A Critical Appraisal of the Evidence for Selective Nerve Root Injection in the Treatment of Lumbosacral Radiculopathy

Penn Spine Center and Department of Physical Medicine and Rehabilitation, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
Archives of Physical Medicine and Rehabilitation (Impact Factor: 2.57). 08/2005; 86(7):1477-83. DOI: 10.1016/j.apmr.2005.01.006
Source: PubMed


To critically review the best available trials of the utility of transforaminal epidural steroid injections (TFESIs) or selective nerve root blocks (SNRBs) to treat lumbosacral radiculopathy.
MEDLINE (PubMed, Ovid, MDConsult), EMBASE, and the Cochrane database. Databases were searched from inception through 2003.
A database search was conducted by using the following key words: prospective , transforaminal and foraminal epidural steroid injections , selective nerve root block and injection , and periradicular and nerve root injection . We included English-language, prospective, randomized studies of patients with lower-limb radicular symptoms treated with fluoroscopically guided nerve root or transforaminal epidural injections.
Data were compiled for each of the following categories: inclusion criteria, randomization protocol, total number of subjects enrolled initially and at final analysis, statistical analysis utilized, documentation of technique, outcome measures, follow-up intervals and results (positive or negative), and reported complications. These data were abstracted by 1 reviewer and reviewed by a second. Study quality was assessed with the system developed by the Agency for Health Care and Policy Research.
We selected 6 articles for review. Our analysis identified a single article as the highest quality study addressing the appropriate use of TFESIs or therapeutic SNRBs. Coupled with the evidence provided by 4 other articles (1 article was excluded because its patients were not truly randomized), our review of the evidence for TFESIs found level III (moderate) evidence in support of these minimally invasive and safe procedures in treating painful radicular symptoms. However, conclusive evidence (level I) is lacking.
The evidence for TFESIs reveals level III (moderate) evidence in support of these minimally invasive and safe procedures in treating painful lumbar radicular symptoms. Current studies support use of TFESIs as a safe and minimally invasive adjunct treatment for lumbar radicular symptoms. However, more prospective, randomized, placebo-controlled studies using sham procedures are needed to provide conclusive evidence for the efficacy of TFESIs in treating lumbar radicular symptoms.

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    • "Les complications des injections foraminales lombaires de corticoïdes sont le plus souvent bénignes [4] [6] [10] [13] : céphalées , majoration des douleurs lombaires, exacerbation des douleurs radiculaires, flush facial, réaction vagale. À notre connaissance, seuls cinq cas de paraplégie dans les suites d'une injection foraminale lombaire de corticoïdes ont été rapportés dans la littérature [10] [11] [24]. "
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    ABSTRACT: ObjectivesWe report a patient in whom paraplegia developed following transforaminal epidural injection of a corticosteroid and discuss the physiopathology of this complication, based on a literature survey.Case reportA 40-year-old man presented with low-back pain and symptoms of L4 radiculopathy due to degenerative disc herniation resistant to conventional medical treatment. Computed tomography revealed posterolateral L4–L5 disc protrusion. A dosage of 125 mg of hydrocortisone was given by epidural transforaminal L4–L5 left injection under radioscopy guidance. Within minutes following the injection, intense pain developed in both legs, with T12 complete paraplegia. Emergency magnetic resonance imaging (MRI) 2 hours later did not reveal spinal cord abnormalities. The patient underwent immediate surgery consisting of excising the protruding disc and extensive L3–L5 laminectomy. MRI performed 3 months later did not reveal medullar abnormalities. Six months later, the patient continued to show slow neurologic improvement, permitting him to walk with crutches and to stop intermittent self-catheterisation.DiscussionThe occurrence of paraplegia following epidural transforaminal injection of corticosteroids is a rare complication. To our knowledge, only 5 similar cases have been described. Most of the authors proposed that the mechanism of this complication is ischemia of the terminal cone due to accidental suppression of medullary blood supply. Direct lesion of a medullar artery, arterial spasm, or corticosteroid-induced occlusion due to undetected intra-arterial injection could lead to this medullar infarction. Anatomical variations of the path followed by the Adamkievicz artery strongly support this hypothesis.
    Annales de Réadaptation et de Médecine Physique 06/2006; 49(5-49):242-247. DOI:10.1016/j.annrmp.2006.03.004
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    ABSTRACT: The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing amongst available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to chronic low back pain, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.
    The Spine Journal 01/2008; 8(1):45-55. DOI:10.1016/j.spinee.2007.09.009 · 2.43 Impact Factor
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    ABSTRACT: Epidural injection of corticosteroids is one of the most commonly used interventions in managing chronic spinal pain. The transforaminal route to the lumbar epidural space for steroid injection has gained rapid and widespread acceptance for the treatment of lumbar and leg pain. However, there are few well-designed randomized, controlled studies to determine the effectiveness of epidural injections. The role and value of transforaminal lumbar epidural steroid injections is still questioned. A systematic review of transforaminal epidural injection therapy for low back and lower extremity pain. To evaluate the effect of transforaminal lumbar epidural steroid injections in managing lumbar (low-back) and sciatica (leg) pain. The available literature of lumbar transforaminal epidural injections in managing chronic low back and lower extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to November 2008, and manual searches of the bibliographies of known primary and review articles. The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. The indicated evidence is Level II-1 for short-term relief and Level II-2 for long-term relief in managing chronic low back and lower extremity pain. The limitations of this systematic review include the paucity of literature. The indicated evidence for transforaminal lumbar epidural steroid injections is Level II-1 for short-term relief and Level II-2 for long-term improvement in the management of lumbar nerve root and low back pain.
    Pain physician 11/2008; 12(1):233-51. · 3.54 Impact Factor
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