The Value of Short-Term Pain Relief in Predicting the Long-Term Outcome of Lumbar Transforaminal Epidural Steroid Injections

Effectiveness of Epidural Steroid Injection Depending on Discoradicular Contact: A Prospective Randomized Trial

Lumbar radicular pain is a major public health and economic problem. It is among the most common reasons for professional disability. The most common cause of lumbar radicular pain is intervertebral disc herniation, which results from degenerative disc changes. The dominant pain mechanisms are direct pressure of the hernia on the nerve root and the local inflammatory process triggered by intervertebral disc herniation. Treatment of lumbar radicular pain includes conservative, minimally invasive, and surgical treatment. The number of minimally invasive procedures is constantly increasing, and among these methods is epidural administration of steroids and local anesthetic through a transforaminal approach (ESI TF). The aim of this research was to examine the effectiveness of ESI TF as measured by a visual analog scale (VAS) and the Oswestry Disability Index (ODI), depending on whether there is contact between the herniated intervertebral disc and the nerve root. In both groups of participants, there was a significant reduction in pain intensity, but there was no significant difference between the groups. In the group with disc herniation and nerve root contact, the only significant reduction was in pain intensity (p < 0.001). There were no significant differences in measurements in other domains of the ODI. In the group without disc herniation and nerve contact, there was a significant difference in all domains except weight lifting. In the group without contact, there was significant improvement after 1 month (p = 0.001) and 3 months (p < 0.001) according to the ODI, while there was no significant improvement in the group with contact. In addition, there were no significant differences in the distribution of participants based on the ODI and whether disc herniation and nerve contact was present. The results suggest that transforaminal epidural administration of steroids is a clinically effective method for treating lumbar radicular pain caused by intervertebral disc herniation in people with and without nerve root contact, without significant differences.

Effects of Local Anesthetics With or Without Steroids in High-Volume Transforaminal Epidural Blocks for Lumbar Disc Herniation: A Randomized, Double-Blind, Controlled Trial

BACKGROUND

Lumbar transforaminal epidural block (TFEB) is an effective treatment modality for radicular pain due to lumbar disc herniation (LDH). The addition of steroids is more effective than local anesthetic alone in TFEBs for patients with LDH. Moreover, the efficacy of TFEBs has been reported to be positively correlated with the volume of injectate. We hypothesized that high-volume TFEBs without steroids effectively alleviate axial back and radicular pain associated with LDH. This study compared the efficacy of high-volume TFEBs with vs. without steroids for the management of the axial and radicular pain caused by LDH.

METHODS

A total of 54 patients were randomly assigned to either group L or group D. Patients in group L received 8-mL injections of 0.33% lidocaine only. Patients in group D received 8-mL injections of 0.33% lidocaine with 5 mg of dexamethasone. The primary outcomes were pain intensity at baseline and 4 weeks after the procedure. The secondary outcomes included the change of functional disability between baseline and 4 weeks after the procedure, pain scores during injection, and adverse effects.

RESULTS

Both groups showed a significant reduction in axial and radicular pain and improvement in the functional status at the outpatient visit 4 weeks after TFEB. However, there were no significant differences between the groups in terms of changes in back pain (10.00 [20.00] vs. 10.00 [22.50]; P = 0.896) or radicular pain (5.00 [20.00] vs. 10.00 [12.50]; P = 0.871).

CONCLUSION

High-volume TFEBs with and without steroid administration yielded similar significant pain reductions and functional improvements among LDH patients 4 weeks after the procedure.

Transforaminal epidural steroid injection combined with radio frequency for the treatment of lumbar disc herniation: a 2-year follow-up

Background

To assess the therapeutic efficacy of transforaminal epidural steroid injection (TFESI) combined with radio frequency (RF) for the treatment of lumbar disc herniation (LDH).

Methods

A total of 230 patients participated in the study: TFESI (Group T, n = 110), TFESI combined with RF (Group TR, n = 120). Visual analogue scale (VAS), Oswestry disability index (ODI) and Global perceived effect (GPE) scale were measured pre-operation, 1, 3, 6, 12 and 24 months after the operation. Hospitalization time, treatment time, complications, and recurrence were compared between the two groups.

Results

The VAS and ODI at each observation point of the post-operation were significantly decreased compared with the pre-operation in both groups (P < 0.05). There was no statistically difference of VAS and ODI between the two groups at 1 and 3 months of the post-operation (P > 0.05). However, The VAS and ODI scores in Group TR were significantly lower than that in Group T at 6, 12 and 24 months of the post-operation (P < 0.05). The GPE in group TR was high in the early days, while that at 1 and 3 months after treatment was significantly higher than that in group T (P < 0.05). The recurrence rate in Group TR was lower than that in Group T (P = 0.002). There was no significant difference in hospitalization time, complications, VAS and ODI score at the pre-operation between the two groups (P > 0.05).

Conclusion

These findings suggest that TFESI combined with RF could effectively improve the pain and function, and had a long-term satisfactory effect for the treatment of LDH.

The Outcome of Epidural Injections in Lumbar Radiculopathy Is Not Dependent on the Presence of Disc Herniation on Magnetic Resonance Imaging: Assessment of Short-Term and Long-Term Efficacy

OBJECTIVE

Lumbar radiculopathy is a condition with major physical, social, and economic consequences. Despite its favorable prognosis, the burden can be significant. In this study, we aimed to determine the value of magnetic resonance imaging (MRI) and the efficacy of transforaminal epidural injections (TEIs) in patients with lumbar radiculopathy secondary to lumbar disc herniation (LDH) and other causes (non-LDH).

METHODS

Patients with lumbar radiculopathy were reviewed for radiologic diagnosis based on MRI. For patients receiving TEI therapy, response after 6-8 weeks (short-term) and 16 weeks (long-term), number of injections, subsequent surgery, and patient outcome were evaluated. Treatment response was assessed by patient-reported symptom relief and numeric rating scale pain scores.

RESULTS

Overall, 66% of MRI examinations showed a clinically relevant LDH. A total of 486 of 1824 patients received TEI, of whom one third did not show LDH. Of patients, 70% reported a short-term effect with significant pain reduction and 44% reported a long-term effect. No significant differences were observed between the LDH and non-LDH groups. Of patients, 59% required multiple injections and reported similar efficacy compared with patients treated with a single injection.

CONCLUSIONS

A considerable part of MRI examinations in patients with lumbar radiculopathy do not show a clinically relevant LDH. Regardless of the radiologic diagnosis, most patients treated with TEI benefit in both the short-term and the long-term after a single-injection or multiple-injection regime. Subsequent injections are advisable if the effect from the first injection is unsatisfactory or wears off. MRI examination before TEI therapy may be redundant, which allows for expedition of this treatment.

Smartphone-Based Self-Assessment of Objective Functional Impairment (6-Minute Walking Test) in Patients Undergoing Epidural Steroid Injection

Epidural steroid injection (ESI) represents a popular treatment option in patients with lumbar degenerative disc disease (DDD). The main objective of the article was to determine whether the 6-minute walking test (6WT) could assist in the discrimination between ESI responders and nonresponders. We used a validated 6WT smartphone application to assess self-measured objective functional impairment (OFI) in 3 patients with DDD undergoing ESI. Patient-reported outcome measures (PROMs), including the Core Outcome Measures Index and the Oswestry Disability Index, were obtained at baseline and at the 3-, 7-, and 28-day follow-up. Descriptive analyses were used to compare PROMs with OFI over time. Two patients responded well to the ESI, illustrated by clinically meaningful improvements in PROMs. This improvement was accompanied by a substantial increase in the 6WT distance (case I: 358 m vs. 517 m and case II: 296 m vs. 625 m). One patient reported only moderate improvement in leg pain and conflicting results in the other PROMs. The 6WT demonstrated a persistent OFI (487 m vs. 488 m). This patient was considered a nonresponder and underwent surgical treatment. This case series illustrates the feasibility of the smartphone-based 6WT as a tool to assess OFI in patients undergoing ESI for lumbar DDD.

Effects of implementing evidence-based appropriateness guidelines for epidural steroid injection in chronic low back pain: the EAGER (Esi Appropriateness GuidElines pRotocol) study

Objective

Chronic low back pain is very common and often treated with epidural steroid injections (ESIs). As ESI referrals had been rapidly increasing at our Veterans’ Administration hospital, we were concerned that they were supplanting more comprehensive care. The objective was to determine how referral patterns and multidisciplinary care might change with the implementation of evidence-based guidelines.

Methods

In this retrospective observational study, multidisciplinary evidence-based guidelines were implemented in 2014 (EAGER: Esi Appropriateness GuidElines pRotocol) as part of the ordering process for an ESI. Time series analysis was performed to assess the primary outcome of subspecialty referral pattern, that is, the number of patients receiving referrals to ancillary services which might serve to provide a more comprehensive approach to their back pain. Secondary outcomes included patient-level changes (ie, body mass index, number of injections, opioid use), which were compared before and after protocol implementation.

Results

Comparing preimplementation and postimplementation protocol periods, referrals to physical medicine/rehabilitation increased 11.7% (p=0.003) per year and integrative health increased 2.1% (p<0.001) per year among the 2294 individual patients who received ESI through the neurointerventional radiology service. Of 100 randomly selected patients for patient-level analysis, the median body mass index decreased from 31.57 to 30.22 (p=<0.001) and the mean number of injections decreased from 1.76 to 0.73 (p<0.001). The percentage of patients using oral opioid analgesics decreased from 72% to 49% (p=<0.001).

Conclusion

Implementation of evidence-based guidelines for ESI referral helps guide patients into a more comprehensive care pathway for chronic low back pain and is correlated with patient-level changes such as decreased body mass index and decreased opioid usage.

Transforaminal epidural injection versus continued conservative care in acute sciatica (TEIAS trial): study protocol for a randomized controlled trial

BACKGROUND

Sciatica is a condition that is characterised by radicular pain in the leg and primarily caused by a herniated lumbar intervertebral disk. In addition to leg pain, patients can experience back pain, leg numbness and leg weakness resulting in decreased productivity and social activity. The majority of sciatica cases recovers spontaneously and therefore patients are initially treated conservatively with oral pain medication. However, some patients experience intractable pain that severely impedes them and no consensus exists on the optimal conservative treatment to reduce this discomfort in the acute phase of sciatica. The aim of the TEIAS trial is to assess the effectiveness, cost-effectiveness and predictive capability on patient outcome of transforaminal epidural injection (TEI) compared to treatment with standard pain medication.

METHODS

This study is designed as a prospective, open-label, mono-centered, randomized controlled trial. Patients that visit their general practitioner with complaints of radicular leg pain and meet the selection criteria are asked to participate in this study. Eligible patients will be randomized to treatment with TEI or to treatment with standard oral pain medication. Treatment of TEI will comprise lidocaine with methylprednisolone acetate for L3 and below and lidocaine with dexamethasone above L3. A total of 142 patients will be recruited and follow-up will occur after 1, 2, 4, 10 and 21 weeks for assessment of pain, functionality, patient received recovery and cost-effectiveness. The primary outcome will be the average score for leg pain at 2 weeks. For this outcome we defined a clinically relevant difference as 1.5 on the 11-point NRS scale.

DISCUSSION

Adequate conservative treatment in the acute phase of sciatica is lacking, particularly for patients with severe symptoms. Focusing on effectiveness, cost-effectiveness and predictive capability on patient outcome of TEI will produce useful information allowing for more lucid decision making in the conservative treatment of sciatica in the acute phase.

TRIAL REGISTRATION

This trial is registered in the ClinicalTrials.gov database under registry number NCT03924791 on April 23, 2019.

The Effectiveness of Lumbar Transforaminal Injection of Steroid for the Treatment of Radicular Pain: A Comprehensive Review of the Published Data

Objective

To determine the effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain.

Design

Comprehensive systematic review.

Outcome Measures

The primary outcome of interest was the proportion of individuals with reduction of pain by ≥50%. Additional outcomes of interest were a more-than-two-point reduction in pain score, patient satisfaction, functional improvement, decreased use of pain medication, and avoidance of spinal surgery.

Results

For patients with disc herniations, using the criterion of ≥50% reduction in pain, success rates across included studies (range) were 63% (58–68%) at one month, 74% (68–80%) at three months, 64% (59–69%) at six months, and 64% (57–71%) at one year. For patients with lumbar spinal stenosis, success rates across included studies (range) were 49% (43–55%) at one month, 48% (35–61%) at three months, 43% (33–53%) at six months, and 59% (45–73%) at one year, but there was a lack of corroboration from appropriately controlled studies.

Conclusions

There is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. There is a lack of high-quality evidence demonstrating their effectiveness for the treatment of radicular pain due to spinal stenosis, though small studies suggest a possible benefit. Lumbar transforaminal injection of nonparticulate steroids is as effective as injections with particulate steroids.

Factors Predicting Favorable Short-Term Response to Transforaminal Epidural Steroid Injections for Lumbosacral Radiculopathy

Background and Objectives: The purpose of this retrospective study was to identify predictors of short-term outcomes associated with a lumbosacral transforaminal epidural steroid injection (TFESI). Materials and Methods: The medical records of 218 patients, who were diagnosed with lumbosacral radiculopathy and treated with a TFESI, were reviewed in this retrospective study. A mixture of corticosteroid, lidocaine, and hyaluronidase was injected during TFESI. Patients with >50% pain relief on the numerical rating scale compared with the initial visit constituted the good responder group. Demographic, clinical, MRI, and electrodiagnostic data were collected to assess the predictive factors for short-term outcomes of the TFESI. Results: A multivariate logistic regression analysis demonstrated that a shorter duration of symptoms and a positive sharp wave (PSW)/fibrillation (Fib) observed in electrodiagnostic study (EDx) increased the odds of significant improvement 2–4 weeks after the TFESI. Conclusions: Shorter duration of symptoms and PSW/Fib on EDx were predictors of favorable short-term response to TFESI.

Correlation of Perfusion Index Change and Analgesic Efficacy in Transforaminal Block for Lumbosacral Radicular Pain

Transforaminal epidural injection is used to treat radicular pain. However, there is no objective method of assessing pain relief following transforaminal injection. Perfusion index is a metric for monitoring peripheral perfusion status. This study evaluates the correlation between perfusion index change and analgesic efficacy in transforaminal blocks for lumbosacral radicular pain. We retrospectively analyzed data of 100 patients receiving transforaminal block for lumbosacral radicular pain. We assessed perfusion index before treatment and at 5, 15, and 30 min following the block. We defined responders (group R) and non-responders (group N) as those with ≥50% and <50% pain reduction, respectively, 30 min following block. Clinical data and perfusion index of the groups were analyzed. Ninety-two patients were examined, of whom 57 (61.9%) and 35 (38.0%) patients reported ≥50% and <50% pain reduction, respectively. Group R had a significantly higher perfusion index change ratio 5 min following the block (p = 0.029). A perfusion index change ratio of ≥0.27 was observed in group R (sensitivity, 75.4%; specificity, 51.4%; AUC (area under the curve), 0.636; p = 0.032). A perfusion index change ratio of ≥0.27 at 5 min after block is associated with, but does not predict improvement in, pain levels following lumbosacral transforaminal block.

Comparison of Epidural Steroid Injection Efficiency with Two Different Doses in Radiculopathies Associated with Lumbar Disc Herniation

OBJECTIVE

Transforaminal epidural steroid injections (TFESIs) have been increasingly used in the treatment of lumbar radicular pain resistant to conservative modalities. Although different steroids can be used at different doses, the minimally effective steroid dose should be used to reduce side effects. The present retrospective study examined and compared the efficacy of 40 mg and 80 mg of methylprednisolone in TFESIs.

METHODS

We included 67 patients who had undergone unilateral L5-S1 TFESIs under fluoroscopic guidance in the present study. Assessments were conducted at baseline and at 1 hour, 3 weeks, and 3 months after the TFESIs. The Short-Form 36-item Health Survey, Numeric Rating Scale, Oswestry Disability Index, and Istanbul Low Back Pain Disability Index were used as outcome measures.

RESULTS

The present study evaluated 33 patients who had undergone TFESIs with 40 mg of methylprednisolone and 34 patients who had undergone TFESIs with 80 mg of methylprednisolone. Although no statistically significant differences were found between the 2 groups' outcome measures, both groups showed significant improvements in pain, disability, and quality of life at 3 weeks and 3 months after treatment.

CONCLUSIONS

TFESIs with 40 mg and 80 mg are effective for the treatment of pain that results from lumbar disc herniation. They also positively affect patients' disability and quality of life. However, neither steroid dose was more efficient than the other dose. Therefore, we believe the smaller dose should be preferred to reduce the potential side effects of steroids.

Repeat epidural steroid injections for radicular pain due to lumbar or cervical disc herniation

Aims

The aim of this study was to determine the efficacy of repeat epidural steroid injections as a form of treatment for patients with insufficiently controlled or recurrent radicular pain due to a lumbar or cervical disc herniation.

Patients and Methods

A cohort of 102 patients was prospectively followed, after an epidural steroid injection for radicular symptoms due to lumbar disc herniation, in 57 patients, and cervical disc herniation, in 45 patients. Those patients with persistent pain who requested a second injection were prospectively followed for one year. Radicular and local pain were assessed on a visual analogue scale (VAS), functional outcome with the Oswestry Disability Index (ODI) or the Neck Pain and Disability Index (NPAD), as well as health-related quality of life (HRQoL) using the 12-Item Short-Form Health Survey questionnaire (SF-12).

Results

A second injection was performed in 17 patients (29.8%) with lumbar herniation and seven (15.6%) with cervical herniation at a mean of 65.3 days (sd 46.5) and 47 days (sd 37.2), respectively, after the initial injection. All but one patient, who underwent lumbar microdiscectomy, responded satisfactorily with a mean VAS for leg pain of 8.8 mm (sd 10.3) and a mean VAS for arm pain of 6.3 mm (sd 9) one year after the second injection, respectively. Similarly, functional outcome and HRQoL were improved significantly from the baseline scores: mean ODI, 12.3 (sd 12.4; p < 0.001); mean NPAD, 19.3 (sd 24.3; p = 0.041); mean SF-12 physical component summary (PCS) in lumbar herniation, 46.8 (sd 7.7; p < 0.001); mean SF-12 PCS in cervical herniation, 43 (sd 6.8; p = 0.103).

Conclusion

Repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection. Cite this article: Bone Joint J 2018;100-B:1364–71.

The value of short-term pain relief in predicting the long-term outcome of 'indirect' cervical epidural steroid injections

BACKGROUND

The predictive value of short-term arm pain relief after 'indirect' cervical epidural steroid injection (ESI) for the 1-month treatment response has been previously demonstrated. It remained to be answered whether the long-term response could be estimated by the early post-interventional pain course as well.

METHODS

Prospective observational study, following a cohort of n = 45 patients for a period of 24 months after 'indirect' ESI for radiculopathy secondary to a single-level cervical disk herniation (CDH). Arm and neck pain on the visual analog scale (VAS), health-related quality of life with the Short Form-12 (SF-12), and functional outcome with the Neck Pain and Disability (NPAD) Scale were assessed. Any additional invasive treatment after a single injection (second injection or surgery) defined treatment outcome as 'non-response'.

RESULTS

At 24 months, n = 30 (66.7%) patients were responders and n = 15 (33.3%) were non-responders. Non-responders exited the follow-up at 1 month (n = 10), at 3 months (n = 4), and at 6 months (n = 1). No patients were injected again or operated on between the 6- and 24-month follow-up. Patients with favorable treatment response at 24 months had significantly lower VAS arm pain (p < 0.05) than non-responders at days 6, 8-11, and at the 3-month follow-up. The previously defined cut-off of > 50% short term pain reduction was not a reliable predictor of the 24-month responder status. SF-12 and NPAD scores were better among treatment responders in the long term.

CONCLUSIONS

Patients who require a second injection or surgery after 'indirect' cervical ESI for a symptomatic CDH do so within the first 6 months. Short-term pain relief cannot reliably predict the long-term outcome.