scholarly journals Epidural Steroids in the Management of Chronic Spinal Pain: A Systematic Review

2007 ◽  
Vol 1;10 (1;1) ◽  
pp. 185-212
Author(s):  
Salahadin Abdi
Keyword(s):  
Spinal Pain ◽  
Radicular Pain ◽  
Low Back ◽  
Short Term ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Nerve Root Pain ◽  
Epidural Steroid ◽  
Chronic Spinal Pain

Background: Epidural injection of corticosteroids is one of the most commonly used interventions in managing chronic spinal pain. However, there has been a lack of well-designed randomized, controlled studies to determine the effectiveness of epidural injections. Consequently, debate continues as to the value of epidural steroid injections in managing spinal pain. Objective: To evaluate the effect of various types of epidural steroid injections (interlaminar, transforaminal, and caudal), in managing various types of chronic spinal pain (axial and radicular) in the neck and low back regions. Study Design: A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials, and criteria of Cochrane Musculoskeletal Review Group for randomized trials were used. Methods: Data sources included relevant English literature performed by a librarian experienced in Evidence Based Medicine (EBM), as well as manual searches of bibliographies of known primary and review articles and abstracts from scientific meetings within the last 2 years. Three reviewers independently assessed the trials for the quality of their methods. Subgroup analyses were performed among trials with different control groups, with different techniques of epidural injections (interlaminar, transforaminal, and caudal), with different injection sites (cervical/thoracic, lumbar/sacral), and with timing of outcome measurement (short- and long-term). Outcome Measures: The primary outcome measure is pain relief. Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term improvement is defined as 6 weeks or less, and long-term relief is defined as 6 weeks or longer. Results: In managing lumbar radicular pain with interlaminar lumbar epidural steroid injections, the evidence is strong for short-term relief and limited for long-term relief. In managing cervical radiculopathy with cervical interlaminar epidural steroid injections, the evidence is moderate. The evidence for lumbar transforaminal epidural steroid injections in managing lumbar radicular pain is strong for short-term and moderate for long-term relief. The evidence for cervical transforaminal epidural steroid injections in managing cervical nerve root pain is moderate. The evidence is moderate in managing lumbar radicular pain in post lumbar laminectomy syndrome. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief, in managing chronic pain of lumbar radiculopathy and postlumbar laminectomy syndrome. Conclusion: There is moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. The evidence for cervical and lumbar transforaminal epidural steroid injections is moderate for long-term improvement in managing nerve root pain. The evidence for caudal epidural steroid injections is moderate for long-term relief in managing nerve root pain and chronic low back pain. Key words: Spinal pain, low back pain, cervicalgia, epidural steroids, interlaminar, caudal, transforaminal, radiculopathy, axial pain, postlaminectomy syndrome, failed back surgery syndrome.

scholarly journals Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain

2007 ◽  
Vol 1;10 (1;1) ◽  
pp. 7-111
Author(s):  
ASIPP ASIPP
Keyword(s):  
Facet Joint ◽  
Spinal Pain ◽  
Evidence Based ◽  
Short Term ◽  
Steroid Injections ◽  
Interventional Techniques ◽  
Epidural Steroid Injections ◽  
Epidural Steroid ◽  
Chronic Spinal Pain

Background: The evidence-based practice guidelines for the management of chronic spinal pain with interventional techniques were developed to provide recommendations to clinicians in the United States. Objective: To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists from academic and clinical practices. Design: Study design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions and statements about relationships between clinical interventions and outcomes. Methods: The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, and blinded peer review. Methodologic quality evaluation criteria utilized included the Agency for Healthcare Research and Quality (AHRQ) criteria, Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), to Level V (indeterminate). Results: Among the diagnostic interventions, the accuracy of facet joint nerve blocks is strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it is moderate in the diagnosis of thoracic facet joint pain. The evidence is strong for lumbar discography, whereas, the evidence is limited for cervical and thoracic discography. The evidence for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies is moderate. The evidence for diagnostic sacroiliac joint injections is limited. The evidence for therapeutic lumbar intraarticular facet injections is moderate for short-term and long-term improvement, whereas, it is limited for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks is moderate. The evidence for medial branch neurotomy is moderate. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief in managing chronic low back and radicular pain, and limited in managing pain of postlumbar laminectomy syndrome. The evidence for interlaminar epidural steroid injections is strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence is moderate. The evidence for transforaminal epidural steroid injections is strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it is moderate for cervical nerve root pain and limited in managing pain secondary to lumbar post laminectomy syndrome and spinal stenosis. The evidence for percutaneous epidural adhesiolysis is strong. For spinal endoscopic adhesiolysis, the evidence is strong for short-term relief and moderate for long-term relief. For sacroiliac intraarticular injections, the evidence is limited. The evidence for radiofrequency neurotomy for sacroiliac joint pain is limited. The evidence for intradiscal electrothermal therapy is moderate in managing chronic discogenic low back pain, whereas for annuloplasty the evidence is limited. Among the various techniques utilized for percutaneous disc decompression, the evidence is moderate for short-term and limited for long-term relief for automated percutaneous lumbar discectomy, and percutaneous laser discectomy, whereas it is limited for nucleoplasty and for DeKompressor technology. For vertebral augmentation procedures, the evidence is moderate for both vertebroplasty and kyphoplasty. The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome is strong for shortterm relief and moderate for long-term relief. The evidence for implantable intrathecal infusion systems is strong for short-term relief and moderate for long-term relief. Conclusion: These guidelines include the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. These guidelines also do not represent a “standard of care.” Key words: Interventional techniques, chronic spinal pain, diagnostic blocks, therapeutic interventions, facet joint interventions, epidural injections, epidural adhesiolysis, discography, radiofrequency, disc decompression, vertebroplasty, kyphoplasty, spinal cord stimulation, intrathecal implantable systems

scholarly journals Systematic Review of Therapeutic Lumbar Transforaminal Epidural Steroid Injections

2009 ◽  
Vol 1;12 (1;1) ◽  
pp. 233-251 ◽  
Author(s):  
Ricardo M. Buenaventura
Keyword(s):  
Systematic Review ◽  
Lower Extremity ◽  
Low Back ◽  
Short Term ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Lower Extremity Pain ◽  
Level Ii ◽  
Epidural Steroid

Background: 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. Study Design: A systematic review of transforaminal epidural injection therapy for low back and lower extremity pain. Objective: To evaluate the effect of transforaminal lumbar epidural steroid injections in managing lumbar (low-back) and sciatica (leg) pain. Methods: 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. Outcome Measures: 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. Results: 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. . Limitations: The limitations of this systematic review include the paucity of literature. Conclusion: 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. Key words: Spinal pain, chronic low back pain, lower extremity pain, transforaminal epidural steroids, radiculopathy, sciatica, steroids, local anesthetic

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

2017 ◽  
Vol 107 ◽  
pp. 764-771 ◽  
Author(s):  
Holger Joswig ◽  
Armin Neff ◽  
Christina Ruppert ◽  
Gerhard Hildebrandt ◽  
Martin Nikolaus Stienen
Keyword(s):  
Pain Relief ◽  
Short Term ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

scholarly journals Comparison of the Oblique Interlaminar and Transforaminal Lumbar Epidural Steroid Injections for Treatment of Low Back and Lumbosacral Radicular Pain

2021 ◽  
Vol Volume 14 ◽  
pp. 407-414
Author(s):  
Eun-Ji Choi ◽  
Soon Ji Park ◽  
Yeong-Min Yoo ◽  
Ji-Uk Yoon ◽  
Sang-Wook Shin ◽  
...  
Keyword(s):  
Radicular Pain ◽  
Low Back ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

scholarly journals Immediate and Acute Adverse Effects Following Transforaminal Epidural Steroid Injections with Dexamethasone

2015 ◽  
Vol 3;18 (3;5) ◽  
pp. 277-286
Author(s):  
Omar Hammam El Abd, MD
Keyword(s):  
Side Effects ◽  
Adverse Effects ◽  
Spinal Pain ◽  
Radicular Pain ◽  
Steroid Injections ◽  
Epidural Injections ◽  
Epidural Steroid Injections ◽  
Phone Calls ◽  
Time Period ◽  
Epidural Steroid

Background: Transforaminal epidural steroid injections (TFESI) are widely used for the conservative treatment of radicular pain. The use of dexamethasone in TFESIs is relatively new; therefore, immediate and acute adverse effects that it may cause are not fully updated. Objective: To evaluate immediate and acute adverse effects following TFESI with dexamethasone. Study Design: Prospective, observational study. Setting: A spine center affiliated with a rehabilitation hospital. Methods: One hundred fifty consecutive patients receiving TFESI for the management of radicular and axial spinal pain at the cervical, lumbar, and sacral levels with dexamethasone using fluoroscopic guidance with digital subtraction technology were enrolled. The occurrence of adverse effects in patients in the 2-week time period following interventions was monitored through a set of questionnaires followed up by phone calls scheduled for 1 day, day 3, and day 14. Intensity and duration of side effects were recorded. Results: Of the 150 patients enrolled, 31 patients (19.5%) experienced adverse effects within the first 30 minutes following the intervention. The most common adverse effects were numbness and tingling in the limb, which developed in 19 patients (11.95%) followed by perineal pruritus that occurred in 7 cases (4.4%). Patients also reported experiencing adverse effects within the 3 days following intervention; most complained of headaches, insomnia, hiccups, flushing, and increased radicular pain. No major complications were noted. Limitations: The sample size enrolled might be too small to perceive possible rare side effects related to the procedure. The 2-week follow-up period is a limitation for evaluating late side effects. Conclusions: This study offers provision to interventionalists that TFESI with dexamethasone when performed by experienced hands and with proper technique has minor self-limited transient adverse effects that can be easily managed. Patients should be made aware of these adverse effects and their management. Further larger studies are needed to validate the safe use of dexamethasone and the safety of transforaminal epidural injections. Key words: Transforaminal epidural steroid injection, complications, dexamethasone

scholarly journals Epidural Steroid Injections for Low Back Pain: A Narrative Review

2021 ◽  
Vol 19 (1) ◽  
pp. 231
Author(s):  
Massimiliano Carassiti ◽  
Giuseppe Pascarella ◽  
Alessandro Strumia ◽  
Fabrizio Russo ◽  
Giuseppe Francesco Papalia ◽  
...  
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Radicular Pain ◽  
Narrative Review ◽  
Low Back ◽  
Current Application ◽  
Medical Treatments ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

Low back pain represents a significant socioeconomic burden. Several nonsurgical medical treatments have been proposed for the treatment of this disabling condition. Epidural steroid injections (ESIs) are commonly used to treat lumbosacral radicular pain and to avoid surgery. Even though it is still not clear which type of conservative intervention is superior, several studies have proved that ESIs are able to increase patients’ quality of life, relieve lumbosacral radicular pain and finally, reduce or delay more invasive interventions, such as spinal surgery. The aim of this narrative review is to analyze the mechanism of action of ESIs in patients affected by low back pain and investigate their current application in treating this widespread pathology.

scholarly journals The value of short-term pain relief in predicting the long-term outcome of ‘indirect’ cervical epidural steroid injections

2018 ◽  
Vol 160 (5) ◽  
pp. 935-943 ◽  
Author(s):  
Holger Joswig ◽  
Armin Neff ◽  
Christina Ruppert ◽  
Gerhard Hildebrandt ◽  
Martin Nikolaus Stienen
Keyword(s):  
Pain Relief ◽  
Short Term ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Cervical Epidural Steroid Injections ◽  
Epidural Steroid

scholarly journals Effectiveness of Therapeutic Lumbar Transforaminal Epidural Steroid Injections in Managing Lumbar Spinal Pain

2012 ◽  
Vol 3;15 (3;5) ◽  
pp. E199-E245 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Systematic Review ◽  
Lower Extremity ◽  
Local Anesthetic ◽  
Spinal Pain ◽  
Low Back ◽  
Steroid Injections ◽  
Epidural Injections ◽  
Epidural Steroid Injections ◽  
Lower Extremity Pain ◽  
Epidural Steroid

Background: Among the multiple interventions used in managing chronic spinal pain, lumbar epidural injections have been used extensively to treat lumbar radicular pain. Among caudal, interlaminar, and transforaminal, transforaminal epidural injections have gained rapid and widespread acceptance for the treatment of lumbar and lower extremity pain. The potential advantages of transforaminal over interlaminar and caudal, include targeted delivery of a steroid to the site of pathology, presumably onto an inflamed nerve root. However, there are only a few well-designed, randomized, controlled studies on the effectiveness of steroid injections. Consequently, multiple systematic reviews with diverse opinions have been published. Study Design: A systematic review of therapeutic transforaminal epidural injection therapy for low back and lower extremity pain. Objective: To evaluate the effect of therapeutic transforaminal lumbar epidural steroid injections in managing low back and lower extremity pain. Methods: The available literature on 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 by the Newcastle-Ottawa Scale criteria for observational studies. Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to December 2011, and manual searches of the bibliographies of known primary and review articles. The level of evidence was classified as good, fair, or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Outcome Measures: 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. Results: For this systematic review, 70 studies were identified. Of these, 43 studies were excluded and a total of 27 studies met inclusion criteria for methodological quality assessment with 15 randomized trials (with 2 duplicate publications) and 10 non-randomized studies. For lumbar disc herniation, the evidence is good for transforaminal epidural with local anesthetic and steroids, whereas it was fair for local anesthetics alone and the ability of transforaminal epidural injections to prevent surgery. For spinal stenosis, the available evidence is fair for local anesthetic and steroids. The evidence for axial low back pain and post lumbar surgery syndrome is poor, inadequate, limited, or unavailable. Limitations: The limitations of this systematic review include the paucity of literature. Conclusion: In summary, the evidence is good for radiculitis secondary to disc herniation with local anesthetics and steroids and fair with local anesthetic only; it is fair for radiculitis secondary to spinal stenosis with local anesthetic and steroids; and limited for axial pain and post surgery syndrome using local anesthetic with or without steroids. Key words: Spinal pain, chronic low back pain, lower extremity pain, transforaminal epidural steroids, radiculopathy, sciatica, steroids, local anesthetic

A Comparative Effectiveness Evaluation of Percutaneous Adhesiolysis and Epidural Steroid Injections in Managing Lumbar Post Surgery Syndrome: A Randomized, Equivalence Controlled Trial

2009 ◽  
Vol 6;12 (6;12) ◽  
pp. E355-E368
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Facet Joint ◽  
Low Back ◽  
Lumbar Surgery ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Post Surgery ◽  
Group I ◽  
Group Ii ◽  
Epidural Steroid ◽  
Caudal Epidural

Background: Speculated causes of post lumbar surgery syndrome include epidural fibrosis, acquired stenosis, and facet joint pain among other causes. Even though fluoroscopically directed caudal epidural injections and facet joint interventions are effective in some patients, others continue to suffer with chronic persistent pain. Percutaneous adhesiolysis with target delivery of medications has been demonstrated to be effective in these patients. However, the evidence for percutaneous adhesiolysis in managing post surgery syndrome has been questioned, coupled with a paucity of controlled trials. Study Design: A randomized, equivalence, controlled trial. Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objectives: To evaluate the effectiveness of percutaneous epidural adhesiolysis in patients with chronic low back and lower extremity pain in post surgery syndrome and compare with fluoroscopically directed caudal epidural steroid injections. Methods: Patients were randomly assigned to one of 2 groups: Group I (60 patients) receiving caudal epidural injections with catheterization up to S3 with local anesthetic, steroids, and 0.9% sodium chloride solution serving as the control group, and Group II (60 patients) receiving percutaneous adhesiolysis with targeted delivery of lidocaine, 10% hypertonic sodium chloride solution, and non-particulate Betamethasone serving as the intervention group. Randomization was performed by computer-generated random allocation sequence by simple randomization. Outcomes Assessment: Multiple outcome measures were utilized including the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3, 6, and 12 months post treatment. Significant pain relief was described as 50% or more, whereas significant improvement in the disability score was defined as a reduction of 40% or more. Results: Significant pain relief (≥ 50%) and functional status improvement was recorded in 73% of patients in Group II versus 12% in Group I (P < 0.001). The average procedures per year were 3.5 with an average total relief of 42 out of 52 weeks in Group II and 2.2 procedures with total relief per year of 13 weeks in Group I (P < 0.001). Limitations: The results of this study are limited by potentially inadequate double blinding, by the lack of a placebo group, and the preliminary report of one-year follow-up. Conclusions: Percutaneous adhesiolysis in chronic function-limiting, recalcitrant low back pain in post lumbar surgery syndrome demonstrated effectiveness in 73% of the patients. Key words: Post lumbar surgery syndrome, post lumbar laminectomy syndrome, chronic low back pain, epidural adhesions, epidural steroid injections, percutaneous adhesiolysis, epidural fibrosis, spinal stenosis, randomized trial, comparative effectiveness

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