ESI and surgery was 10 weeks. 23.1% of patients having preoperative ESI had more than one level injected, and 66.5% had more than one preoperative ESI treatment. Patients with chronic pain were considerably more likely to have an ESI prior to their surgery [OR 1.62 (1.54, 1.69), p < 0.001]. Patients having preoperative ESI within in close proximity to surgery did not have increased rates of infection, dural tear, neurological complications, or surgical complications; however, they did experience higher rates of reoperations and readmissions than those with no preoperative ESI (p < 0.001).

CONCLUSION

Half of patients undergoing lumbar spine surgery for stenosis and/or herniation had a preoperative ESI. These were not associated with an increased risk for postoperative complications, even when the ESI was given in close proximity to surgery. Patients with preoperative ESI were more likely to have readmissions and reoperations following surgery.

Evaluation of persons with suspected lumbosacral and cervical radiculopathy: Electrodiagnostic assessment and implications for treatment and outcomes (Part II)

The electrodiagnostic (EDX) examination with needle electromyography (EMG) is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity and complements imaging of the spine. In this second of a two-part review, the implications of electrodiagnostic findings for diagnosis and clinical management of persons with radiculopathy are reviewed. An EMG confirmed lumbosacral radiculopathy is associated with better clinical outcomes for persons undergoing aggressive conservative management. A positive EMG test portends a better clinical response to epidural corticosteroid injections. If a person undergoes spine surgery, a positive pre-operative EMG for radiculopathy is also associated with better outcomes.

Systematic Review of Outcomes Following 10-Year Mark of Spine Patient Outcomes Research Trial for Intervertebral Disc Herniation

MINI: We summarized the 10-year outcomes of Spine Patient Outcomes Research Trial for intervertebral disc herniation through a systematic review. The observational cohort 2-year analysis and the as-treated analysis of the randomized control trial at 4 and 8 years showed statistically greater improvements in those patients who were treated surgically.

STUDY DESIGN

We performed a comprehensive search of Pubmed, MEDLINE, and EMBASE for English-language studies of all levels of evidence pertaining to SPORT, in accordance with Preferred Reported Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

OBJECTIVE

We aim to summarize the 10-year clinical outcomes of SPORT and its numerous follow-up studies for intervertebral disc herniation.

SUMMARY OF BACKGROUND DATA

The Spine Patient Outcomes Research Trial (SPORT) was a landmark study. SPORT compared surgical and nonoperative management of the three most common spinal pathologies.

METHODS

Keywords utilized included: SPORT, spine patient outcomes research trial, disc herniation, and surgical outcomes.

RESULTS

The observational cohort analysis revealed statically greater improvement in primary outcomes at 3 months and 2 years in patients who had surgery, while analysis of the randomized control trial cohort failed to show a significant difference based on the intent-to-treat principle due to significant patient crossover. However, 4 year and 8 year as-treated analysis showed statistically greater improvements in those patients who were treated surgically. SPORT's subgroup analysis evaluated important factors when considering the treatment of IDH, including patient characteristics, level of herniation, duration of symptoms, recurrence of pain, presence of retrolistheiss, patient functional status, effects of previous treatment with epidural steroid injections and opioid medication, outcomes after incidental durotomy, MRI reader reliability, reoperation rates, and risk factors for reoperation. The clinical impact of SPORT was also investigated and included comparison of SPORT patients to NSQIP patients to determine generalizability, outcome differences in SPORT's surgical center sites, patient preferences, patient expectations, level of education, and effects of watching an evidence-based video.

CONCLUSION

Ten years after its inception, SPORT has made strides in standardization and optimization of treatment for spinal pathologies. SPORT has provided clinicians with insight about outcomes of surgical and nonoperative treatment of IDH. Results showed significantly greater improvements in patients treated surgically.

LEVEL OF EVIDENCE

3.

Effects of implementing evidence-based appropriateness guidelines for epidural steroid injection in chronic low back pain: the EAGER (Esi Appropriateness GuidElines pRotocol) study

Objective

Chronic low back pain is very common and often treated with epidural steroid injections (ESIs). As ESI referrals had been rapidly increasing at our Veterans’ Administration hospital, we were concerned that they were supplanting more comprehensive care. The objective was to determine how referral patterns and multidisciplinary care might change with the implementation of evidence-based guidelines.

Methods

In this retrospective observational study, multidisciplinary evidence-based guidelines were implemented in 2014 (EAGER: Esi Appropriateness GuidElines pRotocol) as part of the ordering process for an ESI. Time series analysis was performed to assess the primary outcome of subspecialty referral pattern, that is, the number of patients receiving referrals to ancillary services which might serve to provide a more comprehensive approach to their back pain. Secondary outcomes included patient-level changes (ie, body mass index, number of injections, opioid use), which were compared before and after protocol implementation.

Results

Comparing preimplementation and postimplementation protocol periods, referrals to physical medicine/rehabilitation increased 11.7% (p=0.003) per year and integrative health increased 2.1% (p<0.001) per year among the 2294 individual patients who received ESI through the neurointerventional radiology service. Of 100 randomly selected patients for patient-level analysis, the median body mass index decreased from 31.57 to 30.22 (p=<0.001) and the mean number of injections decreased from 1.76 to 0.73 (p<0.001). The percentage of patients using oral opioid analgesics decreased from 72% to 49% (p=<0.001).

Conclusion

Implementation of evidence-based guidelines for ESI referral helps guide patients into a more comprehensive care pathway for chronic low back pain and is correlated with patient-level changes such as decreased body mass index and decreased opioid usage.

Recent Preoperative Lumbar Epidural Steroid Injection Is an Independent Risk Factor for Incidental Durotomy During Lumbar Discectomy

STUDY DESIGN

Retrospective review.

OBJECTIVE

To investigate the association between lumbar epidural steroid injection (LESI) and incidental durotomy (ID) in patients with a diagnosis of disc herniation undergoing a primary discectomy.

METHODS

A Medicare patient database was queried for patients between the ages of 65 and 85 years who underwent a primary lumbar discectomy for a diagnosis of lumbar disc herniation or degeneration from 2008 to 2014. Our main cohort of 64 849 patients was then divided into 2 groups: patients who experienced a dural tear (N = 2369) and our matched (age, gender, and history of diabetes) control cohort of patients who did not (N = 62 480). All patients who had a history of LESI were further identified and stratified into 4 subgroups by duration between LESI and discectomy (<3 months, 3-6 months, 6 months to 1 year, and overall), and a comparison of the relative incidence of ID was made among these subgroups. A multivariate logistic regression analysis was employed to determine the relationship between LESI and ID.

RESULTS

Overall incidence of ID was 3.7%. There was a significant difference in incidence of LESI (27.1% vs 35.0%, P < .001) between our control and ID groups. An adjusted odds ratio (OR) showed that prior LESI within 3 to 6 months (OR 1.47, 95% CI 1.20-1.81, P < .001) and within less than 3 months (OR 1.46, 95% CI 1.24-1.72, P < .001) of surgery were significantly associated with ID.

CONCLUSION

LESI increases the risk of ID in patients who undergo a subsequent lumbar discectomy within 6 months of injection.

The effect of lumbar corticosteroid injections on postoperative infection in lumbar arthrodesis surgery

We sought to characterize the association between lumbar corticosteroid injections and postoperative infection rate for patients in the Military Health System undergoing lumbar arthrodesis. The Military Health System Data Repository was searched for all patients undergoing lumbar arthrodesis from 2009 to 2014. Current Procedural Terminology (CPT) codes were used to identify the subset of patients who also received preoperative lumbar corticosteroid injections. These patients were stratified by timing, type, and number of injections. Infection rates were compared to the control group of patients who did not receive preoperative lumbar corticosteroid injections. The search identified 3403 patients who had undergone lumbar arthrodesis from 2009 to 2014 within the Military Health System. 612 patients had received lumbar corticosteroid injections prior to surgery (348 epidural, 264 facet). The control group consisted of the remaining 2791 patients. Overall post-operative infection rate was 1.47% with an infection rate in the injection group of 1.14% versus 1.54% in the control group. When stratified by time, infection rates ranged from 0% to 1.85% in the injection groups. No differences between injection and control groups reached statistical significance in any subgroup analysis. Post-operative infection rate is not significantly increased in patients receiving lumbar corticosteroid injections (LCSIs) prior to lumbar arthrodesis. No differences were observed in infection rates based on timing, type, or number of injections prior to surgery.

Lumbar Spinal Stenosis and Degenerative Spondylolisthesis: A Review of the SPORT Literature

The Spine Patient-Reported Outcomes Related Trial (SPORT) is arguably one of the most impactful and insightful studies conducted in spine surgery. Designed as a prospective, multicenter study with randomized and observational cohorts, SPORT has provided vast data on the pathogenesis, treatment effects, clinical outcomes, cost effectiveness of disk herniation, lumbar spinal stenosis, and degenerative spondylolisthesis. With regards to spinal stenosis and degenerative spondylolisthesis, SPORT has demonstrated a sustained benefit from surgical intervention at 2, 4, and 8 years postoperatively. Myriad subgroup analyses have subsequently been performed that have also resulted in clinically relevant findings. These analyses have assessed incidence and risk factors for reoperations and intraoperative complications, impact of patient comorbidities and host factors, influence of epidural injections, patient decision-making, and role of nonoperative therapy. This has resulted in significant findings that may allow spine surgeons to optimize patient outcomes while managing expectations appropriately.

Lumbar epidural steroid injections for herniation and stenosis: incidence and risk factors of subsequent surgery

BACKGROUND CONTEXT

Lumbosacral epidural steroid injections (ESIs) have increased dramatically despite a narrowing of the clinical indications for use. One potential indication is to avoid or delay surgery, yet little information exists regarding surgery rates after ESI.

PURPOSE

The purpose of this research was to determine the proportion of patients having surgery after lumbar ESI for disc herniation or stenosis and to identify the timing and factors associated with this progression.

STUDY DESIGN/SETTING

This study was a retrospective review of nationally representative administrative claims data from the Truven Health MarketScan databases from 2007 to 2014.

PATIENT SAMPLE

The study cohort was comprised of 179,025 patients (54±15 years, 48% women) having lumbar ESIs for diagnoses of stenosis and/or herniation.

OUTCOME MEASURES

The primary outcome measure was the time from ESI to surgery.

METHODS

Inclusion criteria were ESI for stenosis and/or herniation, age ≥18 years, and health plan enrollment for 1 year before ESI to screen for exclusions. Patients were followed longitudinally until they progressed to surgery or had a lapse in enrollment, at which time they were censored. Rates of surgery were assessed with the Kaplan-Meier survival curves. Demographic and treatment factors associated with surgery were assessed with multivariable Cox proportional hazard models. No external funding was procured for this research and the authors' conflicts of interest are not pertinent to the present work.

RESULTS

Within 6 months, 12.5% of ESI patients underwent lumbar surgery. By 1 year, 16.9% had surgery, and by 5 years, 26.1% had surgery. Patients with herniation had surgery at rates of up to five-fold to seven-fold higher, with the highest rates of surgery in younger patients and those with both herniation and stenosis. Other concomitant spine diagnoses, male sex, previous tobacco use, and residence a rural areas or regions other than the Northeastern United States were associated with higher surgery rates. Medical comorbidities (previous treatment for drug use, congestive heart failure, obesity, chronic obstructive pulmonary disease, hypercholesterolemia, and other cardiac complications) were associated with lower surgery rates.

CONCLUSIONS

In the long term, more than one out of every four patients undergoing ESI for lumbar herniation or stenosis subsequently had surgery, and nearly one of six had surgery within the first year. After adjusting for other patient demographics and comorbidities, patients with herniation were more likely have surgery than those with stenosis. The improved understanding of the progression from lumbar ESI to surgery will help to better inform discussions regarding the value of ESI and aid in the shared decision-making process.

Lumbar Disk Herniation and SPORT: A Review of the Literature

The Spine Patient Outcomes Related Trial (SPORT) is arguably one of the most impactful and insightful studies conducted in spine surgery. Designed as a prospective, multicenter study with a randomized and observational cohort, SPORT has provided vast data on the pathogenesis, treatment effects, clinical outcomes, cost effectiveness of both disk herniation and lumbar spinal stenosis. With regards to lumbar disk herniation, SPORT has demonstrated a sustained benefit from surgical intervention and acceptable cost-effectiveness at 2, 4, and 8 years postoperatively. Myriad subgroup analyses have subsequently been performed that have also resulted in clinically relevant findings. These analyses have assessed optimal timing for surgery, incidence and risk factors for reoperation, impact of obesity and other comorbidities, influence of epidural injections, and evaluation of socioeconomic factors. This has resulted in significant findings that may allow spine surgeons to optimize patient outcomes while managing expectations appropriately.

Clinical research on the efficacy and safety of thread-embedding acupuncture for treatment of herniated intervertebral disc of the lumbar spine: a protocol for a multicenter, randomized, patient-assessor blinded, controlled, parallel, clinical trial

BACKGROUND

A lumbar herniated intervertebral disc (LHIVD) is a common problem that usually causes lower back pain and neurological symptoms that manifest as radiating pain. Several studies have reported that thread-embedding acupuncture (TEA) is effective in the treatment of LHIVD. However, these studies were of low quality and there is therefore little clinical evidence for the effectiveness of TEA in this regard. The aim of the present study is to establish the clinical evidence regarding the efficacy and safety of TEA in the treatment of pain, function, and quality of life in patients with LHIVD. The study uses a rigorously designed, full-scale, randomized clinical trial (RCT) protocol.

METHOD/DESIGN

This is a multicenter, randomized, patient-assessor blinded, sham-controlled trial with two parallel arms. Seventy patients with LHIVD who have lower back pain more severe than 40 mm on the 100-mm visual analogue scale (VAS), and who are aged 19-70 years, will be recruited and randomly allocated to a TEA group and sham TEA (STEA) group. Both groups will receive treatment on 23 predefined acupoints once a week for eight weeks; needles with the thread removed will be used in the STEA group, while normal TEA will be employed in the TEA group. Changes in the 100-mm VAS for lower back pain after eight weeks will be assessed as the primary outcome. Furthermore, the 100-mm VAS for radiating pain, Oswestry Disability Index, Roland-Morris disability questionnaire, EuroQol 5 Dimensions 5 Levels, and global perceived effect will be measured and analyzed as secondary outcomes. All outcomes will be assessed at baseline and at 4, 8, 12, and 16 weeks after screening.

DISCUSSION

The results of this trial will help to establish the clinical evidence regarding TEA in the treatment of patients with LHIVD.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03236753 . Registered on August 2, 2017. Clinical Research Information Service of the Republic of Korea, KCT0002439 . Registered on August 1, 2017.

Relationship between serum levels of miR-204 and clinical features of patients with lumbar disc herniation - an analysis based on 1,589 cases

This study aims to investigate the relationship between serum miR-204 and clinical features of patients with lumbar disc herniation (LDH). Clinical data of 1589 LDH patients were retrospectively analyzed. There were 953 patients (group A) with a duration of disease shorter than 3 months, and another 636 patients (group B) with a duration of disease longer than 3 months. A total of 300 healthy volunteers were also selected in the same period. Results showed that there was no significant difference in miR-204 expression between males and females (p>0.05). No significant differences in miR-204 expression level were found among different ages (p>0.05). miR-204 in patients with LHD at or below the fourth lumbar vertebrae was significantly higher than those in patients with LHD above the fourth lumbar vertebrae (p<0.05). miR-204 in 1485 patients with abnormal lumbar spine activity was higher than those in healthy controls (p<0.05). miR-204 expression levels was higher in patients with low back pain than those in patients without low back pain. Among patients with low back pain, miR-204 level in patients with spasm-like waist pain was significantly higher than that in patients with persistent dull low back pain (p<0.05). miR-204 increased with the increase in degree of limited walking (p<0.05). There was no significant difference in miR-204 expression level between patients with bilateral lower limb symptoms and patients with unilateral lower limb symptoms (p>0.05), while miR-204 was significantly higher in patients with lower limb symptoms than that in patients without the symptoms (p<0.05). miR-204 was correlated with knee tendon reflex, heel tendon reflex and degree of straight leg raise abnormality. miR-204 was significantly decreased in patients with improvement after treatment. miR-204 level was closely related to the clinical characteristics of LDH. miR-204 may potentially serve as a prognostic marker for patients with LDH.

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.

The effect of preoperative lumbar epidural corticosteroid injection on postoperative infection rate in patients undergoing single-level lumbar decompression

BACKGROUND CONTEXT

Lumbar epidural corticosteroid injections (LECIs) are frequently used in the treatment of lumbar intervertebral disc herniation with radiculopathy and lumbar spinal stenosis. Although widely used, their effect on the outcomes and complications of subsequent surgery is unclear. Postoperative infection can be a morbid complication following spine surgery, and recent literature has suggested that the risk may be increased in patients undergoing lumbar spinal surgery who had previously received LECIs.

PURPOSE

The purpose of this study is to define the overall postoperative infection rate in patients undergoing lumbar spine decompression surgery in the Military Health System (MHS) patient population and examine the effects of LECIs on postoperative infection rates.

STUDY DESIGN/SETTING

This is a retrospective case control database study (Level III study).

PATIENT SAMPLE

The sample comprised all patients in the MHS who had a LECI before single-level lumbar decompression surgery from 2009 to 2014.

OUTCOME MEASURES

Postoperative infection within 90 days of surgery was used as the primary outcome measure for this study. Postoperative infection was identified using the International Classification of Diseases, 9th revision (ICD-9) diagnosis codes for postoperative infection.

METHODS

The Military Health System Data Repository (MDR) database was searched for all patients who underwent single-level lumbar spine decompression surgery from 2009 to 2014 using Current Procedural Terminology (CPT) codes. Current Procedural Terminology codes were used to identify the subset of patients who received preoperative LECIs. For patients receiving an injection, cohorts were established based on the timing of the preoperative injection: <30 days, 30-90 days, 91-180 days, 181-365 days, and >365 days. An age-based cohort, composed of patients 65 years of age and older, was also analyzed. A subgroup analysis of patients receiving more than one preoperative injection was performed. Postoperative infection within 90 days of surgery was identified using ICD-9 codes, and infection rates for all groups were calculated and compared with the control group who did not receive preoperative LECIs. No external funding was received for this study.

RESULTS

We identified 6,535 patients (847 preoperative LECI and 5,688 control) for analysis. The overall infection rate for patients undergoing single-level lumbar decompression surgery in the MHS was 0.81%. The rate ranged from 0% to 1.57% in the injection groups, with an overall infection rate in the injection group of 1.18% versus 0.76% in the control group. Despite an increased odds ratio of 1.57 following injection, no statistically significant differences were found between the control group and any injection group based on timing of injection, patient age, or number of preoperative injections.

CONCLUSIONS

The results of this study suggest that within the MHS, preoperative LECIs do not significantly increase the risk of postoperative infection after single-level lumbar decompression. If a difference does exist, it is likely small.

Factors for Predicting Favorable Outcome of Percutaneous Epidural Adhesiolysis for Lumbar Disc Herniation

Background. Lower back pain is a common reason for disability and the most common cause is lumbar disc herniation. Percutaneous epidural adhesiolysis has been applied to relieve pain and increase the functional capacity of patients who present this condition. Objectives. In this study, we retrospectively evaluated the factors which predict the outcome of percutaneous epidural adhesiolysis in patients who were diagnosed with lumbar disc herniation. Methods. Electronic medical records of patients diagnosed with lumbar disc herniation who have received percutaneous epidural adhesiolysis treatment were reviewed. The primary outcome was the factors that were associated with substantial response of ≥4 points or ≥50% of pain relief in the numerical rating scale pain score 12 months after the treatment. Results. Multivariate logistic regression analysis demonstrated that the presence of high-intensity zone (HIZ) at magnetic resonance imaging was a predictor of substantial response to percutaneous epidural adhesiolysis for 12 months (P = 0.007). The presence of a condition involving the vertebral foramen was a predictor for unsuccessful response after 12 months (P = 0.02). Discussion and Conclusion. The presence of HIZ was a predictor of favorable long-term outcome after percutaneous epidural adhesiolysis for the treatment of lower back pain with radicular pain caused by lumbar disc herniation.

Combination of Magnetic Resonance Imaging and Electrophysiological Studies in Lumbar Disc Herniation

Objective We aimed to study the clinical value of magnetic resonance imaging (MRI) and electrophysiological studies in the diagnosis of lumbar disc herniation and in the evaluation of the therapeutic effect of discectomy. Methods In this study, 265 patients with LDH were treated with discectomy after assessment by the Japanese Orthopedic Association (JOA) score, MRI, and electrophysiological studies. All the patients were followed-up for 6 years. The effects of the operation were assessed by determining the angle between the nerve root canal and disc protrusion (AN value), the stenotic ratio of the spinal canal, the width of the lateral recess, motor conduction velocity (MCV), sensory conduction velocity (SCV), and nerve action potential (NAP) before and after operation. Results The AN value, stenotic ratio of the spinal canal, and the width of the lateral recess of protruding intervertebral discs showed significant differences from these values for the patients' unaffected intervertebral discs (P < 0.05). The MCV, SCV, and NAP of the affected limb showed significant differences from these values for the patients' unaffected limbs (P < 0.05). In all the patients the values for these indicators showed significant differences before and after operation (P < 0.05). Conclusion MRI and electrophysiological studies can be used in the diagnosis of lumbar disc herniation, and in the evaluation of the effect of surgery.

Is There an Association of Epidural Corticosteroid Injection With Postoperative Surgical Site Infection After Surgery for Lumbar Degenerative Spine Disease?

STUDY DESIGN

Retrospective study.

OBJECTIVE

To assess the relation between exposure to epidural steroid injection (ESI) before surgery and occurrence of surgical site infection (SSI) for degenerative lumbar spine conditions.

SUMMARY OF BACKGROUND DATA

The effect of local ESI on the occurrence of SSI is controversial.

METHODS

Patients who underwent surgery for degenerative lumbar spine conditions at two centers between 2005 and 2015 were identified. Primary outcome measure was SSI within 90 days requiring surgical intervention.

RESULTS

A total of 5311 patients (age 57 ± 16 years) were analyzed of which 945 (18%) had at least one ESI within 90 days of surgery. One hundred thirty-four (2.5%) patients developed an SSI requiring reoperation. No association of exposure or dose-response relationship was identified between ESI and SSI for any of the time periods (90-, 30-, and 30-90-day). Five (1.7%) of the 290 patients who had at least one ESI within 30 days before surgery had a postoperative infection compared to 129 (2.6%) of the 5021 in the non-ESI group (unadjusted odds ratio: 0.67, 95% CI: 0.27-1.64, P = 0.376). Fifteen (2.0%) of the 761 patients who had at least one ESI within 30 to 90 days before surgery had a postoperative infection, compared to 119 (2.6%) of the 4550 in the non-ESI group (unadjusted odds ratio: 0.75, 95% CI: 0.44-1.29, P = 0.296).

CONCLUSION

In this retrospective study we investigated whether an ESI and its timing influences the postoperative risk of an SSI. We found no association-exposure or dose-response relationship-between ESI and postoperative infection, even after adjusting for potential confounders, for any of the time periods (90-, 30-, and 30-90-day ESI). In addition, we did find that longer hospital stay, greater EBL, posterior approach, and drain placement were associated with higher infection rates.Level of Evidence: 3.

Predictors of the efficacy of epidural steroid injections for structural lumbar degenerative pathology

BACKGROUND

Lumbar epidural steroid injection (LESI) is a valuable therapeutic option when administered to the appropriate patient, for the appropriate disease process, at the appropriate time. There is considerable variability in patient-reported outcomes (PROs) after LESI, creating uncertainty as to who will benefit from the therapy and who will not.

PURPOSE

We set out to identify patient attributes, which are important predictors for the achievement of a minimum clinically important difference (MCID) in the Oswestry Disability Index (ODI) after LESI.

STUDY DESIGN

A prospective cohort study was carried out.

PATIENT SAMPLE

A total of 239 consecutive patients undergoing LESI for back-related disability, back pain (BP), and leg pain (LP) associated with degenerative pathology comprised the patient sample.

OUTCOME MEASURES

Baseline and 3-month patient self-reported ODI, numeric rating scale-BP and LP, Euro-Qol-5D, and Short Form (SF)-12 scores were recorded.

METHODS

A total of 239 consecutive patients undergoing LESI for degenerative pathology over a period of 2 years who were enrolled into a prospective web-based registry were included in the study. Using the previously reported anchor-based approach, an MCID threshold of 7.1% was established for ODI after LESI. Each enrolled patient was then dichotomized as a "responder" (achieving MCID) or a "non-responder." Multiple logistic regression analysis was then performed, with the achievement of MCID serving as the outcome of interest. Candidate variables included in the regression analyses were age, gender, employment, insurance type, smoking status, preoperative ambulation, preinjection narcotic use, comorbidities, predominant LP or BP symptoms, symptom duration, diagnosis, number of levels, prior surgery, baseline PROs, type of stenosis (central, lateral recesses, or foraminal), injection route (transforaminal, interlaminar, or caudal), and number of injections. Subsequently, we also randomly selected 80% of the patients to serve as the training data for a multiple logistic regression model. Once this predictive model was built, it was validated using the remaining 20% of patients.

RESULTS

There were 124 (62%) patients who achieved MCID for ODI. The existence of central stenosis (p=.006), TF or IL injection route (p=.02) compared with caudal epidural steroid injection, higher baseline ODI (p=.00001), and a diagnosis of disc herniation (p=.02) increase the odds of achieving MCID for ODI at 3 months. Symptom duration for over a year (p=.006), prior surgery (p=.08), and preinjection anxiety (p=.001) decrease the odds of achieving MCID. The area under the curve (AUC) for our predictive model's receiver-operator characteristic was 0.81 when using the 80% training data set, and the AUC was 0.72 when using the 20% validation data.

CONCLUSION

We have identified patient attributes that are important predictors for the achievement of MCID in ODI 3 months after LESI. The use of these attributes, in the form of a predictive model for LESI efficacy, has the potential to improve decision making around LESI. Spine care providers can use the information to gain insight into the likelihood that a particular patient will experience a meaningful benefit from LESI.

The Effectiveness of Transforaminal Versus Caudal Routes for Epidural Steroid Injections in Managing Lumbosacral Radicular Pain: A Systematic Review and Meta-Analysis

Epidural steroid injection (ESI) is one of the most commonly used treatments for radiculopathy. Previous studies have described the effectiveness of ESI in the management of radiculopathy. However, controversy exists regarding the route that is most beneficial and effective with respect to the administration of epidural steroids, as both transforaminal (TF) and caudal (C) routes are commonly used.This analysis reviewed studies comparing the effectiveness of TF-ESIs with that of C-ESIs in the treatment of radiculopathy as a means of providing pain relief and improving functionality. This meta-analysis was performed to guide clinical decision-making.The study was a systematic review of comparative studies.A systematic literature search was performed using the PubMed, EMBASE, and Cochrane Library databases for trials written in English. The randomized trials and observational studies that met our inclusion criteria were subsequently included. Two reviewers, respectively, extracted data and estimated the risk of bias. All statistical analyses were performed using Review Manager 5.3.Six prospective and 2 retrospective studies involving 664 patients were included. Statistical analysis was performed utilizing only the 6 prospective studies. Although slight pain and functional improvements were noted in the TF-ESI groups compared with the C-ESI groups, these improvements were neither clinically nor statistically significant.The limitations of this meta-analysis resulted primarily from the weaknesses of the comparative studies and the relative paucity of patients included in each study.Both the TF and C approaches are effective in reducing pain and improving functional scores, and they demonstrated similar efficacies in the management of lumbosacral radicular pain.

Classification of patients with incident non-specific low back pain: implications for research

BACKGROUND CONTEXT

Comparing research studies of low back pain is difficult because of heterogeneity. There is no consensus among researchers on inclusion criteria or the definition of an episode.

PURPOSE

This study aimed to determine pattern(s) of recurrent non-specific low back pain from data collected over 27 months.

STUDY DESIGN/SETTING

This study used retrospective cohort study using administrative claims from multiple payers. Although claims are designed for capturing costs, not clinical complexity, they are valid for describing utilization patterns, which are not affected by potential "upcoding."

PATIENT SAMPLE

The patient sample consisted of population-based, nationally generalizable sample of 65,790 adults with continuous medical and pharmaceutical commercial health insurance who received health care for incident, non-specific low back pain. Potential subjects were excluded for plausible cause of the pain, severe mental illness, or cognitive impairment.

OUTCOME MEASURES

Diagnostic and therapeutic health-care services, including medical, surgical, pharmaceutical, and complementary, received in inpatient, outpatient, and emergency settings were the outcome measures for this study.

METHODS

The methods used for this study were latent class analysis of health-care utilization over 27 months (9 quarters) following index diagnosis of non-specific low back pain occurring in January-March 2009 and an analysis sample with 60% of subjects (n=39,597) and validation sample of 40% (n=26,193).

RESULTS

Four distinct groups of patients were identified and validated. One group (53.4%) of patients recovered immediately. One third of patients (31.7%) may appear to recover over 6 months, but maintain a 37-48% likelihood of receiving care for low back pain in every subsequent quarter, implying frequent relapse. Two remaining groups of patients each maintain very high probabilities of receiving care in every quarter (65-78% and 84-90%), predominantly utilizing therapeutic services and pain medication, respectively. Probabilistic grouping relative to alternatives was very high (89.6-99.3%). Grouping was not related to demographic or clinical characteristics.

CONCLUSIONS

The four distinct sets of patient experiences have clear implications for research. Inclusion criteria should specify incident or recurrent cases. A 6-month clean period may not be sufficiently long to assess incidence. Reporting should specify the proportion recovering immediately to prevent mean recovery rates from masking between-group differences. Continuous measurement of pain or disability may be more reliable than measuring outcomes at distinct endpoints.

Which Variables Are Associated With Patient-reported Outcomes After Discectomy? Review of SPORT Disc Herniation Studies

BACKGROUND

The Spine Patient Outcomes Research Trial (SPORT) evaluated the effects of surgery versus nonoperative treatment for lumbar intervertebral disc herniation (IDH), among other pathologies. Multiple subgroup analyses have been completed since the initial publications, which have further defined which patient factors lead to better or worse patient-reported outcomes; however, the degree to which these factors influence patient-reported outcomes has not been explored.

QUESTIONS/PURPOSES

We reviewed the subgroup analyses of the SPORT IDH studies to answer the following questions: (1) What factors predicted improvement in patient-reported outcomes after operative or nonoperative treatment of lumbar IDH? (2) What factors predicted worse patient-reported outcomes compared to baseline after operative or nonoperative treatment of lumbar IDH? And (3) what factors influenced patient-reported outcomes of surgery in patients with lumbar IDH?

METHODS

We conducted a MEDLINE(®) search to identify the subgroup analyses of the SPORT IDH data that were responsive to our study questions. Eleven articles were identified that met our search criteria.

RESULTS

The patient factors associated with larger improvements in Oswestry Disability Index at 4 years with either surgical or nonoperative treatment included a higher baseline Oswestry Disability Index, BMI of less than 30, not being depressed, being insured, having no litigation pending, not having workers compensation, and having symptoms for less than 6 weeks, though there were others. Factors leading to improvement with surgical treatment were mostly related to anatomic characteristics of the disc herniation such as posterolateral and sequestered herniations. There were no patient or clinical factors identified that were associated with worse patient-reported outcomes compared to baseline after either operative or nonoperative treatment. At 2-year followup, the treatment effects were greater for those patients with upper-level herniations, patients not receiving workers compensation, and nondiabetic patients. In a 4-year multivariate analysis, being married, without joint problems, and having worse symptoms at baseline resulted in greater treatment effect with surgery.

CONCLUSIONS

While most patients with IDH will likely see improvement with either surgical or nonoperative treatment, there are patient-related factors that can help predict which subgroups will demonstrate a greater improvement with surgery, such as not having joint problems, being married, having worsening symptoms at baseline, and not having diabetes. These results can help providers and patients when discussing treatment options.

LEVEL OF EVIDENCE

Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

The Influence of Exercise on Perceived Pain and Disability in Patients With Lumbar Spinal Stenosis: A Systematic Review of Randomized Controlled Trials

Lumbar spinal stenosis (LSS) is an increasingly prevalent condition that has major health and economic implications. While there are many options for the treatment of LSS, exercise is widely considered a first-line intervention as it is associated with reduced complications and cost as compared to more invasive options. Currently, it is not clear if exercise is an effective approach to managing pain and perceived disability in patients with symptomatic LSS. Therefore, the purpose of this systematic review is to evaluate the published literature that has investigated exercise as a primary intervention for LSS. A search was conducted in electronic databases including PubMed, PEDro, SPORTDiscus, CINAHL, and AMED using the key words lumbar spinal stenosis, exercise, physical therapy, rehabilitation, and conservative treatment. Inclusion criteria consisted of published randomized controlled trials written in English that included exercise as the primary treatment in at least one of the groups, and had reported measures of pain and disability clearly stated. The search identified 310 studies of which 5 met all the inclusion parameters. Exercise appears to be an efficacious intervention for pain, disability, analgesic intake, depression, anger, and mood disturbance among patients with LSS. Further research is needed to determine which type of exercise is the most effective in managing symptoms associated with lumbar spinal stenosis.

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.

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.

Does anterior trunk pain predict a different course of recovery in chronic low back pain?

Patient characteristics associated with the course and severity of low back pain (LBP) and disability have been the focus of extensive research, however, known characteristics do not explain much of the variance in outcomes. The relationship between anterior trunk pain (ATP) and LBP has not been explored, though mechanisms for visceral referred pain have been described. Study objectives were: (1) determine prevalence of ATP in chronic LBP patients, (2) determine whether ATP is associated with increased pain and disability in these patients, and (3) evaluate whether ATP predicts the course of pain and disability in these patients. In this study, spinal outpatient department patients mapped the distribution of their pain and patients describing pain in their chest, abdomen or groin were classified with ATP. Generalized estimating equations were performed to investigate the relationship between ATP and LBP outcomes. A total of 2974 patients were included and 19.6% of patients reported ATP. At all time points, there were significant differences in absolute pain intensity and disability in those with ATP compared with those without. The presence of ATP did not affect the clinical course of LBP outcomes. The results of this study suggest that patients who present with LBP and ATP have higher pain and disability levels than patients with localised LBP. Visceral referred pain mechanisms may help to explain some of this difference.

The influence of pain sensitivity on the treatment outcome of transforaminal epidural steroid injection in patients with lumbar spinal stenosis

The aim of this study was to investigate the effect of individual pain sensitivity on the results of transforaminal epidural steroid injection (TFESI) for the patients with lumbar spinal stenosis (LSS). Seventy-seven patients with LSS were included in this study. Prospectively planned evaluations were performed twice consecutively before and 2 months after TFESI. These included a detailed medical history, a physical examination, and completion of a series of questionnaires, including pain sensitivity questionnaire (PSQ), Oswestry disability index (ODI), and visual analog scale (VAS) for back and leg pain. The correlations were analyzed among variables between total PSQ/PSQ-moderate/PSQ-minor and pain and disability level measured by VAS for back/leg pain and ODI both before and 2 months after TFESI. Two months after TFESI, there were significant decreases in VAS for back/leg pain and ODI compared with those before injection. Before injection, VAS for back pain and leg pain was highly associated with the PSQ scores including total PSQ and PSQ subscores after adjustment for age, BMI, and grade of canal stenosis. However, any subscores of PSQ and total PSQ scores were not correlated with either VAS for back pain/leg pain or ODI 2 months after TFESI with adjustment made to age, BMI, gender, and grade of canal stenosis. This study highlights that individual pain sensitivity does not influence the outcomes of TFESI treatment in patients with LSS, even though pain sensitivity has a significant negative correlation with symptom severity of LSS.