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Mahmoud AM, Shawky MA, Farghaly OS, Botros JM, Alsaeid MA, Ragab SG. A systematic review and network meta-analysis comparing different epidural steroid injection approaches. Pain Pract 2024; 24:341-363. [PMID: 37700550 DOI: 10.1111/papr.13297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/31/2023] [Accepted: 08/23/2023] [Indexed: 09/14/2023]
Abstract
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.
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Affiliation(s)
- Atef Mohamed Mahmoud
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Fayoum University, Faiyum, Egypt
| | - Mohamed Ahmed Shawky
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Fayoum University, Faiyum, Egypt
| | - Omer Sayed Farghaly
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Fayoum University, Faiyum, Egypt
| | - Joseph Makram Botros
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Fayoum University, Faiyum, Egypt
| | - Mohamed Awad Alsaeid
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Fayoum University, Faiyum, Egypt
| | - Safaa Gaber Ragab
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Fayoum University, Faiyum, Egypt
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Shamov T, Al-Hashel JY, Rоusseff RT. Fluoroscopic Epidural Steroid Injection: Pain Relief in Discogenic Sciatica Versus Lumbar Spinal Stenosis. A Study on Middle Eastern Patients. ACTA MEDICA (HRADEC KRÁLOVÉ) 2020; 63:73-78. [PMID: 32771072 DOI: 10.14712/18059694.2020.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To compare the effect of epidural steroid injections (ESI) in patients with discogenic sciatica (Sci) versus patients with lumbar canal stenosis (LSS), not controlled by conservative treatment. MATERIALS AND METHODS In our study, 80 patients with Sci and 66 with LSS were included. A single ESI (10 mg dexamethasone in 3 cc 0.25% bupivacaine) was applied under fluoroscopic control: one level above the highest stenotic level, in the posterior epidural space, via interlaminar approach in LSS and at the prolapse level, in the anterior epidural space, via transforaminal route in Sci. Pain intensity was assessed by VAS at baseline and on days 1, 15 and 30 after intervention. RESULTS The procedure was successful in 78 Sci and 63 LSS patients. Patients with Sci responded significantly better. At one month, pain reduction over 50% was achieved in 63% (52.3-73.7% at p = 0.95) of Sci but only in 35% (23.2-46.8%) of LSS (p = 0.03). Return to pre-intervention level happened in 47% (34.7-59.3%) of LSS versus 14% (6.3-21.7%) of Sci patients (p = 0.01). In 5 patients the procedure failed, without resulting morbidity. CONCLUSION ESI are more effective in patients with Sci than in single level LSS. In multiple level LSS, results are disappointing.
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Affiliation(s)
- Todor Shamov
- Armed Forces Hospital "Jaber Al-Ahmad Al-Sabah", Subhan, 46012, Kuwait.,Department of Neurosurgery, Military Medical Academy, St Georgi Sofijski Str 3, 1606, Sofia, Bulgaria
| | - Jasem Y Al-Hashel
- Department of Neurology, Ibn-Sina Hospital, Sabah Health Area, Safat 13115, Kuwait
| | - Rossen T Rоusseff
- Department of Neurology, Ibn-Sina Hospital, Sabah Health Area, Safat 13115, Kuwait.
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Smith CC, McCormick ZL, Mattie R, MacVicar J, Duszynski B, Stojanovic MP. The Effectiveness of Lumbar Transforaminal Injection of Steroid for the Treatment of Radicular Pain: A Comprehensive Review of the Published Data. PAIN MEDICINE 2019; 21:472-487. [DOI: 10.1093/pm/pnz160] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Abstract
Objective
To determine the effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain.
Design
Comprehensive systematic review.
Outcome Measures
The primary outcome of interest was the proportion of individuals with reduction of pain by ≥50%. Additional outcomes of interest were a more-than-two-point reduction in pain score, patient satisfaction, functional improvement, decreased use of pain medication, and avoidance of spinal surgery.
Results
For patients with disc herniations, using the criterion of ≥50% reduction in pain, success rates across included studies (range) were 63% (58–68%) at one month, 74% (68–80%) at three months, 64% (59–69%) at six months, and 64% (57–71%) at one year. For patients with lumbar spinal stenosis, success rates across included studies (range) were 49% (43–55%) at one month, 48% (35–61%) at three months, 43% (33–53%) at six months, and 59% (45–73%) at one year, but there was a lack of corroboration from appropriately controlled studies.
Conclusions
There is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. There is a lack of high-quality evidence demonstrating their effectiveness for the treatment of radicular pain due to spinal stenosis, though small studies suggest a possible benefit. Lumbar transforaminal injection of nonparticulate steroids is as effective as injections with particulate steroids.
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Affiliation(s)
- Clark C Smith
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ryan Mattie
- Providence Cedars-Sinai Tarzana Hospital, Providence Specialty Medical Group, Comprehensive Spine & Interventional Pain Management, Tarzana, California
| | | | | | - Milan P Stojanovic
- Anesthesiology, Critical Care and Pain Medicine Service, VA Boston Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
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Long-term comparative study between transforaminal and interlaminar epidural injection of steroids in lumbar radiculopathy due to single-level disc herniation. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sharma AK, Vorobeychik Y, Wasserman R, Jameson J, Moradian M, Duszynski B, Kennedy DJ. The Effectiveness and Risks of Fluoroscopically Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data. PAIN MEDICINE 2017; 18:239-251. [PMID: 28204730 DOI: 10.1093/pm/pnw131] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective To determine the effectiveness and risks of fluoroscopically guided lumbar interlaminar epidural steroid injections. Design Systematic review of the literature with comprehensive analysis of the published data. Interventions Three reviewers with formal training in evidence-based medicine searched the literature on fluoroscopically guided lumbar interlaminar epidural steroid injections. A larger team consisting of five reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented. Outcome Measures The primary outcome assessed was pain relief. Other outcomes such as functional improvement, reduction in surgery rate, decreased use of opioids/medications, and complications were noted, if reported. The evidence on each outcome was appraised in accordance with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system of evaluating evidence. Results The search yielded 71 primary publications addressing fluoroscopically guided lumbar interlaminar epidural steroid injections. There were no explanatory studies and all pragmatic studies identified were of low quality, yielding evidence comparable to observational studies. Conclusions The body of evidence regarding effectiveness of fluoroscopically guided interlaminar epidural steroid injection is of low quality according to GRADE. Studies suggest a lack of effectiveness of fluoroscopically guided lumbar interlaminar epidural steroid injections in treating primarily axial pain regardless of etiology. Most studies on radicular pain due to lumbar disc herniation and stenosis do, however, report statistically significant short-term improvement in pain.
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Affiliation(s)
- Anil K Sharma
- Spine and Pain Centers, Shrewsbury, New Jersey, NJ, USA
| | - Yakov Vorobeychik
- Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Ronald Wasserman
- Back and Pain Center, University of Michigan, Ann Arbor, Michigan, MI, USA
| | | | | | | | - David J Kennedy
- Department of Orthopedics, Stanford University, Redwood City, California, USA
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Park HS, Son YR, Choi KH. Differences of Therapeutic Responses to Epidural Steroid Injection in Elderly Patients With Radiculopathy. Ann Geriatr Med Res 2016. [DOI: 10.4235/agmr.2016.20.3.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Hyun Sik Park
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yu Ri Son
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung Hyo Choi
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Bhatti AB, Kim S. Role of Epidural Injections to Prevent Surgical Intervention in Patients with Chronic Sciatica: A Systematic Review and Meta-Analysis. Cureus 2016; 8:e723. [PMID: 27625909 PMCID: PMC5010373 DOI: 10.7759/cureus.723] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Objective: The aim of this study is to evaluate the efficacy of the different types of epidural injections (EI) to prevent surgical intervention in patients suffering from chronic sciatica due to lumbar disc herniation (LDH). Material and Methods: Studies were identified by searching PubMed, MEDLINE, and Google Scholar to retrieve all available relevant articles. Lists of references of several systematic reviews were also used for scanning further references. Publications from the past ten years (2006-2016) were considered, and all studies selected were in the English language only. The studies employed specified the use of EI to treat sciatica caused by LDH. A total of 19 papers meeting the eligibility criteria (mentioned below) were included in this study. The pain scores, functional disability scores, and surgical rates from these studies were considered, and meta-analysis was performed. Outcome measures: Pain scores, functional disability scores, and surgical rates were assessed from the included studies. The Numeric Rating Scale (NRS) and Visual Analogue Scale (VAS) have been the most commonly used baseline scales for pain evaluation followed by the Verbal Numerical Rating Scale (VNRS) and Japanese Orthopedic Association (JOA). The Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ) scales were used for the functional disability scoring system in the literature. Results: Significant improvement in the pain scores and functional disability scores were observed. Additionally, greater than 80% of the patients suffering from chronic sciatica caused by LDH could successfully prevent surgical intervention after EI treatment with or without steroids. Conclusion: The management of sciatica with EI treatment results in significant improvements in the pain score, functional disability score, and surgical rate. We concluded that EI provides new hope to prevent surgical intervention in patients suffering from sciatica caused by LDH.
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Affiliation(s)
- Adnan Bashir Bhatti
- Medical Director of Clinical Research, Spine Surgery, Tristate Brain and Spine Institute
| | - Sunny Kim
- Spine Surgery, Tristate Brain and Spine Institute
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Comparison of transforaminal verse interlaminar epidural steroid injection in low back pain with lumbosacral radicular pain: a meta-analysis of the literature. INTERNATIONAL ORTHOPAEDICS 2016; 40:2533-2545. [DOI: 10.1007/s00264-016-3220-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 04/28/2016] [Indexed: 12/15/2022]
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Sari S, Aydın ON, Tasdemir B, Galimberti F, Turan A. Effect of statin use on pain relief by transforaminal epidural steroid injection. J Int Med Res 2016; 44:389-94. [PMID: 26912508 PMCID: PMC5580055 DOI: 10.1177/0300060515597934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 07/06/2015] [Indexed: 11/17/2022] Open
Abstract
Aim To investigate the impact of statin use on response to fluoroscopy-assisted transforaminal anterior epidural steroid injection (TAESI). Methods Patients undergoing TAESI for low back pain were recruited and stratified according to statin use. Pain was evaluated with a visual analogue scale (VAS) before and at 1, 3, and 6 months after TAESI. Health-related quality-of-life was evaluated using the Short Form 36 (SF-36) questionnaire 6 months after TAESI. Results There were no significant differences in VAS scores after TAESI between statin users (n = 40) and statin nonusers (n = 253). The SF-36 subgroup: role limitations due to emotional problems score was significantly lower in statin users than statin nonusers. There were no significant between-group differences in any other SF-36 parameter. Conclusion Statin use had no effect on pain scores after TAESI.
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Affiliation(s)
- Sinem Sari
- Department of Anaesthesia and Reanimation, Adnan Menderes University Medical Faculty, Aydin, Turkey
| | - Osman Nuri Aydın
- Department of Algology, Adnan Menderes University, Aydin, Turkey
| | - Banu Tasdemir
- Department of Anaesthesia and Reanimation, Adnan Menderes University Medical Faculty, Aydin, Turkey
| | | | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
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