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Epidural steroid injections are useful for the treatment of low back pain and radicular symptoms: Pro
Abstract
Epidural steroid injection has been used to treat low back pain for many decades. Numerous randomized trials have examined the efficacy of this approach. This review details the findings of older systematic reviews, newer randomized controlled trials, and two recent systematic reviews that examine the effectiveness of this treatment. Collectively, studies in acute radicular pain due to herniated nucleus pulposus have failed to show that epidural steroid injection reduces long-term pain or obviates the need for surgery. Similarly, there is scant evidence that epidural steroids have any beneficial effect in those with acute low back pain without leg pain or in those with chronic low back or leg pain. However, most studies have demonstrated more rapid resolution of leg pain in those who received epidural steroid injections versus those who did not. The role of epidural steroid injections in the management of acute radicular pain due to herniated nucleus pulposus is simply to provide earlier pain relief.
... On the basis of a series of articles previously published by the authors, we found that spinal surgeries are associated with high cost and longer claim duration. [27][28][29][30][31][32][33] We have also observed in other studies 4,7,9,[34][35][36] that lumbar ESIs were commonly associated with lumbar surgical procedures, and there was no reported reduction in surgery rates associated with ESI. Most studies have not looked at the sequential relationship between ESI and surgery. ...
... For the postoperative lumbar ESI group, the ratio of surgical procedures actually increased slightly (2.06; Table 1). As has been noted in other studies, 7,9,[34][35][36] lumbar ESIs were commonly associated with lumbar surgical procedures. In addition, there was no reported reduction in surgery rates associated with ESI. ...
... Also, persisting with a lumbar ESI treatment strategy that is associated with only short-term benefits may explain the poor outcomes after three ESIs. [7][8][9][10]13,24,36,45 Although lumbar fusion surgeries are more costly than nonlumbar fusion surgeries, 37 the cost and duration of the nonfusion surgery claims approach the cost and duration of the fusion claims as postoperative ESI increase more than three (Figs. 4 and 5). As stated previously, the cost of the ESI itself does not account for this increase. ...
Assess the relationship between performing lumbar epidural steroid injections (ESIs) after lumbar surgery and workers' compensation claim duration and cost.
A multivariate logistic regression was used to determine the association between performing ESI after the first lumbar surgery in 11,394 lost time injury claims filed from 1999 to 2002 followed for 7 years postinjury.
Odds ratio of costs more than $100,000 is 6.49 (95% confidence interval: 4.30 to 9.81) for ever having lumbar ESI after the first lumbar surgery, compared with no spinal procedures, controlling for sex, age, attorney involvement, opioid use, other spinal procedures, and claim duration. Odds ratio of having claim duration longer than 1000 days was 14.73 (95% confidence interval: 7.01 to 30.95).
Lumbar ESI after the first lumbar surgery was associated with high cost and longer claim duration.
... Im letzten Jahr wurde ein systematischer Review zu Einstellungen und Haltungen von Ärzten gegenüber der Behandlung akuter Kreuzschmerzen publi-ziert [4]. standes bei chronischen Erkrankung widersprüchlich beurteilt wird [5]. Michie et al. [5] beschreiben zwei wesentliche Konzepte einer patientenzentrierten Medizin. ...
... standes bei chronischen Erkrankung widersprüchlich beurteilt wird [5]. Michie et al. [5] beschreiben zwei wesentliche Konzepte einer patientenzentrierten Medizin. Im Konzept der Patientensicht kommt es zu einem Abgleichen der Ansichten der Gesundheitsberufe und des Patienten, wobei der Patient wahrnehmen kann, ob seine psychosozialen Probleme angesprochen und seinen Bedürfnissen bei der Konsultation entsprochen wird. ...
... Der Nachweis einer nur geringen Effektstärke dieser Therapie erklärt den wachsenden Einsatz der Injektionstherapie bei Kreuzschmerzpatienten, der sich in den USA von 1994 bis 2001 um 279% erhöht hat, nicht, zumal nur 40% der behandelten Patienten wegen radikulären Schmerzen behandelt worden waren [4]. Auf die Problematik der zunehmenden Therapiekosten für epidurale Injektionen geht auch eine kürzlich publizierte Kontroverse zum Nutzen epiduraler Injektionen bei unspezifischen Kreuzschmerzen und radikulären Schmerzen ein [5,6]. Die Befürworter der epiduralen Injektionstherapie weisen auf die Widersprüche in den systematischen Reviews zu dieser Behandlungsform hin und zitieren einzelne Studien, die ihrer Meinung nach eine Wirksamkeit der epiduralen Behandlung stützen [5]. ...
... Similar results were obtained in the repeated measurements for VAS (p < 0.05). The volume administered through the caudal epidural space is controversial [11][12][13] . Many studies were done to determine the best volume and concentration [10] . ...
... Thus, corticosteroids are able to interrupt effectively the vicious circle of abacterial neural inflammation, which is usually followed by swelling and pressure as well as pain (22). The clinical benefit of EGI, however, has been discussed somewhat controversial (8)(9)(10), and it should be noted that it was not the aim of the present study to evaluate the efficiency of EGI, but rather to assess its effects on the function of the HPA axis. ...
Intact hypothalamic-pituitary-adrenal (HPA)-axis plays an important role in trauma due to stress upon major surgery. Normal HPA-axis function may be impaired in patients receiving epidural glucocorticoid injection (EGI) for acute pain. We aimed to identify these putative at-risk patients and examined the effect of EGI on the HPA-axis. Methods: We enrolled 28 patients with acute low-back pain who received EGI due to lumbar disc herniation. Baseline and stimulated plasma cortisol concentrations were measured before and 14 days after EGI. Stimulated cortisol concentrations were measured 30min after intravenous low-dose (1mcg) ACTH (adrenocorticotropic hormone) infusion. Normal responses to ACTH were defined as stimulated plasma cortisol concentration > 550nmol/L or a cortisol increase of at least 250nmol/L. Results: Baseline and stimulated cortisol concentrations were different between day 0 and day 14 (p < 0.01). Seven patients (27%) had a normal response to ACTH, but in comparison to day 0, the stimulated plasma cortisol levels were significantly lower at day 14 (p = 0.02). Nineteen patients (73%) had a substantially deficient adrenal response to ACTH after EGI (day 14). This group revealed significantly lower stimulated cortisol concentrations prior to EGI (p < 0.05) and thereafter (p < 0.001) compared to normal responders. Discussion: The HPA-axis suppression in 73% of the patients could be characterized by significantly reduced plasma cortisol levels after low-dose ACTH infusion prior to EGI. Given their particularly low cortisol response upon ACTH following EGI, these patients apparently inherent at risk to suffer adrenal insufficiency in stressful events after EGI.
... Однако он не должен быть исключен, так как, вероятно, существуют группы пациентов, позитивно реагирующие на данный вид локальной инъекционной терапии [56,57]. Кроме того, при острой радикулопатии цель эпидурального введения ГК -достижение раннего (до 3 нед) ослабления боли [58]. ...
... The reviews conducted by evidence-based practice centers concluded that there are short-term but not long-term benefits with epidural steroids in patients with sciatica (see Appendix 1 Table 3). 31,32,[59][60][61][62][63] The authors of one recent highquality review 31,32 converted continuous measurements of pain and disability to common scales from 0 (no pain or disability) to 100 (worst possible pain or disability), and reported weighted means of short-term pain reduction of 6% and disability of 3%. These small statistically significant effects have questionable clinical importance. ...
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.
... This finding is consistent with previous reports [29]. Other studies in different countries, have confirmed the efficacy of ESI in treatment of LBP, but similar to our results, no significant differences have reported between two groups [23,3031323334. As conclusion, considering the fact that neurologic disorders and deficits are common353637, epidural steroid injections either alone or combined with Bupivacaine with no priority are effectively relief chronic low back pain due to discopathy. ...
Chronic low back pain is defined as consistent or pendulous pain over 3 months. Epidural steroid injections (ESI) are common in treatment of chronic back pain. The present study was aimed to investigate the effects of epidural injection of glucocorticoid and bupivacaine compared to glucocorticoid alone in relieving chronic back pain due to discopathy. A randomized clinical trial was performed in the Shohada Medical Educational Center, Tabriz, Iran. Patients with chronic back pain who were candidates for epidural drug injection were recruited. They were divided into two groups of steroids or steroid and bupivacaine. Pain intensity, Oswestry Disability Index (ODI), Straight Leg Rising (SLR) test as well as clinical variables were evaluated before treatment and 3th month thereafter. Overall, 17 males and 23 females with a mean age ± SD of 47.54 ± 12.11 years were enrolled in two equal groups. No significant difference was observed between two groups in terms of gender and body mass index. In both groups, a significant relationship was observed for ODI (p =0.001), pain intensity (p =0.001), and SLR test (p=0.001) before and after treatment. However, the corresponding association was not observed for ODI, pain intensity and SLR test (p>0.05). Epidural steroid injections either alone or combined with Bupivacaine with no priority are effectively relief chronic low back pain due to discopathy.
Cysteinyl-tRNACys (Cys-tRNACys) is required for translation and is typically synthesized by cysteinyl-tRNA synthetase (CysRS). However, Methanocaldococcus jannaschii synthesizes Cys-tRNACys by an indirect pathway, whereby O-phosphoseryl–tRNA synthetase (SepRS) acylates tRNACys with phosphoserine (Sep), and Sep-tRNA–Cys-tRNA synthase (SepCysS) converts the tRNA-bound phosphoserine to cysteine. We show here that M. jannaschii SepRS differs from CysRS by recruiting the m1G37 modification as a determinant for aminoacylation, and in showing limited discrimination against mutations of conserved nucleotides. Kinetic and binding measurements show that both SepRS and SepCysS bind the reaction intermediate Sep-tRNACys tightly, and these two enzymes form a stable binary complex that promotes conversion of the intermediate to the product and sequesters the intermediate from binding to elongation factor EF-1 or infiltrating into the ribosome. These results highlight the importance of the protein binary complex for efficient synthesis of Cys-tRNACys.
Local anesthetic blocks have limited value in diagnosing and treating chronic pain. Peripheral nerve blocks have shown some utility in treating occipital neuralgia and meralgia paresthetica. Sympathetic blocks of the upper and lower extremities can provide pain relief to facilitate functional restoration in patients with complex regional pain syndrome. Neurolytic celiac plexus block can provide effective pain relief in those with cancer-related pain of the abdominal viscera. Epidural injection of steroids has proven beneficial for reducing the severity and duration of acute radicular pain associated with intervertebral disc herniation. In patients with chronic neck or low back pain related to facet arthropathy, diagnostic blocks of the medial branch nerves can identify those patients who are most likely to attain durable pain relief with radiofrequency neurolysis.
The use of fluoroscopy, computed tomography, and, most recently, ultrasound in the pain clinic all have advanced rapidly, yet there is scant evidence that this improves the safety or efficacy of pain treatment. In this manuscript, the available evidence about the usefulness of diagnostic imaging and image guidance in planning and delivering pain treatment is critically reviewed. The use of image guidance has become a routine and integral component of pain treatment; however, there is insufficient scientific evidence to judge whether this has improved safety. The logical appeal is overwhelming, to the point that it is now unlikely that scientific comparisons of most techniques with and without radiographic guidance will ever be conducted. This analysis can serve to guide future investigators who set out to understand how to apply new imaging techniques, and in the process, how to rigorously evaluate their usefulness.
To assess the efficacy of caudal epidural steroid or saline injection in chronic lumbar radiculopathy in the short (6 weeks), intermediate (12 weeks), and long term (52 weeks).
Multicentre, blinded, randomised controlled trial.
Outpatient multidisciplinary back clinics of five Norwegian hospitals.
Between October 2005 and February 2009, 461 patients assessed for inclusion (presenting with lumbar radiculopathy >12 weeks). 328 patients excluded for cauda equina syndrome, severe paresis, severe pain, previous spinal injection or surgery, deformity, pregnancy, ongoing breast feeding, warfarin therapy, ongoing treatment with non-steroidal anti-inflammatory drugs, body mass index >30, poorly controlled psychiatric conditions with possible secondary gain, and severe comorbidity.
Subcutaneous sham injections of 2 mL 0.9% saline, caudal epidural injections of 30 mL 0.9% saline, and caudal epidural injections of 40 mg triamcinolone acetonide in 29 mL 0.9% saline. Participants received two injections with a two week interval.
Primary: Oswestry disability index scores. Secondary: European quality of life measure, visual analogue scale scores for low back pain and for leg pain.
Power calculations required the inclusion of 41 patients per group. We did not allocate 17 of 133 eligible patients because their symptoms improved before randomisation. All groups improved after the interventions, but we found no statistical or clinical differences between the groups over time. For the sham group (n = 40), estimated change in the Oswestry disability index from the adjusted baseline value was -4.7 (95% confidence intervals -0.6 to -8.8) at 6 weeks, -11.4 (-6.3 to -14.5) at 12 weeks, and -14.3 (-10.0 to -18.7) at 52 weeks. For the epidural saline intervention group (n = 39) compared with the sham group, differences in primary outcome were -0.5 (-6.3 to 5.4) at 6 weeks, 1.4 (-4.5 to 7.2) at 12 weeks, and -1.9 (-8.0 to 4.3) at 52 weeks; for the epidural steroid group (n=37), corresponding differences were -2.9 (-8.7 to 3.0), 4.0 (-1.9 to 9.9), and 1.9 (-4.2 to 8.0). Analysis adjusted for duration of leg pain, back pain, and sick leave did not change this trend.
Caudal epidural steroid or saline injections are not recommended for chronic lumbar radiculopathy. Trial registration Current Controlled Trials ISRCTN No 12574253.
The literature is limited in the comparative efficacy and safety of dexamethasone phosphate (DP) compared with methylprednisolone acetate (MPA) in the treatment of lumbar radiculopathy by epidural injection. This study attempts to test the hypothesis that 2 corticosteroids are equivalent in efficacy and side effects.
Patients with lumbar radicular symptoms for at least 6 months were randomized to equipotent doses of MPA 80 mg or DP 15 mg by lumbar translaminar epidurals administered under fluoroscopy. The epidurals were administered by different nonblinded practitioners other than the authors. Preprocedure Visual Analog Scale (VAS) pain scores by preoperative pain clinic nursing staff not involved in the study. On follow-up for the second epidural at 1 to 2 months, VAS scores and any reports of adverse side effects were obtained by pain clinic nursing staff who were blinded to the type of corticosteroid used. Electronic records were also reviewed for intervening changes in medication, additional therapeutic modalities, emergency room visits, and any other complications missed on nursing follow-up.
There were no significant demographic differences between the DP group (N = 30) and MPA group (N = 30). The mean days to follow-up was less for the DP group (41.1) versus the MPA group (51.1), although the difference was not statistically significant (P = 0.4284). Comparing the DP group and MPA group, there was a smaller mean decrease in VAS for the DP group (-19.7%) versus the MPA group (-27.2%), although the difference was not statistically significant (P = 0.3672). Eighty-seven percent of patients in the MPA group and 90% in the DP group had decreases in postprocedure VAS with no statistically significant difference between the 2 groups (P = 0.999). Thirteen percent of the MPA group and 10% of the DP group had increases in postprocedure VAS with no significant difference between the 2 groups (P = 0.999). The percentage increase in postprocedure VAS for those who had increase in pain was 34.3% and 31.7% for the MPA and DP group, respectively with no statistically significant difference noted (P = 0.8657). Review of electronic medical records showed no change in pain medication prescribed, emergency room visits for pain, or any new treatments for pain in either group. No complications were reported by patients on nursing follow-up or seen in review of medical records including new neurological symptoms or new areas of pain.
Nonparticulate DP seems to be close to the safety and effectiveness of particulate MPA in the treatment of lumbar radiculopathy. There is, however, a statistically nonsignificant trend toward less pain relief and shorter duration of action that may be clarified in a larger and longer duration study.
To determine the difference in short- and long-term pain improvement between lumbar Epidural Steroid Injections (ESIs) and conservative management in patients with lumbar radiculopathy.
Quasi-experimental study.
The Postgraduate Medical Institute of Hayatabad Medical Complex, Peshawar, from April 2005 to March 2007.
Fifty elective patients fulfilling the inclusion criteria were randomly divided into two groups. Patients in the steroid group were treated with 80 mg of methylprednisolone injected in combination with 3 ml of 2% plain xylocaine and 3 ml of normal saline in the lumbar epidural space, while patients in the conservative group were treated with bed rest, non-steroidal anti-inflammatory agents, muscle relaxants, and opioids. All the 50 patients in the two groups were regularly assessed at 2 weeks, 1 month, 3 months and 6 months of periods for pain score by the Visual Analogue Scale (VAS), patients satisfaction score and any unwanted side effects.
A marked improvement of the pain score and patients satisfaction score were noticed in the steroid group. Less significant improvement was seen in the conservative group during the initial period i.e 2 weeks and 1 month (p < 0.05). The difference in Visual Analogue Scale (VAS) and patients satisfaction score was non-significant in chronic stages of treatment in both groups (p > 0.05).
Epidural steroid injections in acute symptoms of sciatica are considered to be a better option compared to conservative treatment.
In this prospective randomized clinical trial, the results of epidural corticosteroid injections were evaluated in patients with lumbosciatic pain caused by herniated nucleus pulposus. Thirty-six patients with radicular lumbosciatic pain and positive straight leg raising test because of confirmed prolapsed intervertebral lumbar discs were randomized into two groups with (17 patients) and without (19 patients) epidural corticosteroid injection. Members of the treatment groups received three injections of 100 mg methylprednisolone in 10 mL bupivacaine 0.25% each. Additional therapy was standardized and identical in both groups. Followup examinations were performed at 2 weeks, 6 weeks, and 6 months. The examinations included pain level (visual analogue scale), straight leg raising test, and functional status (Hannover Functional Ability Questionnaire). At 2 weeks, patients receiving methylprednisolone injection showed a significant improvement in straight leg raising test results compared with patients in the control group. Results were better in the methylprednisolone group, although not statistically significant for pain relief and mobility. At 6 weeks and 6 months, pain relief, improvement of straight leg raising, and improvement of functional status showed no statistical significance. Epidural corticosteroid injections can be recommended as additional therapy only in the acute phase of the conservative management of lumbosciatic pain.
We have assessed whether an epidural steroid injection is effective in the treatment of symptoms due to compression of a nerve root in the lumbar spine by carrying out a prospective, randomised, controlled trial in which patients received either an epidural steroid injection or an intramuscular injection of local anaesthetic and steroid. We assessed a total of 93 patients according to the Oxford pain chart and the Oswestry disability index and followed up for a minimum of two years. All the patients had been categorised as potential candidates for surgery.
There was a significant reduction in pain early on in those having an epidural steroid injection but no difference in the long term between the two groups. The rate of subsequent operation in the groups was similar.
To determine the effectiveness and predictors of response to lumbar epidural corticosteroid injections (ESI) in patients with sciatica. We performed a 12-month, multicentre, double-blind, randomized, placebo-controlled, parallel-group trial in four secondary pain-care clinics in the Wessex Region.
Two hundred and twenty-eight patients with a clinical diagnosis of unilateral sciatica of 1-18 months' duration were randomized to either three lumbar ESIs of triamcinolone acetonide or interligamentous saline injections at intervals of 3 weeks. The main outcome measure was the Oswestry low back pain disability questionnaire (ODQ).
At 3 weeks, the ESI group demonstrated a transient benefit over the placebo group (patients achieving a 75% improvement in ODQ, 12.5 vs 3.7%; number needed to treat, 11.4). No benefit was demonstrated from 6 to 52 weeks. ESIs did not improve physical function, hasten return to work or reduce the need for surgery. There was no benefit of repeated ESIs over single injection. No clinical predictors of response were found. At the end of the study the majority of patients still had significant pain and disability regardless of intervention.
In this pragmatic study, ESIs offered transient benefit in symptoms at 3 weeks in patients with sciatica, but no sustained benefits in terms of pain, function or need for surgery. Sciatica is a chronic condition requiring a multidisciplinary approach. To fully investigate the value of ESIs, they need to be evaluated as part of a multidisciplinary approach.
Study Design. This study is an analysis of national survey data from 5 sample years. Objectives. The authors characterized the frequency of office visits for low back pain, the content of ambulatory care, and how these vary by physician specialty. Summary of Background Data. Few recent data are available regarding ambulatory care for low back pain or how case mix and patient management vary by physician specialty. Methods. Data from the National Ambulatory Medical Care Survey were grouped into three time periods (1980-81, 1985, 1989-90). Frequency of visits for low back pain, referral status, tests, and treatments were tabulated by physician speciatly. Results. There were almost 15 million office visity for "mechanical" low back pain in 1990, ranking this problem fifth as a reason for all physician visits. Low back pain accounted for 2.8 percent of office visity in all three time periods. Nonspecific diagnostic lables were most common, and 56 percent of visits were to primary care physicians. Specialty variations were observed in caseload, diagnostic mix, and management. Conclusion. Back pain remains a major reason for all physician office visity. This study describes visit, referral, and management patterns among specialties providing the most care.
Lumbar epidural steroid injections are used to manage low back and leg pain (ie, sciatica). Utilization of the procedure is increasing, with Medicare spending for lumbar epidural procedures topping $175 million annually. Few prospective randomized controlled trials have clearly demonstrated the efficacy of epidural steroid injections; many have shown conflicting results. Several studies show favorable short-term outcomes with epidural steroid injection for radicular pain, but less conclusive results are achieved >6 months. Methodologic flaws limit interpretation of results from most scientific studies. As a tool for predicting surgical outcome, epidural spinal injection has been found to have a sensitivity between 65% and 100%, a specificity between 71% and 95%, and a positive predictive value as high as 95% for 1-year surgical outcome. Despite inconclusive evidence, when weighing the surgical alternatives and associated risk, cost, and outcomes, lumbar epidural steroid injections are a reasonable nonsurgical option in select patients.
The rates of epidural steroid injections have increased dramatically over time, with conflicting evidence regarding the efficacy of epidural steroid injections for the treatment of various low-back pain disorders. Given the uncertainty about their role, we sought to evaluate the geographic variation in the use of epidural steroid injections for low back pain within the United States. We also sought to determine whether greater rates of epidural steroid injections are associated with lower rates of lumbar surgery.
We used the 2001 Medicare Physician Part-B claims to examine the geographic variation in the use of epidural steroid injections. Current Procedural Technology codes were used to identify the number of procedures performed as well as the percentage of injections that were fluoroscopically guided. Procedure rates were analyzed with use of several geographic indicators, including state, United States Census Bureau regions (Northeast, South, Midwest, and West), and health referral regions as defined by the Dartmouth Atlas of Health Care.
In 2001, there was a 7.7-fold difference between the state with the lowest rate (Hawaii at 5.2 per 1000) and the state with the highest rate (Alabama at 39.9 per 1000). The variation among health referral regions, which are smaller in size, was even greater, with an 18.4-fold difference from 5.6 per 1000 in Honolulu, Hawaii, to 103.6 per 1000 in Palm Springs, California. Higher statewide rates of epidural steroid injections were associated with significantly higher rates of lumbar surgery (p = 0.001). In areas with high injection rates, a significantly higher percentage of patients who sought care for low back pain received injections (p < 0.001). In addition, in areas with high injection rates, a significantly higher percentage of patients who presented with low back pain received both injections and lumbar surgery within the same year (p < 0.001).
There is substantial geographic variation in the rates of epidural steroid injections within the United States. Southern states tend to have the highest procedure rates, whereas northeastern states have the lowest. Injection rates are positively correlated with lumbar surgery rates; therefore, epidural steroid injections do not appear to be substituting for lumbar surgeries or reducing overall rates of lumbar surgery.
This study is an analysis of national survey data from 5 sample years.
The authors characterized the frequency of office visits for low back pain, the content of ambulatory care, and how these vary by physician specialty.
Few recent data are available regarding ambulatory care for low back pain or how case mix and patient management vary by physician specialty.
Data from the National Ambulatory Medical Care Survey were grouped into three time periods (1980-81, 1985, 1989-90). Frequency of visits for low back pain, referral status, tests, and treatments were tabulated by physician specialty.
There were almost 15 million office visits for "mechanical" low back pain in 1990, ranking this problem fifth as a reason for all physician visits. Low back pain accounted for 2.8 percent of office visits in all three time periods. Nonspecific diagnostic labels were most common, and 56 percent of visits were to primary care physicians. Specialty variations were observed in caseload, diagnostic mix, and management.
Back pain remains a major reason for all physician office visits. This study describes visit, referral, and management patterns among specialties providing the most care.
The purpose of the study was to assess the efficacy of epidural steroid injections for low-back pain. Data was obtained using computer-aided search of published randomized clinical trials and assessment of the methods of the studies. Twelve randomized clinical trials evaluating epidural steroid injections were identified. Data was extracted based on scores for quality of the methods, using 4 categories (study population, interventions, effect measurement, and data presentation and analysis) and the conclusion of the author(s) with regard to the efficacy of epidural steroid injections. Method scores of the trials ranged from 17 to 72 points (maximum 100 points). Eight trials showed method scores of 50 points or more. Of the 4 best studies (> 60 points), 2 reported positive outcomes and 2 reported negative results. Overall, 6 studies indicated that the epidural steroid injection was more effective than the reference treatment and 6 reported it to be no better or worse than the reference treatment. There appeared to be no relationship between the methodological quality of the trials and reported outcomes. In conclusion, there are flaws in the design of most studies. The best studies showed inconsistent results of epidural steroid injections. The efficacy of epidural steroid injections has not been established. The benefits of epidural steroid injections, if any, seem to be of short duration only. Future research efforts are warranted, but more attention should be paid to the methods of the trials.
The efficacy of epidural corticosteroids in the treatment of sciatica was investigated by meta-analysis of all randomized controlled trials. Eleven suitable trials of good quality were identified involving a total of 907 patients.
The use of epidural (caudal or lumbar) steroid in the short-term (up to 60 days) increased the odds ratio (OR) of pain relief (>75% improvement) to 2.61 (95% CI 1.90–3.77) when compared with placebo. Despite some variations in trial characteristics there was little evidence of significant heterogeneity (P=0.07). When the trials were analysed for near or total relief of pain in the short-term the OR is 2.79 (95% CI 1.92–4.06), for heterogeneity (P=0.07). For longterm relief of pain (up to 12 months) the OR is 1.87 (95% CI 1.31–2.68).
Efficacy is independent of the route of injection; for caudal epidural steroid the OR is 3.80 (95% CI 1.36–10.6) and for the lumbar epidural steroid 2.43 (95% CI 1.77–3.74).
Adverse events included dural tap (2.5%), transient headache (2.3%) and a transient increase in pain (1.9%). There were no reported longterm adverse events.
In conclusion we present quantitative evidence from meta-analysis of pooled data from randomized trials that epidural administration of corticosteroids is effective in the management of lumbosacral radicular pain.
Although epidural corticosteroid injections are commonly used for sciatica, their efficacy has not been established.
In a randomized, double-blind trial, we administered up to three epidural injections of methylprednisolone acetate (80 mg in 8 ml of isotonic saline) or isotonic saline (1 ml) to 158 patients with sciatica due to a herniated nucleus pulposus. All patients had Oswestry disability scores higher than 20 (on a scale of 1 to 100, with scores of 20 or less indicating minimal disability, and higher scores greater disability).
At three weeks, the Oswestry score had improved by a mean of -8.0 in the methylprednisolone group and -5.5 in the placebo group (95 percent confidence interval for the difference, -7.1 to 2.2). Differences in improvements between the groups were not significant, except for improvements in the finger-to-floor distance (P=0.006) and sensory deficits (P=0.03), which were greater in the methylprednisolone group. After six weeks, the only significant difference was the improvement in leg pain, which was greater in the methylprednisolone group (P=0.03). After three months, there were no significant differences between the groups. The Oswestry score had improved by a mean of -17.3 in the methylprednisolone group and -15.4 in the placebo group (95 percent confidence interval for the difference, -9.3 to 5.4). At 12 months, the cumulative probability of back surgery was 25.8 percent in the methylprednisolone group and 24.8 percent in the placebo group (P=0.90).
Although epidural injections of methylprednisolone may afford short-term improvement in leg pain and sensory deficits in patients with sciatica due to a herniated nucleus pulposus, this treatment offers no significant functional benefit, nor does it reduce the need for surgery.
The possible role of phospholipase A2 in an animal model for lumbar radiculopathy and mechanisms of epidural steroid injections were studied.
To clarify the pathophysiologic mechanism of the recently proved animal model for lumbar radiculopathy and to characterize further the mechanisms of action of steroids.
There have been several reported animal models of peripheral neuropathy. Recently an animal model that shows reliable behavioral and neurochemical changes was proposed, and epidural steroid injections in this model were effective in the reduction of thermal hyperalgesia and allodynia.
In a behavioral study, 24 rats were divided into 4 groups: Group I, loose ligature of the left L4 and L5 nerve roots with 4-0 chromic gut sutures and an epidural injection of 0.1 mL of saline at 3 days after surgery; Group II, same as Group I but with an epidural injection of 0.1 mL of betamethasone on the day before the operation; Group II, same as Group II except injection at 1 day after surgery; Group IV, same as Group II except injection at 3 days after surgery. To test the phospholipase A2 activity in the nerve roots and dorsal root ganglia after the operation, eight rats were killed at given intervals. Analysis of variance techniques were used to test behavioral pattern changes and phospholipase A2 activity across time in each group.
Thermal hyperalgesia reached its maximal point at 3 weeks after surgery in Group I, but in steroid injection groups, the recovery from hyperalgesia was faster than in Group I. However, there was no significant difference in recovery time among steroid injection groups. The level of phospholipase A2 activity was at its maximum at 1 week after surgery in Groups I and IV. It showed a steady reduction in the steroid group, whereas it remained relatively high and dropped rapidly after 3 weeks in the saline-treated group, and returned to the level of a normal nerve root at 6 weeks after surgery.
These results suggest that the behavioral pattern changes observed in the irritated nerve root model are caused in part by a high level of phospholipase A2 activity initiated by inflammation, and that the mechanism of action of epidural steroid injection in this model is inhibition of phospholipase A2 activity.
Although the literature is filled with information about the prevalence and incidence of back pain in general, there is less information about chronic back pain, partly because of a lack of agreement about definition. Chronic back pain is sometimes defined as back pain that lasts for longer than 7-12 weeks. Others define it as pain that lasts beyond the expected period of healing, and acknowledge that chronic pain may not have well-defined underlying pathological causes. Others classify frequently recurring back pain as chronic pain since it intermittently affects an individual over a long period. Most national insurance and industrial sources of data include only those individuals in whom symptoms result in loss of days at work or other disability. Thus, even less is known about the epidemiology of chronic low-back pain with no associated work disability or compensation. Chronic low-back pain has also become a diagnosis of convenience for many people who are actually disabled for socioeconomic, work-related, or psychological reasons. In fact, some people argue that chronic disability in back pain is primarily related to a psychosocial dysfunction. Because the validity and reliability of some of the existing data are uncertain, caution is needed in an assessment of the information on this type of pain.
Injection with anaesthetics and/or steroids is one of the treatment modalities used in patients with chronic low back pain which needs evaluation with respect to the effectiveness on short and long term pain relief.
To evaluate the effectiveness of injection therapy in patients with low back pain lasting longer than one month. We distinguished between three injection sites: facet joint, epidural or local injections.
We searched the Medline and Embase databases up to 1996 and other search methods as advocated by the Back Review Group search strategy. Abstracts and unpublished studies were not included.
Randomized controlled trials of injection therapy for pain relief (although additional treatments were allowed) in patients with benign low back pain lasting longer than one month and not originating from cancer.
Two reviewers independently assessed the trials for methodological quality. Subgroup analyses were made between trials with different control groups (placebo and active injections), with different injection site (facet joint, epidural and local injection), and timing of outcome measurement (short and long term). Within the resulting 12 subcategories of studies (2*3*2), the overall relative risks and corresponding 95% confidence intervals were estimated, using a random effects model (DerSimonian and Laird). In the case of trials in which control groups were active injections, we refrained from pooling the results.
Twenty-one randomized trials were included in this review. All studies involved patients with low back pain lasting longer than one month. Only 11 studies compared injection therapy with placebo injections (explanatory trials). The methodologic quality of many studies was low: only 8 studies had a methodologic score of 50 or more points. There were only three well designed explanatory clinical trials: one on injections into the facet joints with a short-term RR of 0.89 (95% CI: 0.65-1.21) and a long-term RR of 0.90 (95% CI: 0.69-1.17); one on epidural injections with a short-term RR of 0.94 (95% CI: 0.76-1.15) and a long-term RR of 1.00 (95% CI: 0.71-1.41); and one on local injections with a long-term RR of 0.79 (95% CI: 0.65-0.96). Within the 6 subcategories of explanatory studies the pooled RRs with 95% confidence intervals were: facet joint, short-term: RR=0.89 (0.65-1.21); facet joint, long-term: RR=0.90 (0.69-1.17); epidural, short-term: RR=0.93 (0. 79-1.09); epidural, long-term: RR=0.92 (0.76-1.11); local, short-term: RR=0.80 (0.40-1.59); local, long-term: RR=0.79 (0.65-0. 96).
Convincing evidence is lacking on the effects of injection therapies for low back pain. There is a need for more, well designed explanatory trials in this field.
A prospective, randomised, double-blind study was carried out to compare the respective efficacies of transforaminal and interspinous epidural corticosteroid injections in discal radiculalgia. Thirty-one patients (18 females, 13 males) with discal radicular pain of less than 3 months' duration were consecutively randomised to receive either radio-guided transforaminal or blindly performed interspinous epidural corticosteroid injections. Post-treatment outcome was evaluated clinically at 6 and 30 days, and then at 6 months, but only by mailed questionnaire. At day 6, the between-group difference was significantly in favour of the transforaminal group with respect to Schober's index, finger-to-floor distance, daily activities, and work and leisure activities on the Dallas pain scale. At day 30, pain relief was significantly better in the transforaminal group. At month 6, answers to the mailed questionnaire still showed significantly better results for transforaminal injection concerning pain, daily activities, work and leisure activities and anxiety and depression, with a decline in the Roland-Morris score. In recent discal radiculalgia, the efficacy of radio-guided transforaminal epidural corticosteroid injections was higher than that obtained with blindly-performed interspinous injections.
Epidural steroid injection (ESI) is one of the most common nonsurgical interventions prescribed for back and leg pain symptoms. Although the use of ESI is widespread, proof of efficacy among the broad population of low back pain patients is lacking and use is predicated to a great extent on the cost and morbidity of the perceived "next step" in many patient's care-surgery.
To review the relative indications and clinical features that predict success with ESI therapy, and to provide a physiological rationale to guide clinical decision-making.
Review of literature and clinical experience.
Clinical studies have alternately supported and refuted the efficacy of ESI in the treatment of patients with back and leg pain. Steroid medications do benefit some patients with radicular pain, but the benefit is often limited in duration, making efficacy difficult to prove over time. Steroids appear to speed the rate of recovery and return to function, however, allowing patients to reduce medication levels and increase activity while awaiting the natural improvement expected in most spinal disorders. Fluoroscopic verification of needle placement, with contrast injection, greatly improves steroid delivery while reducing risks. Although it is assumed that the benefit of steroids is related to their effect on inflammation, that remains unproven, and it is possible that benefit is gained through an unrecognized action.
Randomized, controlled trials are needed to conclusively identify those patients most likely to benefit from ESI, and when and for how long. Until then, epidural steroids provide a reasonable alternative to surgical intervention in selected patients with back and/or leg pain, whose symptoms are functionally limiting. When appropriate goals are established and proper patients are selected, sufficient short-term benefit has been documented to warrant continued use of this tool.
Retrospective cohort study using national sample administrative data.
To determine if lumbar fusion rates increased in the 1990s and to compare lumbar fusion rates with those of other major musculoskeletal procedures.
Previous studies found that lumbar fusion rates rose more rapidly during the 1980s than did other types of lumbar surgery.
We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1988 through 2001 to examine trends. U.S. Census data were used for calculating age and sex-adjusted population-based rates. We excluded patients with vertebral fractures, cancer, or infection.
In 2001, over 122,000 lumbar fusions were performed nationwide for degenerative conditions. This represented a 220% increase from 1990 in fusions per 100,000. The increase accelerated after 1996, when fusion cages were approved. From 1996 to 2001, the number of lumbar fusions increased 113%, compared with 13 to 15% for hip replacement and knee arthroplasty. Rates of lumbar fusion rose most rapidly among patients aged 60 and above. The proportion of lumbar operations involving a fusion increased for all diagnoses.
Lumbar fusion rates rose even more rapidly in the 90s than in the 80s. The most rapid increases followed the approval of new surgical implants and were much greater than increases in other major orthopedic procedures. The most rapid increases in fusion rates were among adults aged 60 and above. These increases were not associated with reports of clarified indications or improved efficacy, suggesting a need for better data on the efficacy of various fusion techniques for various indications.
Based on the available evidence, the Therapeutics and Technology Assessment subcommittee concluded that 1) epidural steroid injections may result in some improvement in radicular lumbosacral pain when assessed between 2 and 6 weeks following the injection, compared to control treatments (Level C, Class I-III evidence). The average magnitude of effect is small and generalizability of the observation is limited by the small number of studies, highly selected patient populations, few techniques and doses, and variable comparison treatments; 2) in general, epidural steroid injection for radicular lumbosacral pain does not impact average impairment of function, need for surgery, or provide long-term pain relief beyond 3 months. Their routine use for these indications is not recommended (Level B, Class I-III evidence); 3) there is insufficient evidence to make any recommendation for the use of epidural steroid injections to treat radicular cervical pain (Level U).
Injection with anaesthetics and/or steroids is one of the treatment modalities used in patients with chronic low back pain which needs evaluation with respect to the effectiveness on short and long term pain relief.
To evaluate the effectiveness of injection therapy in patients with low back pain lasting longer than one month. We distinguished between three injection sites: facet joint, epidural or local injections.
We searched the Medline and Embase databases up to 1996 and other search methods as advocated by the Back Review Group search strategy. Abstracts and unpublished studies were not included.
Randomized controlled trials of injection therapy for pain relief (although additional treatments were allowed) in patients with benign low back pain lasting longer than one month and not originating from cancer.
Two authors independently assessed the trials for methodological quality. Subgroup analyses were made between trials with different control groups (placebo and active injections), with different injection site (facet joint, epidural and local injection), and timing of outcome measurement (short and long term). Within the resulting 12 subcategories of studies (2*3*2), the overall relative risks and corresponding 95% confidence intervals were estimated, using a random effects model (DerSimonian and Laird). In the case of trials in which control groups were active injections, we refrained from pooling the results.
Twenty-one randomized trials were included in this review. All studies involved patients with low back pain lasting longer than one month. Only 11 studies compared injection therapy with placebo injections (explanatory trials). The methodologic quality of many studies was low: only 8 studies had a methodologic score of 50 or more points. There were only three well designed explanatory clinical trials: one on injections into the facet joints with a short-term RR of 0.89 (95% CI: 0.65-1.21) and a long-term RR of 0.90 (95% CI: 0.69-1.17); one on epidural injections with a short-term RR of 0.94 (95% CI: 0.76-1.15) and a long-term RR of 1.00 (95% CI: 0.71-1.41); and one on local injections with a long-term RR of 0.79 (95% CI: 0.65-0.96). Within the 6 subcategories of explanatory studies the pooled RRs with 95% confidence intervals were: facet joint, short-term: RR=0.89 (0.65-1.21); facet joint, long-term: RR=0.90 (0.69-1.17); epidural, short-term: RR=0.93 (0.79-1.09); epidural, long-term: RR=0.92 (0.76-1.11); local, short-term: RR=0.80 (0.40-1.59); local, long-term: RR=0.79 (0.65-0.96).
Convincing evidence is lacking on the effects of injection therapies for low back pain. There is a need for more, well designed explanatory trials in this field.
The role of steroids and their effects on phospholipase A2. An animal model of radiculopathy
- H M Lee
- J N Weinstein
- S T Meller
- H.M. Lee