Article

Injection therapy for subacute and chronic benign low back pain.

Department of Epidemiology, University of Maastricht, The Netherlands.
Spine (Impact Factor: 2.45). 04/2001; 26(5):501-15. DOI: 10.1097/00007632-200103010-00014
Source: PubMed

ABSTRACT The Medline and Embase databases containing randomized controlled trials of injection therapy published to 1998 were systematically reviewed.
To evaluate the effectiveness of injection therapy with anesthetics, steroids, or both in patients with low back pain persisting longer than 1 month.
Two reviewers independently assessed the trials for the quality of their methods. The primary outcome measure was pain relief. Subgroup analyses were performed between trials with different control groups (placebo and active injections), with different injection sites (facet-joint, epidural, and local injections), and with timing of outcome measurement (short- and long-term). Within the resulting 12 (2 x 3 x 2) subcategories of studies, the overall relative risks and corresponding 95% confidence intervals were estimated, using the random effects model of DerSimonian and Laird. In the case of trials using active injections as a control, the results were not pooled.
This review included 21 randomized trials. All the studies involved patients with low back pain persisting longer than 1 month. Only 11 studies compared injection therapy with placebo injections (explanatory trials). The methodologic quality of many studies was low: Only eight studies had a methodologic score of 50 points or more. There were only three well-designed explanatory clinical trials: one on injections into the facet joints with a short-term relative risk of 0.89 (95% confidence interval = 0.65-1.21) and a long-term relative risk of 0.90 (95% confidence interval = 0.69-1.17), one on epidural injections with a short-term relative risk of of 0.94 (95% confidence interval = 0.76-1.15) and a long-term relative risk of 1.00 (95% confidence interval = 0.71-1.41), and one on local injections with a long-term relative risk of 0.79 (95% confidence interval = 0.65-0.96). Within the six subcategories of explanatory studies, the pooled relative risks were as follows: facet joint, short-term: relative risk = 0.89 (95% confidence interval = 0.65-1.21); facet joint, long-term: relative risk = 0.90 (95% confidence interval = 0.69-1.17); epidural, short-term: relative risk = 0.93 (95% confidence interval = 0.79-1.09); epidural, long-term: relative risk = 0.92 (95% confidence interval = 0.76-1.11); local, short-term: relative risk = 0.80 (95% confidence interval = 0.40-1.59); and local, long-term: relative risk = 0.79 (95% confidence interval = 0.65-0.96).
Convincing evidence is lacking regarding the effects of injection therapy on low back pain. Additional well-designed explanatory trials in this field are needed.

2 Followers
 · 
97 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: The aim of this retrospective study was to investigate the therapeutic effect of transforaminal epidural steroid injection in patients with chronic low back pain and radicular leg pain due to lumbar disc herniation.
    Journal of Back and Musculoskeletal Rehabilitation 10/2014; DOI:10.3233/BMR-140539 · 1.04 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: On behalf of the American Society of Interventional Pain Physicians (ASIPP), the board and membership, the Executive Committee thanks Washington State Health Care Authority for providing us with an opportunity to present public comments for key questions on spinal injections. ASIPP is a not-for-profit professional organization comprised of over 4,500 interventional pain physicians and other practitioners who are dedicated to ensuring safe, appropriate, and equal access to essential pain management services for patients across the country suffering with chronic and acute pain. There are approximately 7,000 appropriately trained and qualified physicians practicing interventional pain management in the United States. Interventional pain management is defined as the discipline of medicine devoted to the diagnosis and treatment of pain related disorders principally with the application of interventional techniques in managing sub acute, chronic, persistent, and intractable pain, independently or in conjunction with other modalities of treatment (1). Interventional pain management techniques are minimally invasive procedures, including percutaneous precision needle placement, with placement of drugs in targeted areas or ablation of targeted nerves; and some surgical techniques such as laser or endoscopic diskectomy, intrathecal infusion pumps and spinal cord stimulators, for the diagnosis and management of chronic, persistent or intractable pain (2).
  • [Show abstract] [Hide abstract]
    ABSTRACT: Epidural steroid injections (ESI) have been used for a number of years in the treatment of radicular pain caused by nerve root impingement or stenosis following failed conservative treatments with oral medications, physical therapy, and life style modifications. Evaluation of predictive tools for epidural steroid injection outcomes in treating radicular pain. A comprehensive, systematic review of the prognostic accuracy of certain predictive methods used to determine epidural steroid injection outcomes. Fifty articles were obtained via the Pubmed database, using keywords and cross referencing works cited. Inclusion criteria included patients with radicular pain; analysis of a specific prediction tool; and outcomes measured by improvement in pain and/or function. Exclusion criteria included literature review articles and animal or cadaver studies. Eight articles studying imaging techniques or lab markers as prediction tools underwent quality evaluation and evidence classification based on the 2011 American Academy of Neurology Clinical Practice Guideline Process Manual. The authors received no institutional or private funding for this literature review. For patients with radicular pain, there is insufficient evidence to either support or refute the prognostic accuracy of spinal stenosis seen on imaging in determining epidural steroid outcomes (two Class IV studies). It is possible that low grade nerve root compression as seen on lumbar MRIs, does predict short term reduction in pain after transforaminal epidural steroid injection (TFESI) (Class II and Class III studies). For patients with lumbar radicular pain, there is both insufficient and conflicting evidence that either supports or refutes prognostic accuracy of hs-CRP in determining epidural steroid outcomes (two Class III studies). It is probable IFN-y >10pg/mL from epidural lavage is predictive of short term pain reduction following lumbar epidural steroid injection (ESI) (single Class I study). There is insufficient evidence that either supports or refutes prognostic accuracy of fibronectin-aggrecan complex from epidural lavage to determine epidural steroid outcome (single Class IV study). Predictive tools for ESI outcomes such as nerve root compression grading and inflammatory markers, particularly, elevated IFN-y from epidural lavage fluid, seem promising in the future. At this time, future research is needed with a larger sample size, broader spectrum of patients and a more defined system of outcome measurements at standardized follow-up time periods before practice recommendations can be made.
    The spine journal: official journal of the North American Spine Society 04/2014; 14(10). DOI:10.1016/j.spinee.2014.04.003 · 2.80 Impact Factor

Full-text (2 Sources)

Download
171 Downloads
Available from
May 20, 2014