Epidural Steroid Injections for Radicular Lumbosacral Pain

Shamliyan, Tatyana A.; Staal, J. Bart; Goldmann, David R.; Sands-Lincoln, Megan

doi:10.1016/j.pmr.2014.02.001

Cited by 51 publications

(39 citation statements)

References 139 publications

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“…There are conflicting data in the literature regarding the long-term efficacy of LESIs for lumbar radiculopathy. 2,7,20,28,29 Although epidural injections are generally considered to be relatively safe, reported risks include vasovagal episodes, procedure interruption because of intravascular flow, pain exacerbation, injection site soreness, and headache. 11,25 In addition to the adverse effects and the questionable long-term efficacy of epidural injections, their use may compromise subsequent surgical procedures and their outcomes.…”

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confidence: 99%

The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery

Singla

Yang

Werner

et al. 2017

Journal of Neurosurgery: Spine

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OBJECTIVELumbar epidural steroid injections (LESIs) are performed for both diagnostic and therapeutic purposes for a variety of indications, including low-back pain, the leading cause of disability and expense due to work-related conditions in the US. The steroid agent used in epidural injections is reported to relieve nerve root inflammation, local ischemia, and resultant pain, but the injection may also have an adverse impact on spinal surgery performed thereafter. In particular, the possibility that preoperative epidural injections may increase the risk of surgical site infection after lumbar spinal fusion has been reported but has not been studied in detail. The goal of the present study was to use a large national insurance database to analyze the association of preoperative LESIs with surgical site infection after lumbar spinal fusion.METHODSA nationwide insurance database of patient records was used for this retrospective analysis. Current Procedural Terminology codes were used to query the database for patients who had undergone LESI and 1- or 2-level lumbar posterior spinal fusion procedures. The rate of postoperative infection after 1- or 2-level posterior spinal fusion was analyzed. These study patients were then divided into 3 separate cohorts: 1) lumbar spinal fusion performed within 1 month after LESI, 2) fusion performed between 1 and 3 months after LESI, and 3) fusion performed between 3 and 6 months after LESI. The study patients were compared with a control cohort of patients who underwent lumbar fusion without previous LESI.RESULTSThe overall 3-month infection rate after lumbar spinal fusion procedure was 1.6% (1411 of 88,540 patients). The infection risk increased in patients who received LESI within 1 month (OR 2.6, p < 0.0001) or 1–3 months (OR 1.4, p = 0.0002) prior to surgery compared with controls. The infection risk was not significantly different from controls in patients who underwent lumbar fusion more than 3 months after LESI.CONCLUSIONSLumbar spinal fusion performed within 3 months after LESI may be associated with an increased rate of postoperative infection. This association was not found when lumbar fusion was performed more than 3 months after LESI.

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confidence: 99%

The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery

Singla

Yang

Werner

et al. 2017

Journal of Neurosurgery: Spine

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“…First, published reviews have included trials of a variety of epidural delivery routes besides transforaminal (e.g., interlaminar and caudal), 15,16 but these routes often do not result in the steroids reaching the exiting spinal nerve, anterior epidural space, and the dorsal root ganglion 17,18 -the desired sites of action to counteract the inflammation secondary to compression from herniated intervertebral disks. It is now recognized that fluoroscopically guided injections through the transforaminal epidural (TFE) route (i.e., around the emerging spinal nerve roots) are the best option for ensuring delivery of steroids near the site of the pathology and are likely to be more effective.…”

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confidence: 99%

“…Data from patients with lumbosacral radicular pain attributable to spinal stenosis (a chronic, often multivertebral level pathology) often are combined with data from subjects with herniated intervertebral disks. 4,16,19 This makes it difficult for readers to appreciate the true therapeutic benefit of epidural steroids in patients with lumbosacral radicular pain due to herniated intervertebral disks. In the most recent SR-MA on TFE steroids for lumbosacral radicular pain published in 2012, data from only 3 trials conducted before 2010 could be used for quantitative analysis, and there was no attempt to stratify administered doses of steroids or to examine the quality of evidence.…”

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confidence: 99%

Transforaminal Epidural Steroid Injections for Treating Lumbosacral Radicular Pain from Herniated Intervertebral Discs

Bhatia

Flamer

Shah

et al. 2016

Anesthesia &Amp; Analgesia

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TFE steroids provide modest analgesic benefit at 3 months in patients with lumbosacral radicular pain secondary to herniated intervertebral disks, but they have no impact on physical disability or incidence of surgery. There was a high degree of heterogeneity among the publications included in this meta-analysis. Well-designed, large, randomized studies are required to evaluate appropriate dosages, adverse effects, number of procedures, and the effect of this intervention on psychological disability and quality of life.

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“…Of the 163 articles initially found in the search, and an additional systematic review article, 3 only 39 were included in the final cohort. Five were meta-analyses/reviews, 5 were prospective observational studies, 1 was a retrospective observational study, and 28 were randomized trials.…”

Section: Resultsmentioning

confidence: 99%

When Do Lumbar Epidural Steroid Injections Help? A Systematic Review

Kiritsy¹,

Siefferman²

2016

Topics in Pain Management

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L ow back pain (LBP) is a common symptom, and patients often present to interventional pain specialists for an epidural steroid injection (ESI). However, much of the data surrounding the efficacy of ESI for LBP is conflicting. Part 1 of this 2-part series is a general review of the literature with best available recommendations. In part 2, some of the more relevant articles analyzed are reviewed as an appendix.The goal of this systematic review article is to determine under which conditions an ESI may be helpful for LBP. All meta-analyses and clinical trials known by the authors to have been published within the last 5 years were reviewed.In the review, there was a vast degree of heterogeneity in causes of LBP, injection approach, volume, and composition. The data demonstrated consistent level I evidence supporting the use of ESI for short-term relief of radicular pain from herniated discs, with a transforaminal approach being the most common technique. For spinal stenosis, epidural injections with or without steroids were equally effective and superior to placebo or to no epidural injection.The results suggest that the cause of LBP is likely an important factor for determining whether an epidural injection will Learning Objectives: After participating in this CME activity, the physician should be better able to: 1. Explain the current literature regarding the efficacy of lumbar epidural injections for low back pain. 2. Understand the effect that approach may have on the efficacy of epidural injections. 3. Describe variables in injected medications and how they affect the efficacy of lumbar epidural injections. 4. Increase awareness about the challenges that exist in studying epidural injection efficacy for low back pain.

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Epidural Steroid Injections for Radicular Lumbosacral Pain

Cited by 51 publications

References 139 publications

The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery

The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery

Transforaminal Epidural Steroid Injections for Treating Lumbosacral Radicular Pain from Herniated Intervertebral Discs

When Do Lumbar Epidural Steroid Injections Help? A Systematic Review

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