Epidural Steroid Injections for Low Back Pain: A Narrative Review

The Impact of Preoperative Spinal Injection Timing on the Postoperative Complications of Lumbar Fusion

OBJECTIVE

To determine the impact of epidural spinal injections (ESIs) on postoperative surgical complications.

METHODS

This retrospective all-payer database analysis identified 202,181 adult patients undergoing one- to three-level transforaminal lumbar interbody fusion (TLIF) from 2010 to 2020. A 1:1 exact matching on comorbidities and demographics was performed, creating 2 cohorts: 1) patients who received an ESI within 90 days of surgery and 2) patients who did not receive an ESI. The primary outcome was surgical complication rates between groups at 30 days postoperatively. For the secondary outcome, patients were stratified based on injection time before surgery: 1-30, 31-45, 46-60, 61-75, and 76-90 days. Logistic regression was performed between groups to identify temporal associations of complication rates. The P value was set to 0.05 for the primary analysis, and the Bonferroni correction was utilized for the secondary outcome.

RESULTS

Exact matching produced 12,491 pairs for analysis. Groups were well-matched on demographics, comorbidities, and fusion levels. The 30-day postoperative rates of surgical complications, hematomas, wound disruptions, or surgical site infections did not differ between groups (P > 0.05). The rate of cerebrospinal fluid (CSF) leak was increased in the ESI group (0.19% vs. 0.09%, P = 0.042). When temporally stratified, patients receiving an ESI within 30 days had significantly higher odds of CSF leak (odds ratio: 4.24, 95% confidence interval: 1.97-9.14).

CONCLUSIONS

Patients who receive an ESI within 30 days of transforaminal lumbar interbody fusion are at an increased risk for CSF leak. While the incidence of CSF leak remains small, it may be advisable to avoid ESIs at least 30 days before surgery for certain patients.

Effectiveness of Hybrid Form Impulse Therapy (HFIT) Compared to Traditional Transcutaneous Electronic Nerve Stimulation (TENS) in Patients with Chronic Low Back and Knee Pain: A Randomized Controlled Trial

Purpose

Physical therapy (PT) and conservative care are recommended first-line treatments for musculoskeletal (MSK) pain. While essential to high-quality care, these solutions often do not provide immediate or sufficient pain relief. Traditional transcutaneous electronic nerve stimulation (TENS) devices are often recommended; however, there is mixed evidence behind their effectiveness. A novel approach called hybrid form impulse therapy (HFIT) incorporates a priming pulse with a traditional TENS pulse width and frequency. This randomized controlled trial (RCT) aimed to compare the effectiveness of HFIT versus traditional TENS versus usual care among members of a digital MSK program.

Patients and Methods

A three-arm RCT comparing HFIT versus TENS versus usual care was conducted. A total of 325 people with chronic back or knee pain who were members of a digital MSK program consisting of PT-guided exercise therapy, education, and coaching were randomized. Outcomes including pain, function, anxiety, and depression were examined at 1, 2, and 4 weeks (primary endpoint). Engagement was measured through exercise therapy (ET) sessions completed. Unadjusted and adjusted logistic generalized estimating equations were conducted.

Results

Adjusted per-protocol results at 4 weeks showed significantly lower odds of achieving pain improvement for both TENS (OR: 0.42, 95% CI: [0.19, 0.92]) and usual care (OR: 0.35, 95% CI: [0.17, 0.72]) groups, compared to HFIT group. Both HFIT and usual care users had significantly higher engagement than the TENS users (p=0.026 and p=0.002, respectively). No adverse events were reported throughout the study.

Conclusion

More participants of a digital MSK program who were randomized to the HFIT group experienced meaningful pain improvement at 4 weeks than participants who used TENS and usual care. HFIT can be an effective, non-pharmaceutical solution for relief as a complement to first-line treatments for patients with chronic back and knee pain.

Intrathecal dexamethasone as an adjuvant for spinal anesthesia: a systematic review

INTRODUCTION

Spinal anesthesia is a common anesthetic technique for lower limb and abdominal surgery. Despite its efficacy, its use is limited because of its duration and potential severe side effects, especially in high-risk patients undergoing major surgery. Adjuvants such as dexamethasone offer the potential to prolong the anesthetic effect and reduce the need for local anesthetics while reducing the incidence of serious adverse events. The purpose of this systematic review is to evaluate the efficacy of dexamethasone as an intrathecal adjuvant in prolonging anesthetic duration, delaying pain onset, and minimizing adverse events (PROSPERO registration: CRD42022350218).

EVIDENCE ACQUISITION

We included randomized controlled trials conducted in adult patients undergoing spinal anesthesia for lower limb or abdominal surgery and comparing the performance of dexamethasone with alternative spinal treatments. A comprehensive systematic search was conducted on PubMed/MEDLINE, Scopus, CINAHL, EMBASE, CENTRAL, and Cochrane Library from February to June 2023 without language restriction. Risk of bias was assessed using the Cochrane Risk of Bias Tool (RoB2).

EVIDENCE SYNTHESIS

Ten studies, nine of which were at high risk of bias, were included (N.=685 patients). Overall, intrathecal dexamethasone was associated with a longer duration of sensory block, improvement in the duration or extent of postoperative analgesia, and significant shortening of block onset. The role of dexamethasone in prolonging motor block was not clear. The incidence of adverse events was low. Intrathecal dexamethasone has been shown to be a potentially valuable adjuvant to prolong the duration of sensory block and improve postoperative analgesia without increasing adverse events.

CONCLUSIONS

Given the wide heterogeneity of methodological approaches, further investigation is needed. Considering the limitations of the included studies and awaiting more conclusive evidence, the prudent use of dexamethasone could be recommended in those specific situations where general anesthesia or higher local anesthetics should be avoided.

Lumbar epidural steroid injection for spasticity in paraplegic spinal cord injury: A case report

This is the case of a 33-year-old male with traumatic paraplegic lumbar spinal cord injury after knife assault, who was unable to participate in an intensive inpatient rehabilitation course due to bilateral lower limb spasticity. For therapeutic management of spasticity at the bedside in the inpatient rehabilitation setting, we performed an epidural steroid injection to the right L4-L5 interspace. After the intervention, a significant decrease in spasticity was noted. The patient could subsequently tolerate sit-to-stand transfers with a standing frame and ambulate with the an exoskeleton device in inpatient physical therapy, significantly improving his overall functional level in therapies. This case demonstrates that bedside epidural steroid injection can dramatically improve paraplegic spasticity secondary to lumbar spinal cord injury in the inpatient rehabilitation setting.

Efficacy of epidural steroid injection in the treatment of sciatica secondary to lumbar disc herniation: a systematic review and meta-analysis

Epidural steroid injection for the treatment of sciatica caused by disc herniation is increasingly used worldwide, but its effectiveness remains controversial. The review aiming to analyze the efficacy of epidural steroid injection on sciatica caused by lumbar disc herniation. Randomized controlled trials (RCTs) investigating the use of epidural steroid injections in the management of sciatica induced by lumbar disc herniation were collected from PubMed and other databases from January, 2008 to December, 2023, with epidural steroid injection in the test group and epidural local anesthetic and/or placebo in the control group. Pain relief rate, assessed by numerical rating scale (NRS) and visual analogue scale (VAS) scores, and function recovery, evaluated by Roland Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI) scores, were recorded and compared. Meta-analysis was performed by Review Manager. In comparison to the control group, epidural steroid injections have been shown to be effective for providing short- (within 3 months) [MD = 0.44, 95%CI (0.20, 0.68), p = 0.0003] and medium-term (within 6 months) [MD = 0.66, 95%CI (0.09,1.22), p = 0.02] pain relief for sciatica caused by lumbar disc herniation, while its long-term pain-relief effect were limited. However, the administration of epidural steroid injections did not lead to a significant improvement on sciatic nerve function in short- [MD = 0.79, 95%CI = (0.39, 1.98), p = 0.19] and long-term [MD = 0.47, 95% CI = (-0.86, 1.80), p = 0.49] assessed by IOD. Furthermore, the analysis revealed that administering epidural steroid injections resulted in a reduction in opioid usage among patients with lumbar disc herniation [MD = -14.45, 95% CI = (-24.61, -4.29), p = 0.005]. The incidence of epidural steroid injection was low. Epidural steroid injection has demonstrated notable efficacy in relieving sciatica caused by lumbar disc herniation in short to medium-term. Therefore, it is recommended as a viable treatment option for individuals suffering from sciatica.

Repeated epidural delivery of Shinbaro2: effects on neural recovery, inflammation, and pain modulation in a rat model of lumbar spinal stenosis

The choice of treatment for lumbar spinal stenosis (LSS) depends on symptom severity. When severe motor issues with urinary dysfunction are not present, conservative treatment is often considered to be the priority. One such conservative treatment is epidural injection, which is effective in alleviating inflammation and the pain caused by LSS-affected nerves. In this study, Shinbaro2 (Sh2), pharmacopuncture using natural herbal medicines for patients with disc diseases, is introduced as an epidural to treat LSS in a rat model. The treatment of primary sensory neurons from the rats' dorsal root ganglion (DRG) neurons with Sh2 at various concentrations (0.5, 1, and 2 mg/mL) was found to be safe and non-toxic. Furthermore, it remarkably stimulated axonal outgrowth even under H2O2-treated conditions, indicating its potential for stimulating nerve regeneration. When LSS rats received epidural injections of two different concentrations of Sh2 (1 and 2 mg/kg) once daily for 4 weeks, a significant reduction was seen in ED1+ macrophages surrounding the silicone block used for LSS induction. Moreover, epidural injection of Sh2 in the DRG led to a significant suppression of pain-related factors. Notably, Sh2 treatment resulted in improved locomotor recovery, as evaluated by the Basso, Beattie, and Bresnahan scale and the horizontal ladder test. Additionally, hind paw hypersensitivity, assessed using the Von Frey test, was reduced, and normal gait was restored. Our findings demonstrate that epidural Sh2 injection not only reduced inflammation but also improved locomotor function and pain in LSS model rats. Thus, Sh2 delivery via epidural injection has potential as an effective treatment option for LSS.

Mineralocorticoid Receptor Antagonism Reduces Inflammatory Pain Measures in Mice Independent of the Receptors on Sensory Neurons

Corticosteroids are commonly used in the treatment of inflammatory low back pain, and their nominal target is the glucocorticoid receptor (GR) to relieve inflammation. They can also have similar potency at the mineralocorticoid receptor (MR). The MR has been shown to be widespread in rodent and human dorsal root ganglia (DRG) neurons and non-neuronal cells, and when MR antagonists are administered during a variety of inflammatory pain models in rats, pain measures are reduced. In this study we selectively knockout (KO) the MR in sensory neurons to determine the role of MR in sensory neurons of the mouse DRG in pain measures as MR antagonism during the local inflammation of the DRG (LID) pain model. We found that MR antagonism using eplerenone reduced evoked mechanical hypersensitivity during LID, but MR KO in paw-innervating sensory neurons only did not. This could be a result of differences between prolonged (MR KO) versus acute (drug) MR block or an indicator that non-neuronal cells in the DRG are driving the effect of MR antagonists. MR KO unmyelinated C neurons are more excitable under normal and inflamed conditions, while MR KO does not affect excitability of myelinated A cells. MR KO in sensory neurons causes a reduction in overall GR mRNA but is protective against reduction of the anti-inflammatory GRα isoform during LID. These effects of MR KO in sensory neurons expanded our understanding of MR's functional role in different neuronal subtypes (A and C neurons), and its interactions with the GR.

A systematic review and network meta-analysis comparing different epidural steroid injection approaches

BACKGROUND

Low back pain (LBP) and lumbosacral radiculopathy are frequent disorders that cause nerve root injury, resulting in a variety of symptoms ranging from loss of sensation to loss of motor function depending on the degree of nerve compression.

OBJECTIVES

The goal of this study was to investigate the effectiveness of various epidural injection procedures in adult LBP patients.

STUDY DESIGN

Systematic review and network meta-analysis.

SETTING

Egypt.

METHODS

PubMed, Scopus, Web of Science, Cochrane Database, and Embase were used to conduct an electronic literature search. We included RCTs, cohorts, case controls, patients 30 years old with a clinical presentation of low back pain, and comprehensive data on the effects of the intervention on patients with lumbosacral radicular pain who got epidural steroid injections via various techniques. Only papers written in English were eligible.

RESULTS

Our analysis showed that parasagittal intralaminar (PIL) was the most effective approach in decreasing VAS (0-10) in the short term (< 6 months) (MD = -1.16 [95% CI -2.04, -0.28]). The next significant approach was transforaminal (TF) (MD = -0.37 [95% CI -1.14, -0.32]) in the long term; TF was the most effective approach (MD = -0.56 [95% CI -1, -0.13]). According to VAS (0-100) in the short term (< 6 months), our analysis showed an insignificant difference among the injection approaches and in the long term; TF was the most effective approach (MD = -24.20 [95% CI -43.80, -4.60]) and the next significant approach was PIL (MD = -23.89 [95% CI -45.78, -1.99]).

LIMITATIONS

The main limitations are the heterogeneity encountered in some of our analyses in addition to studies assessed as high risk of bias in some domains.

CONCLUSION

TF was the most effective steroid injection approach. In decreasing VAS for short-term PIL and TF were the most significant approaches, but TF was the most effective approach in decreasing VAS for the long term. Also, TF was the most effective approach in decreasing ODI for the long term.

Parasagittal Interlaminar and Transforaminal Epidural Steroid Injections for Radicular Low Back Pain; Which is More Comfortable?

Objective

This study aimed to compare parasagittal interlaminar (PS) and transforaminal (TF) epidural steroid injections for unilateral L5 and S1 radicular lower back pain in terms of patient comfort, efficacy, safety, contrast enhancement, and radiation exposure.

Methods

This was a prospective randomized single-blind study. A total of 59 participants were included in this study. The visual analog scale (VAS) and Oswestry Disability Index (ODI) were obtained. A comfort questionnaire was administered to all participants. The total fluoroscopy time and contrast distribution levels were recorded.

Results

Pre- and post-treatment VAS scores were similar between the groups. The ODI scores increased in favor of the PS group at week 2 (P < 0.041); however, there was no difference between the two groups at other times. The VAS and ODI scores improved significantly with treatment in both the groups (P < 0.001). Total fluoroscopy time was shorter in the PS group (P < 0.001). PS application was more comfortable (P < 0.001). While no complications were observed in the PS group, three complications occurred in the TF group. Anterior epidural contrast spread to three or more levels was observed in 57% of the participants in the PS group, whereas no spread to more than two levels was observed in the TF group.

Conclusion

The PS epidural approach is superior to the TF approach in terms of a low incidence of side effects, less radiation exposure, better patient comfort, higher epidural contrast spread, and single-level needle access.

Epidural Injection Method for Long-Term Pain Management in Rats with Spinal Stenosis

Epidural injection is one of the most common nonsurgical treatment options for long-term pain relief in lumbar spinal stenosis. Recently, various nerve block injections have been used for pain management. Among them, nerve block through epidural injection is a safe and effective method for the clinical treatment of low back or lower extremity pain. Although the epidural injection method has a long history, the effectiveness of long-term epidural injections in disc diseases has not been scientifically proven. In particular, to verify the safety and efficacy of drugs in preclinical studies, the route and method of drug administration in terms of the clinical application method and duration of use must be established. However, there is no standardized method for long-term epidural injections in a rat model of stenosis to identify the precise efficacy and safety of epidural injections. Therefore, standardizing the epidural injection method is very important for evaluating the efficacy and safety of drugs used for back or lower extremity pain. We describe the first standardized long-term epidural injection method for evaluating the efficacy and safety of drugs according to their route of administration in rats with lumbar spinal stenosis.

Effectiveness of Epidural Steroid Injection Depending on Discoradicular Contact: A Prospective Randomized Trial

Lumbar radicular pain is a major public health and economic problem. It is among the most common reasons for professional disability. The most common cause of lumbar radicular pain is intervertebral disc herniation, which results from degenerative disc changes. The dominant pain mechanisms are direct pressure of the hernia on the nerve root and the local inflammatory process triggered by intervertebral disc herniation. Treatment of lumbar radicular pain includes conservative, minimally invasive, and surgical treatment. The number of minimally invasive procedures is constantly increasing, and among these methods is epidural administration of steroids and local anesthetic through a transforaminal approach (ESI TF). The aim of this research was to examine the effectiveness of ESI TF as measured by a visual analog scale (VAS) and the Oswestry Disability Index (ODI), depending on whether there is contact between the herniated intervertebral disc and the nerve root. In both groups of participants, there was a significant reduction in pain intensity, but there was no significant difference between the groups. In the group with disc herniation and nerve root contact, the only significant reduction was in pain intensity (p < 0.001). There were no significant differences in measurements in other domains of the ODI. In the group without disc herniation and nerve contact, there was a significant difference in all domains except weight lifting. In the group without contact, there was significant improvement after 1 month (p = 0.001) and 3 months (p < 0.001) according to the ODI, while there was no significant improvement in the group with contact. In addition, there were no significant differences in the distribution of participants based on the ODI and whether disc herniation and nerve contact was present. The results suggest that transforaminal epidural administration of steroids is a clinically effective method for treating lumbar radicular pain caused by intervertebral disc herniation in people with and without nerve root contact, without significant differences.

The Benefit of Early Epidural Corticosteroid Injections for Acute Sciatica-Associated Lower Back Pain: A Four-Year Case Series in Lebanon

Background Early epidural steroid injections are currently widely used for patients experiencing lumbago. However, there is uncertainty about their efficacy, such as the limitation of continuous drug infusion and the need for well-trained physicians on this technique. The main objective of this study was to evaluate the effectiveness of early epidural steroid injections in treating patients with acute sciatica in the lower back in terms of symptom relief and recurrence rate. Methods A case series was conducted in Lebanon from 2015 to 2019. We recruited 98 patients suffering from sciatica due to disc disease over three-time intervals: two weeks, one, and three months. The immediate results accounted for the intensity of various symptoms (numerical rating scale (NRS) for pain) and the assessment of patient satisfaction (Macnab criteria). Results The clinical results showed at least a three-point pain relief according to Numerical Rating Scale (NRS) and a good grade according to MacNab (P <0.001), with only 10.4% of the total population having a positive leg raise test post-injection. The maximum benefit was noted after two weeks from the injection with a 5.7 mean change in NRS (p<0.001) with a good/excellent response in MacNab and a 4.9 change with only a good response after one month. This study noticed a rebound phenomenon where around half of the patients needed two steroid injections after three months (39.6 % after three months and 17.9 % after six months). Conclusion Even though current guidelines worldwide may suggest the use of conservative treatment for low back pain with acute sciatica, our study has demonstrated the effectiveness of epidural steroid injections in the Lebanese population with a significant outcome.

Transforaminal Epidural Steroid Injection for Patients with Lumbosacral Disc Herniation in the Absence of Spine Magnetic Resonance Imaging - Is Better Really the Enemy of the Best?

Purpose

This study aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) in patients with lumbosacral disc herniation by comparing its effect between those diagnosed by clinical evaluation and plain radiography only (X-ray group) and those by additional magnetic resonance imaging (MRI) (MRI group). Additionally, we investigated the accuracy of the preliminary clinical assumption in the X-ray group using confirmative post-injection MRI.

Patients and Methods

We retrospectively recruited 367 patients with back and radicular pain due to lumbosacral disc herniation from a single pain clinic. Among them, 201 and 166 patients were categorized into the X-ray and MRI groups, respectively. In the X-ray group, the pathological level assumed initially by clinical evaluation and plain radiography concurred with that confirmed later on post-injection MRI in 139 patients (corresponding group); the remaining 62 patients lacked this concurrence (non-corresponding group). The NRS scores and Macnab criteria results were compared between the X-ray and MRI groups as well as the corresponding and non-corresponding groups.

Results

Both the X-ray and MRI groups showed significant reductions in the NRS scores at 2 and 10 weeks post-injection when compared with the pretreatment scores. However, no significant difference was noted between the groups in terms of the magnitude of clinical improvement assessed by successful reduction in the NRS or Macnab scores. Furthermore, similar results were obtained in the comparison between the corresponding and non-corresponding groups of the X-ray group.

Conclusion

TFESI guarantees favorable clinical outcomes even in the absence of confirmative MRI in patients with back and radicular pain. The preemptive application of this procedure could be prioritized and justified in patients suspected of lumbosacral disc herniation based on clinical evaluation and plain radiography only without the preceding MRI verification.

The Effectiveness of Facet Joint Injection with Steroid and Botulinum Toxin in Severe Lumbar Central Spinal Stenosis: A Randomized Controlled Trial

Lumbar central spinal stenosis (LCSS) is a common disorder that causes disability and pain in the elderly. It causes pain in the radicular leg. Recently, transforaminal epidural steroid injection (TFESI) has been widely used to control radicular leg pain caused by LCSS. However, in cases of severe LCSS, drugs injected using TFESI cannot spread into the spinal canal and would have less therapeutic effects than in mild LCSS. To compensate for this limitation of TFESI, we injected steroids and botulinum toxin type A into the bilateral facet joints, evaluated their effects, and compared them with those of TFESI. One hundred patients with severe LCSS were included in the study and randomly allocated to either the facet injection (FI) or TFESI group. For 50 patients in the FI group, 30 mg (40 mg/mL) of triamcinolone with 50 IU of botulinum toxin type A mixed with a 1 mL solution of 100 mL of 50% dextrose water and 30 mL of 4% lidocaine were administered into the bilateral facet joints under fluoroscopy. For 50 patients in the TFESI group, 30 mg (40 mg/mL) of triamcinolone with 0.8 mL of 2% lidocaine and 2.5 mL of 50% dextrose water was injected bilaterally under fluoroscopy. Radicular leg pain (measured with a numeric rating scale) and pain-related disability (measured with the modified Oswestry Disability Index) due to severe LCSS were significantly reduced after facet joint injection. The therapeutic effects were greater after facet joint injection than after bilateral TFESI. The injection of a mixed solution of steroids and botulinum toxin type A into the bilateral facet joints would be a beneficial therapeutic option in patients with severe LCSS.

Analgesic effect of epidural anesthesia via the intervertebral foramen approach in percutaneous transforaminal endoscopic discectomy: a retrospective study

BACKGROUND

Satisfactory intraoperative analgesia is critical for percutaneous transforaminal endoscopic discectomy (PTED). Local anesthesia (LA) and epidural anesthesia (EA) are recommended for PTED. LA alone does not achieve satisfactory pain management during PTED and other analgesics or sedatives are usually needed. Traditional EA, which involves implanting an epidural catheter through the midline or paramedian, has disadvantages such as difficulty in catheterization and increased preoperative preparation time. Rather than performing conventional EA, we injected local anesthetics through the intervertebral foramen during the puncture process, which we termed lumbar transforaminal EA (LTEA), and observed its feasibility and safety. This study aimed to conduct a comprehensive comparison of differences in analgesia between LA and LTEA in patients with PTED.

METHODS

We performed a retrospective analysis of patients who underwent PTED between January 2018 and January 2021. Patients were divided into LA and LTEA groups. Data obtained from the electronic medical records included primary outcomes (visual analog scale [VAS] scores and anesthesia satisfaction rate) and secondary outcomes, including vital signs such as heart rate (HR), mean arterial pressure (MAP), total dosage of fentanyl, operation time, X-ray exposure time, Oswestry Disability Index (ODI) scores, and complications.

RESULTS

In total, 160 patients (80 in each group) were analyzed in this study. The VAS scores for lumbar and leg pain were significantly lower in the LTEA group than in the LA group (P < 0.0001). The anesthesia satisfaction rate was 90.0% in the LTEA group and 72.5% in the LA group (P < 0.005). MAP and HR values in the LTEA group were significantly lower than those in the LA group (P < 0.05). The total dose of fentanyl in the LTEA group was significantly lower than that in the LA group (P < 0.05). As for ODI values, the average operation time, X-ray exposure time, and incidence of complications were not significantly different between the two groups (P > 0.05).

CONCLUSIONS

LTEA simplifies the process of EA and can achieve a good analgesic effect intraoperatively without increasing the preoperative preparation time; thus, it may be adopted as an alternative mode of anesthesia during PTED surgery.

Non-Invasive Treatments for Failed Back Surgery Syndrome: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVES

The aim of this systematic review is to evaluate the efficacy of non-invasive procedures in relieving chronic pain due to Failed Back Surgery Syndrome (FBSS).

METHODS

Since patients who suffered from FBBS are often non-responders to analgesics, we compared Visual Analogical Scale for low back and leg pain, Oswestry Disability Index, trial success rate, adverse events and complications between conservative treatment groups and control groups.

RESULTS

The included studies were 15. Spinal Cord Stimulation (SCS) was performed in 11 trials; 4 studies assessed the efficacy of different epidural injections; one study evaluated repetitive Transcranial Magnetic Stimulation. All the studies reported back and leg pain relief after treatment with SCS, with a significant superiority in high frequences (HFS) group, compared to low frequences (LFS) group. Moreover, disability decreased with each non-invasive treatment evaluated. Epidural injections of steroids and hyaluronidase have shown controversial results. Adverse events were described in 7 studies: lead migration, hardware-related events, infection and incisional pain were the most reported. Finally, trial success rate showed better outcomes for HFS.

CONCLUSIONS

Our systematic review highlights the efficacy of conservative treatments in FBSS patients, with an improvement in pain scores and a decrease in disability index, especially after SCS with HFS. However, due to the lack of homogeneity among trials and population characteristics, further studies are needed to confirm the effectiveness of non-invasive interventions in patients affected by FBSS.

FBG-Based Soft System for Assisted Epidural Anesthesia: Design Optimization and Clinical Assessment

Fiber Bragg grating sensors (FBGs) are considered a valid sensing solution for a variety of medical applications. The last decade witnessed the exploitation of these sensors in applications ranging from minimally invasive surgery to biomechanics and monitoring physiological parameters. Recently, preliminary studies investigated the potential impact of FBGs in the management of epidural procedures by detecting when the needle reaches the epidural space with the loss of resistance (LOR) technique. In this article, we propose a soft and flexible FBG-based system capable of detecting the LOR, we optimized the solution by considering different designs and materials, and we assessed the feasibility of the optimized soft sensor (SS) in clinical settings. The proposed SS addresses some of the open challenges in the use of a sensing solution during epidural punctures: it has high sensitivity, it is non-invasive, the sensing element does not need to be inserted within the needle, and the clinician can follow the standard clinical practice. Our analysis highlights how the material and the design impact the system response, and thus its performance in this scenario. We also demonstrated the system’s feasibility of detecting the LOR during epidural procedures.