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de Bruijn TM, de Groot IB, Miedema HS, Haumann J, Ostelo RW. Clinical Relevance of Epidural Steroid Injections on Lumbosacral Radicular Syndrome-related Synptoms: Systematic Review and Meta-Analysis. Clin J Pain 2021; 37:524-537. [PMID: 33859113 PMCID: PMC8162229 DOI: 10.1097/ajp.0000000000000943] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Epidural steroid injections (ESIs) can be used to reduce lumbosacral radicular syndrome (LRS) related pain. The clinical relevance of ESIs are currently unknown. This systematic review and meta-analyses aims to assess whether ESIs are clinically relevant for patients with LRS. MATERIALS AND METHODS Comprehensive literature searches for randomized controlled trials regarding steroid injections for LRS were conducted in PudMed, EMBASE, CINAHL, and CENTRAL from their inception to September 2018 (December 2019 for PubMed). For each homogenous comparison, the outcomes function, pain intensity and health-related quality of life at different follow-up intervals were pooled separately. The GRADE approach was used to determine the overall certainty of the evidence. RESULTS Seventeen studies were included. Two different homogenous comparisons were identified for which the randomized controlled trials could be pooled. In 36 of the 40 analyses no clinically relevant effect was found. The certainty of evidence varied between very low to high. Four analyses found a clinically relevant effect, all on pain intensity and health-related quality of life, but the certainty of the evidence was either low or very low. Two of the 33 subgroup analyses showed a clinically relevant effect. However, according to the GRADE approach the certainty of these findings are low to very low. DISCUSSION On the basis of the analyses we conclude there is insufficient evidence that ESIs for patients with LRS are clinically relevant at any follow-up moment. High-quality studies utilizing a predefined clinical success are necessary to identify potential clinically relevant effects of ESIs. Until the results of these studies are available, there is reason to consider whether the current daily practice of ESIs for patients with LRS should continue.
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Affiliation(s)
- Thomas M. de Bruijn
- Department Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam
- National Health Care Institute, Diemen
| | | | - Harald S. Miedema
- National Health Care Institute, Diemen
- Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | | | - Raymond W.J.G. Ostelo
- Department Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam
- Department of Epidemiology and Biostatistics, Amsterdam UMC (Location VUmc) and Amsterdam Movement Sciences, Amsterdam
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Verheijen EJA, Bonke CA, Amorij EMJ, Vleggeert-Lankamp CLA. Epidural steroid compared to placebo injection in sciatica: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3255-3264. [PMID: 33974132 DOI: 10.1007/s00586-021-06854-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/18/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE The purpose of this systematic review and meta-analysis was to determine whether epidural steroid injections (ESI) are superior to epidural or non-epidural placebo injections in sciatica patients. METHODS The PubMed, Embase, Cochrane Library, and Web of science databases were searched for trials comparing ESI to epidural or non-epidural placebo. Risk of bias was assessed using the Cochrane RoB 2 tool. The primary outcome measures were pooled using a random-effects model for 6-week, 3-month, and 6-month follow-up. Secondary outcomes were described qualitatively. Quality of evidence was graded using GRADE classification. RESULTS Seventeen out of 732 articles were included. ESI was superior compared to epidural placebo at 6 weeks (- 8.6 [- 13.4; - 3.9]) and 3 months (- 5.2 [- 10.1; - 0.2]) for leg pain and at 6 weeks for functional status (- 4.1 [- 6.5; - 1.6]), though the minimally clinical important difference (MCID) was not met. There was no difference in ESI and placebo for back pain, except for non-epidural placebo at 3 months (6.9 [1.3; 12.5]). Proportions of treatment success were not different. ESI reduced analgesic intake in some studies and complication rates are low. CONCLUSION The literature indicates that ESI induces larger improvements in pain and disability on the short term compared to epidural placebo, though evidence is of low to moderate quality and MCID is not met. Strong conclusions for longer follow-up or for comparisons with non-epidural placebo cannot be drawn due to general low quality of evidence and limited number of studies. Epidural injections can be considered a safe therapy.
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Affiliation(s)
- E J A Verheijen
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands. .,Department of Neurosurgery, Spaarne Gasthuis Hospital, Haarlem/Hoofddorp, The Netherlands.
| | - C A Bonke
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - E M J Amorij
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - C L A Vleggeert-Lankamp
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Department of Neurosurgery, Spaarne Gasthuis Hospital, Haarlem/Hoofddorp, The Netherlands
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Gjefsen E, Bråten LCH, Goll GL, Wigemyr M, Bolstad N, Valberg M, Schistad EI, Marchand GH, Granviken F, Selmer KK, Froholdt A, Haugen AJ, Dagestad MH, Vetti N, Bakland G, Lie BA, Haavardsholm EA, Nilsen AT, Holmgard TE, Kadar TI, Kvien T, Skouen JS, Grøvle L, Brox JI, Espeland A, Storheim K, Zwart JA. The effect of infliximab in patients with chronic low back pain and Modic changes (the BackToBasic study): study protocol of a randomized, double blind, placebo-controlled, multicenter trial. BMC Musculoskelet Disord 2020; 21:698. [PMID: 33087100 PMCID: PMC7580023 DOI: 10.1186/s12891-020-03720-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/14/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Low back pain is common and a significant number of patients experience chronic low back pain. Current treatment options offer small to moderate effects. Patients with vertebral bone marrow lesions visualized as Modic changes on magnetic resonance imaging may represent a subgroup within the low back pain population. There is evidence for inflammatory mediators being involved in development of Modic changes; hence, suppression of inflammation could be a treatment strategy for these patients. This study examines the effect of anti-inflammatory treatment with the TNF-α inhibitor infliximab in patients with chronic low back pain and Modic changes. METHODS/DESIGN The BackToBasic trial is a multicenter, double blind, randomized controlled trial conducted at six hospitals in Norway, comparing intravenous infusions with infliximab with placebo. One hundred twenty-six patients aged 18-65 with chronic low back pain and type 1 Modic changes will be recruited from secondary care outpatients' clinics. The primary outcome is back pain-specific disability at day 154 (5 months). The study is designed to detect a difference in change of 10 (SD 18) in the Oswestry Disability Index at day 154/ 5 months. The study also aims to refine MRI-assessment, investigate safety and cost-effectiveness and explore the underlying biological mechanisms of Modic changes. DISCUSSION Finding treatments that target underlying mechanisms could pose new treatment options for patients with low back pain. Suppression of inflammation could be a treatment strategy for patients with low back pain and Modic changes. This paper presents the design of the BackToBasic study, where we will assess the effect of an anti-inflammatory treatment versus placebo in patients with chronic low back pain and type 1 Modic changes. The study is registered at ClinicalTrials.gov under the identifier NCT03704363 . The EudraCT Number: 2017-004861-29.
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Affiliation(s)
- Elisabeth Gjefsen
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital HF, Ulleval, Bygg 37b, P.O. Box 4956 Nydalen, 0424, Oslo, Norway. .,Faculty of Medicine, University of Oslo, P.O. Box 1072 Blindern, 0316, Oslo, Norway.
| | - Lars Christian Haugli Bråten
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital HF, Ulleval, Bygg 37b, P.O. Box 4956 Nydalen, 0424, Oslo, Norway
| | - Guro Løvik Goll
- Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vinderen, 0319, Oslo, Norway
| | - Monica Wigemyr
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424, Oslo, Norway
| | - Nils Bolstad
- Department of Medical Biochemistry, Oslo University Hospital, Radiumhospitalet, Box 4953 Nydalen, 0424, Oslo, Norway
| | - Morten Valberg
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Sogn Arena 3.etg, P.O.Box 4950 Nydalen, Oslo, Norway
| | - Elina Iordanova Schistad
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, P.O. Box 4956 Nydalen, 0424, Oslo, Norway
| | - Gunn Hege Marchand
- Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, P.O. Box 3250 Torgarden, NO-7006, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, 7491, Norway
| | - Fredrik Granviken
- Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, P.O. Box 3250 Torgarden, NO-7006, Trondheim, Norway.,Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, 7491, Norway
| | - Kaja Kristine Selmer
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424, Oslo, Norway.,National Centre for Epilepsy, Oslo University Hospital, Oslo, Norway
| | - Anne Froholdt
- Department of Physical Medicine and Rehabilitation, Drammen Hospital, Vestre Viken Hospital Trust Drammen, P.O. Box 800, 3004, Drammen, Norway
| | - Anne Julsrud Haugen
- Department of Rheumatology, Østfold Hospital Trust, P.O. Box 300, 1714 Grålum, Moss, Norway
| | - Magnhild Hammersland Dagestad
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway
| | - Nils Vetti
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway
| | - Gunnstein Bakland
- Department of Rheumatology, University Hospital of North Norway, P.O. Box 100, 9038, Tromsø, Norway
| | - Benedicte Alexandra Lie
- Department of Medical Genetics, University of Oslo and Oslo University Hospital, P.O. Box 4956 Nydalen, 0424, Oslo, Norway
| | - Espen A Haavardsholm
- Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vinderen, 0319, Oslo, Norway
| | - Aksel Thuv Nilsen
- Department of Rheumatology, University Hospital of North Norway, P.O. Box 100, 9038, Tromsø, Norway
| | - Thor Einar Holmgard
- Norwegian Back Pain Association, P.O.Box 9612 Fjellhagen, 3065, Drammen, Norway
| | - Thomas Istvan Kadar
- Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Helse Bergen HF, Box 1, 5021, Bergen, Norway
| | - Tore Kvien
- Faculty of Medicine, University of Oslo, P.O. Box 1072 Blindern, 0316, Oslo, Norway.,Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vinderen, 0319, Oslo, Norway
| | - Jan Sture Skouen
- Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Helse Bergen HF, Box 1, 5021, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway
| | - Lars Grøvle
- Department of Rheumatology, Østfold Hospital Trust, P.O. Box 300, 1714 Grålum, Moss, Norway
| | - Jens Ivar Brox
- Faculty of Medicine, University of Oslo, P.O. Box 1072 Blindern, 0316, Oslo, Norway.,Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, P.O. Box 4956 Nydalen, 0424, Oslo, Norway
| | - Ansgar Espeland
- Department of Radiology, Haukeland University Hospital, Jonas Liesvei 65, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway
| | - Kjersti Storheim
- Research and Communication Unit for Musculoskeletal Health (FORMI), Oslo University Hospital HF, Ulleval, Bygg 37b, P.O. Box 4956 Nydalen, 0424, Oslo, Norway.,Department of Physiotherapy, Oslo Metropolitan University, P.O. Box 4 St. Olavs plass, NO-0130, Oslo, Norway
| | - John Anker Zwart
- Faculty of Medicine, University of Oslo, P.O. Box 1072 Blindern, 0316, Oslo, Norway.,Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424, Oslo, Norway
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Abstract
A limited number of peripheral targets generate pain. Inflammatory mediators can sensitize these. The review addresses targets acting exclusively or predominantly on sensory neurons, mediators involved in inflammation targeting sensory neurons, and mediators involved in a more general inflammatory process, of which an analgesic effect secondary to an anti-inflammatory effect can be expected. Different approaches to address these systems are discussed, including scavenging proinflammatory mediators, applying anti-inflammatory mediators, and inhibiting proinflammatory or facilitating anti-inflammatory receptors. New approaches are contrasted to established ones; the current stage of progress is mentioned, in particular considering whether there is data from a molecular and cellular level, from animals, or from human trials, including an early stage after a market release. An overview of publication activity is presented, considering a IuPhar/BPS-curated list of targets with restriction to pain-related publications, which was also used to identify topics.
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Affiliation(s)
- Cosmin I Ciotu
- Center of Physiology and Pharmacology, Medical University of Vienna, Schwarzspanierstrasse 17, 1090, Vienna, Austria
| | - Michael J M Fischer
- Center of Physiology and Pharmacology, Medical University of Vienna, Schwarzspanierstrasse 17, 1090, Vienna, Austria.
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Oliveira CB, Maher CG, Ferreira ML, Hancock MJ, Oliveira VC, McLachlan AJ, Koes BW, Ferreira PH, Cohen SP, Pinto RZ. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev 2020; 4:CD013577. [PMID: 32271952 PMCID: PMC7145384 DOI: 10.1002/14651858.cd013577] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Lumbosacral radicular pain (commonly called sciatica) is a syndrome involving patients who report radiating leg pain. Epidural corticosteroid injections deliver a corticosteroid dose into the epidural space, with the aim of reducing the local inflammatory process and, consequently, relieving the symptoms of lumbosacral radicular pain. This Cochrane Review is an update of a review published in Annals of Internal Medicine in 2012. Some placebo-controlled trials have been published recently, which highlights the importance of updating the previous review. OBJECTIVES To investigate the efficacy and safety of epidural corticosteroid injections compared with placebo injection on pain and disability in patients with lumbosacral radicular pain. SEARCH METHODS We searched the following databases without language limitations up to 25 September 2019: Cochrane Back and Neck group trial register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and two trial registers. We also performed citation tracking of included studies and relevant systematic reviews in the field. SELECTION CRITERIA We included studies that compared epidural corticosteroid injections of any corticosteroid drug to placebo injections in patients with lumbosacral radicular pain. We accepted all three anatomical approaches (caudal, interlaminar, and transforaminal) to delivering corticosteroids into the epidural space. We considered trials that included a placebo treatment as delivery of an inert substance (i.e. one with no pharmacologic activity), an innocuous substance (e.g. normal saline solution), or a pharmacologically active substance but not one considered to provide sustained benefit (e.g. local anaesthetic), either into the epidural space (i.e. to mimic epidural corticosteroid injection) or adjacent spinal tissue (i.e. subcutaneous, intramuscular, or interspinous tissue). We also included trials in which a local anaesthetic with a short duration of action was used as a placebo and injected together with corticosteroid in the intervention group. DATA COLLECTION AND ANALYSIS Two authors independently performed the screening, data extraction, and 'Risk of bias' assessments. In case of insufficient information, we contacted the authors of the original studies or estimated the data. We grouped the outcome data into four time points of assessment: immediate (≤ 2 weeks), short term (> 2 weeks but ≤ 3 months), intermediate term (> 3 months but < 12 months), and long term (≥ 12 months). We assessed the overall quality of evidence for each outcome and time point using the GRADE approach. MAIN RESULTS We included 25 clinical trials (from 29 publications) investigating the effects of epidural corticosteroid injections compared to placebo in patients with lumbosacral radicular pain. The included studies provided data for a total of 2470 participants with a mean age ranging from 37.3 to 52.8 years. Seventeen studies included participants with lumbosacral radicular pain with a diagnosis based on clinical assessment and 15 studies included participants with mixed duration of symptoms. The included studies were conducted mainly in North America and Europe. Fifteen studies did not report funding sources, five studies reported not receiving funding, and five reported receiving funding from a non-profit or government source. Eight trials reported data on pain intensity, 12 reported data on disability, and eight studies reported data on adverse events. The duration of the follow-up assessments ranged from 12 hours to 1 year. We considered eight trials to be of high quality because we judged them as having low risk of bias in four out of the five bias domains. We identified one ongoing trial in a trial registry. Epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing leg pain at short-term follow-up (mean difference (MD) -4.93, 95% confidence interval (CI) -8.77 to -1.09 on a 0 to 100 scale; 8 trials, n = 949; moderate-quality evidence (downgraded for risk of bias)). For disability, epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing disability at short-term follow-up (MD -4.18, 95% CI -6.04 to -2.17, on a 0 to 100 scale; 12 trials, n = 1367; moderate-quality evidence (downgraded for risk of bias)). The treatment effects are small, however, and may not be considered clinically important by patients and clinicians (i.e. MD lower than 10%). Most trials provided insufficient information on how or when adverse events were assessed (immediate or short-term follow-up) and only reported adverse drug reactions - that is, adverse events that the trialists attributed to the study treatment. We are very uncertain that epidural corticosteroid injections make no difference compared to placebo injection in the frequency of minor adverse events (risk ratio (RR) 1.14, 95% CI 0.91 to 1.42; 8 trials, n = 877; very low quality evidence (downgraded for risk of bias, inconsistency and imprecision)). Minor adverse events included increased pain during or after the injection, non-specific headache, post-dural puncture headache, irregular periods, accidental dural puncture, thoracic pain, non-local rash, sinusitis, vasovagal response, hypotension, nausea, and tinnitus. One study reported a major drug reaction for one patient on anticoagulant therapy who had a retroperitoneal haematoma as a complication of the corticosteroid injection. AUTHORS' CONCLUSIONS This study found that epidural corticosteroid injections probably slightly reduced leg pain and disability at short-term follow-up in people with lumbosacral radicular pain. In addition, no minor or major adverse events were reported at short-term follow-up after epidural corticosteroid injections or placebo injection. Although the current review identified additional clinical trials, the available evidence still provides only limited support for the use of epidural corticosteroid injections in people with lumbosacral radicular pain as the treatment effects are small, mainly evident at short-term follow-up and may not be considered clinically important by patients and clinicians (i.e. mean difference lower than 10%). According to GRADE, the quality of the evidence ranged from very low to moderate, suggesting that further studies are likely to play an important role in clarifying the efficacy and tolerability of this treatment. We recommend that further trials should attend to methodological features such as appropriate allocation concealment and blinding of care providers to minimise the potential for biased estimates of treatment and harmful effects.
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Affiliation(s)
- Crystian B Oliveira
- São Paulo State UniversityDepartment of PhysiotherapyRua Roberto Simonsen, 305Presidente PrudenteSão PauloBrazilCEP 19060‐900
| | - Christopher G Maher
- University of SydneySydney School of Public HealthLevel 10 North, King George V Building, Missenden Road, CamperdownSydneyNSWAustralia2050
| | - Manuela L Ferreira
- Sydney Medical School, The University of SydneyInstitute of Bone and Joint Research, The Kolling InstituteSydneyNSWAustralia
| | - Mark J Hancock
- Macquarie UniversityDiscipline of Physiotherapy, Faculty of Medicine and Health SciencesSydneyAustralia
| | - Vinicius Cunha Oliveira
- Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM)Departamento de FisioterapiaCampus JK ‐ Rodovia MGT 367‐ Km 583, nº 5000 ‐ Alto da JacubaDiamantinaMinas GeraisBrazil39100‐000
| | - Andrew J McLachlan
- University of SydneyFaculty of PharmacyA15 ‐ PharmacyRoom N405SydneyNSWAustralia2006
| | - Bart W Koes
- University of Southern DenmarkCenter for Muscle and HealthOdenseDenmark
| | - Paulo H Ferreira
- The University of SydneyDiscipline of Physiotherapy, Faculty of Health Sciences75 East StreetSydneyLidcombe NSWAustralia1825
| | - Steven P Cohen
- Johns Hopkins University School of MedicineBlaustein Pain Treatment Center, Department of AnesthesiologyBaltimoreMarylandUSA
| | - Rafael Zambelli Pinto
- Universidade Federal de Minas Gerais (UFMG)Department of PhysiotherapyAv. Pres. Antônio Carlos, 6627Belo Horizonte ‐ MGBelo Horizonte, Minas GeraisMinas Gerais(MG)BrazilCEP 31270‐901
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Farhang N, Ginley-Hidinger M, Berrett KC, Gertz J, Lawrence B, Bowles RD. Lentiviral CRISPR Epigenome Editing of Inflammatory Receptors as a Gene Therapy Strategy for Disc Degeneration. Hum Gene Ther 2019; 30:1161-1175. [PMID: 31140325 PMCID: PMC6761595 DOI: 10.1089/hum.2019.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/22/2019] [Indexed: 02/07/2023] Open
Abstract
Degenerative disc disease (DDD) is a primary contributor to low-back pain, a leading cause of disability. Progression of DDD is aided by inflammatory cytokines in the intervertebral disc (IVD), particularly TNF-α and IL-1β, but current treatments fail to effectively target this mechanism. The objective of this study was to explore the feasibility of Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR) epigenome editing-based therapy for DDD, by modulation of TNFR1/IL1R1 signaling in pathological human IVD cells. Human IVD cells from the nucleus pulposus of patients receiving surgery for back pain were obtained and the regulation of TNFR1/IL1R1 signaling by a lentiviral CRISPR epigenome editing system was tested. These cells were tested for successful lentiviral transduction/expression of deactivated Cas9 fused to Krüppel Associated Box system and regulation of TNFR1/IL1R1 expression. TNFR1/IL1R1 signaling disruption was investigated through measurement of NF-κB activity, apoptosis, and anabolic/catabolic changes in gene expression postinflammatory challenge. CRISPR epigenome editing systems were effectively introduced into pathological human IVD cells and significantly downregulated TNFR1 and IL1R1. This downregulation significantly attenuated deleterious TNFR1 signaling but not IL1R1 signaling. This is attributed to less robust IL1R1 expression downregulation, and IL-1β-driven reversal of IL1R1 expression downregulation in a portion of patient IVD cells. In addition, RNAseq data indicated novel transcription factor targets, IRF1 and TFAP2C, as being primary regulators of inflammatory signaling in IVD cells. These results demonstrate the feasibility of CRISPR epigenome editing of inflammatory receptors in pathological IVD cells, but highlight a limitation in epigenome targeting of IL1R1. This method has potential application as a novel gene therapy for DDD, to attenuate the deleterious effect of inflammatory cytokines present in the degenerative IVD.
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MESH Headings
- Apoptosis
- Biomarkers
- Cells, Cultured
- Clustered Regularly Interspaced Short Palindromic Repeats
- Epigenesis, Genetic
- Gene Editing
- Gene Expression Regulation
- Gene Order
- Gene Transfer Techniques
- Genetic Therapy/methods
- Genetic Vectors/genetics
- Humans
- Intervertebral Disc Degeneration/genetics
- Intervertebral Disc Degeneration/therapy
- Lentivirus/genetics
- Receptors, Immunologic/genetics
- Receptors, Immunologic/metabolism
- Receptors, Interleukin-1 Type I/genetics
- Receptors, Interleukin-1 Type I/metabolism
- Receptors, Tumor Necrosis Factor, Type I/genetics
- Receptors, Tumor Necrosis Factor, Type I/metabolism
- Signal Transduction
- Transduction, Genetic
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Affiliation(s)
- Niloofar Farhang
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
| | | | | | - Jason Gertz
- Department of Oncological Sciences, University of Utah, Salt Lake City, Utah
| | - Brandon Lawrence
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Robby D. Bowles
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
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7
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Unique aspects of clinical trials of invasive therapies for chronic pain. Pain Rep 2018; 4:e687. [PMID: 31583336 PMCID: PMC6749926 DOI: 10.1097/pr9.0000000000000687] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/07/2018] [Indexed: 12/18/2022] Open
Abstract
Nearly all who review the literature conclude that the role of invasive procedures to treat chronic pain is poorly characterized because of the lack of “definitive” studies. The overt nature of invasive treatments, along with the risks, technical skills, and costs involved create challenges to study them. However, these challenges do not completely preclude evaluating invasive procedure effectiveness and safety using well-designed methods. This article reviews the challenges of studying outcomes of invasive therapies to treat pain and discuss possible solutions. Although the following discussion can apply to most invasive therapies to treat chronic pain, it is beyond the scope of the article to individually cover every invasive therapy used. Therefore, most of the examples focus on injection therapies to treat spine pain, spinal cord stimulation, and intrathecal drug therapies.
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Lassere MN, Johnson KR, Thom J, Pickard G, Smerdely P. Protocol of the randomised placebo controlled pilot trial of the management of acute sciatica (SCIATICA): a feasibility study. BMJ Open 2018; 8:e020435. [PMID: 29980542 PMCID: PMC6042624 DOI: 10.1136/bmjopen-2017-020435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Acute sciatica (symptom duration less than 4 weeks), a major cause of pain and disability, is a common presentation to medical practices and hospital emergency departments. Selective CT fluoroscopy transforaminal epidural steroid injection is often used with the hope of reducing pain and improving function. Recently, there has been interest in using systemic corticosteroids in acute sciatica. However, there is limited evidence to inform management of selective CT fluoroscopy transforaminal epidural steroid in subacute and chronic sciatica and there is no evidence in acute sciatica, even though the practice is widespread. There is also limited evidence for the use of systemic corticosteroids in acute sciatica. Furthermore, the management of selective CT fluoroscopy transforaminal epidural steroid versus systemic steroids has never been directly studied. METHODS AND ANALYSIS SCIATICA is a pilot/feasibility study of patients with acute sciatica designed to evaluate the feasibility of undertaking a blinded four-arm randomised controlled intervention study of (1) selective CT fluoroscopy transforaminal epidural steroid (arm 1), (2) selective CT fluoroscopy transforaminal epidural saline (arm 2), (3) 15 days tapering dose of oral steroids (arm 3) and (4) a sham epidural and oral placebo control (arm 4). This feasibility study is designed to evaluate head-to-head, route versus pharmacology of interventions. The primary outcome measure is the Oswestry Disability Index (ODI) at 3 weeks. Secondary outcome is the ODI at 48 weeks. Other outcomes include numerical rating scale for leg pain, Pain DETECT Questionnaire, quality of life, medication use, rescue procedures or surgery, and adverse events. Results of outcomes from this randomised controlled trial will be used to determine the feasibility, sample size and power calculations for a large multicentre study. ETHICS AND DISSEMINATION The study has been approved by South Eastern Sydney Local Health District Human Research Ethics Committee (HREC/15/331/POHW/586). TRIAL REGISTRATION NUMBER NCT03240783; Pre-results.
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Affiliation(s)
| | - Kent Robert Johnson
- St George Clinical School, University of New South Wales, Kogarah, New South Wales, Australia
| | - Jeanette Thom
- School of Medical Sciences, University of New South Wales, Kensington, New South Wales, Australia
| | - Grant Pickard
- Medical Assessment Unit, St George Hospital, Kogarah, New South Wales, Australia
| | - Peter Smerdely
- Department of Aged Care, St George Hospital, Kogarah, New South Wales, Australia
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9
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Hung AL, Lim M, Doshi TL. Targeting cytokines for treatment of neuropathic pain. Scand J Pain 2017; 17:287-293. [PMID: 29229214 DOI: 10.1016/j.sjpain.2017.08.002] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 07/26/2017] [Accepted: 08/01/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Neuropathic pain is a challenging condition often refractory to existing therapies. An increasing number of studies have indicated that the immune system plays a crucial role in the mediation of neuropathic pain. Exploration of the various functions of individual cytokines in neuropathic pain will provide greater insight into the mechanisms of neuropathic pain and suggest potential opportunities to expand the repertoire of treatment options. METHODS A literature review was performed to assess the role of pro-inflammatory and anti-inflammatory cytokines in the development of neuropathic pain. Both direct and indirect therapeutic approaches that target various cytokines for pain were reviewed. The current understanding based on preclinical and clinical studies is summarized. RESULTS AND CONCLUSIONS In both human and animal studies, neuropathic pain has been associated with a pro-inflammatory state. Analgesic therapies involving direct manipulation of various cytokines and indirect methods to alter the balance of the immune system have been explored, although there have been few large-scale clinical trials evaluating the efficacy of immune modulators in the treatment of neuropathic pain. TNF-α is perhaps the widely studied pro-inflammatory cytokine in the context of neuropathic pain, but other pro-inflammatory (IL-1β, IL-6, and IL-17) and anti-inflammatory (IL-4, IL-10, TGF-β) signaling molecules are garnering increased interest. With better appreciation and understanding of the interaction between the immune system and neuropathic pain, novel therapies may be developed to target this condition.
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Affiliation(s)
- Alice L Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael Lim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tina L Doshi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Gulizia MM, Colivicchi F, Ricciardi G, Giampaoli S, Maggioni AP, Averna M, Graziani MS, Ceriotti F, Mugelli A, Rossi F, Medea G, Parretti D, Abrignani MG, Arca M, Perrone Filardi P, Perticone F, Catapano A, Griffo R, Nardi F, Riccio C, Di Lenarda A, Scherillo M, Musacchio N, Panno AV, Zito GB, Campanini M, Bolognese L, Faggiano PM, Musumeci G, Pusineri E, Ciaccio M, Bonora E, Cantelli Forti G, Ruggieri MP, Cricelli C, Romeo F, Ferrari R, Maseri A. ANMCO/ISS/AMD/ANCE/ARCA/FADOI/GICR-IACPR/SICI-GISE/SIBioC/SIC/SICOA/SID/SIF/SIMEU/SIMG/SIMI/SISA Joint Consensus Document on cholesterol and cardiovascular risk: diagnostic-therapeutic pathway in Italy. Eur Heart J Suppl 2017; 19:D3-D54. [PMID: 28751833 PMCID: PMC5526476 DOI: 10.1093/eurheartj/sux029] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Atherosclerotic cardiovascular disease still represents the leading cause of death in Western countries. A wealth of scientific evidence demonstrates that increased blood cholesterol levels have a major impact on the outbreak and progression of atherosclerotic plaques. Moreover, several cholesterol-lowering pharmacological agents, including statins and ezetimibe, have proved effective in improving clinical outcomes. This document focuses on the clinical management of hypercholesterolaemia and has been conceived by 16 Italian medical associations with the support of the Italian National Institute of Health. The authors discuss in detail the role of hypercholesterolaemia in the genesis of atherosclerotic cardiovascular disease. In addition, the implications for high cholesterol levels in the definition of the individual cardiovascular risk profile have been carefully analysed, while all available therapeutic options for blood cholesterol reduction and cardiovascular risk mitigation have been explored. Finally, this document outlines the diagnostic and therapeutic pathways for the clinical management of patients with hypercholesterolaemia.
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Affiliation(s)
- Michele Massimo Gulizia
- Italian Association of Hospital Cardiologists (ANMCO)
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione ‘Garibaldi’, Via Palermo 636, 95122 Catania, Italy
| | | | | | | | | | | | | | - Ferruccio Ceriotti
- Italian Society of Clinical Biochemistry and Clinical Molecular Biology (SIBioC)
| | | | | | | | | | | | - Marcello Arca
- Italian Society for the Study of Arteriosclerosis (SISA)
| | | | | | | | - Raffaele Griffo
- Italian Group of Rehabilitation and Preventative Cardiology (GICR-IACPR)
| | | | | | | | | | | | | | | | | | | | | | | | - Enrico Pusineri
- Italian Society of Accredited Cardiology Hospital Care (SICOA)
| | - Marcello Ciaccio
- Italian Society of Clinical Biochemistry and Clinical Molecular Biology (SIBioC)
| | | | | | | | | | | | | | - Attilio Maseri
- Fondazione ‘per il Tuo cuore’ Heart Care Foundation Onlus
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11
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Bicket MC, Pasquina PF, Cohen SP. Which Regional Pain Rating Best Predicts Patient-Reported Improvement in Lumbar Radiculopathy? Pain Pract 2017; 17:1058-1065. [PMID: 28226408 DOI: 10.1111/papr.12569] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 11/21/2016] [Accepted: 01/13/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the best regional pain score cutoff value that corresponds with patient-reported improvement in lumbosacral radiculopathy (LSR). DESIGN Retrospective pooled data analysis from 3 randomized, controlled, multicenter trials using similar outcome assessments. All participants were exposed to interventions (epidural injections). SETTING Military medical centers (6 U.S.A., 1 Germany) and large tertiary care hospitals (4 urban, 1 Veterans Affairs) between 2008 and 2014. SUBJECTS A total of 352 active duty military personnel and civilians ≥ 18 years of age with LSR. METHODS Receiver operating characteristics (ROC) with area under the curve (AUC) were calculated for 1-month outcomes for pain (numeric rating scale) using absolute and relative change in regional pain scores (back, leg) to predict clinical improvement (global perceived effect). RESULTS Leg pain demonstrated greater predictive ability to identify clinical improvement compared to back pain for both absolute (ROC AUC [95% confidence interval (CI)] 0.855 [0.813, 0.896] vs. 0.753 [0.702, 0.805]; P < 0.001) and relative (AUC [95% CI]; 0.867 [0.826, 0.909] vs. 0.780 [0.729, 0.831]; P = 0.002) reduction in reported pain. Clinical improvement was best identified using a leg pain reduction threshold of ≥ 1.75 points (absolute) and ≥ 23.5% (relative). CONCLUSIONS Region-specific pain cutoff ratings predicted clinical improvement for patients with LSR. Cutoff points using newly identified, smaller reductions of 1.75 points and 23.5% more accurately predicted clinical improvement for LSR than conventionally used cutoffs (2 points and 30%). LSR patients report meaningful clinical improvement with smaller reductions in pain compared to other chronic pain diagnoses, suggesting LSR patients may have different expectations.
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Affiliation(s)
- Mark C Bicket
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Paul F Pasquina
- Departments of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A.,Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.,Departments of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A.,Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A.,Departments of Neurology and Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland, U.S.A.,Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
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12
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Shanthanna H, Busse JW, Thabane L, Paul J, Couban R, Choudhary H, Kaushal A, Suzumura E, Kim I, Harsha P. Local anesthetic injections with or without steroid for chronic non-cancer pain: a protocol for a systematic review and meta-analysis of randomized controlled trials. Syst Rev 2016; 5:18. [PMID: 26831725 PMCID: PMC4736179 DOI: 10.1186/s13643-016-0190-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 01/15/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Steroids are often combined with local anesthetic (LA) and injected to reduce pain associated with various chronic non-cancer pain (CNCP) complaints. The biological rationale behind injection of a steroid solution is unclear, and it is uncertain whether the addition of steroids offers any additional benefits over injection of LA alone. We propose to conduct a systematic review and meta-analysis to summarize the evidence for using steroids and LA vs. LA alone in the treatment of CNCP. METHODS An experienced librarian will perform a comprehensive search of EMBASE, MEDLINE, and the Cochrane Central Registry of Controlled Trials (CENTRAL) databases with search terms for clinical indications, LA, and steroid agents. We will review bibliographies of all relevant published reviews in the last 5 years for additional studies. Eligible trials will be published in English and randomly allocate patients with CNCP to treatment with steroid and LA injection therapy or injection with LA alone. We will use the guidelines published by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) to inform the outcomes that we collect and present. Teams of reviewers will independently and in duplicate assess trial eligibility, abstract data, and assess risk of bias among eligible trials. We will prioritize intention to treat analysis and, when possible, pool outcomes across trials using random effects models. We will report our findings as risk differences, weighted mean differences, or standardized mean differences for individual outcomes. Further, to ensure interpretability of our results, we will present risk differences and measures of relative effect for pain reduction based on anchor-based minimally important clinical differences. We will conduct a priori defined subgroup analyses and use the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to evaluate the certainty of the evidence on an outcome-by-outcome basis. DISCUSSION Our review will evaluate both the effectiveness and the adverse events associated with steroid plus LA vs. LA alone for CNCP, evaluate the quality of the evidence using the GRADE approach, and prioritize patient-important outcomes guided by IMMPACT recommendations. Our results will facilitate evidence-based management of patients with chronic non-cancer pain and identify key areas for future research. TRIAL REGISTRATION PROSPERO CRD42015020614.
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Affiliation(s)
- Harsha Shanthanna
- Department of Anesthesia, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada. .,The Michael G. DeGroote Institute for Pain Research and Care, Hamilton, Canada.
| | - Jason W Busse
- Department of Anesthesia, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada. .,The Michael G. DeGroote Institute for Pain Research and Care, Hamilton, Canada. .,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
| | - Lehana Thabane
- Department of Anesthesia, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada. .,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
| | - James Paul
- Department of Anesthesia, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada. .,The Michael G. DeGroote Institute for Pain Research and Care, Hamilton, Canada.
| | - Rachel Couban
- Department of Anesthesia, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada. .,The Michael G. DeGroote Institute for Pain Research and Care, Hamilton, Canada.
| | - Harman Choudhary
- Department of Orthopedics, McMaster University, Hamilton, Canada.
| | - Alka Kaushal
- Department of Anesthesia, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
| | - Erica Suzumura
- Research Institute - Hospital do Coração (HCor), São Paulo, Brazil.
| | - Isabel Kim
- Michael G. DeGroote School of Medicine, McMaster University, Ontario, Hamilton, Canada.
| | - Prathiba Harsha
- Department of Anesthesia, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
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13
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Manchikanti L, Hirsch JA. Neurological complications associated with epidural steroid injections. Curr Pain Headache Rep 2015; 19:482. [PMID: 25795154 DOI: 10.1007/s11916-015-0482-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Multiple case reports of neurological complications resulting from intraarterial injection of corticosteroids have led the Food and Drug Administration (FDA) to issue a warning, requiring label changes, warning of serious neurological events, some resulting in death. The FDA has identified 131 cases of neurological adverse events, including 41 cases of arachnoiditis. A review of the literature reveals an overwhelming proportion of the complications are related to transforaminal epidural injections, of which cervical transforaminal epidural injections constituted the majority of neurological complications. Utilization data of epidural injections in the Medicare population revealed that cervical transforaminal epidural injections constitute only 2.4 % of total epidural injections and <5 % of all transforaminal epidural injections. Multiple theories have been proposed as the cause of neurological injury including particulate steroid, arterial intimal flaps, arterial dissection, dislodgement of plaque causing embolism, arterial muscle spasm, and embolism of a fresh thrombus following disruption of the intima.
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14
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Niemier K, Schindler M, Volk T, Baum K, Wolf B, Eberitsch J, Seidel W. [Study on epidural steroid injection]. Schmerz 2015; 30:94-6. [PMID: 26589713 DOI: 10.1007/s00482-015-0078-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- K Niemier
- Klinik für Manuelle Therapie Hamm, Ostenallee 83, 59071, Hamm, Deutschland.
| | - M Schindler
- Krankenhaus Henningsdorf, Henningsdorf, Deutschland
| | - T Volk
- Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - K Baum
- Krankenhaus Henningsdorf, Henningsdorf, Deutschland
| | - B Wolf
- Sanaklinken Sommerfeld, Kremmen, Deutschland
| | - J Eberitsch
- Sanaklinken Sommerfeld, Kremmen, Deutschland
| | - W Seidel
- Sanaklinken Sommerfeld, Kremmen, Deutschland
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15
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Nguyen C, Palazzo C, Grabar S, Feydy A, Sanchez K, Zee N, Quinquis L, Ben Boutieb M, Revel M, Lefèvre-Colau MM, Poiraudeau S, Rannou F. Tumor necrosis factor-α blockade in recurrent and disabling chronic sciatica associated with post-operative peridural lumbar fibrosis: results of a double-blind, placebo randomized controlled study. Arthritis Res Ther 2015; 17:330. [PMID: 26596627 PMCID: PMC4655494 DOI: 10.1186/s13075-015-0838-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 10/27/2015] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION The aim of this study was to assess the efficacy and safety of tumor necrosis factor (TNF)-α inhibition with infliximab (IFX) in treating recurrent and disabling chronic sciatica pain associated with post-operative peridural lumbar fibrosis. METHOD A double-blind, placebo-controlled study randomized 35 patients presenting with sciatica pain associated with post-operative peridural lumbar fibrosis to two groups: IFX (n = 18), a single intravenous injection of 3 mg/kg IFX; and placebo (n = 17), a single saline serum injection. The primary outcome was a 50 % reduction in sciatica pain on a visual analog scale (VAS) at day 10. Secondary outcomes were radicular and lumbar VAS pain at day 0 and radicular and lumbar VAS pain, Québec disability score, drug-sparing effect and tolerance at days 10, 30, 90, and 180. RESULTS At day 10, the placebo and IFX groups did not differ in the primary outcome (50 % reduction in sciatica pain observed in three (17.6 %) versus five (27.8 %) patients; p = 0.69). The number of patients reaching the patient acceptable symptom state for radicular pain was significantly higher in the placebo than IFX group after injection (12 (70.6 %) versus five (27.8 %) patients; p = 0.01). The two groups were comparable for all other secondary outcomes. CONCLUSION Treatment with a single 3 mg/kg IFX injection for post-operative peridural lumbar fibrosis-associated sciatica pain does not significantly reduce radicular symptoms at day 10 after injection. TRIAL REGISTRATION ClinicalTrials.gov NCT00385086 ; registered 4 October 2006 (last updated 15 October 2015).
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Affiliation(s)
- Christelle Nguyen
- Univ. Paris Descartes, PRES Sorbonne Paris Cité, Service de Rééducation et Réadaptation de l'Appareil Locomoteur et des Pathologies du Rachis, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France.
- Univ. Paris Descartes, PRES Sorbonne Paris, Cité Laboratoire de Pharmacologie, Toxicologie et Signalisation Cellulaire, INSERM UMR-S 1124, UFR Biomédicale des Saints Pères, Paris, France.
| | - Clémence Palazzo
- Univ. Paris Descartes, PRES Sorbonne Paris Cité, Service de Rééducation et Réadaptation de l'Appareil Locomoteur et des Pathologies du Rachis, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France.
- Univ. Paris Descartes, PRES Sorbonne Paris, INSERM UMR-S 1153 et Institut Fédératif de Recherche sur le Handicap, Paris, France.
| | - Sophie Grabar
- Univ. Paris Descartes, PRES Sorbonne Paris, Biostatistics and Epidemiology Unit, Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris, France.
- INSERM UMR-S 1136, Institut Pierre Louis d'Épidémiologie et de Santé Publique, F-75013, Paris, France.
| | - Antoine Feydy
- Univ. Paris Descartes, PRES Sorbonne Paris Cité, Service de Radiologie B, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France.
| | - Katherine Sanchez
- Univ. Paris Descartes, PRES Sorbonne Paris Cité, Service de Rééducation et Réadaptation de l'Appareil Locomoteur et des Pathologies du Rachis, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France.
| | - Nathalie Zee
- Univ. Paris Descartes, PRES Sorbonne Paris Cité, Service de Radiologie B, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France.
| | - Laurent Quinquis
- Univ. Paris Descartes, PRES Sorbonne Paris, Biostatistics and Epidemiology Unit, Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Myriam Ben Boutieb
- Univ. Paris Descartes, PRES Sorbonne Paris, Biostatistics and Epidemiology Unit, Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Michel Revel
- Univ. Paris Descartes, PRES Sorbonne Paris Cité, Service de Rééducation et Réadaptation de l'Appareil Locomoteur et des Pathologies du Rachis, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France.
| | - Marie-Martine Lefèvre-Colau
- Univ. Paris Descartes, PRES Sorbonne Paris Cité, Service de Rééducation et Réadaptation de l'Appareil Locomoteur et des Pathologies du Rachis, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France.
| | - Serge Poiraudeau
- Univ. Paris Descartes, PRES Sorbonne Paris Cité, Service de Rééducation et Réadaptation de l'Appareil Locomoteur et des Pathologies du Rachis, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France.
- Univ. Paris Descartes, PRES Sorbonne Paris, INSERM UMR-S 1153 et Institut Fédératif de Recherche sur le Handicap, Paris, France.
| | - François Rannou
- Univ. Paris Descartes, PRES Sorbonne Paris Cité, Service de Rééducation et Réadaptation de l'Appareil Locomoteur et des Pathologies du Rachis, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France.
- Univ. Paris Descartes, PRES Sorbonne Paris, Cité Laboratoire de Pharmacologie, Toxicologie et Signalisation Cellulaire, INSERM UMR-S 1124, UFR Biomédicale des Saints Pères, Paris, France.
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Likhitpanichkul M, Kim Y, Torre OM, See E, Kazezian Z, Pandit A, Hecht AC, Iatridis JC. Fibrin-genipin annulus fibrosus sealant as a delivery system for anti-TNFα drug. Spine J 2015; 15:2045-54. [PMID: 25912501 PMCID: PMC4550557 DOI: 10.1016/j.spinee.2015.04.026] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 03/11/2015] [Accepted: 04/15/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Intervertebral discs (IVDs) are attractive targets for local drug delivery because they are avascular structures with limited transport. Painful IVDs are in a chronic inflammatory state. Although anti-inflammatories show poor performance in clinical trials, their efficacy treating IVD cells suggests that sustained, local drug delivery directly to painful IVDs may be beneficial. PURPOSE The purpose of this study was to determine if genipin cross-linked fibrin (FibGen) with collagen Type I hollow spheres (CHS) can serve as a drug-delivery carrier for infliximab, the anti-tumor necrosis factor α (TNFα) drug. Infliximab was chosen as a model drug because of the known role of TNFα in increasing downstream production of several pro-inflammatory cytokines and pain mediators. Genipin cross-linked fibrin was used as drug carrier because it is adhesive, injectable, and slowly degrading hydrogel with the potential to seal annulus fibrosus (AF) defects. CHS allow simple and nondamaging drug loading and could act as a drug reservoir to improve sustained delivery. STUDY DESIGN/SETTING This is a study of biomaterials and human AF cell culture to determine drug release kinetics and efficacy. METHODS Infliximab was delivered at low and high concentrations using FibGen with and without CHS. Gels were analyzed for structure, drug release kinetics, and efficacy treating human AF cells after release. RESULTS Fibrin showed rapid infliximab drug release but degraded quickly. CHS alone showed a sustained release profile, but the small spheres may not remain in a degenerated IVD with fissures. Genipin cross-linked fibrin showed steady and low levels of infliximab release that was increased when loaded with higher drug concentrations. Infliximab was bound in CHS when delivered within FibGen and was only released after enzymatic degradation. The infliximab released over 20 days retained its bioactivity as confirmed by the sustained reduction of interleukin (IL)-1β, IL-6, IL-8, and TNFα concentrations produced by AF cells. CONCLUSIONS Direct mixing of infliximab into FibGen was the simplest drug-loading protocol capable of sustained release. Results show feasibility of using drug-loaded FibGen for delivery of infliximab and, in the context with the literature, show potential to seal AF defects and partially restore IVD biomechanics. Future investigations are required to determine if drug-loaded FibGen can effectively deliver drugs, seal AF defects, and promote IVD repair or prevent further IVD degeneration in vivo.
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Affiliation(s)
- Morakot Likhitpanichkul
- Leni & Peter W. May Dept of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Collaborative Research Partner, Annulus Fibrosus Rupture Program, AO Foundation, Davos, Switzerland
| | - Yesul Kim
- Leni & Peter W. May Dept of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Olivia M Torre
- Leni & Peter W. May Dept of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eugene See
- Network of Excellence for Functional Biomaterials, National University of Ireland, Galway, Ireland
| | - Zepur Kazezian
- Collaborative Research Partner, Annulus Fibrosus Rupture Program, AO Foundation, Davos, Switzerland,Network of Excellence for Functional Biomaterials, National University of Ireland, Galway, Ireland
| | - Abhay Pandit
- Collaborative Research Partner, Annulus Fibrosus Rupture Program, AO Foundation, Davos, Switzerland,Network of Excellence for Functional Biomaterials, National University of Ireland, Galway, Ireland
| | - Andrew C Hecht
- Leni & Peter W. May Dept of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James C Iatridis
- Leni & Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Collaborative Research Partner, Annulus Fibrosus Rupture Program, AO Foundation, Davos, Switzerland.
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Manchikanti L, Benyamin RM, Falco FJE, Kaye AD, Hirsch JA. Do Epidural Injections Provide Short- and Long-term Relief for Lumbar Disc Herniation? A Systematic Review. Clin Orthop Relat Res 2015; 473:1940-56. [PMID: 24515404 PMCID: PMC4419020 DOI: 10.1007/s11999-014-3490-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND As part of a comprehensive nonsurgical approach, epidural injections often are used in the management of lumbar disc herniation. Recent guidelines and systematic reviews have reached different conclusions about the efficacy of epidural injections in managing lumbar disc herniation. QUESTIONS/PURPOSES In this systematic review, we determined the efficacy (pain relief and functional improvement) of the three anatomic approaches (caudal, lumbar interlaminar, and transforaminal) for epidural injections in the treatment of disc herniation. METHODS We performed a literature search from 1966 to June 2013 in PubMed, Cochrane library, US National Guideline Clearinghouse, previous systematic reviews, and cross-references for trials studying all types of epidural injections in managing chronic or chronic and subacute lumbar disc herniation. We wanted only randomized controlled trials (RCTs) (either placebo or active controlled) to be included in our analysis, and 66 studies found in our search fulfilled these criteria. We then assessed the methodologic quality of these 66 studies using the Cochrane review criteria for RCTs. Thirty-nine studies were excluded, leaving 23 RCTs of high and moderate methodologic quality for analysis. Evidence for the efficacy of all three approaches for epidural injection under fluoroscopy was strong for short-term (< 6 months) and moderate for long-term (≥ 6 months) based on the Cochrane rating system with five levels of evidence (best evidence synthesis), with strong evidence denoting consistent findings among multiple high-quality RCTs and moderate evidence denoting consistent findings among multiple low-quality RCTs or one high-quality RCT. The primary outcome measure was pain relief, defined as at least 50% improvement in pain or 3-point improvement in pain scores in at least 50% of the patients. The secondary outcome measure was functional improvement, defined as 50% reduction in disability or 30% reduction in the disability scores. RESULTS Based on strong evidence for short-term efficacy from multiple high-quality trials and moderate evidence for long-term efficacy from at least one high quality trial, we found that fluoroscopic caudal, lumbar interlaminar, and transforaminal epidural injections were efficacious at managing lumbar disc herniation in terms of pain relief and functional improvement. CONCLUSIONS The available evidence suggests that epidural injections performed under fluoroscopy by trained physicians offer improvement in pain and function in well-selected patients with lumbar disc herniation.
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Affiliation(s)
- Laxmaiah Manchikanti
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA,
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Goldberg H, Firtch W, Tyburski M, Pressman A, Ackerson L, Hamilton L, Smith W, Carver R, Maratukulam A, Won LA, Carragee E, Avins AL. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA 2015; 313:1915-23. [PMID: 25988461 PMCID: PMC5875432 DOI: 10.1001/jama.2015.4468] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Oral steroids are commonly used to treat acute sciatica due to a herniated disk but have not been evaluated in an appropriately powered clinical trial. OBJECTIVE To determine if oral prednisone is more effective than placebo in improving function and pain among patients with acute sciatica. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, placebo-controlled clinical trial conducted from 2008 to 2013 in a large integrated health care delivery system in Northern California. Adults (n=269) with radicular pain for 3 months or less, an Oswestry Disability Index (ODI) score of 30 or higher (range, 0-100; higher scores indicate greater dysfunction), and a herniated disk confirmed by magnetic resonance imaging were eligible. INTERVENTIONS Participants were randomly assigned in a 2:1 ratio to receive a tapering 15-day course of oral prednisone (5 days each of 60 mg, 40 mg, and 20 mg; total cumulative dose = 600 mg; n = 181) or matching placebo (n = 88). MAIN OUTCOMES AND MEASURES The primary outcome was ODI change at 3 weeks; secondary outcomes were ODI change at 1 year, change in lower extremity pain (measured on a 0-10 scale; higher scores indicate more pain), spine surgery, and Short Form 36 Health Survey (SF-36) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores (0-100 scale; higher scores better). RESULTS Observed baseline and 3-week mean ODI scores were 51.2 and 32.2 for the prednisone group and 51.1 and 37.5 for the placebo group, respectively. The prednisone-treated group showed an adjusted mean 6.4-point (95% CI, 1.9-10.9; P = .006) greater improvement in ODI scores at 3 weeks than the placebo group and a mean 7.4-point (95% CI, 2.2-12.5; P = .005) greater improvement at 52 weeks. Compared with the placebo group, the prednisone group showed an adjusted mean 0.3-point (95% CI, -0.4 to 1.0; P = .34) greater reduction in pain at 3 weeks and a mean 0.6-point (95% CI, -0.2 to 1.3; P = .15) greater reduction at 52 weeks. The prednisone group showed an adjusted mean 3.3-point (95% CI, 1.3-5.2; P = .001) greater improvement in the SF-36 PCS score at 3 weeks, no difference in the SF-36 PCS score at 52 weeks (mean, 2.5; 95% CI, -0.3 to 5.4; P = .08), no change in the SF-36 MCS score at 3 weeks (mean, 2.2; 95% CI, -0.4 to 4.8; P = .10), and an adjusted 3.6-point (95% CI, 0.6-6.7; P = .02) greater improvement in the SF-36 MCS score at 52 weeks. There were no differences in surgery rates at 52-week follow-up. Having 1 or more adverse events at 3-week follow-up was more common in the prednisone group than in the placebo group (49.2% vs 23.9%; P < .001). CONCLUSIONS AND RELEVANCE Among patients with acute radiculopathy due to a herniated lumbar disk, a short course of oral steroids, compared with placebo, resulted in modestly improved function and no improvement in pain. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00668434.
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Affiliation(s)
- Harley Goldberg
- Kaiser Permanente Northern California Spine Care Program, San Jose2Division of Research, Kaiser Permanente Northern California, Oakland
| | - William Firtch
- Kaiser Permanente Northern California Spine Care Program, Redwood City
| | - Mark Tyburski
- Kaiser Permanente Northern California Spine Care Program, Roseville
| | - Alice Pressman
- Division of Research, Kaiser Permanente Northern California, Oakland5Sutter Health Research, Development, and Dissemination, Walnut Creek, California
| | - Lynn Ackerson
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Luisa Hamilton
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Wayne Smith
- Kaiser Permanente Northern California Spine Care Program, San Jose
| | - Ryan Carver
- Kaiser Permanente Northern California Spine Care Program, Roseville
| | - Annu Maratukulam
- Kaiser Permanente Northern California Spine Care Program, Redwood City
| | - Lawrence A Won
- Kaiser Permanente Northern California Spine Care Program, San Jose
| | - Eugene Carragee
- Orthopedic Spine Surgery Division, Department of Orthopedics, Stanford University, Palo Alto, California
| | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland7Department of Medicine, University of California, San Francisco8Department of Epidemiology and Biostatistics, University of California, San Francisco
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Manchikanti L, Nampiaparampil DE, Manchikanti KN, Falco FJ, Singh V, Benyamin RM, Kaye AD, Sehgal N, Soin A, Simopoulos TT, Bakshi S, Gharibo CG, Gilligan CJ, Hirsch JA. Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: A systematic review of randomized controlled trials. Surg Neurol Int 2015; 6:S194-235. [PMID: 26005584 PMCID: PMC4431057 DOI: 10.4103/2152-7806.156598] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 12/14/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The efficacy of epidural and facet joint injections has been assessed utilizing multiple solutions including saline, local anesthetic, steroids, and others. The responses to these various solutions have been variable and have not been systematically assessed with long-term follow-ups. METHODS Randomized trials utilizing a true active control design were included. The primary outcome measure was pain relief and the secondary outcome measure was functional improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the criteria developed by the American Society of Interventional Pain Physicians (ASIPP) for assessing interventional techniques. An evidence analysis was conducted based on the qualitative level of evidence (Level I to IV). RESULTS A total of 31 trials met the inclusion criteria. There was Level I evidence that local anesthetic with steroids was effective in managing chronic spinal pain based on multiple high-quality randomized controlled trials. The evidence also showed that local anesthetic with steroids and local anesthetic alone were equally effective except in disc herniation, where the superiority of local anesthetic with steroids was demonstrated over local anesthetic alone. CONCLUSION This systematic review showed equal efficacy for local anesthetic with steroids and local anesthetic alone in multiple spinal conditions except for disc herniation where the superiority of local anesthetic with steroids was seen over local anesthetic alone.
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Affiliation(s)
- Laxmaiah Manchikanti
- Medical Director of the Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, KY, 42003, and Clinical Professor, Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | | | - Kavita N. Manchikanti
- Fourth Year Resident in Department of Physical Medicine and Rehabilitation at the University of Kentucky, Lexington, KY, USA
| | - Frank J.E. Falco
- Medical Director of Mid Atlantic Spine and Pain Physicians, Newark, DE, Pain Medicine Fellowship Program, Temple University Hospital, Philadelphia, PA, Department of PM and R, Temple University Medical School, Philadelphia, PA, USA
| | - Vijay Singh
- Medical Director, Spine Pain Diagnostics Associates, Niagara, WI, USA
| | - Ramsin M. Benyamin
- Medical Director, Millennium Pain Center, Bloomington, IL, and Clinical Assistant Professor of Surgery, College of Medicine, University of Illinois, Urbana-Champaign, IL, USA
| | - Alan D. Kaye
- Department of Anesthesia, LSU Health Science Center, New Orleans, LA, USA
| | - Nalini Sehgal
- Interventional Pain Program, Professor and Director Pain Fellowship, Department of Orthopedics and Rehabilitation Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Amol Soin
- Ohio Pain Clinic, Centerville, OH, USA
| | - Thomas T. Simopoulos
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA., USA
| | - Sanjay Bakshi
- President of Manhattan Spine and Pain Medicine, Department of Anesthesiology, NYU Langone-Hospital for Joint Diseases, NYU School of Medicine, New York, NY, USA
| | - Christopher G. Gharibo
- Medical Director of Pain Medicine and Associate Professor of Anesthesiology and Orthopedics, Department of Anesthesiology, NYU Langone-Hospital for Joint Diseases, NYU School of Medicine, New York, NY, USA
| | - Christopher J. Gilligan
- Department of Anesthesia, Critical Care, and Pain Medicine at Beth Israel Deaconess Medical Center, Boston, MA, and Assistant Professor of Anesthesiology at Harvard Medical School, Harvard Medical School, Boston, MA, USA
| | - Joshua A. Hirsch
- Vice Chief of Interventional Care, Chief of Minimally Invasive Spine Surgery, Service Line Chief of Interventional Radiology, Director of Endovascular Neurosurgery and Neuroendovascular Program, Massachusetts General Hospital; and Associate Professor, Department of Radiology, Harvard Medical School, Boston, MA, USA
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20
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Cohen SP, Hanling S, Bicket MC, White RL, Veizi E, Kurihara C, Zhao Z, Hayek S, Guthmiller KB, Griffith SR, Gordin V, White MA, Vorobeychik Y, Pasquina PF. Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study. BMJ 2015; 350:h1748. [PMID: 25883095 PMCID: PMC4410617 DOI: 10.1136/bmj.h1748] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To evaluate whether an epidural steroid injection or gabapentin is a better treatment for lumbosacral radiculopathy. DESIGN A multicenter randomized study conducted between 2011 and 2014. Computer generated randomization was stratified by site. Patients and evaluating physicians were blinded to treatment outcomes. SETTINGS Eight military, Veterans Administration, and civilian hospitals. PARTICIPANTS 145 people with lumbosacral radicular pain secondary to herniated disc or spinal stenosis for less than four years in duration and in whom leg pain is as severe or more severe than back pain. INTERVENTIONS Participants received either epidural steroid injection plus placebo pills or sham injection plus gabapentin. MAIN OUTCOME MEASURES Average leg pain one and three months after the injection on a 0-10 numerical rating scale. A positive outcome was defined as a ≥ 2 point decrease in leg pain coupled with a positive global perceived effect. All patients had one month follow-up visits; patients whose condition improved remained blinded for their three month visit. RESULTS There were no significant differences for the primary outcome measure at one month (mean pain score 3.3 (SD 2.6) and mean change from baseline -2.2 (SD 2.4) in epidural steroid injection group versus 3.7 (SD 2.6) and -1.7 (SD 2.6) in gabapentin group; adjusted difference 0.4, 95% confidence interval -0.3 to 1.2; P=0.25) and three months (mean pain score 3.4 (SD 2.7) and mean change from baseline -2.0 (SD 2.6) versus 3.7 (SD 2.8) and -1.6 (SD 2.7), respectively; adjusted difference 0.3, -0.5 to 1.2; P=0.43). Among secondary outcomes, one month after treatment those who received epidural steroid injection had greater reductions in worst leg pain (-3.0, SD 2.8) than those treated with gabapentin (-2.0, SD 2.9; P=0.04) and were more likely to experience a positive successful outcome (66% v 46%; number needed to treat=5.0, 95% confidence interval 2.8 to 27.0; P=0.02). At three months, there were no significant differences between treatments. CONCLUSIONS Although epidural steroid injection might provide greater benefit than gabapentin for some outcome measures, the differences are modest and are transient for most people.Trial registration ClinicalTrials.gov Identifier: NCT01495923.
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Affiliation(s)
- Steven P Cohen
- Blaustein Pain Treatment Center, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, MD, USA Walter Reed National Military Medical Center, Bethesda, MD, USA Blaustein Pain Treatment Center, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Steven Hanling
- Pain Medicine Division, Department of Anesthesiology, Naval Medical Center-San Diego, USA
| | - Mark C Bicket
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA, USA
| | - Ronald L White
- Interdisciplinary Pain Medicine, Department of Surgery, Landstuhl, Regional Medical Center, Landstuhl, Germany
| | - Elias Veizi
- Pain Medicine Service Department of Anesthesiology, Louis Stokes Cleveland VA Medical Center, Case Western University, Cleveland, OH, USA
| | - Connie Kurihara
- Anesthesia Service, Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Zirong Zhao
- Department of Neurology, District of Columbia VA Hospital, Washington DC, MD, USA Department of Medicine, George Washington University, Washington DC, MD, USA
| | - Salim Hayek
- Pain Medicine Division, Department of Anesthesiology, Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Kevin B Guthmiller
- Interdisciplinary Pain Management Clinic, Department of Anesthesiology, San Antonio Military Medical Center, San Antonio, TX, USA Pain Medicine Fellowship Program, Department of Anesthesiology, San Antonio Military Medical Center, San Antonio, TX, USA
| | | | - Vitaly Gordin
- Pain Medicine Division, Department of Anesthesiology, Penn State Hershey Medical Center, Hershey, PA, USA
| | | | - Yakov Vorobeychik
- Departments of Anesthesiology and Neurology, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Paul F Pasquina
- Department of Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Developments in intervertebral disc disease research: pathophysiology, mechanobiology, and therapeutics. Curr Rev Musculoskelet Med 2015; 8:18-31. [PMID: 25694233 DOI: 10.1007/s12178-014-9253-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Low back pain is a leading cause of disability worldwide and the second most common cause of physician visits. There are many causes of back pain, and among them, disc herniation and intervertebral disc degeneration are the most common diagnoses and targets for intervention. Currently, clinical treatment outcomes are not strongly correlated with diagnoses, emphasizing the importance for characterizing more completely the mechanisms of degeneration and their relationships with symptoms. This review covers recent studies elucidating cellular and molecular changes associated with disc mechanobiology, as it relates to degeneration and regeneration. Specifically, we review findings on the biochemical changes in disc diseases, including cytokines, chemokines, and proteases; advancements in disc disease diagnostics using imaging modalities; updates on studies examining the response of the intervertebral disc to injury; and recent developments in repair strategies, including cell-based repair, biomaterials, and tissue engineering. Findings on the effects of the omega-6 fatty acid, linoleic acid, on nucleus pulposus tissue engineering are presented. Studies described in this review provide greater insights into the pathogenesis of disc degeneration and may define new paradigms for early or differential diagnostics of degeneration using new techniques such as systemic biomarkers. In addition, research on the mechanobiology of disease enriches the development of therapeutics for disc repair, with potential to diminish pain and disability associated with disc degeneration.
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22
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Holtedahl R, Brox JI, Tjomsland O. Placebo effects in trials evaluating 12 selected minimally invasive interventions: a systematic review and meta-analysis. BMJ Open 2015; 5:e007331. [PMID: 25636794 PMCID: PMC4316431 DOI: 10.1136/bmjopen-2014-007331] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 12/18/2014] [Accepted: 12/22/2014] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To analyse the impact of placebo effects on outcome in trials of selected minimally invasive procedures and to assess reported adverse events in both trial arms. DESIGN A systematic review and meta-analysis. DATA SOURCES AND STUDY SELECTION We searched MEDLINE and Cochrane library to identify systematic reviews of musculoskeletal, neurological and cardiac conditions published between January 2009 and January 2014 comparing selected minimally invasive with placebo (sham) procedures. We searched MEDLINE for additional randomised controlled trials published between January 2000 and January 2014. DATA SYNTHESIS Effect sizes (ES) in the active and placebo arms in the trials' primary and pooled secondary end points were calculated. Linear regression was used to analyse the association between end points in the active and sham groups. Reported adverse events in both trial arms were registered. RESULTS We included 21 trials involving 2519 adult participants. For primary end points, there was a large clinical effect (ES≥0.8) after active treatment in 12 trials and after sham procedures in 11 trials. For secondary end points, 7 and 5 trials showed a large clinical effect. Three trials showed a moderate difference in ES between active treatment and sham on primary end points (ES ≥0.5) but no trials reported a large difference. No trials showed large or moderate differences in ES on pooled secondary end points. Regression analysis of end points in active treatment and sham arms estimated an R(2) of 0.78 for primary and 0.84 for secondary end points. Adverse events after sham were in most cases minor and of short duration. CONCLUSIONS The generally small differences in ES between active treatment and sham suggest that non-specific mechanisms, including placebo, are major predictors of the observed effects. Adverse events related to sham procedures were mainly minor and short-lived. Ethical arguments frequently raised against sham-controlled trials were generally not substantiated.
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Affiliation(s)
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Ole Tjomsland
- South-Eastern Norway Regional Health Authority, Hamar, Norway
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23
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Wang YF, Chen PY, Chang W, Zhu FQ, Xu LL, Wang SL, Chang LY, Luo J, Liu GJ. Clinical significance of tumor necrosis factor-α inhibitors in the treatment of sciatica: a systematic review and meta-analysis. PLoS One 2014; 9:e103147. [PMID: 25050851 PMCID: PMC4106891 DOI: 10.1371/journal.pone.0103147] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 06/26/2014] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Currently, no satisfactory treatment is available for sciatica caused by herniated discs and/or spinal stenosis. The objective of this study is to assess the value of tumor necrosis factor (TNF)-α inhibitors in the treatment of sciatica. METHODS Without language restrictions, we searched PubMed, OVID, EMBASE, the Web of Science, the Clinical Trials Registers, the Cochrane Central Register of Controlled Trials and the China Academic Library and Information System. We then performed a systematic review and meta-analysis on the enrolled trials that met the inclusion criteria. RESULTS Nine prospective randomized controlled trials (RCTs) and two before-after controlled trials involving 531 patients met our inclusion criteria and were included in this study. Our systematic assessment and meta-analysis demonstrated that in terms of the natural course of the disease, compared with the control condition, TNF-α inhibitors neither significantly relieved lower back and leg pain (both p > 0.05) nor enhanced the proportion of patients who felt overall satisfaction (global perceived effect (satisfaction)) or were able to return to work (return to work) (combined endpoint; p > 0.05) at the short-term, medium-term and long-term follow-ups. In addition, compared with the control condition, TNF-α inhibitors could reduce the risk ratio (RR) of discectomy or radicular block (combined endpoint; RR = 0.51, 95% CI 0.26 to 1.00, p = 0.049) at medium-term follow-up, but did not decrease RR at the short-term (RR = 0.64, 95% CI 0.17 to 2.40, p = 0.508) and long-term follow-ups (RR = 0.64, 95% CI 0.40 to 1.03, p = 0.065). CONCLUSION The currently available evidence demonstrated that other than reducing the RR of discectomy or radicular block (combined endpoint) at medium-term follow-up, TNF-α inhibitors showed limited clinical value in the treatment of sciatica caused by herniated discs and/or spinal stenosis.
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Affiliation(s)
- Yun Fu Wang
- Department of Neurology, Taihe Hospital Affiliated to Hubei University of Medicine, Shiyan City, Hubei Province, China
| | - Ping You Chen
- Medical Imaging Center, Taihe Hospital Affiliated to Hubei University of Medicine, Shiyan City, Hubei Province, China
| | - Wei Chang
- Department of Spine Surgery, Taihe Hospital Affiliated to Hubei University of Medicine, Shiyan City, Hubei Province, China
| | - Fi Qi Zhu
- Department of Neurology, Yuebei People’s Hospital Affiliated to Shantou University Medical College, Shaoguan City, Guangdong Province, China
| | - Li Li Xu
- Department of Neurology, Taihe Hospital Affiliated to Hubei University of Medicine, Shiyan City, Hubei Province, China
| | - Song Lin Wang
- Department of Neurology, Taihe Hospital Affiliated to Hubei University of Medicine, Shiyan City, Hubei Province, China
| | - Li Ying Chang
- Department of Neurology, Xiangyang Center Hospital Affiliated to Hubei University of Arts and Science, Xiangyang City, Hubei Province, China
| | - Jie Luo
- Department of Neurology, Taihe Hospital Affiliated to Hubei University of Medicine, Shiyan City, Hubei Province, China
| | - Guang Jian Liu
- Department of Neurology, Taihe Hospital Affiliated to Hubei University of Medicine, Shiyan City, Hubei Province, China
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Modulating the delicate glial-neuronal interactions in neuropathic pain: promises and potential caveats. Neurosci Biobehav Rev 2014; 45:19-27. [PMID: 24820245 DOI: 10.1016/j.neubiorev.2014.05.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 04/22/2014] [Accepted: 05/02/2014] [Indexed: 12/27/2022]
Abstract
During neuropathic pain, glial cells (mainly astrocytes and microglia) become activated and initiate a series of signaling cascades that modulate pain processing at both spinal and supraspinal levels. It has been generally accepted that glial cell activation contributes to neuropathic pain because glia release proinflammatory cytokines, chemokines, and factors such as calcitonin gene-related peptide, substance P, and glutamate, which are known to facilitate pain signaling. However, recent research has shown that activation of glia also leads to some beneficial outcomes. Glia release anti-inflammatory factors that protect against neurotoxicity and restore normal pain. Accordingly, use of glial inhibitors might compromise the protective functions of glia in addition to suppressing their detrimental effects. With a better understanding of how different conditions affect glial cell activation, we may be able to promote the protective function of glia and pave the way for future development of novel, safe, and effective treatments of neuropathic pain.
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Moser C, Thiel HJ, Grönemeyer D. [Biotechnological therapies for the treatment of back pain: alternatives to corticosteroids]. DER ORTHOPADE 2013; 42:1054-61. [PMID: 24201832 DOI: 10.1007/s00132-013-2197-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In recent years, it is increasingly clear that back pain is not only caused by biomechanical problems. Currently, biologically-based local therapy concepts for the treatment of affected spinal regions as an alternative to the standard treatment with steroids are in development or in early stages of clinical application. The common features of these new therapies are to intervene in the regulation of homeostasis at various key points at the affected region and specifically to suppress or block catabolic influences as well as to provide with anti-inflammatory substances and growth factors. These include on one hand the genetically produced Biologicals such as TNF-α inhibitors and cytokine antagonists and on the other hand therapies with autologous blood preparations (Autologous Conditioned Serum [ACS], and Platelet Rich Plasma formulations [PRP]). This article presents the individual methods, gives an overview of developments and results of various studies and discusses current recommendations.
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Affiliation(s)
- C Moser
- Grönemeyer Institut für Mikrotherapie; Lehrstuhl für Radiologie und Mikrotherapie, Universität Witten/Herdecke, Universitätsstr. 142, 44799, Bochum, Deutschland,
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Risbud MV, Shapiro IM. Role of cytokines in intervertebral disc degeneration: pain and disc content. Nat Rev Rheumatol 2013; 10:44-56. [PMID: 24166242 DOI: 10.1038/nrrheum.2013.160] [Citation(s) in RCA: 1054] [Impact Index Per Article: 95.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Degeneration of the intervertebral discs (IVDs) is a major contributor to back, neck and radicular pain. IVD degeneration is characterized by increases in levels of the proinflammatory cytokines TNF, IL-1α, IL-1β, IL-6 and IL-17 secreted by the IVD cells; these cytokines promote extracellular matrix degradation, chemokine production and changes in IVD cell phenotype. The resulting imbalance in catabolic and anabolic responses leads to the degeneration of IVD tissues, as well as disc herniation and radicular pain. The release of chemokines from degenerating discs promotes the infiltration and activation of immune cells, further amplifying the inflammatory cascade. Leukocyte migration into the IVD is accompanied by the appearance of microvasculature tissue and nerve fibres. Furthermore, neurogenic factors, generated by both disc and immune cells, induce expression of pain-associated cation channels in the dorsal root ganglion. Depolarization of these ion channels is likely to promote discogenic and radicular pain, and reinforce the cytokine-mediated degenerative cascade. Taken together, an enhanced understanding of the contribution of cytokines and immune cells to these catabolic, angiogenic and nociceptive processes could provide new targets for the treatment of symptomatic disc disease. In this Review, the role of key inflammatory cytokines during each of the individual phases of degenerative disc disease, as well as the outcomes of major clinical studies aimed at blocking cytokine function, are discussed.
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Affiliation(s)
- Makarand V Risbud
- Department of Orthopaedic Surgery, Jefferson Medical College, 1025 Walnut Street, 511 College Building, Philadelphia, PA 19107, USA
| | - Irving M Shapiro
- Department of Orthopaedic Surgery, Jefferson Medical College, 1025 Walnut Street, 511 College Building, Philadelphia, PA 19107, USA
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Abstract
BACKGROUND Persistent pain is measured by means of self-report, the sole reliance on which hampers diagnosis and treatment. Functional magnetic resonance imaging (fMRI) holds promise for identifying objective measures of pain, but brain measures that are sensitive and specific to physical pain have not yet been identified. METHODS In four studies involving a total of 114 participants, we developed an fMRI-based measure that predicts pain intensity at the level of the individual person. In study 1, we used machine-learning analyses to identify a pattern of fMRI activity across brain regions--a neurologic signature--that was associated with heat-induced pain. The pattern included the thalamus, the posterior and anterior insulae, the secondary somatosensory cortex, the anterior cingulate cortex, the periaqueductal gray matter, and other regions. In study 2, we tested the sensitivity and specificity of the signature to pain versus warmth in a new sample. In study 3, we assessed specificity relative to social pain, which activates many of the same brain regions as physical pain. In study 4, we assessed the responsiveness of the measure to the analgesic agent remifentanil. RESULTS In study 1, the neurologic signature showed sensitivity and specificity of 94% or more (95% confidence interval [CI], 89 to 98) in discriminating painful heat from nonpainful warmth, pain anticipation, and pain recall. In study 2, the signature discriminated between painful heat and nonpainful warmth with 93% sensitivity and specificity (95% CI, 84 to 100). In study 3, it discriminated between physical pain and social pain with 85% sensitivity (95% CI, 76 to 94) and 73% specificity (95% CI, 61 to 84) and with 95% sensitivity and specificity in a forced-choice test of which of two conditions was more painful. In study 4, the strength of the signature response was substantially reduced when remifentanil was administered. CONCLUSIONS It is possible to use fMRI to assess pain elicited by noxious heat in healthy persons. Future studies are needed to assess whether the signature predicts clinical pain. (Funded by the National Institute on Drug Abuse and others.).
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Affiliation(s)
- Tor D Wager
- Department of Psychology and Neuroscience, University of Colorado, Boulder, 80305, USA.
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Strong JA, Xie W, Bataille FJ, Zhang JM. Preclinical studies of low back pain. Mol Pain 2013; 9:17. [PMID: 23537369 PMCID: PMC3617092 DOI: 10.1186/1744-8069-9-17] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 03/18/2013] [Indexed: 12/12/2022] Open
Abstract
Chronic low back pain is a major cause of disability and health care costs. Current treatments are inadequate for many patients. A number of preclinical models have been developed that attempt to mimic aspects of clinical conditions that contribute to low back pain. These involve application of nucleus pulposus material near the lumbar dorsal root ganglia (DRG), chronic compression of the DRG, or localized inflammation of the DRG. These models, which are primarily implemented in rats, have many common features including behavioral hypersensitivity of the hindpaw, enhanced excitability and spontaneous activity of sensory neurons, and locally elevated levels of inflammatory mediators including cytokines. Clinically, epidural injection of steroids (glucocorticoids) is commonly used when more conservative treatments fail, but clinical trials evaluating these treatments have yielded mixed results. There are relatively few preclinical studies of steroid effects in low back pain models. One preclinical study suggests that the mineralocorticoid receptor, also present in the DRG, may have pro-inflammatory effects that oppose the activation of the glucocorticoid receptor. Although the glucocorticoid receptor is the target of anti-inflammatory steroids, many clinically used steroids activate both receptors. This could be one explanation for the limited effects of epidural steroids in some patients. Additional preclinical research is needed to address other possible reasons for limited efficacy of steroids, such as central sensitization or presence of an ongoing inflammatory stimulus in some forms of low back pain.
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Affiliation(s)
- Judith A Strong
- Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0531, USA
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Williams NH, Lewis R, Din NU, Matar HE, Fitzsimmons D, Phillips CJ, Sutton A, Burton K, Hendry M, Nafees S, Wilkinson C. A systematic review and meta-analysis of biological treatments targeting tumour necrosis factor α for sciatica. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 22:1921-35. [PMID: 23529742 DOI: 10.1007/s00586-013-2739-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 02/11/2013] [Accepted: 03/02/2013] [Indexed: 12/27/2022]
Abstract
PURPOSE Systematic review comparing biological agents, targeting tumour necrosis factor α, for sciatica with placebo and alternative interventions. METHODS We searched 21 electronic databases and bibliographies of included studies. We included randomised controlled trials (RCTs), non-RCTs and controlled observational studies of adults who had sciatica treated by biological agents compared with placebo or alternative interventions. RESULTS We pooled the results of six studies (five RCTs and one non-RCT) in meta-analyses. Compared with placebo biological agents had: better global effects in the short-term odds ratio (OR) 2.0 (95 % CI 0.7-6.0), medium-term OR 2.7 (95 % CI 1.0-7.1) and long-term OR 2.3 [95 % CI 0.5 to 9.7); improved leg pain intensity in the short-term weighted mean difference (WMD) -13.6 (95 % CI -26.8 to -0.4), medium-term WMD -7.0 (95 % CI -15.4 to 1.5), but not long-term WMD 0.2 (95 % CI -20.3 to 20.8); improved Oswestry Disability Index (ODI) in the short-term WMD -5.2 (95 % CI -14.1 to 3.7), medium-term WMD -8.2 (95 % CI -14.4 to -2.0), and long-term WMD -5.0 (95 % CI -11.8 to 1.8). There was heterogeneity in the leg pain intensity and ODI results and improvements were no longer statistically significant when studies were restricted to RCTs. There was a reduction in the need for discectomy, which was not statistically significant, and no difference in the number of adverse effects. CONCLUSIONS There was insufficient evidence to recommend these agents when treating sciatica, but sufficient evidence to suggest that larger RCTs are needed.
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Affiliation(s)
- Nefyn H Williams
- North Wales Centre for Primary Care Research, North Wales Clinical School, Bangor University, Gwenfro 4-8, Wrexham Technology Park, Wrexham, LL13 7YP, UK,
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Whynes DK, McCahon RA, Ravenscroft A, Hardman J. Cost effectiveness of epidural steroid injections to manage chronic lower back pain. BMC Anesthesiol 2012; 12:26. [PMID: 23016755 PMCID: PMC3468401 DOI: 10.1186/1471-2253-12-26] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 09/25/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The efficacy of epidural steroid injections in the management of chronic low back pain is disputed, yet the technique remains popular amongst physicians and patients alike. This study assesses the cost effectiveness of injections administered in a routine outpatient setting in England. METHODS Patients attending the Nottingham University Hospitals' Pain Clinic received two injections of methylprednisolone plus levobupivacaine at different dosages, separated by at least 12 weeks. Prior to each injection, and every week thereafter for 12 weeks, participants completed the EQ-5D health-related quality of life instrument. For each patient for each injection, total health state utility gain relative to baseline was calculated. The cost of the procedure was modelled from observed clinical practice. Cost effectiveness was calculated as procedure cost relative to utility gain. RESULTS 39 patients provided records. Over a 13-week period commencing with injection, mean quality adjusted life year (QALY) gains per patient for the two dosages were 0.028 (SD 0.063) and 0.021 (SD 0.057). The difference in QALYs gained by dosage was insignificant (paired t-test, CIs -0.019 - 0.033). Based on modelled resource use and data from other studies, the mean cost of an injection was estimated at £219 (SD 83). The cost utility ratio of the two injections amounted to £8,975 per QALY gained (CIs 5,480 - 22,915). However, at costs equivalent to the tariff price typically paid to providers by health care purchasers, the ratio increased to £27,459 (CIs 16,779 - 70,091). CONCLUSIONS When provided in an outpatient setting, epidural steroid injections are a short term, but nevertheless cost effective, means of managing chronic low back pain. However, designation of the procedure as a day case requires the National Health Service to reimburse providers at a price which pushes the procedure to the margin of cost effectiveness. TRIAL REGISTRATION ISRCTN 43299460.
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Affiliation(s)
- David K Whynes
- School of Economics, University of Nottingham, Nottingham, NG7 2RD, UK.
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