Efficacy of epidural neuroplasty versus transforaminal epidural steroid injection for the radiating pain caused by a herniated lumbar disc

Effectiveness of intradiscal ozone injections for treating pain following herniated lumbar disc: A systematic review and meta-analysis

BACKGROUND

Low back pain and sciatica caused by herniated lumbar discs (HLDs) are common complaints among patients visiting pain clinics. Among the various therapeutic methods, intradiscal ozone injections have emerged as an effective alternative or additional treatment option for HLDs.

OBJECTIVE

This meta-analysis aimed to investigate the effectiveness of intradiscal ozone injections in the treatment of HLDs.

METHODS

We searched the PubMed, Embase, Cochrane Library, and Scopus databases for relevant studies published until January 25, 2024. We included studies that investigated the efficacy of intradiscal ozone injections in patients with HLDs. We evaluated the methodological quality of individual studies using the Cochrane Collaboration tool.

RESULTS

At ⩾ 6 months after treatment, the therapeutic effect of intradiscal ozone injections in patients with HLDs was greater than that of steroid injections (treatment success rate, 6 months: odds ratio = 3.95, 95% confidence interval [CI] [2.44, 6.39], P< 0.01) or conventional medications (changes in the Visual Analog Scale [VAS], 6 months: standardized mean difference [SMD] = 1.65, 95% CI [1.08, 2.22], P< 0.01; 12 months: SMD = 1.52, 95% CI [0.96, 2.08], P< 0.01) but similar to that of microdiscectomy (changes in VAS, 18 months: SMD =-0.05, 95% CI [-0.67, 0.57], P= 0.87). At < 6 months after treatment, the reduction in the VAS score after intradiscal ozone injections was higher than that after steroid injections (changes in VAS, 1 month: SMD = 2.53, 95% CI [1.84, 3.21], P< 0.01).

CONCLUSION

Intradiscal ozone injections may be a useful therapeutic tool in patients with HLDs. Compared with other conventional treatment methods such as steroid injections and oral medications, intradiscal ozone injection has great long-term (⩾ 6 months) effectiveness.

Percutaneous epidural balloon neuroplasty: a narrative review of current evidence

Percutaneous epidural balloon neuroplasty (PEBN) can be used to perform balloon decompression combined with percutaneous epidural neuroplasty (PEN), leading to significant pain relief and functional improvement in patients with lumbar spinal stenosis. Several studies have demonstrated the effectiveness of PEBN and supported its relatively long-term outcomes (at least 6 months, sustained for up to 12 months). Balloon neuroplasty appears to be superior to conventional PEN. Moreover, it has been shown to be effective in patients unresponsive to conventional PEN or in those with post lumbar surgery syndrome. In addition, balloon neuroplasty achieved successful outcomes regardless of the approach used, such as retrodiscal, transforaminal, contralateral interlaminar, or caudal. Chronic lumbar radicular pain without back pain, neurogenic claudication, and minimal neuropathic component were favorable predictors of successful PEBN from a symptomatic perspective. A short duration of pain after lumbar surgery, lumbar foraminal stenosis caused primarily by degenerative disc, mild foraminal stenosis, and perineural adhesion by degenerative discs were associated with successful outcomes of PEBN from pathological aspects. Ballooning ≥ 50% of the target sites and complete contrast dispersion after ballooning seemed to be crucial for successful outcomes from a technical perspective. In addition, PEBN was effective regardless of the accompanying redundant nerve roots or a mild degree of spondylolisthesis. Studies on balloon neuroplasty have reported occasional minor and self-limiting complications; however, no PEBN-related significant complications have been reported. Given the present evidence, balloon neuroplasty appears to be a safe and effective procedure with minimal complications for the treatment of lumbar spinal stenosis.

The effect of additional transforaminal epidural blocks on percutaneous epidural neuroplasty with a wire-type catheter: A retrospective observational study

Percutaneous epidural neuroplasty (PEN) is an effective interventional treatment for radicular pain. However, in some cases, contrast runoff to the spinal nerve root does not occur. We investigated whether contrast runoff to the spinal nerve root affects the success rate of PEN and whether additional transforaminal epidural blocks for intentional contrast runoff affect the success rate of PEN in cases in which contrast runoff is absent.This study was registered at ClinicalTrials.gov (Identifier: NCT03867630) in March 2019. We reviewed the medical records of 112 patients who underwent PEN with a wire-type catheter from May 2016 to August 2018. Patients were divided in 3 groups (Runoff group, Non-runoff group, Transforaminal group).Patients with low back pain and leg radicular pain who did not respond to lumbar epidural steroid injectionsPEN was performed in 112 patients with a wire-type catheter in target segment. We compared the success rate of PEN betweenThe success rate was significantly different between the Runoff group and the Non-runoff group (P < .0007) and between the Non-runoff group and the Transforaminal group (P = .0047), but not between the Runoff group and the Transforaminal group (P = .57).Contrast runoff influenced the success rate of PEN. In cases without contrast runoff, additional transforaminal epidural blocks for intentional contrast runoff increased the success rate of PEN with a wire-type catheter.

Factors Associated with Successful Response to Balloon Decompressive Adhesiolysis Neuroplasty in Patients with Chronic Lumbar Foraminal Stenosis

Epidural neuroplasty, often called percutaneous epidural adhesiolysis, is often performed in refractory patients with chronic lumbar radiculopathy or neurogenic claudication. Recent studies have showed that decompressive adhesiolysis with an inflatable balloon catheter (balloon neuroplasty) is efficient in patients who experience refractory pain from epidural steroid injection or even epidural neuroplasty with a balloon-less catheter. However, exact indications or predictive factors for epidural balloon neuroplasty have not been fully evaluated. Therefore, to assess associated factors that could affect a favorable outcome, we analyzed a prospectively collected multicenter cohort of patients with chronic refractory lumbar foraminal stenosis after balloon neuroplasty. At the 6-month point in follow-up, 92 (44.4%) patients among 207 subjects were classified as successful responders according to a robust combination of outcome measures. Multivariate logistic regression analysis also showed that mild grade lumbar foraminal stenosis may be an independent factor associated with a successful response 6 months after balloon neuroplasty (odds ratio = 2.829; 95% confidence interval = 1.351–5.923; p = 0.006). However, we found that there were 29.4% and 24.6% successful responders with moderate and severe foraminal stenosis, respectively. Attempting balloon neuroplasty in refractory lumbar foraminal stenosis, especially mild grade, may be worthwhile.

Nonsurgical treatments for patients with radicular pain from lumbosacral disc herniation

BACKGROUND CONTEXT

Lumbosacral disc herniation (LDH) is one of the most frequent musculoskeletal diseases causative of sick leave in the workplace and morbidity in daily activities. Nonsurgical managements are considered as first line treatment before surgical treatment.

PURPOSE

This clinical practice guideline (CPG) is intended to provide physicians who treat patients diagnosed with LDH with a guideline supported by scientific evidence to assist in decision-making for appropriate and reasonable treatments.

STUDY DESIGN/SETTING

A systematic review.

PATIENT SAMPLE

Studies of human subjects written in Korean or English that met the following criteria were selected: patients aged ≥18 years, clinical presentation of low back and radicular leg pain, diagnosis of LDH on radiological evaluation including computed tomography or magnetic resonance imaging.

OUTCOMES MEASURES

Pain and functional evaluation scales such as visual analogue scale, numeric rating scale, and Oswestry disability index METHODS: The MEDLINE (PubMed), EMBASE, Cochrane Review, and KoreaMed databases were searched for articles regarding non-surgical treatments for LDH published up to July 2017. Of the studies fulfilling these criteria, those investigating clinical results after non-surgical treatment including physical and behavioral therapy, medication, and interventional treatment in terms of pain control and functional improvements were chosen for this study.

RESULTS

Nonsurgical treatments were determined to be clinically effective with regards to pain reduction and functional improvement in patients with LDH. Nevertheless, the evidence level was generally not evaluated as high degree, which might be attributed to the paucity of well-designed randomized controlled trials. Exercise and traction were strongly recommended despite moderate level of evidence. Epidural injection was strongly recommended with high degree of evidence and transforaminal approach was more strongly recommended than caudal approach.

CONCLUSIONS

This CPG provides new and updated evidence-based recommendations for treatment of the patients with LDH, which suggested that, despite an absence of high degrees of evidence level, non-surgical treatments were clinically effective.

Safety of Epidural Corticosteroid Injections

BACKGROUND AND OBJECTIVE

Epidural corticosteroid injections (ESIs) have been used for several decades and now represent the most common intervention performed for the management of back pain with a radicular component. However, several reports have presented devastating complications and adverse effects, which fuelled concerns over the risk versus clinical effectiveness. The authors offer a comprehensive review of the available literature and analyse the data derived from studies and case reports.

METHODS

Studies were identified by searching PubMed MEDLINE, Ovid MEDLINE, EMBASE, Scopus, Google Scholar and the Cochrane Library to retrieve all available relevant articles. Publications from the last 20 years (September 1994 to September 2014) were considered for further analysis. Studies selected were English-language original articles publishing results on complications related to the technique used for cervical and lumbar ESIs. The studies had to specify the approach used for injection. All studies that did not fulfil these eligibility criteria were excluded from further analysis.

RESULTS

Overall, the available literature supports the view that serious complications following injections of corticosteroid suspensions into the cervical and lumbar epidural space are uncommon, but if they occur they can be devastating.

CONCLUSIONS

The true incidence of such complications remains unclear. Direct vascular injury and/or administration of injectates intra-arterially represent a major concern and could account for the vast majority of the adverse events reported. Accurate placement of the needle, use of a non-particulate corticosteroid, live fluoroscopy, digital subtraction angiography, and familiarisation of the operator with contrast patterns on fluoroscopy should minimise these risks. The available literature has several limitations including incomplete documentation, unreported data and inherent bias. Large registries and well-structured observational studies are needed to determine the true incidence of adverse events and address the safety concerns.