A minimum of 5-year follow-up after lumbar transforaminal epidural steroid injections in patients with lumbar radicular pain due to intervertebral disc herniation

Kennedy, David J.; Zheng, Patricia; Smuck, Matthew; McCormick, Zachary L.; Huynh, Lisa; Schneider, Byron J.

doi:10.1016/j.spinee.2017.08.264

Cited by 62 publications

(36 citation statements)

References 13 publications

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“…The short-term follow-up period was 2 weeks to 1 month, while the long-term follow-up period was 4 to 6 months because pain and functional data in this period could be most abundantly obtained and clinically meaningful. Clinical data after 6 months was not considered due to clinical effects from previously performed ESI deteriorating substantially by this time (2,29).…”

Section: Search Resultsmentioning

confidence: 99%

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Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis

Lee

2018

Pain Phys

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Background: Epidural injection (EI) is used to treat back or radicular pain from lumbosacral disc herniation (LDH). Although several reports have stated that the transforaminal approach in EI (TFEI) has an advantage in target specificity and yields better clinical efficacy than the interlaminar approach in EI (ILEI), other studies have indicated that the clinical efficacy of ILEI was not inferior to that of TFEI and that ILEI also has the ability to spread medication into the ventral space to a degree similar to that of TFEI. There has been controversy about whether TFEI is superior to ILEI in clinical efficacy. Objectives: This systematic review and meta-analysis aimed to investigate whether TFEI is more useful than ILEI for achieving clinical outcomes in patients with LDH. Study design: A systematic review and meta-analysis using a random effects model on randomized controlled studies (RCT). Methods: A literature search was performed in MEDLINE, EMBASE, Cochrane review, and KoreaMed for studies published from January 1996 until July 2017. From those found fulfilling the search criteria, manuscripts that compared the clinical efficacy of steroids and control agents, such as local anesthetics or saline, in terms of pain control and functional improvement were included in this study. Exclusion criteria included a previous history of lumbosacral surgery, nonspecific low back pain, severe spinal stenosis, and severe disc degeneration. After reviewing titles, abstracts, and the full text of 6,711 studies; 12 studies were included in the qualitative synthesis. Data including pain scores, functional scores, and follow-up period were extracted from 10 studies and analyzed using a random effects model to obtain effect size and its statistical significance. The quality and level of evidence were analyzed in accordance with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Results: In terms of pain control, TFEI showed significantly better short-term (2 weeks to 1 month) outcomes and slightly favorable long-term (4 - 6 month) outcomes, but without significance, in comparison with ILEI. In terms of functional improvement, TFEI also showed favorable short- and long-term outcomes, but without significance, in comparison with ILEI. TFEI had target specificity, required no additional cost and resources, and had equal applicability to ILEI. However, TFEI was more associated with a higher frequency of discomfort or adverse events during the procedure. Overall, better results were reported with TFEI over ILEI, but with low-grade evidence due to the inconsistency and imprecision of the selected studies. Limitation: Analyses of safety or adverse effects could not be performed due to a lack of available data from the included studies. Conclusions: Based on low-grade evidence, TFEI showed significantly better short-term pain control and slightly favorable outcomes in long-term pain reduction and short- and long-term functional improvement in comparison with ILEI. Key words: Epidural injection, interlaminar, transforaminal, meta-analysis, systemic review, pain, function

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Section: Search Resultsmentioning

confidence: 99%

“…L umbar epidural injections (EI) have been used to treat low back and lower extremity pain from lumbosacral disc herniation (LDH) (1,2). The epidural administration of the drugs provides targeted delivery of the medications and supresses inflammatory mediators that irritate nervous tissues.…”

Section: Data Collectionmentioning

confidence: 99%

Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis

Lee

2018

Pain Phys

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“…Steroid superiority deteriorated from 3 months to 1 year, which could be explained by the fact that the steroid efficacy was usually not maintained over the long term, thus the differences in clinical efficacy diminish over time. Several reports have stated that clinical data at long-term follow-up are difficult to be considered as clinical effects from previously performed epidural steroid injection because the effects substantially deteriorate over this duration (47)(48)(49). However, physicians should not be discouraged because about 2-3 sessions per year usually achieve satisfactory results, and other strategies such as exercise and lifestyle modification may help to maintain the clinical benefits obtained through epidural injection (37,40,50,51).…”

Section: Discussionmentioning

confidence: 99%

Comparison of Clinical Efficacy of Epidural Injection With or Without Steroid in Lumbosacral Disc Herniation: A Systematic Review and Meta-analysis

Lee

Kim

et al. 2018

Pain Phys

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Background: Epidural injection is performed for treatment of back and radicular pain in patients with lumbosacral disc herniation (LDH). Steroids are usually administered to effectively remove inflammatory mediators, and local anesthetics or saline also contribute to pain reduction by washing out chemical mediators or blocking the nociceptor activity. Controversy exists regarding whether steroids produce superior clinical effects compared with local anesthetics or saline. Objectives: This study investigated whether epidural injection of steroids produces better clinical effects than local anesthetics or saline in the treatment of LDH. Study design: A literature search was performed in MEDLINE, EMBASE, Cochrane review, and KoreaMed for studies published from January 1996 until July 2017. From among the studies fulfilling the search criteria, those that compared the clinical efficacy of steroids and control agents, such as local anesthetics or saline, in terms of pain control and functional improvement were included in this study. Exclusion criteria included a previous history of lumbosacral surgery, non-specific low back pain, severe spinal stenosis, and severe disc degeneration. Setting: A systematic review and meta-analysis using a random effects model on randomized controlled studies (RCTs). Methods: After reviewing titles, abstracts, and full texts of 6,711 studies that were chosen following removal of duplicates after the initial database search, 15 randomized controlled studies were included in our qualitative synthesis. Data including pain score, functional score, and follow-up period were extracted from 14 studies and analyzed using a random effects model to calculate the effect size and its corresponding statistical significance. Quality and level of evidence were established in accordance with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Results: Steroids and local anesthetics were shown to be effective. Steroid showed significantly better pain control than control agents at 1 month, 3 months, and 6 months. The superiority of steroid in pain control was more prominent at one month, but diminished from 3 months to 1 year, showing no significant superiority in terms of mean difference, With respect to functional score, no significant difference was observed between steroids and control agents. The subgroup analysis showed that steroid revealed significant superiority in pain and functional score at 1 month to saline rather than local anesthetics. Generally, the quality of included studies was evaluated as high-grade, but the evidence level was determined to be moderate, due to inconsistencies. Limitation: Analyses of safety or adverse effects could not be performed due to a lack of available data from the included studies. Conclusions: Steroid is recommended over local anesthetics or saline for pain control in Systematic Review Comparison of Clinical Efficacy of Epidural Injection With or Without Steroid in Lumbosacral Disc Herniation: A Systematic Review and Meta-analysis From: 1 Department of Physical and Rehabilitation Medicine, Spine Health Wooridul Hospital, Seoul, South Korea; 2 Department of Physical and Rehabilitation Medicine, Kyung Hee University, Hospital, Seoul, South Korea; 3 Department of Physical and Rehabilitation Medicine,Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, South Korea; 4 Heal & Teun Rehabilitation & Pain Clinic, Bundang, South Korea; 5 Seocho SeBarun Hospital , Department of Physical and Rehabilitation Medicine, Seoul, South Korea; 6 Chungbuk National University Hospital,, Department of Physical and Rehabilitation Medicine, Cheongjoo, South Korea; 7 Department of Physical and Rehabilitation Medicine, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan, South Korea; 8 Department of Physical and Rehabilitation Medicine, Veterans Medical Center, Seoul, South Korea Address Correspondence: Jung Hwan Lee, MD, PhD Department of Physical and Rehabilitation Medicine Spine Health Wooridul Hospital 445, Hakdong-ro, Gangnam-gu, Seoul, South Korea E-mail: j986802@hanmail.net Disclaimer: There was no external funding in the preparation of this manuscript. Conflict of interest: Each author certifies that he or she, or a member of his or her immediate family, has no commercial association (i.e., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of Jung Hwan Lee, MD, PhD1 , Dong Hwan Kim, MD, PhD2 , Du Hwan Kim, MD, PhD3 , Kyoung-ho Shin, MD4 , Sung Jin Park, MD5 , Goo Joo Lee, MD6 , Chang-Hyung Lee, MD, PhD7 , and Hee Seung Yang, MD8 www.painphysicianjournal.com Pain Physician 2018; 21:449-467 • ISSN 1533-3159 patients with LDH, with a weak strength of recommendation. The superiority of steroids was remarkable, especially at relatively short-term follow-ups, and maintained until the 1 year followup. The clinical benefits of steroids at 1 month were more prominent when compared with saline, than when compared with local anesthetics. Key words: Steroid, local anesthetics, saline, epidural injection, pain, function, meta-analysis, systemic review

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“…Epidural steroid injections are used with the aim of reducing the inflammation of the neural structures which may serve to reduce the oedema around the nerves and reduce the degree of impingement on them. (7)(8)(9)(10)(11)(12) This modality of treatment is usually used when other conservative methods of treatment have yielded suboptimal results or in combination with other non-operative modalities. (13,14) In some instances, steroid injections may be used post-operatively in patients with persistent radicular pain following surgery.…”

Section: Introductionmentioning

confidence: 99%

The Efficacy of Epidural Steroid Injections in the Management of Patients With Lumbosacral Degenerative Spine Diseases

B¹,

O²,

Amupitan³

et al. 2018

jemds

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BACKGROUND Degenerative diseases of the lumbosacral region are becoming a more frequent presentation to the clinician, particularly with the increasing ageing population worldwide. These conditions result in impingement of the nerve roots and inflammation, causing radiculopathy along the course of the affected nerve root. Epidural steroid injections are commonly employed to alleviate the radiculopathy when the use of conservative methods of treatment have failed. The objective of the study was to determine the efficacy of this treatment modality in our setting. MATERIALS AND METHODS This study was an observational study carried out at the Jos University Teaching Hospital, Nigeria. Patients who had epidural steroids within one-year period (July 2016-June 2017), who were being managed for degenerative spine disease of the lumbosacral region were included in the study. The data was obtained from the case records of the patients. Epidural steroids were administered under sterile conditions. 80 mg of Methylprednisolone was used with 3 mL of 1% lignocaine. This was administered via the interlaminar route to the epidural space. The patients' responses were assessed using the numeric pain scale (11-point scale from 10 to 0). Data was analysed using Statistical Package for Social Sciences (SPSS). Pain before the procedure, pain after the procedure and the pain differential on the scale were assessed as well as complications. The paired t-test was used to analyse the mean pain scores at 95% confidence interval and a p-value < 0.05 was considered statistically significant. RESULTS A total of 34 patients were involved in the study. 11 males and 23 females with a male: female ratio of 1: 2.1. The ages of the patients ranged from 20 to 80 years with a mean age of 57.2. The pathologies were disc degeneration and herniation 21 (61.8%), degenerative spondylolisthesis 6 (17.5%), spinal canal stenosis 4 (11.8%) and prolapsed intervertebral disc 3 (8.8%). The mean score before the procedure was 8.8 ± 0.81; 6 (17.6%) patients scored 10, 17 (50%) scored 9, 9 (26.5%) scored 8 and 2 (5.9%) scored 7. Mean pain scores after the procedure was 2.2 ± 1.34; 14 (41.2%) patients scored 1, 9 (26.5%) scored 2, 5 (14.7%) scored 3, 4 (11.8%) scored 4 and 1 each (2.9%) scored 5 and 6; 31 (85.3%) patients had a reduction by 50% or more in their pain scores. A statistically significant difference (t= 25.09; p < 0.000 at 95% confidence interval) was observed between the mean pain scores before and after epidural steroid injection. CONCLUSION Epidural steroid injections are a safe and effective method of treating patients with radiculopathy from lumbosacral degenerative spine diseases.

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A minimum of 5-year follow-up after lumbar transforaminal epidural steroid injections in patients with lumbar radicular pain due to intervertebral disc herniation

Cited by 62 publications

References 13 publications

Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis

Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis

Comparison of Clinical Efficacy of Epidural Injection With or Without Steroid in Lumbosacral Disc Herniation: A Systematic Review and Meta-analysis

The Efficacy of Epidural Steroid Injections in the Management of Patients With Lumbosacral Degenerative Spine Diseases

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