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: 2.44). 08/2005; 86(7):1477-83. DOI: 10.1016/j.apmr.2005.01.006
Source: PubMed

ABSTRACT 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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    ABSTRACT: Study Design. A pragmatic, randomized, controlled, single-blinded trial in Dutch general practice.Objective. Assessing the costs and cost-effectiveness of adding segmental epidural steroid injections to care as usual in radiculopathy in general practice.Summary of Background Data. Lumbosacral radicular syndrome (LRS, radiculopathy) is a benign, generally self-limiting but painful condition caused by a herniated lumbar intervertebral disc which results in an inflammatory process around the nerve root. Segmental epidural steroid injections could lessen pain. Low back pain and sciatica form a large financial burden on national healthcare systems. Improving pain treatment could lower costs to society by diminishing loss of productivity.Methods. Patients with acute radiculopathy were included by general practitioners. All patients received usual care. Patients in the intervention group received one segmental epidural steroid injection containing 80 mg triamcinolone as well. Follow-up was performed using postal questionnaires at 2, 4, 6, 13, 26, 52 weeks. Main outcomes were pain, disability and costs. Economic evaluation was performed from a societal perspective with a time horizon of one year.Results. 63 patients were included in the analysis. Mean total costs were &OV0556;4414 / US $5985 in the intervention group and &OV0556;5121 / US $6943 in the control group. This difference was mostly due to loss of productivity. The point estimate for the ICER was - &OV0556;730 / - US $990 (one point diminishment on the NRS back pain score in one patient in the course of one year would save &OV0556;730 or US $990). Bootstrapping showed a 95% CI of -&OV0556;4476 to &OV0556;951 or -US $6068 to US $1289. The CEAC showed that without additional investment the probability that epidural steroids are cost-effective is more than 80%.Conclusion. The effect on pain and disability of epidural steroids in lumbosacral radicular syndrome is small but significant, and at lower costs with no reported complications or adverse effects. Segmental epidural steroid injections could be considered by policy makers as an additional treatment option.
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    ABSTRACT: Lumbosacral radicular syndrome (LRS) is a self-limiting, benign, painful and impairing condition caused by lumbar disc herniation and inflammatory processes around the nerve root. Segmental epidural steroid injections (SESIs) are helpful to reduce radicular pain on a short-term basis. It is unknown whether SESIs are an effective addition to usual pain treatment of LRS in general practice. In our study, we assessed the effectiveness of SESIs on pain and disability as an addition to usual care for acute LRS in general practice.
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