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Raffet A, Laslett M, Lee R, Khaled N, Mohamed GAM, Sayed HY, Omar AH, Hawana MM, Ali MM, Elhafez SM, ElMeligie MM, Fawaz HE. A nerve root decompression position identified by 3D CT scan: the modified reversed contralateral axial rotation position for patients with lumbar disc prolapse. J Orthop Surg Res 2025; 20:386. [PMID: 40247336 PMCID: PMC12007341 DOI: 10.1186/s13018-025-05762-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2025] [Accepted: 03/26/2025] [Indexed: 04/19/2025] Open
Abstract
BACKGROUND Nerve root compression in the lumbar intervertebral foramen (LIVF) is a consistent feature of radicular syndrome. There is debate about movements and positions that may reduce compression for possible use in conservative treatment. PURPOSE To investigate real-time effects of specific 3 dimensional positioning of the trunk on the cross sectional area (CSA) of the LIVF in patients with lumbar disc prolapse and radiculopathy using 3D-CT scan imaging. METHODS Ninety males aged between 20 and 40 years with unilateral lumbar disc prolapse and radiculopathy were separated into three equal groups based on the level of disc prolapse. Group (A): L3/L4, group (B): L4/L5, and group (C): L5/S1. All underwent three separate imaging sessions; first in the supine position to establish baseline data (Baseline-Image 1), followed by a modified reversed contralateral axial rotation position (Image 2), and finally the same position as Image 2 but after 48 h of using the position as a therapeutic intervention (Image 3). The CSA of LIVF at L3/L4, L4/L5, and L5/S1 levels and the angles of straight leg raising (SLR) test were measured following each imaging session. RESULTS Two-way mixed MANOVA analysis revealed that the mean values of the CSA of LIVF and the angle of SLR test were significantly increased in Image 2 compared with Baseline-Image 1 across all tested groups (P = 0.001). Moreover, the measured outcome variables were significantly increased in Image 3 compared with Image 2 and Baseline-Image 1 across all tested groups (P = 0.001). CONCLUSION The modified reversed contralateral axial rotation position of the trunk had a real-time decompression effect on the impinged nerve roots in patients with unilateral lumbar disc prolapse and radiculopathy.
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Affiliation(s)
- Ahmed Raffet
- Department of Biomechanics, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
| | - Mark Laslett
- The Sports Clinic, 156 Bealey Avenue, Christchurch, 8014, New Zealand
| | - Raymond Lee
- Department of Biomechanics, Faculty of Technology, Portsmouth University, Portsmouth, UK
| | - Noha Khaled
- Department of Biomechanics, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
| | | | - Hossam Y Sayed
- Department of Anatomy and Embryology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed H Omar
- Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maged M Hawana
- Department of Radiology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mahmoud M Ali
- Department of Physical Therapy for Neurology and its Surgery, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
| | - Salam M Elhafez
- Department of Biomechanics, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
| | - Mohamed M ElMeligie
- Department of Basic Sciences for Physical Therapy, Faculty of Physical Therapy, Ahram Canadian University, Giza, Egypt.
- Department of Basic Sciences for Physical Therapy, Faculty of Physical Therapy, Al Hayah University, Cairo, Egypt.
| | - Hossam Eddein Fawaz
- Department of Biomechanics, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
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Raouf MM, Salem GIA, Malek FAA, Hamawy TYE, Sadik SAM, Elsaed MA. Transforaminal lumbar epidural injection of dexmedetomidine versus magnesium sulfate combined with dexamethasone for lower limb radicular pain management: a randomized, clinical trial. Anesth Pain Med (Seoul) 2025; 20:151-159. [PMID: 39809501 PMCID: PMC12066206 DOI: 10.17085/apm.24125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Revised: 10/23/2024] [Accepted: 10/30/2024] [Indexed: 01/16/2025] Open
Abstract
BACKGROUND Epidural steroid injections are frequently used to treat chronic radicular pain of a discogenic origin; however, their efficacy remains limited. Magnesium sulfate and dexmedetomidine are emerging adjuvants with the potential to enhance the effectiveness and prolong the therapeutic duration of steroid injections. METHODS In this randomized, double-blind study, 90 patients with unilateral lower limb radiculopathy due to lumbar disc prolapse who did not respond to conservative treatment for 12 weeks were assigned to three groups. The control group received dexamethasone (4 mg), lidocaine 2% (40 mg), and saline. The magnesium group received magnesium sulfate (200 mg) with dexamethasone and lidocaine. The dexmedetomidine group received dexmedetomidine (50 mg), dexamethasone, lidocaine, and saline. Pain intensity was assessed using the visual analog scale at 1 week and 1, 3, and 6 months post-treatment. Secondary outcomes included the Modified Oswestry Disability Index (MODI), analgesic consumption, and procedure-related complications. RESULTS Both magnesium and dexmedetomidine significantly reduced pain, disability, and analgesic consumption for up to 3 months. By 6 months, the magnesium group demonstrated significant improvement in pain scores and MODI and a decline in ibuprofen use compared to the control and dexmedetomidine groups. CONCLUSIONS Magnesium significantly reduced pain intensity, disability, and analgesic consumption over a 6-month observation period.
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Affiliation(s)
- Mina Maher Raouf
- Department of Anesthesia, Intensive Care and Pain Medicine, Faculty of Medicine, Minia University, Minia, Egypt
| | | | - Fady Adib Abdel Malek
- Department of Anesthesia, Intensive Care and Pain Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Tamer Youssef Elie Hamawy
- Department of Anesthesia, Intensive Care and Pain Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sadik Abdel-Maseeh Sadik
- Department of Anesthesia, Intensive Care and Pain Medicine, Faculty of Medicine, Almenofyia University, Cairo, Egypt
| | - Mohammad Awad Elsaed
- Department of Anesthesia, Intensive Care and Pain Medicine, Faculty of Medicine, Alfayoum University, Alfayoum, Egypt
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Natsios P, Golini L, Park BH, Steffen F. Effect of local epidural application of methylprednisolone acetate on time to ambulation in non-ambulatory dogs with thoracolumbar intervertebral disc disease: A prospective randomised, blinded control trial. Vet Rec 2025; 196:e4962. [PMID: 39727220 PMCID: PMC11869356 DOI: 10.1002/vetr.4962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 10/10/2024] [Accepted: 11/04/2024] [Indexed: 12/28/2024]
Abstract
BACKGROUND The objective of this study was to analyse the potential benefit of the epidural application of steroids on time to ambulation in non-ambulatory dogs affected by intervertebral disc disease (IVDD) treated with decompressive surgery. METHODS This prospective, randomised, blinded control trial involved 41 dogs with thoracolumbar disc extrusion, which were randomly allocated into two groups. In the control group, saline was locally applied after surgical decompression of the spinal cord (n = 23). In the treatment group (n = 18), local epidural application of methylprednisolone acetate (1 mg/kg) was used. Ambulation time was the primary outcome measure, defined as the ability to take 10 independent steps. RESULTS The median number of days to ambulation was 7 days (range: 1‒17 days) for the control group and 3 days (range: 1‒8 days) for the treatment group. One dog from the treatment group developed discospondylitis and abscess formation. LIMITATIONS The study's heterogeneity in dog breeds, ages and pre-existing health conditions could affect the generalisability of the findings. CONCLUSION Epidural methylprednisolone acetate applied locally at the time of surgery may accelerate recovery in dogs following IVDD surgery.
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Affiliation(s)
- Pavlos Natsios
- Small Animal Surgery ClinicVetsuisse FacultyUniversity of ZurichZurichSwitzerland
| | - Lorenzo Golini
- Division of NeurologyVetsuisse FacultyUniversity of ZurichZurichSwitzerland
| | - Brian H. Park
- Small Animal Surgery ClinicVetsuisse FacultyUniversity of ZurichZurichSwitzerland
| | - Frank Steffen
- Division of NeurologyVetsuisse FacultyUniversity of ZurichZurichSwitzerland
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Laslett M, Kennedy J, Shackel D, Johnson A, Boet R, McDonald B. Anaesthetic and corticosteroid response immediately following epidural injection in patients with MRI confirmed lumbar disc herniation. Musculoskelet Sci Pract 2025; 75:103249. [PMID: 39740642 DOI: 10.1016/j.msksp.2024.103249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 12/19/2024] [Accepted: 12/21/2024] [Indexed: 01/02/2025]
Abstract
OBJECTIVES To describe a rapid, community-based assessment, referral and management system for acute symptomatic LDH. To identify and describe specific local anaesthetic and corticosteroid patterns of pain intensity change during the first week post-epidural injection. SETTING Private practice, specialist physiotherapy clinic, community-based radiology facility. DESIGN Cohort study. METHOD Consecutive patients with clinical and MRI diagnosis of acute LDH causing radicular pain and/or radiculopathy were referred for lumbar epidural injection. Pre- and post-procedure measures of back, buttock and lower limb pain intensity were acquired at 1,2,4,6 h, and at 1 week. Analysis of changes in back, buttock and lower limb pain intensity to identify different patterns that may influence clinical management. RESULTS A detailed clinical assessment, MRI and epidural steroid injection was completed for 51 patients. Pain intensity change patterns were highly heterogeneous. Three broadly different pain intensity response patterns: "Steroid Responsive" (41%), "Mechanical" (37%) and Unconfirmed Diagnosis (22%), were identified. Psychosocial factors did not influence tendency of patients to follow one clinical pathway versus another. CONCLUSIONS Radicular pain associated with LDH responds to epidural injection in patterns that may be described as "steroid responsive" or "mechanical". LDH is not confirmed as the cause of pain in the remainder. Immediate post procedure anaesthetic and one week corticosteroid responses can guide management pathway and identify a subgroup requiring further diagnostic workup.
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Affiliation(s)
- Mark Laslett
- The Sports Clinic 156 Bealey Ave, Christchurch, New Zealand.
| | - Jo Kennedy
- The Sports Clinic 156 Bealey Ave, Christchurch, New Zealand; Te Whatu Ora Waitaha / Christchurch, Canterbury Public Hospital Emergency Department, Christchurch Hospital Riccarton Avenue Christchurch, New Zealand
| | - Dayle Shackel
- The Sports Clinic 156 Bealey Ave, Christchurch, New Zealand; New Zealand Cricket, New Zealand
| | - Amos Johnson
- Te Whatu Ora Waitaha / Christchurch, Canterbury Public Hospital Emergency Department, Christchurch Hospital Riccarton Avenue Christchurch, New Zealand; PhysioSouth Ltd, Christchurch, New Zealand
| | - Ronald Boet
- Te Whatu Ora Waitaha / Christchurch, Canterbury Public Hospital Emergency Department, Christchurch Hospital Riccarton Avenue Christchurch, New Zealand; Private Neurosurgical Practice, Specialists@256, 256 Papanui Road, Strowan, Christchurch, Canterbury, 8014, New Zealand
| | - Barry McDonald
- Department of Mathematics, Massey University, East Precinct Albany Expressway, SH17, Albany, Auckland, 0632, New Zealand
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Xu B, Zhao X, Zhang L, Feng S, Li J, Xu Y. Radiofrequency vs Steroid Injections for Spinal Facet and Sacroiliac Joint Pain: A Systematic Review and Meta-Analysis. J Pain Res 2024; 17:2903-2916. [PMID: 39247173 PMCID: PMC11380878 DOI: 10.2147/jpr.s469615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 08/18/2024] [Indexed: 09/10/2024] Open
Abstract
Purpose Pain management for spinal facet joint (SFJ) and sacroiliac joint (SIJ) pain is challenging, often requiring interventions like radiofrequency ablation (RFA) or corticosteroid injections (CI). This study aims to assess and compare the effectiveness of CI and RFA in treating SFJ and SIJ pain. We combine these treatments due to their shared pathophysiology, similar therapeutic interventions, and the necessity for an integrated approach to spinal pain management. Patients and methods Literature search from PubMed, Scopus, CENTRAL and Google Scholar for published studies upto 31st December 2023, and reporting data of patients who were treated using CI of RFA for SFJ and SIJ pain. Pooled standardized mean difference (SMD) with a 95% Confidence Interval (CI) was calculated. Results Our meta-analysis incorporated thirteen studies. Overall, patients, treated with CI had a higher pain intensity score compared to patients treated with RFA (SMD=0.92; 95% CI: 0.19 to 1.65) at 3 months, and at 6 months (SMD=1.53; 95% CI: 0.66 to 2.40) after the treatment. No significant association was reported at 12 months (SMD=1.47; 95% CI: -0.03 to 2.97). Subgroup analysis based on joint types revealed increased pain intensity scores in patients who were treated with CI for SIJ (SMD=1.25; 95% CI: 0.39 to 2.11) and SFJ (SMD=1.33; 95% CI: 0.09 to 2.57) pain. A negative but not significant effect was detected in patients, treated with CI for cervical joint pain (SMD=-0.40; 95% CI: -0.90 to 0.10). Patients treated with CI exhibited higher functional disability score compared to patients treated with RFA at 3 months (SMD=1.28; 95% CI: 0.20 to 2.35) post-treatment. Conclusion This study suggests that RFA may offer superior pain relief with longer duration compared to steroid injections for spinal facet and sacroiliac joint pain. Decision regarding specific interventions should be individualized and consider patient preferences, clinical context, and potential risks.
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Affiliation(s)
- Bo Xu
- Acupuncture and Rehabilitation Department, Huzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, Huzhou, Zhejiang, People's Republic of China
| | - Xudong Zhao
- Physical Therapy Center, Huzhou Third Municipal Hospital, the Affiliated Hospital of Huzhou University, Huzhou, Zhejiang, People's Republic of China
| | - Lei Zhang
- Acupuncture and Rehabilitation Department, Huzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, Huzhou, Zhejiang, People's Republic of China
| | - Shouhan Feng
- Oncology Department, Huzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, Huzhou, Zhejiang, People's Republic of China
| | - Jinxia Li
- Acupuncture and Rehabilitation Department, Huzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, Huzhou, Zhejiang, People's Republic of China
| | - Ye Xu
- Rehabilitation Department, Huzhou Third Municipal Hospital, the Affiliated Hospital of Huzhou University, Huzhou, Zhejiang, People's Republic of China
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Grifka J, Götz J, Fenk-Mayer A, Benditz A. [Injection treatment for cervical and lumbar syndromes: principles, indications and general performance]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:1017-1024. [PMID: 38015212 DOI: 10.1007/s00132-023-04449-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 11/29/2023]
Abstract
An intensive conservative treatment that exhausts all treatment options should fundamentally be carried out before every surgical intervention in the region of the spinal column. The therapeutic measures are determined by the extent of the cervical or lumbar syndrome. As a rule, in cases of local complaints symptomatic measures with physiotherapy or digital healthcare applications are indicated. In cases of referred cervical and lumbar syndromes targeted injections can be employed. Before targeted injection treatment a detailed orthopedic clarification with respect to the intensity of local, radicular or pseudoradicular complaints must be carried out. When carrying out minimally invasive injection treatment specific prerequisites with respect to spatial, personnel and technical conditions must be fulfilled. The indications and contraindications must be strictly controlled.
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Affiliation(s)
- J Grifka
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach GmbH, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - J Götz
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach GmbH, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - A Fenk-Mayer
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach GmbH, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - A Benditz
- Klinikum Fichtelgebirge Marktredwitz, Schillerhain 1-8, 95615, Marktredwitz, Deutschland
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Liu Y, Kim Y, Park CW, Suvithayasiri S, Jitpakdee K, Kim JS. Interlaminar Endoscopic Lumbar Discectomy Versus Microscopic Lumbar Discectomy: A Preliminary Analysis of L5-S1 Lumbar Disc Herniation Outcomes in Prospective Randomized Controlled Trials. Neurospine 2023; 20:1457-1468. [PMID: 38171312 PMCID: PMC10762397 DOI: 10.14245/ns.2346674.337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/24/2023] [Accepted: 08/28/2020] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE A preliminary report from a single institution, noninferiority, prospective randomized controlled trial is conducted to determine the effectiveness of interlaminar endoscopic lumbar discectomy (IELD) versus microscopic lumbar discectomy (MLD) for the treatment of L5-S1 lumbar disc herniation (LDH). METHODS This prospective, noncrossover, randomized controlled trials was conducted at a single neurosurgical center. Patients with symptomatic radiculopathy or intermittent neurogenic claudication caused by LDH were enrolled from July 2016 to July 2021. The study compared the effectiveness of microscopic and full-endoscopic discectomy procedures. Outcome measures included visual analogue scale (VAS) scores for back and leg pain, Oswestry Disability Index scores, radiologic measurements, endurance time of walking, and satisfaction rate. RESULTS Of 37 assessed patients, both IELD and MLD groups demonstrated significant improvements in VAS scores for pain over time, with no significant difference between them. For secondary outcomes, the IELD group had a shorter hospital stay and reduced blood loss but a longer operation time than the MLD group. Radiographic evaluations showed no change compared to preoperative data. Patient satisfaction and recovery rates were slightly higher for the MLD group, but both groups were comparable in most evaluations, with complications being minimal. CONCLUSION The IELD was noninferior in improving the intensity of back and leg pain and functional disability, compared to the MLD. Additionally, the IELD showed no difference in clinical outcomes for patients in terms of radiographic results and patient satisfaction rates. The results of this research preliminarily demonstrate that the IELD could be considered an effective alternative to MLD for L5-S1 central or paracentral LDH.
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Affiliation(s)
- Yanting Liu
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Youngjin Kim
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chan Woong Park
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Siravich Suvithayasiri
- Department of Orthopedics, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok, Thailand
- Bone and Joint Excellence Center, Thonburi Hospital, Bangkok, Thailand
| | - Khanathip Jitpakdee
- Department of Orthopedics, Thai Red Cross Society, Queen Savang Vadhana Memorial Hospital, Sriracha, Thailand
| | - Jin-Sung Kim
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Bise S, Langlet B, Pesquer L, Poussange N, Silvestre A, Dallaudiere B. Transforaminal versus interlaminar CT-guided lumbar epidural steroid injections: prospective study of 237 patients with unilateral radicular pain and up to 5 years of follow-up. Skeletal Radiol 2023; 52:1959-1967. [PMID: 36729210 DOI: 10.1007/s00256-023-04290-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/25/2023] [Accepted: 01/25/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare the efficacy of the transforaminal approach (TFA) versus the interlaminar approach (ILA) for CT-guided epidural steroid injection (CTESI) in the treatment of persistent lumbosacral radicular pain (LRP > 6 weeks) with long-term follow-up. METHODS Patients were prospectively assessed for pain by visual analogue scale (VAS) and functional disability (Oswestry Disability Index, (ODI)) before treatment, then 6 weeks (6W), 6 months (6 M), and 5 years (5Y) after CTESI. RESULTS Overall, n = 237 patients (TFA, n = 71 and ILA, n = 166) were included, and 96 patients had 5 years of follow-up. Both groups showed a statistically significant improvement in VAS and ODI values at 6W (TFA, n = 60 and ILA, n = 146, P < 0.001 for both), at 6 M (TFA, n = 34 and ILA, n = 96, P < 0.001 for both), and at 5Y (TFA, n = 32 and ILA, n = 64, P < 0.001 for both). No significant differences were observed between the two approaches in VAS or ODI decreases at 6W (P = 0.38 and P = 0.33 respectively), 6 M (P = 0.13 and P = 0.51 respectively), or 5Y (P = 0.15 and P = 0.57 respectively). No major complications were noted. CONCLUSION Outcomes after CTESI by ILA approaches are similar to those by TFA for the treatment of persistent LRP.
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Affiliation(s)
- Sylvain Bise
- Centre d'imagerie ostéo-articulaire, Clinique du sport de Bordeaux, 2 Rue Georges-Negrevergne, 33700, Mérignac, France
- Département d'imagerie musculo-squelettique, centre hospitalier universitaire Pellegrin, Place Amélie-Léon-Rabat, 33000, Bordeaux, France
| | - Benjamin Langlet
- Centre d'imagerie ostéo-articulaire, Clinique du sport de Bordeaux, 2 Rue Georges-Negrevergne, 33700, Mérignac, France
| | - Lionel Pesquer
- Centre d'imagerie ostéo-articulaire, Clinique du sport de Bordeaux, 2 Rue Georges-Negrevergne, 33700, Mérignac, France
| | - Nicolas Poussange
- Centre d'imagerie ostéo-articulaire, Clinique du sport de Bordeaux, 2 Rue Georges-Negrevergne, 33700, Mérignac, France
| | - Alain Silvestre
- Centre d'imagerie ostéo-articulaire, Clinique du sport de Bordeaux, 2 Rue Georges-Negrevergne, 33700, Mérignac, France
| | - Benjamin Dallaudiere
- Centre d'imagerie ostéo-articulaire, Clinique du sport de Bordeaux, 2 Rue Georges-Negrevergne, 33700, Mérignac, France.
- Département d'imagerie musculo-squelettique, centre hospitalier universitaire Pellegrin, Place Amélie-Léon-Rabat, 33000, Bordeaux, France.
- Centre de Résonance Magnétique des Systèmes Biologiques, UMR 5536, CNRS, Univ. Bordeaux, 146 Rue Léo Saignat, 33076, Bordeaux, France.
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Singjie LC, Kusuma SA, Saleh I, Kholinne E. The Potency of Platelet-Rich Plasma for Chronic Low Back Pain: A Systematic Review and Metaanalysis of Randomized Controlled Trial. Asian Spine J 2023; 17:782-789. [PMID: 37183000 PMCID: PMC10460651 DOI: 10.31616/asj.2022.0209] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/12/2022] [Accepted: 09/13/2022] [Indexed: 05/16/2023] Open
Abstract
Low back pain is one of the leading causes of disability in the world. Regenerative medicine can be one of the novel treatment breakthroughs in patients with low back pain, yet its use is still debatable. We performed a systematic evaluation and meta-analysis to determine the efficacy of platelet-rich plasma (PRP) treatment for patients with chronic low back pain. Comprehensive database searches were performed in four databases. This study was conducted and reported based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses Guideline and registered to PROSPERO. We included and examined randomized controlled trials that looked into research employing PRP for patients with chronic low back pain. Outcomes of interest include clinical enhancement of pain, which is demonstrated in pain scores. Three studies were included comprising 138 patients with chronic low back pain. After 1, 3, and 6 months after injection, there was a substantial reduction in the pain score difference between the PRP and control groups, demonstrating PRP's superiority over the control group in the treatment of chronic low back pain. PRP injection significantly enhances chronic low back pain in the first, third, and sixth months after injection compared to controls.
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Affiliation(s)
| | | | - Ifran Saleh
- Bone and Joint Center, St. Carolus Hospital, Jakarta,
Indonesia
| | - Erica Kholinne
- Bone and Joint Center, St. Carolus Hospital, Jakarta,
Indonesia
- Department of Surgery, Faculty of Medicine, Universitas Trisakti, Jakarta,
Indonesia
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Chu ECP, Sabourdy E. Non-surgical Restoration of L3/L4 Disc Herniation. Cureus 2023; 15:e40941. [PMID: 37496528 PMCID: PMC10368486 DOI: 10.7759/cureus.40941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 07/28/2023] Open
Abstract
We report the case of a 52-year-old Asian man presenting with severe lower back pain and bilateral radiculopathy due to acute L3/L4 disc extrusion, causing severe spinal canal stenosis and bilateral L4 nerve root compression. Following a ten-week conservative management plan consisting of high-velocity, low-amplitude spinal manipulation, adjunctive therapies, and home exercise, the patient experienced significant pain relief, functional improvement, and near resolution of deficits. A six-month follow-up MRI revealed the resolution of the L3/L4 disc extrusion, and the patient remained asymptomatic at nine months. This case highlights the potential for spontaneous resorption of a lumbar disc herniation and symptomatic improvement with conservative management, including chiropractic treatment. A favorable natural course of a disc herniation should be considered when deciding between early surgical intervention and conservative management, warranting further prospective studies to evaluate the effectiveness of chiropractic treatment and the role of spontaneous regression in symptomatic lumbar disc herniation.
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Affiliation(s)
- Eric Chun-Pu Chu
- Chiropractic and Physiotherapy Centre, New York Medical Group, Hong Kong, CHN
- Research, Mctimoney College of Chiropractic, Abingdon, GBR
| | - Edouard Sabourdy
- Chiropractic Clinic, FV (Franco-Vietnamese) Hospital, Ho Chi Minh, VNM
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Lumbar Spinal Stenosis Treatment: Is Surgery Better than Non-Surgical Treatments in Afro-Descendant Populations? Biomedicines 2022; 10:biomedicines10123144. [PMID: 36551900 PMCID: PMC9776287 DOI: 10.3390/biomedicines10123144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 11/28/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
(1) Background: Limited data are available on lumbar spine stenosis management in sub-Saharan African populations and Afro-descendant patients are underrepresented in European and US clinical trials. We aimed to compare the clinical response between decompressive surgery and conservative treatments in a population of self-reported Afro-Caribbean patients with lumbar spine stenosis over a 2-year follow-up period. (2) Methods: Prospective cohort of 137 self-reported Afro Caribbeans with lumbar spine stenosis based on clinical and radiological criteria. Patients were assigned to decompression surgery or to conservative treatments according to their outcome after a first course of steroid epidural injection and their preferences. The primary outcome was evolution of the Oswestry disability index at 3 months (3 M), 12 M, 18 M and 24 M follow-up. (3) Results: Decrease of ODI was significantly more important in the “decompression surgery” arm compared to “conservative treatment” arm at 3 M, 12 M and 18 M: −17.36 vs. 1.03 p < 10−4; −16.38 vs. −1.53 p = 0.0059 and −19.00 vs. −4.52 p = 0.021, respectively. No difference was reported at 24 M. (4) Conclusions: In this first comparative study between surgery and conservative treatments in an exclusively afro-descendant lumbar spine stenosis cohort, we report long term superiority of decompression surgery versus conservative treatments over an 18-month period.
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Shirado O, Arai Y, Iguchi T, Imagama S, Kawakami M, Nikaido T, Ogata T, Orita S, Sakai D, Sato K, Takahata M, Takeshita K, Tsuji T. Formulation of Japanese Orthopaedic Association (JOA) clinical practice guideline for the management of low back pain- the revised 2019 edition. J Orthop Sci 2022; 27:3-30. [PMID: 34836746 DOI: 10.1016/j.jos.2021.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/12/2021] [Accepted: 06/22/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The latest clinical guidelines are mandatory for physicians to follow when practicing evidence-based medicine in the treatment of low back pain. Those guidelines should target not only Japanese board-certified orthopaedic surgeons, but also primary physicians, and they should be prepared based entirely on evidence-based medicine. The Japanese Orthopaedic Association Low Back Pain guideline committee decided to update the guideline and launched the formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline with the latest data of evidence-based medicine. METHODS The Japanese Orthopaedic Association Low Back Pain guideline formulation committee revised the previous guideline based on a method for preparing clinical guidelines in Japan proposed by Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Two key phrases, "body of evidence" and "benefit and harm balance" were focused on in the revised version. Background and clinical questions were determined, followed by literature search related to each question. Appropriate articles were selected from all the searched literature. Structured abstracts were prepared, and then meta-analyses were performed. The strength of both the body of evidence and the recommendation was decided by the committee members. RESULTS Nine background and nine clinical qvuestions were determined. For each clinical question, outcomes from the literature were collected and meta-analysis was performed. Answers and explanations were described for each clinical question, and the strength of the recommendation was decided. For background questions, the recommendations were described based on previous literature. CONCLUSIONS The 2019 clinical practice guideline for the management of low back pain was completed according to the latest evidence-based medicine. We strongly hope that this guideline serves as a benchmark for all physicians, as well as patients, in the management of low back pain.
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Affiliation(s)
- Osamu Shirado
- Department of Orthopaedic and Spinal Surgery, Aizu Medical Center (AMEC) at Fukushima Medical University, Japan.
| | - Yoshiyasu Arai
- Department of Orthopaedic Surgery, Saiseikai Kawaguchi General Hospital, Japan
| | - Tetsuhiro Iguchi
- Department of Orthopaedic Surgery, Saiseikai Hyogo Prefectural Hospital, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Japan
| | | | - Takuya Nikaido
- Department of Orthopaedic Surgery, Fukushima Medical University, Japan
| | | | - Sumihisa Orita
- Center for Frontier Medical Engineering (CFME), Department of Orthopaedic Surgery, Chiba University, Japan
| | - Daisuke Sakai
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Japan
| | - Kimiaki Sato
- Department of Orthopaedic Surgery, Kurume University, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Japan
| | | | - Takashi Tsuji
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Japan
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Wong O, Zhang G, Matthews H, Skalski M, Asadi H, Lalloo S, Kurda D. Image-guided spinal injection for pain management. J Med Imaging Radiat Oncol 2021; 66:79-91. [PMID: 34369081 DOI: 10.1111/1754-9485.13308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/11/2021] [Accepted: 07/15/2021] [Indexed: 01/12/2023]
Abstract
Radiculopathy and spinal pain are debilitating conditions affecting millions of people worldwide each year. While most cases can be managed conservatively with physiotherapy and nonsteroidal anti-inflammatory medications, minimally invasive corticosteroid injections are the mainstay intervention for those not responsive to conservative treatment. Historically, spinal injections were performed in the absence of imaging guidance; however, imaging modalities, in particular fluoroscopy and computer tomography (CT), have become the standard of care in performing most of these procedures. Under imaging guidance, operators can accurately confirm needle placement and safely target localised pathologies.
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Affiliation(s)
- Osanna Wong
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - George Zhang
- Department of Medical Imaging, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Hayden Matthews
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Mathew Skalski
- Palmer College of Chiropractic - West Campus, San Jose, California, USA
| | - Hamed Asadi
- Department of Radiology, Austin Health, Melbourne, Victoria, Australia.,Department of Radiology, Monash Health, Melbourne, Victoria, Australia.,Deakin University, Geelong, Victoria, Australia
| | - Shivendra Lalloo
- Department of Medical Imaging, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Dylan Kurda
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia.,Department of Medical Imaging, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
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Hegmann KT, Travis R, Andersson GBJ, Belcourt RM, Carragee EJ, Eskay-Auerbach M, Galper J, Goertz M, Haldeman S, Hooper PD, Lessenger JE, Mayer T, Mueller KL, Murphy DR, Tellin WG, Thiese MS, Weiss MS, Harris JS. Invasive Treatments for Low Back Disorders. J Occup Environ Med 2021; 63:e215-e241. [PMID: 33769405 DOI: 10.1097/jom.0000000000001983] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders. METHODS Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders. RESULTS Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations. CONCLUSION Quality evidence should guide invasive treatment for all phases of managing low back disorders.
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Affiliation(s)
- Kurt T Hegmann
- American College of Occupational and Environmental Medicine, Elk Grove Village, Illinois
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Awad M, Raouf MM, Mikhail HK, Megalla SA, Hamawy TY, Mohamed AH. Efficacy of transforaminal epidural magnesium administration when combined with a local anaesthetic and steroid in the management of lower limb radicular pain. Eur J Pain 2021; 25:1274-1282. [PMID: 33559245 DOI: 10.1002/ejp.1748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Lower limb radicular pain resulting from a herniated intervertebral disc is a cause of functional disability and could lead to increased consumption of opioids. We evaluated the efficacy of epidural magnesium combined with a local anaesthetic and steroid in the management of this pain. METHODS This was a prospective, case-control, randomized, double-blind study. Fifty patients each received 2 ml bupivacaine, 1 ml (40 mg) methylprednisolone and 1 ml saline (0.9%) (group C) or magnesium (200 mg) instead of saline (group M). The primary outcome measure was the improvement in the pain score (assessed using a visual analogue scale (VAS)), and the secondary outcome was the improvement in the functional ability (assessed using the Modified Oswestry Disability Questionnaire (MODQ)). The VAS and MODQ scores were assessed before and at 1 day, 1 week, 1 month and 3 months post-intervention. RESULTS The VAS and MODQ scores were significantly better in group M compared to those in group C at all times post-injection (p-value < 0.001). Comparisons within the same group showed that the VAS and MODQ scores were significantly better at all post-injection time points compared to the pre-injection scores in both group C and group M (p-values < 0.0001). CONCLUSIONS Adding magnesium to a local anaesthetic and steroid to be injected in the transforaminal epidural space could improve the pain and the quality of life in patients suffering from lower limb radicular pain due to lumbo-sacral disc herniation, and this improvement could last for up to 3 months. SIGNIFICANCE Magnesium is efficient when added to local anaesthetics and steroids for management of lower limb radicular pain.
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Affiliation(s)
- Mohammed Awad
- Anesthesia and Pain Management, Faculty of Medicine, Al-Fayoum Univeresity, Al-Fayoum, Egypt
| | - Mina M Raouf
- Faculty of medicine, ElMinia university, ElMinia, Egypt
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Ryska P, Jandura J, Hoffmann P, Dvorak P, Klimova B, Valis M, Vajda M. Comparison of Pulsed Radiofrequency, Oxygen-Ozone Therapy and Epidural Steroid Injections for the Treatment of Chronic Unilateral Radicular Syndrome. MEDICINA-LITHUANIA 2021; 57:medicina57020136. [PMID: 33557175 PMCID: PMC7913960 DOI: 10.3390/medicina57020136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/25/2021] [Accepted: 02/01/2021] [Indexed: 02/04/2023]
Abstract
Background and objectives: For the treatment of chronic unilateral radicular syndrome, there are various methods including three minimally invasive computed tomography (CT)-guided methods, namely, pulsed radiofrequency (PRF), transforaminal oxygen ozone therapy (TFOOT), and transforaminal epidural steroid injection (TFESI). Despite this, it is still unclear which of these methods is the best in terms of pain reduction and disability improvement. Therefore, the purpose of this study was to evaluate the short and long-term effectiveness of these methods by measuring pain relief using the visual analogue scale (VAS) and improvement in disability (per the Oswestry disability index (ODI)) in patients with chronic unilateral radicular syndrome at L5 or S1 that do not respond to conservative treatment. Materials and Methods: After screening 692 patients, we enrolled 178 subjects, each of whom underwent one of the above CT-guided procedures. The PRF settings were as follows: pulse width = 20 ms, f = 2 Hz, U = 45 V, Z ˂ 500 Ω, and interval = 2 × 120 s. For TFOOT, an injection of 4–5 mL of an O2-O3 mixture (24 μg/mL) was administered. For the TFESI, 1 mL of a corticosteroid (betamethasone dipropionate), 3 mL of an anaesthetic (bupivacaine hydrochloride), and a 0.5 mL mixture of a non-ionic contrast agent (Iomeron 300) were administered. Pain intensity was assessed with a questionnaire. Results: The data from 178 patients (PRF, n = 57; TFOOT, n = 69; TFESI, n = 52) who submitted correctly completed questionnaires in the third month of the follow-up period were used for statistical analysis. The median pre-treatment visual analogue scale (VAS) score in all groups was six points. Immediately after treatment, the largest decrease in the median VAS score was observed in the TFESI group, with a score of 3.5 points (a decrease of 41.7%). In the PRF and TFOOT groups, the median VAS score decreased to 4 and 5 points (decreases of 33% and 16.7%, respectively). The difference in the early (immediately after) post-treatment VAS score between the TFESI and TFOOT groups was statistically significant (p = 0.0152). At the third and sixth months after treatment, the median VAS score was five points in all groups, without a statistically significant difference (p > 0.05). Additionally, there were no significant differences in the Oswestry disability index (ODI) values among the groups at any of the follow-up visits. Finally, there were no significant effects of age or body mass index (BMI) on both treatment outcomes (maximum absolute value of Spearman’s rank correlation coefficient = 0.193). Conclusions: Although the three methods are equally efficient in reducing pain over the entire follow-up, we observed that TFESI (a corticosteroid with a local anaesthetic) proved to be the most effective method for early post-treatment pain relief.
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Affiliation(s)
- Pavel Ryska
- Department of Diagnostic Radiology, University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic; (P.R.); (J.J.); (P.H.); (P.D.); (M.V.)
- Department of Diagnostic Radiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 50003 Hradec Kralove, Czech Republic
| | - Jiri Jandura
- Department of Diagnostic Radiology, University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic; (P.R.); (J.J.); (P.H.); (P.D.); (M.V.)
- Department of Diagnostic Radiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 50003 Hradec Kralove, Czech Republic
| | - Petr Hoffmann
- Department of Diagnostic Radiology, University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic; (P.R.); (J.J.); (P.H.); (P.D.); (M.V.)
- Department of Diagnostic Radiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 50003 Hradec Kralove, Czech Republic
| | - Petr Dvorak
- Department of Diagnostic Radiology, University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic; (P.R.); (J.J.); (P.H.); (P.D.); (M.V.)
- Department of Diagnostic Radiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 50003 Hradec Kralove, Czech Republic
| | - Blanka Klimova
- Department of Neurology, University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic;
- Correspondence:
| | - Martin Valis
- Department of Neurology, University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic;
| | - Milan Vajda
- Department of Diagnostic Radiology, University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic; (P.R.); (J.J.); (P.H.); (P.D.); (M.V.)
- Department of Diagnostic Radiology, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, 50003 Hradec Kralove, Czech Republic
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Faber F, Benditz A, Boluki D, Grifka J. [Application of image-guided injection for cervical and lumbar syndromes]. Z Rheumatol 2020; 79:367-378. [PMID: 32333102 DOI: 10.1007/s00393-020-00776-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The X‑ray image-guided injection methods are an important tool for the treatment of cervical and lumbar pain syndromes. For the application of these methods it is necessary to have a differentiated consideration of cervical and lumbar pain syndromes. This leads to a decoding of complaints to assignable pain generators, which enables a targeted injection method. Depending on the origin of pain, injections are placed at the nerve root or the joints. Thus, the vicious cycle of pain can be stopped. A correct technical procedure is of enormous importance. Particular attention must be paid to the pharmacological effects and special complications. A monitoring and precautionary measures are mandatory.
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Affiliation(s)
- F Faber
- Orthopädische Universitätsklinik Regensburg, Asklepios Klinikum Bad Abbach, Kaiser Karl V. Allee 3, 93077, Bad Abbach, Deutschland.
| | - A Benditz
- Orthopädische Klinik, Universität Regensburg, Bad Abbach, Deutschland
| | - D Boluki
- Orthopädische Klinik, Universität Regensburg, Bad Abbach, Deutschland
| | - J Grifka
- Orthopädische Klinik, Universität Regensburg, Bad Abbach, Deutschland
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19
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Comparing the short-term cost-effectiveness of epidural steroid injections and medical management alone for discogenic lumbar radiculopathy. Clin Neurol Neurosurg 2020; 191:105675. [PMID: 31954364 DOI: 10.1016/j.clineuro.2020.105675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 10/19/2019] [Accepted: 01/11/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Epidural steroid injections (ESIs) are a commonly used treatment strategy for low back pain and lumbar radiculopathy. However, their cost-effectiveness and ability to mediate long-term quality of life (QOL) improvements is debated. We sought to analyze the cost-effectiveness of lumbar epidural steroid injections (ESIs) compared to medical management alone for patients with lumbar radiculopathy and low back pain. PATIENTS AND METHODS QOL outcomes were prospectively collected at 3- and 6-months following initial consultation. Metrics included the EuroQol-5 Dimensions (EQ-5D) questionnaire, the Pain Disability Questionnaire (PDQ), the Patient Health Questionnaire (PHQ-9) and the Visual Analogue Scale (VAS). Cost estimations were based on Medicare national payment amounts, median income, and missed workdays. A cost-utility analysis was performed based upon cost estimations and a cost-effectiveness threshold of $100,000/Quality-adjusted life year (QALY). RESULTS One hundred forty-one patients met our inclusion/exclusion criteria; 89 received ESI and 52 were treated with medical management alone. Both cohorts showed improved EQ-5D scores at 3 months but were similar to one another: ESI (ΔEQ-5D = 0.06; p = 0.03) and medical-alone (ΔEQ-5D = 0.07; p = 0.03). No significant difference was seen between groups for total costs ($2,190 vs. $1,772; p = 0.18) or cost-utility ratios ($38,710/QALY vs. $27,313/QALY; p = 0.73). At both the 3-month and 6-month endpoints, absolute differences in cost-utility was driven by overall costs as opposed to QALY gains. Medical management alone was more cost effective at both points owing to lower expenditures, however these differences were not significant. No benefits were seen in either group on the EQ-5D or any of the patient reported outcomes at the 6-month time point. CONCLUSION ESIs were not cost-effective at either the 3-month or 6-month follow-up period. At 3 months, ESIs provide similar improvements in QOL outcomes relative to medical management and at similar costs. At 6 months, neither ESIs nor conservative management provide significant improvements in QOL outcomes.
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Hashemi M, Dadkhah P, Taheri M, Ghasemi M, Hosseinpour A, Farjam M. Patient-Reported Outcomes and Satisfaction after Cervical Epidural Steroid Injection for Cervical Radiculopathy. Galen Med J 2019; 8:e1478. [PMID: 34466515 PMCID: PMC8343784 DOI: 10.31661/gmj.v8i0.1478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/10/2019] [Accepted: 03/15/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Cervical radiculopathy caused by disc herniation is a frequent public health issue with economical and socio-professional impacts. The objective of the present study is to evaluate the patient-reported outcomes and satisfaction from cervical epidural steroid injection during a 2-year follow-up. MATERIALS AND METHODS Results based on patients' reports from a previously performed intervention of cervical epidural steroid injection on patients with cervical radiculopathy due to cervical disc herniation are prospectively collected. Outcome measures are Neck Disability Index (NDI), numerical rating scale (NRS) for pain assessment, and 5-scale patient satisfaction questionnaire (PSQ) plus opioid medication for pain relief, additional injections, and progression to surgery. RESULTS Of total 37 cases, 34 were available for follow-up after 2-year postoperatively. The mean preoperative NDI was 21.17 and improved to 17.38, and the mean NRS was 7.7 and improved to 5.00; both were statistically significant. Mean patient satisfaction after 2 years was 3.17 out of 5. 11 cases needed additional injections, and 4 of patients proceeded to surgery. CONCLUSION We showed that transforaminal cervical epidural steroid injection for cervical radiculopathy is an effective non-surgical treatment option, providing significant pain relief and functional improvement during 2-years follow-up along with higher-than-average patient satisfaction in most of our patients.
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Affiliation(s)
- Masoud Hashemi
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Payman Dadkhah
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Taheri
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahshid Ghasemi
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Hosseinpour
- Non-Communicable Disease Research Center, Fasa University of Medical Sciences, Fasa, Fars, Iran
| | - Mojtaba Farjam
- Non-Communicable Disease Research Center, Fasa University of Medical Sciences, Fasa, Fars, Iran
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Lin CK, Borresen A, Kroll M, Annaswamy TM. Predicting Response to Epidural Steroid Injections for Lumbar Spinal Stenosis with Biomarkers and Electromyography. PM R 2019; 12:663-670. [PMID: 31659847 DOI: 10.1002/pmrj.12272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 10/21/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Epidural steroid injections (ESIs) may be beneficial for lumbar spinal stenosis (LSS) symptoms. Past studies found interferon-gamma, fibronectin-aggrecan complex, and electromyography (EMG) to predict patients' response to ESIs for other spinal pathologies, but no similar studies have been done for LSS. OBJECTIVE To explore the ability of biomarkers and EMG to help predict outcome after ESI in LSS. DESIGN Prospective observational cohort. SETTING The physical medicine & rehabilitation spine clinic at a tertiary care center. PARTICIPANTS Eleven patients with LSS were recruited from the spine clinic at a Veterans Affairs Medical Center. INTERVENTIONS Participants underwent one interlaminar ESI. Before ESI, the following data were collected: pain intensity on visual analog scale (VAS), disability via the Pain Disability Questionnaire (PDQ) and LSS symptoms via the Swiss Spinal Stenosis Questionnaire (SSSQ), serum high-sensitivity C-reactive protein level, standard diagnostic EMG, assay of epidural lavasate (epidural saline lavage performed immediately prior to ESI) and serum cytokine biomarkers indicative of inflammation. OUTCOME MEASURES Leg pain intensity (VAS), disability (PDQ), LSS symptoms (SSSQ) and satisfaction (SSSQ satisfaction subscale) were assessed at 1 and 2 months following ESI. Pearson correlational coefficients were calculated between independent variables and outcome measures. RESULTS Serum monocyte chemoattractant protein-1 (MCP-1) level positively correlated with improvement on 2-month satisfaction. Abnormal EMG finding of radiculopathy positively correlated with improvement in PDQ score at 1 month. Epidural cytokine levels were not detectable in most samples, except for scattered marginally elevated levels in a few cytokines such as MCP-1, RANTES (Regulated on Activation, Normal T Cell Expressed and Secreted) and interleukin-1b. CONCLUSIONS This exploratory pilot study revealed that some biomarkers and EMG findings indicative of inflammation and nerve root injury may be predictive of improvement following ESI in patients with LSS. The results of this study will be used to inform a fully powered study to further evaluate these relationships in LSS patients.
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Affiliation(s)
| | - Aleksander Borresen
- Department of Physical Medicine & Rehabilitation, University of Alabama at Birmingham, Birmingham, AL
| | - Mitchell Kroll
- Dallas VA Research Corporation, VA North Texas Health Care System, Dallas, TX
| | - Thiru M Annaswamy
- Dallas VA Research Corporation, VA North Texas Health Care System, Dallas VA Medical Center, Dallas, TX.,Department of PM&R, UT Southwestern Medical Center, Dallas, TX
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Huang R, Meng Z, Cao Y, Yu J, Wang S, Luo C, Yu L, Xu Y, Sun Y, Jiang L. Nonsurgical medical treatment in the management of pain due to lumbar disc prolapse: A network meta-analysis. Semin Arthritis Rheum 2019; 49:303-313. [PMID: 30940466 DOI: 10.1016/j.semarthrit.2019.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 02/20/2019] [Accepted: 02/22/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Evaluate the comparative effectiveness of treatment strategies for patients with pain due to lumbar disc prolapse (LDP). METHODS PubMed, EMBASE, and the Cochrane Database were searched through September 2017. Randomized controlled trials on LDP reporting on pain intensity and/or global pain effects which compared included treatments head-to-head, against placebo, and/or against conventional care were included. Study data were independently double-extracted and data on patient traits and outcomes were collected. Risk of bias was assessed using the Cochrane risk of bias tool. Separate Bayesian network meta-analyses were undertaken to synthesize direct and indirect, short-term and long-term outcomes, summarized as odds ratios (OR) or weighted mean differences (WMD) with 95% credible intervals (CI) as well as surface under the cumulative ranking curve (SUCRA) values. RESULTS 58 studies in global effects and 74 studies in pain intensity analysis were included. Thirty-eight (65.5%) of these studies reported a possible elevated risk of bias. Autonomic drugs and transforminal epidural steroid injections (TESIs) had the highest SUCRA scores at short-term follow up (86.7 and 83.5 respectively), while Cytokines/Immunomodulators and TESI had the highest SUCRA values at long-term-follow-up in the global effect's analysis (86.6 and 80.9 respectively). Caudal steroid injections and TESIs had the highest SUCRA scores at short-term follow up (79.4 and 75.9 respectively), while at long-term follow-up biological agents and manipulation had the highest SUCRA scores (86.4 and 68.5 respectively) for pain intensity. Some treatments had few studies and/or no associated placebo-controlled trials. Studies often did not report on co-interventions, systematically differed, and reported an overall elevated risk of bias. CONCLUSION No treatment stands out as superior when compared on multiple outcomes and time periods but TESIs show promise as an effective short-term treatment. High quality studies are needed to confirm many nodes of this network meta-analysis.
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Affiliation(s)
- Rongzhong Huang
- Department of Gerontology, First People's Hospital of YunNan Province, YunNan 662299, China.
| | - Zengdong Meng
- Department of Orthopedics, First People's Hospital of YunNan Province, YunNan 662299, China.
| | - Yu Cao
- Department of cardiothoracic surgery, The First People's Hospital of YunNan Province, YunNan, China
| | - Jing Yu
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, United States.
| | - Sanrong Wang
- Department of Rehabilitation Medicine, The second Affiliated Hospital of Chongqing Medical University, No. 76 Linjiang Road, Chongqing 400010, China.
| | - Chong Luo
- Department of Orthopedics, First People's Hospital of YunNan Province, YunNan 662299, China
| | - Lehua Yu
- Department of Rehabilitation Medicine, The second Affiliated Hospital of Chongqing Medical University, No. 76 Linjiang Road, Chongqing 400010, China.
| | - Yu Xu
- Statistical laboratory, Chuang Xu Institue of Lifescience, Chongqing, China.
| | - Yang Sun
- Institute of Ultrasound Imaging, the Second Affiliated Hospital of Chongqing Medical University, No. 76 Linjiang Road, Chongqing 400010, China
| | - Lihong Jiang
- Department of cardiothoracic surgery, The First People's Hospital of YunNan Province, YunNan, China.
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Yakovlev AE, Yakovleva MV, Chaykovskaya MK, Ardashev AV. [The First in Russia Experience of Successful Implementation of Constant Neurostimulation of the Spinal Cord in the Complex Treatment of a Patient with Permanent Form of Atrial Fibrillation Combined with Spinal Stenosis]. ACTA ACUST UNITED AC 2019; 59:83-90. [PMID: 31540579 DOI: 10.18087/cardio.2019.9.10272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 09/20/2019] [Indexed: 11/18/2022]
Abstract
This article describes for the first time in the domestic literature a clinical case of the therapeutic effect of neuromodulation on the permanent form of atrial fibrillation and chronic heart failure in an elderly patient with spinal stenosis which led to the development of pain syndrome and movement disorders. For the treatment of neurological pathology, at the beginning epidural administration of drugs was applied, followed by spinal cord stimulation trial and implantation of permanent neurostimulator. At each stage of treatment conducted by a functional neurosurgeon the patient had a spontaneous restoration of sinus rhythm, and during continuous neurostimulation a stable retention of sinus rhythm and regression of heart failure symptoms have been observed throughout a long observation period. The article also presents the data of a few experimental and clinical studies on the use of neuromodulation in cardiology, describes the method of implantation of spinal electrodes and analyzes possible mechanisms of modulation of the autonomic innervation of the heart, implemented by spinal cord stimulation.
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Affiliation(s)
- A E Yakovlev
- National Medical and Research Center of Traumatology and Orthopaedics N. N. Priorov
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Hosseini B, Mosaffa F, Dabir S, Tanghatari H, Taheri M. Effects of Epidural Needle Rotation on Evolution of Unilateral Epidural Block and Patients' Hemodynamics beside Recovery Profile in Patients Undergoing Arthroscopic Knee Surgeries; A Randomized Clinical Trial. Bull Emerg Trauma 2019; 7:130-136. [PMID: 31198801 PMCID: PMC6555220 DOI: 10.29252/beat-070207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective: To evaluate the evolution pattern of epidural block after rotating the needle tip 45° to the operative side and evaluate its effects on patients’ hemodynamics and recovery profile in those undergoing arthroscopic knee surgery. Methods: Forty participants were randomly subdivided into control and rotation group (n=20). An 18-gauge, 3.5 inch, Tuohy needle was placed at the level of L4-5 and pushed forward into the epidural space through parasagittal approach, in control group, the needle was pushed forward to the epidural space in cephaldad 90 degrees. For the rotation group, the needle was pushed forward to the epidural space and the tip was rotated 45 degrees to the surgical side.15 mL of bupivacaine 0.5% was injected and evolution of sensory and motor blocks until 2-segment regression of the sensory level below to T10 as well as total duration of motor block and surgery were recorded. Hemodynamic parameters (HR, MAP, and SPO2), hypotension, fluid intake, vasopressors, first ambulation and spontaneous urination were recorded. Statistical analysis was performed using SPSS and P≤0.5 considered significant. Results: Sensory block up to T10 level, Complete motor block and time for 2-segment regression of sensory level were earlier in the 45°-rotation than in the control group (p<0.001). Total duration of motor block in control group was lower than rotation group (p<0.001).Hypotension, N&V, vasopressors and fluid intake showed no statistically difference between the two groups (p=0.219). First spontaneous urination and ambulation were significantly lower in rotation group (p<0.001). Conclusion: 45 degrees’ needle rotation to the surgical side provides a faster block evolution and hastened recovery profile with no significant difference in hemodynamic fluctuations. Clinical trial registry: IRCT20130518013364N7
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Affiliation(s)
- Behnam Hosseini
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Faramarz Mosaffa
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shideh Dabir
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamed Tanghatari
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Taheri
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Hashemi M, Dadkhah P, Taheri M, Ghasemi M, Hosseinpour A. Lumbar Transforaminal Epidural Steroid Injection in Patients with Lumbar Radicular Pain; Outcome Results of 2-Year Follow-Up. Bull Emerg Trauma 2019; 7:144-149. [PMID: 31198803 PMCID: PMC6555206 DOI: 10.29252/beat-070209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 01/28/2018] [Accepted: 02/21/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To evaluate the effectiveness of transforaminal lumbar epidural steroid injections (TFESI) in patients with unilateral radiculopathy due to lumbar intervertebral disc protrusion regarding pain intensity, functional disability, current opioid intake and patients' satisfaction. METHODS The study is conducted in a pain management center (Tehran, Iran), during 2018. Inclusion criteria were age ≥18 years, radiculopathy for more than 6 months due to imagine-proved lumbar intervertebral disc protrusion and no response to conservative treatments. Exclusion criteria were spinal canal stenosis, lumbar surgery, and inability to communicate in Persian language. During a phone call interview, cases were instructed to rate their pain intensity according to the visual analogue scale (VAS), functional ability, satisfaction according to the patient satisfaction score (PSQ) and report current opioid use and additional injection and/or surgery. RESULTS Forty-three (89.5%) of the 48 subjects were reachable for study with mean age of 59.14 years and 16 subjects were men (37.2 %). Mean VAS after intervention was 4.67 and before the intervention was 6.91 (p=0.002). Mean functional disability before intervention was 47.23 and after intervention was 37 (p<0.001). Mean patient satisfaction score was 3.07 while 18 cases reported a PSQ level ≥4. 10 cases reported using opioid for analgesia, 23 cases reported receiving additional TFESIs and 11 reported having undergone lumbar surgery. CONCLUSION Lumbar Epidural steroid injection is an effective non-surgical treatment option with regard to pain relief and improvement in functional ability with an average patients' satisfaction during 2 years follow up although nearly 25% of patients may need additional injections and half of the patients may finally proceed to surgery.
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Affiliation(s)
- Masoud Hashemi
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Payman Dadkhah
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Taheri
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahshid Ghasemi
- Department of Anesthesiology, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Hosseinpour
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Non-communicable disease research center, Fasa University of Medical Sciences, Fasa, Iran
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Ignjatovic S, Omidi R, Kubik-Huch RA, Anderson S, Ahlhelm FJ. The retroneural approach: an alternative technique for lumbar transforaminal epidural steroid injections. Acta Radiol 2018. [PMID: 29523042 DOI: 10.1177/0284185118762248] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Compared with other available injection techniques for lumbar transforaminal epidural steroid injections (LTFESIs), the traditionally performed subpedicular approach is associated with a higher risk of spinal cord infarction, a rare but catastrophic complication. PURPOSE To assess the short-term efficacy of the retroneural approach for computed tomography (CT)-guided LTFESIs with respect to different needle-tip positions. MATERIAL AND METHODS This retrospective analysis included 238 patients receiving 286 CT-guided LTFESIs from January 2013 to January 2016. Short-term outcomes in terms of pain relief were assessed using the visual analogue scale (VAS) at baseline and 30 min after. The needle-tip location was categorized as extraforaminal, junctional, or foraminal relative to the neural foramen. Additionally, the distance from the needle tip to the nerve root was measured. RESULTS A mean pain reduction of 3.22 points (±2.17 points) on the VAS was achieved. The needle-tip location was extraforaminal in 48% (136/286), junctional in 42% (120/286), and foraminal in 10% (28/286) of the cases. The mean distance from the needle tip to the nerve root was 3.83 mm (±3.37 mm). There was no significant correlation between pain relief and needle-tip position in relation to the neural foramen. Therapy success was not dependent on the distance between the needle tip and the nerve root. No major complications were observed. CONCLUSION In our population treated with LTFESIs, the retroneural approach was shown to be an effective technique, with no significant differences in pain relief following different needle-tip positions.
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Affiliation(s)
| | - Reza Omidi
- Institute of Radiology, Kantonsspital Baden AG, Baden, Switzerland
| | | | - Suzanne Anderson
- Institute of Radiology, Kantonsspital Baden AG, Baden, Switzerland
| | - Frank J Ahlhelm
- Institute of Radiology, Kantonsspital Baden AG, Baden, Switzerland
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Ibrahim SIA, Xie W, Strong JA, Tonello R, Berta T, Zhang JM. Mineralocorticoid Antagonist Improves Glucocorticoid Receptor Signaling and Dexamethasone Analgesia in an Animal Model of Low Back Pain. Front Cell Neurosci 2018; 12:453. [PMID: 30524245 PMCID: PMC6262081 DOI: 10.3389/fncel.2018.00453] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 11/09/2018] [Indexed: 11/13/2022] Open
Abstract
Low back pain, a leading cause of disability, is commonly treated by epidural steroid injections that target the anti-inflammatory glucocorticoid receptor (GR). However, their efficacy has been controversial. All currently used epidural steroids also activate the pro-inflammatory mineralocorticoid receptor (MR) with significant potency. Local inflammation of the dorsal root ganglia (DRG), a rat model of low back pain, was used. This model causes static and dynamic mechanical allodynia, cold allodynia and guarding behavior (a measure of spontaneous pain), and activates the MR, with pro-nociceptive effects. In this study, effects of local Dexamethasone (DEX; a glucocorticoid used in epidural injections), and eplerenone (EPL; a second generation, more selective MR antagonist) applied to the DRG at the time of inflammation were examined. Mechanical and spontaneous pain behaviors were more effectively reduced by the combination of DEX and EPL than by either alone. The combination of steroids was particularly more effective than DEX alone or the model alone (3-fold improvement for mechanical allodynia) at later times (day 14). Immunohistochemical analysis of the GR in the DRG showed that the receptor was expressed in neurons of all size classes, and in non-neuronal cells including satellite glia. The GR immunoreactivity was downregulated by DRG inflammation (48%) starting on day 1, consistent with the reduction of GR (57%) observed by Western blot, when compared to control animals. On day 14, the combination of DEX and EPL resulted in rescue of GR immunoreactivity that was not seen with DEX alone, and was more effective in reducing a marker for satellite glia activation/neuroinflammation. The results suggest that EPL may enhance the effectiveness of clinically used epidural steroid injections, in part by enhancing the availability of the GR. Thus, the glucocorticoid-mineralocorticoid interactions may limit the effectiveness of epidural steroids through the regulation of the GR in the DRG.
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Affiliation(s)
- Shaimaa I A Ibrahim
- Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States.,Graduate Program in Molecular, Cellular, and Biochemical Pharmacology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Wenrui Xie
- Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Judith A Strong
- Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Raquel Tonello
- Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Temugin Berta
- Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Jun-Ming Zhang
- Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Fletcher JWA, Khan M, Thorpe PLPJ. Study protocol for a randomised controlled trial of consenting processes and their effects on patient decision-making when undergoing spinal injections: the Risks In Spinal Consenting for Surgery (RISCS) trial. BMJ Open 2018; 8:e023426. [PMID: 30206091 PMCID: PMC6144337 DOI: 10.1136/bmjopen-2018-023426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 08/08/2018] [Accepted: 08/09/2018] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION There are major differences between legal and medical approaches to informed consent. Medically, consent is obtained prospectively for an intended procedure, to inform the patient of choices, risks and benefits, and to manage expectations. Legally, consent is reviewed retrospectively, usually following unmet expectations and/or the occurrence of complications. Recent legal cases relating to clinical negligence define the establishment of causation and breach of duty related to informed consent. However, there is no prospective evidence to validate the current judicial perspectives on causation and thus clinical negligence. The aim of this randomised controlled trial (RCT) is to investigate whether variations in consenting processes for the same procedure lead to changes in patient decision-making related to consent for that procedure. METHODS AND ANALYSIS The Risks In Spinal Consenting for Surgery trial is a single-centre, non-inferiority RCT, where 220 patients, aged over 18 years, receiving an elective, day case spinal injection, will be randomised to either a 'legally styled' consent form with 55 risks identified in the world literature, or a 'medically styled' consent form with the 13 serious or most common risks usually quoted by reference to specialist society guidelines. Following explanation of the medical reasons for considering an injection therapy and consent to the trial, participants will be randomly allocated to one of two groups (1:1). The patients are then given the opportunity to discuss any concerns relating to the procedure and/or risks with a single specialist practitioner. The primary outcome will be rates of consent withdrawal due to the risks explained. Secondary outcomes include scores from the State-Trait Anxiety Inventory, Visual Analogue Scale, EuroQol 5-dimension questionnaire and Oswestry Disability Index. ETHICS AND DISSEMINATION Results will be presented in peer-reviewed journals and at international conferences. This study is approved by the Health Research Authority: REC 16/SC/0510. TRIAL REGISTRATION NUMBER ISRCTN67513618; Pre-results.
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Affiliation(s)
- James W A Fletcher
- Department for Health, University of Bath, Bath, UK
- Severn School of Surgery, Health Education England, Bristol, UK
| | - Mohsin Khan
- Severn School of Surgery, Health Education England, Bristol, UK
- Department of Trauma and Orthopaedics, Bristol Royal Hospital for Children, Bristol, UK
| | - Paul L P J Thorpe
- Somerset Spinal Surgery Service, Musgrove Park Hospital Taunton and Somerset NHS Foundation Trust, Taunton, UK
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Dexamethasone as an Adjuvant to Femoral Nerve Block in Children and Adolescents Undergoing Knee Arthroscopy. Reg Anesth Pain Med 2018; 43:438-444. [DOI: 10.1097/aap.0000000000000739] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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30
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Cotten A, Drapé JL, Sans N, Feydy A, Bartoli JM, Meder JF. Société d'imagerie musculosquelettique (SIMS), Fédération de radiologie interventionnelle (FRI), and Société française de radiologie (SFR) recommendations for epidural and transforaminal corticosteroid injections. Diagn Interv Imaging 2018; 99:219-224. [PMID: 29454550 DOI: 10.1016/j.diii.2018.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 01/24/2018] [Indexed: 12/14/2022]
Affiliation(s)
- A Cotten
- Centre de consultation et d'imagerie de l'appareil locomoteur, CHRU de Lille, rue du professeur Emile-Laine, 59037 Lille cedex, France.
| | - J-L Drapé
- AP-HP, site Cochin, 27, rue du Faubourg St-Jacques, 75679 Paris, France.
| | - N Sans
- CHU Purpan, hôpital Pierre-Paul-Riquet, TSA 40031, 31059 Toulouse cedex 9, France.
| | - A Feydy
- AP-HP, site Cochin, 27, rue du Faubourg St-Jacques, 75679 Paris, France.
| | - J-M Bartoli
- Université d'Aix-Marseille, rue Saint-Pierre, 13385 Marseille cedex 05, France.
| | - J-F Meder
- Université Paris V, 1, rue Cabanis, 75674 Paris cedex 14, France.
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Zhang X, Zhang Z, Wen J, Lu J, Sun Y, Sang D. The effectiveness of therapeutic strategies for patients with radiculopathy: A network meta-analysis. Mol Pain 2018; 14:1744806918768972. [PMID: 29651898 PMCID: PMC5900815 DOI: 10.1177/1744806918768972] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 01/16/2018] [Accepted: 02/07/2018] [Indexed: 12/16/2022] Open
Abstract
Objectives The aim of this network meta-analysis is to assess the effectiveness of therapeutic strategies for patients with radiculopathy, including physical, medical, surgical, and other therapies. Methods We electronically searched electronic databases including PubMed and Embase for randomized controlled trials. The response rate and visual analog scale of pain change were considered as primary outcomes. The outcomes were measured by odds ratio (OR) value and corresponding 95% credible intervals (CrIs) or standardized mean difference (MD) with 95% CrIs. Besides, surface under cumulative ranking curve (SUCRA) were performed to rank efficacy and safety of treatments on each end points. Results A total of 16 eligible studies with 1071 subjects were included in this analysis. Our results showed that corticosteroid was significantly more effective than control regarding the response rate (OR = 3.86, 95% CrI: 1.16, 12.55). Surgery had a better performance in pain change compared with control (MD = -1.92, 95% CrI: -3.58, -0.15). According to the SUCRA results, corticosteroid, collar, and physiotherapy ranked the highest concerning response rate (SUCRA = 0.656, 0.652, and 0.610, respectively). Surgery, traction, and corticosteroid were superior to others in pain change (SUCRA = 0.866, 0.748, and 0.589, respectively). Conclusion According to the network meta-analysis result, we recommended surgery as the optimal treatment for radiculopathy patients; traction and corticosteroids were also recommended for their beneficial interventions.
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Affiliation(s)
- Xiaoyu Zhang
- Department of General Rehabilitation, Capital Medical University School of Rehabilitation Medicine, China Rehabilitation Research Center, Beijing Boai Hospital, Beijing, China
| | - Zhiqiang Zhang
- Community Chronic Disease Research Center, Institute of Chinese Basic Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jianzhong Wen
- Department of Anesthesiology, Second Affiliated Hospital of Shanxi Medical University, Taiyuan, China
| | - Jie Lu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yingchun Sun
- Chinese Medicine Treatment Center, Capital Medical University School of Rehabilitation Medicine, China Rehabilitation Research Center, Beijing Boai Hospital, Beijing, China
| | - Dechun Sang
- Department of General Rehabilitation, Capital Medical University School of Rehabilitation Medicine, China Rehabilitation Research Center, Beijing Boai Hospital, Beijing, China
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Kamawal Y, Raab P, Rudert M, Konrads C. [Targeted injections can relieve pain]. MMW Fortschr Med 2017; 159:58-62. [PMID: 29124580 DOI: 10.1007/s15006-017-0280-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Yama Kamawal
- Orthopädische Universitätsklinik König-Ludwig-Haus, Brettreichstr. 11, D-97074, Würzburg, Deutschland.
| | - Peter Raab
- Orthopädische Universitätsklinik König-Ludwig-Haus, Brettreichstr. 11, D-97074, Würzburg, Deutschland
| | - Maximilian Rudert
- Orthopädische Universitätsklinik König-Ludwig-Haus, Brettreichstr. 11, D-97074, Würzburg, Deutschland
| | - Christian Konrads
- Orthopädische Universitätsklinik König-Ludwig-Haus, Brettreichstr. 11, D-97074, Würzburg, Deutschland
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Grifka J, Benditz A, Boluki D. [Injection therapy for cervical and lumbar syndromes]. DER ORTHOPADE 2017; 46:195-214. [PMID: 28108775 DOI: 10.1007/s00132-016-3382-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In cervical and lumbar pain syndromes special injections are key for effective pain therapy. Depending on the origin of pain injections are placed at the nerve root or the joints. Thus, the vicious cycle can be stopped. A correct technical procedure is of enormous importance. Because pharmacological effects and special complications are possible, monitoring and precautions are mandatory.
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Affiliation(s)
- J Grifka
- Orthopädische Klinik, Universität Regensburg, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - A Benditz
- Orthopädische Klinik, Universität Regensburg, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - D Boluki
- Orthopädische Klinik, Universität Regensburg, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Deutschland
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Ibrahim SIA, Strong JA, Zhang JM. Mineralocorticoid Receptor, A Promising Target for Improving Management of Low Back Pain by Epidural Steroid Injections. ACTA ACUST UNITED AC 2016; 3:177-184. [PMID: 28956026 PMCID: PMC5611848 DOI: 10.24015/japm.2016.0023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AIM OF REVIEW Low back pain is a major health problem in United States and worldwide. In this review, we aim to show that mineralocorticoid receptor (MR) activation has a critical role in the initiation of immune and inflammatory responses, which in turn can impact the effectiveness of the currently used steroids for epidural injections in low back pain management since most steroids activate MR in addition to the primary target, glucocorticoid receptor (GR). Moreover, we would like to determine some of the benefits of blocking the MR-induced negative effects. Overall, we propose a novel therapeutic approach for low back pain management by using a combination of a MR antagonist and a GR agonist in the epidural injections. METHOD We will first introduce the societal cost of low back pain and discuss how epidural steroid injections became a popular treatment for this condition. We will then describe several preclinical models used for the study of low back pain conditions and the findings with respect to the role of MR in the development of inflammatory low back pain. RECENT FINDINGS MR has pro-inflammatory effects in many tissues which can counteract the anti-inflammatory effects induced by GR activation. Blocking MR using the selective MR antagonist eplerenone can reduce pain and sensory neuron excitability in experimental models of low back pain. Moreover, combining the MR antagonist with clinically used steroids is more effective in reducing pain behaviors than using the steroids alone. SUMMARY MR antagonists are promising candidates to increase the effectiveness of currently used steroids. Since the activation of the MR is evident in preclinical models of low back pain, blocking its deleterious effects can be beneficial in managing inflammatory pain conditions.
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Affiliation(s)
- Shaimaa I A Ibrahim
- Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, USA.,Graduate Program in Molecular, Cellular, and Biochemical Pharmacology, University of Cincinnati, Cincinnati, USA
| | - Judith A Strong
- Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Jun-Ming Zhang
- Pain Research Center, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, USA
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Pandey RA. Efficacy of Epidural Steroid Injection in Management of Lumbar Prolapsed Intervertebral Disc: A Comparison of Caudal, Transforaminal and Interlaminar Routes. J Clin Diagn Res 2016; 10:RC05-11. [PMID: 27630917 PMCID: PMC5020256 DOI: 10.7860/jcdr/2016/18208.8127] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 05/16/2016] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Epidural steroid is an important modality in the conservative management of prolapsed lumbar disc and is being used for over 50 years. However, controversy still persists regarding their effectiveness in reducing the pain and improving the function with literature both supporting and opposing them are available. AIM To study the efficacy of epidural steroid injection in the management of pain due to prolapsed lumbar intervertebral disc and to compare the effectiveness between caudal, transforaminal and interlaminar routes of injection. MATERIALS AND METHODS A total of 152 patients with back pain with or without radiculopathy with a lumbar disc prolapse confirmed on MRI, were included in the study and their pre injection Japanese Orthopaedic Association (JOA) Score was calculated. By simple randomization method (picking a card), patients were enrolled into one of the three groups and then injected methyl prednisone in the epidural space by one of the techniques of injection i.e. caudal, transforaminal and interlaminar. Twelve patients didn't turn up for the treatment and hence were excluded from the study. Remaining 140 patients were treated and were included for the analysis of the results. Eighty two patients received injection by caudal route, 40 by transforaminal route and 18 by interlaminar route. Post injection JOA Score was calculated at six month and one year and effectiveness of the medication was calculated for each route. The data was compared by LSD and ANOVA method to prove the significance. Average follow-up was one year. RESULTS At one year after injecting the steroid, all three routes were found to be effective in improving the JOA Score (Caudal route in 74.3%, transforaminal in 90% and interlaminar in 77.7%). Transforaminal route was significantly more effective than caudal (p=0.00) and interlaminar route (p=0.03) at both 6 months and one year after injection. No significant difference was seen between the caudal and interlaminar route (p=0.36). CONCLUSION The management of low back pain and radicular pain due to a prolapsed lumbar intervertebral disc by injecting methyl prednisone in epidural space is satisfactory in the current study. All three injection techniques are effective with the best result obtained by transforaminal route.
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Affiliation(s)
- Ritesh Arvind Pandey
- Assistant Professor, Department of Orthopaedics, CMC and Hospital, Brown Road, Ludhiana, India
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Chou R, Hashimoto R, Friedly J, Fu R, Bougatsos C, Dana T, Sullivan SD, Jarvik J. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med 2015; 163:373-81. [PMID: 26302454 DOI: 10.7326/m15-0934] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Use of epidural corticosteroid injections is increasing. PURPOSE To review evidence on the benefits and harms of epidural corticosteroid injections in adults with radicular low back pain or spinal stenosis of any duration. DATA SOURCES Ovid MEDLINE (through May 2015), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, prior systematic reviews, and reference lists. STUDY SELECTION Randomized trials of epidural corticosteroid injections versus placebo interventions, or that compared epidural injection techniques, corticosteroids, or doses. DATA EXTRACTION Dual extraction and quality assessment of individual studies, which were used to determine the overall strength of evidence (SOE). DATA SYNTHESIS 30 placebo-controlled trials evaluated epidural corticosteroid injections for radiculopathy, and 8 trials were done for spinal stenosis. For radiculopathy, epidural corticosteroids were associated with greater immediate-term reduction in pain (weighted mean difference on a scale of 0 to 100, -7.55 [95% CI, -11.4 to -3.74]; SOE, moderate), function (standardized mean difference after exclusion of an outlier trial, -0.33 [CI, -0.56 to -0.09]; SOE, low), and short-term surgery risk (relative risk, 0.62 [CI, 0.41 to 0.92]; SOE, low). Effects were below predefined minimum clinically important difference thresholds, and there were no longer-term benefits. Limited evidence showed no clear effects of technical factors, patient characteristics, or comparator interventions on estimates. There were no clear effects of epidural corticosteroid injections for spinal stenosis (SOE, low to moderate). Serious harms were rare, but harms reporting was suboptimal (SOE, low). LIMITATIONS The review was restricted to English-language studies. Some meta-analyses were based on small numbers of trials (particularly for spinal stenosis), and most trials had methodological shortcomings. CONCLUSION Epidural corticosteroid injections for radiculopathy were associated with immediate reductions in pain and function. However, benefits were small and not sustained, and there was no effect on long-term surgery risk. Limited evidence suggested no effectiveness for spinal stenosis.
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Affiliation(s)
- Roger Chou
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Robin Hashimoto
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Janna Friedly
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Rongwei Fu
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Christina Bougatsos
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Tracy Dana
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Sean D. Sullivan
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Jeffrey Jarvik
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
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Ray WZ, Akbari S, Shah LM, Bisson E. Correlation of Foraminal Area and Response to Cervical Nerve Root Injections. Cureus 2015. [PMID: 26203404 PMCID: PMC4509621 DOI: 10.7759/cureus.286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Introduction: Patients with age-related degenerative changes in the cervical spine leading to cervical spondylosis may be symptomatic or asymptomatic. Older patients with radicular pain tend to have a better response to epidural steroid injections, but it is often difficult to predict which patients will have a positive response to selective nerve root block (SNRB). We analyzed whether the cervical neuroforaminal area measured on MRI predicts immediate therapeutic responses to SNRB in patients who have cervical radiculopathy. Methods: We retrospectively reviewed all patients who had cervical SNRBs treated at a single tertiary referral center. We recorded patient demographics, the neuroforaminal area of the symptomatic and contralateral sides, Visual Analog Scale (VAS) score pre- and post-injection, history of previous cervical surgery, comorbidities, and history of tobacco use. Results: Sixty-four patients with symptoms of cervical radiculopathy treated with neuroforaminal nerve root injections had appropriate imaging and VAS scores recorded. The average foraminal area of the symptomatic side before treatment was significantly smaller than the contralateral asymptomatic neuroforamen (p<0.0001). Those patients with the smallest neuroforamen had a positive response to SNRB. Diabetes and tobacco use did not influence patient response to treatment. Conclusions: Measurement of neuroforaminal areas on MRI may represent a useful pre-procedural technique to predict which patients with symptoms of cervical radiculopathy secondary to foraminal stenosis are likely to respond to selective nerve root injections. The predictive ability appears to be limited to those patients with severe stenosis and was less useful in those patients with moderate or mild stenosis.
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Affiliation(s)
- Wilson Z Ray
- Neurological Surgery, Washington University School of Medicine in St. Louis
| | - Syed Akbari
- School of Medicine, Washington University School of Medicine in St. Louis
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Epidural steroid injections for radicular lumbosacral pain: a systematic review. Phys Med Rehabil Clin N Am 2014; 25:471-89.e1-50. [PMID: 24787344 DOI: 10.1016/j.pmr.2014.02.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Most clinical guidelines do not recommend routine use of epidural steroid injections for the management of chronic low back pain. However, many clinicians do not adhere to these guidelines. This comprehensive evidence overview concluded that off-label epidural steroid injections provide small short-term but not long- term leg-pain relief and improvement in function; injection of steroids is no more effective than injection of local anesthetics alone; post-procedural complications are uncommon, but the risk of contamination and serious infections is very high. The evidence does not support routine use of off-label epidural steroid injections in adults with benign radicular lumbosacral pain.
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Blocking the mineralocorticoid receptor improves effectiveness of steroid treatment for low back pain in rats. Anesthesiology 2014; 121:632-43. [PMID: 24781496 DOI: 10.1097/aln.0000000000000277] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Localized inflammation of lumbar dorsal root ganglia (DRG) may contribute to low back pain. Local injections of corticosteroids used for low back pain are sometimes ineffective. Many corticosteroids activate not only the target glucocorticoid receptor (GR) but also the mineralocorticoid receptor (MR), which may have proinflammatory effects countering the effects of GR activation. METHODS A low back pain model was implemented in rats (n = 6 to 10 per group) by locally inflaming the L5 DRG. Sensory neuron excitability and mechanical hypersensitivity of the hind paws were measured. Tested steroids were applied locally to the inflamed DRG or orally. RESULTS The selective MR blocker eplerenone reduced pain behaviors when given orally starting at the time of surgery, or starting 7 days later. The highly GR-selective agonist fluticasone, applied locally to the inflamed DRG, was much more effective in reducing mechanical hypersensitivity. The MR/GR agonist 6-α methylprednisolone, commonly injected for low back pain, reduced mechanical hypersensitivity when applied locally to the DRG but was less effective than fluticasone. Its effectiveness was improved by combining it with local eplerenone. All tested steroids reduced hyperexcitability of myelinated sensory neurons (n = 71 to 220 cells per group) after inflammation, particularly abnormal spontaneous activity. CONCLUSIONS This preclinical study indicates the MR may play an important role in low back pain involving inflammation. Some MR effects may occur at the level of the sensory neuron. It may be useful to consider the action of clinically used steroids at the MR as well as at the GR.
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Leem JG. Epidural steroid injection: a need for a new clinical practice guideline. Korean J Pain 2014; 27:197-9. [PMID: 25031804 PMCID: PMC4099231 DOI: 10.3344/kjp.2014.27.3.197] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 06/10/2014] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jeong Gill Leem
- Deptartment of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea
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Fernandes SA, Douglas AGL, Varela MA, Wood MJA, Aoki Y. Oligonucleotide-Based Therapy for FTD/ALS Caused by the C9orf72 Repeat Expansion: A Perspective. J Nucleic Acids 2013; 2013:208245. [PMID: 24349764 PMCID: PMC3855979 DOI: 10.1155/2013/208245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 09/19/2013] [Indexed: 12/12/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive and lethal disease of motor neuron degeneration, leading to paralysis of voluntary muscles and death by respiratory failure within five years of onset. Frontotemporal dementia (FTD) is characterised by degeneration of frontal and temporal lobes, leading to changes in personality, behaviour, and language, culminating in death within 5-10 years. Both of these diseases form a clinical, pathological, and genetic continuum of diseases, and this link has become clearer recently with the discovery of a hexanucleotide repeat expansion in the C9orf72 gene that causes the FTD/ALS spectrum, that is, c9FTD/ALS. Two basic mechanisms have been proposed as being potentially responsible for c9FTD/ALS: loss-of-function of the protein encoded by this gene (associated with aberrant DNA methylation) and gain of function through the formation of RNA foci or protein aggregates. These diseases currently lack any cure or effective treatment. Antisense oligonucleotides (ASOs) are modified nucleic acids that are able to silence targeted mRNAs or perform splice modulation, and the fact that they have proved efficient in repeat expansion diseases including myotonic dystrophy type 1 makes them ideal candidates for c9FTD/ALS therapy. Here, we discuss potential mechanisms and challenges for developing oligonucleotide-based therapy for c9FTD/ALS.
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Affiliation(s)
- Stephanie A. Fernandes
- Department of Physiology, Anatomy and Genetics, University of Oxford, South Parks Road, Oxford OX1 3QX, UK
- Institute of Biosciences, University of Sao Paulo, Rua do Matao, 05508-090 Sao Paulo, SP, Brazil
| | - Andrew G. L. Douglas
- Department of Physiology, Anatomy and Genetics, University of Oxford, South Parks Road, Oxford OX1 3QX, UK
| | - Miguel A. Varela
- Department of Physiology, Anatomy and Genetics, University of Oxford, South Parks Road, Oxford OX1 3QX, UK
| | - Matthew J. A. Wood
- Department of Physiology, Anatomy and Genetics, University of Oxford, South Parks Road, Oxford OX1 3QX, UK
| | - Yoshitsugu Aoki
- Department of Physiology, Anatomy and Genetics, University of Oxford, South Parks Road, Oxford OX1 3QX, UK
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Hyle EP, Wood BR, Backman ES, Noubary F, Hwang J, Lu Z, Losina E, Walensky RP, Gandhi RT. High frequency of hypothalamic-pituitary-adrenal axis dysfunction after local corticosteroid injection in HIV-infected patients on protease inhibitor therapy. J Acquir Immune Defic Syndr 2013; 63:602-8. [PMID: 23714741 DOI: 10.1097/qai.0b013e31829b662b] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The frequency of hypothalamic-pituitary-adrenal axis dysfunction among HIV-infected patients receiving steroid injections has not been reported, and the risk factors for this adverse event are poorly characterized. METHODS We conducted a retrospective analysis of data from HIV-infected patients in the Partners HealthCare system (Boston, MA) who received corticosteroid injection(s) between 2002 and 2011. Chart review focused on HIV status, antiretroviral therapy [eg, protease inhibitors (PI)], steroid injection(s), and adrenal axis dysfunction (eg, adrenal insufficiency and/or Cushing syndrome). Because all cases occurred among patients on PIs, we performed additional detailed data extraction and conducted univariate and multivariate analyses to identify risk factors in this group. RESULTS One hundred seventy-one HIV-infected patients received ≥1 corticosteroid injection(s) in the study period. Nine cases (event frequency: 5.3%; 95% confidence interval: 2.4% to 9.8%) of secondary adrenal insufficiency were diagnosed; 5 (55%) of these 9 patients also had clinical evidence of Cushing syndrome. All cases occurred among the 81 patients on PIs (event frequency among those on PIs: 11.1%; 95% confidence interval: 5.2% to 20.0%). Among patients on PIs, the major risk factor for hypothalamic-pituitary-adrenal axis dysfunction was having ≥2 injections within 6 months. CONCLUSIONS In this retrospective cohort study, 11% of HIV-infected patients on PIs at the time of steroid injection were later diagnosed with hypothalamic-pituitary-adrenal axis dysfunction. Corticosteroid injections in HIV-infected patients on PIs should only be used with great caution and close monitoring.
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Affiliation(s)
- Emily P Hyle
- *Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA; †Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA; ‡Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA; §Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA; ‖Department of Pharmacy, Massachusetts General Hospital, Boston, MA; ¶Research Design Center/Biostatistics Research Center, Clinical and Translational Science Institute, Tufts University, Boston, MA; #Division of Endocrinology, Yale University School of Medicine, New Haven, CT; **Division of Endocrinology, Massachusetts General Hospital, Boston, MA; ††Department of Newborn Medicine, Brigham and Women's Hospital, Boston, MA; ‡‡Harvard University Center for AIDS Research, Boston, MA; §§Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA; and ‖‖Ragon Institute of Massachusetts General Hospital, MIT and Harvard, Charlestown, MA
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Abstract
Abstract
Background:
Epidural steroid injection is the most frequently performed pain procedure. This study of epidural steroid “control” injections aimed to determine whether epidural nonsteroid injections constitute a treatment or true placebo in comparison with nonepidural injections for back and neck pain treatment.
Methods:
This systematic review with direct and indirect meta-analyses used PubMed and EMBASE searches from inception through October 2012 without language restrictions. Study selection included randomized controlled trials with a treatment group receiving epidural injections of corticosteroids or another analgesic and study control groups receiving either an epidural injection devoid of treatment drug or a nonepidural injection. Two reviewers independently extracted data including short-term (up to 12 weeks) pain scores and pain outcomes. All reviewers evaluated studies for eligibility and quality.
Results:
A total of 3,641 patients from 43 studies were included in this systematic review and meta-analysis. Indirect comparisons suggested epidural nonsteroid were more likely than nonepidural injections to achieve positive outcomes (risk ratio, 2.17; 95% CI, 1.87–2.53) and provide greater pain score reduction (mean difference, −0.15; 95% CI, −0.55 to 0.25). In the very limited direct comparisons, no significant differences were noted between epidural nonsteroid and nonepidural injections for either outcome (risk ratio [95% CI], 1.05 [0.88–1.25]; mean difference [95% CI], 0.22 [−0.50 to 0.94]).
Conclusion:
Epidural nonsteroid injections may provide improved benefit compared with nonepidural injections on some measures, though few, low-quality studies directly compared controlled treatments, and only short-term outcomes (≤12 weeks) were examined.
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Schmid AB, Nee RJ, Coppieters MW. Reappraising entrapment neuropathies--mechanisms, diagnosis and management. ACTA ACUST UNITED AC 2013; 18:449-57. [PMID: 24008054 DOI: 10.1016/j.math.2013.07.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 07/10/2013] [Accepted: 07/13/2013] [Indexed: 12/13/2022]
Abstract
The diagnosis of entrapment neuropathies can be difficult because symptoms and signs often do not follow textbook descriptions and vary significantly between patients with the same diagnosis. Signs and symptoms which spread outside of the innervation territory of the affected nerve or nerve root are common. This Masterclass provides insight into relevant mechanisms that may account for this extraterritorial spread in patients with entrapment neuropathies, with an emphasis on neuroinflammation at the level of the dorsal root ganglia and spinal cord, as well as changes in subcortical and cortical regions. Furthermore, we describe how clinical tests and technical investigations may identify these mechanisms if interpreted in the context of gain or loss of function. The management of neuropathies also remains challenging. Common treatment strategies such as joint mobilisation, neurodynamic exercises, education, and medications are discussed in terms of their potential to influence certain mechanisms at the site of nerve injury or in the central nervous system. The mechanism-oriented approach for this Masterclass seems warranted given the limitations in the current evidence for the diagnosis and management of entrapment neuropathies.
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Affiliation(s)
- Annina B Schmid
- The University of Queensland, Division of Physiotherapy, School of Health and Rehabilitation Sciences, Brisbane (St Lucia), Australia; University of Oxford, Nuffield Department of Clinical Neurosciences, Oxford, United Kingdom.
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Harris IA, Buchbinder R. Time to reconsider steroid injections in the spine? Med J Aust 2013; 199:237. [DOI: 10.5694/mja12.11696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 03/24/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Ian A Harris
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Health, Melbourne, VIC
- Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC
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Abstract
Adequate therapies are lacking for Alzheimer's disease, Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis, and other neurodegenerative diseases. The ability to use antisense oligonucleotides (ASOs) to target disease-associated genes by means of RNA may offer a potent approach for the treatment of these, and other, neurodegenerative disorders. In modifying the basic backbone chemistry, chemical groups, and target sequence, ASOs can act through numerous mechanisms to decrease or increase total protein levels, preferentially shift splicing patterns, and inhibit microRNAs, all at the level of the RNA molecule. Here, we discuss many of the more commonly used ASO chemistries, as well as the different mechanisms of action that can result from these specific chemical modifications. When applied to multiple neurodegenerative mouse models, ASOs that specifically target the detrimental transgenes have been shown to rescue disease associated phenotypes in vivo. These supporting mouse model data have moved the ASOs from the bench to the clinic, with two neuro-focused human clinical trials now underway and several more being proposed. Although still early in development, translating ASOs into human patients for neurodegeneration appears promising.
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Affiliation(s)
- Sarah L. DeVos
- Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, MO 63110 USA
| | - Timothy M. Miller
- Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, MO 63110 USA
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Grifka J, Boluki D. [Injection therapy of cervical spine syndromes]. DER ORTHOPADE 2013; 42:573-82; quiz 583. [PMID: 23801359 DOI: 10.1007/s00132-013-2136-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In cervical spine syndromes, specific injections can reach the pain focus or diminish the nerve root irritation, thus overcoming the vicious circle. Indications, contra-indications, complications, the exact procedure of placing the needle, and the combined use with conservative treatment must be taken into consideration.
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Affiliation(s)
- J Grifka
- Orthopädische Klinik für die Universität Regensburg, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland.
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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: 1.9] [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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