PURPOSE: To determine a critical canal dimension in patients with spinal stenosis that predicts response to epidural steroid injections (ESI).
METHODS: Lumbar spinal stenosis patients with a computed tomography scan before ESI were identified through ICD-9/CPT codes. Using a digital caliper, canal dimensions on axial cuts of each lumbar intervertebral level were recorded: the transverse canal diameter in line with the facets including the soft tissues, TC; the transverse osseous canal diameter, OS; and the mid-sagittal anteroposterior diameter, MS. Minimum and maximum measurements were determined. Patients who improved after ESI and those that required a decompression after ESI were differentiated.
RESULTS: Eighty-four patients were included in the study. Fifty required surgical decompression after ESI and 34 patients improved after ESI. There were no statistically significant differences in the demographics between the 2 groups. Mean minimum dimensions in the surgical group were 9.47 mm (TC), 16.53 mm (OS), and 12.40 mm (MS); and 9.75 mm (TC), 16.65 mm (OS), and 12.39 mm (MS) in the nonsurgical group. Mean ratio between the maximum and minimum dimensions in the surgical group was 1.76 (TC), 1.35 (OS), and 1.57 (MS); and 1.86 (TC), 1.47 (OS), and 1.63 (MS) in the nonsurgical group. There was no statistically significant difference in the minimum measurement in any dimension between the surgical and the nonsurgical group. There was also no statistically significant difference in the ratio between the minimum and maximum measurement in any dimension between the surgical and the nonsurgical group.
CONCLUSIONS: Spinal canal dimension is not predictive of success or failure of ESI in patients with spinal stenosis.
OBJECTIVE: 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.
METHODS: 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).
RESULTS: 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.
CONCLUSIONS: 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.
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.
BACKGROUND: No conclusive evidence exists to determine that spinal steroid injections give lasting improvement in patients with predominantly axial low back pain resulting from lumbar degenerative disc disease (DDD).
PURPOSE: The objectives of the study were to determine the effect of epidural steroid injections (ESIs) and intradiscal steroid injections (ISIs) in patients who exhibit DDD symptoms for more than 1 year and to determine whether patients with inflammatory end-plate changes are a unique subgroup of DDD patients in terms of treatment response.
STUDY DESIGN: Pain and function in patients with DDD were prospectively assessed by an outcomes questionnaire before and after various spinal injections. Further correlation was made with end-plate inflammatory (Modic Type 1) changes identified on magnetic resonance imaging (MRI).
PATIENT SAMPLE: ESI was performed in 232 patients who were referred for treatment of DDD, and discography with or without intradiscal steroid was performed in 171 patients who were possible spinal arthrodesis candidates.
OUTCOME MEASURES: Pain and function were determined by a self-administered outcomes questionnaire that consisted of a visual analog pain scale, pain drawing, Oswestry Disability Index, use of pain medication and opinion of treatment success.
METHODS: ESI was performed in 93 patients with DDD and inflammatory end-plate changes and in 139 patients without inflammatory end-plate changes. Patients with inflammatory end-plate changes (n=78) or without inflammatory end-plate changes (n=93), all of whom were considered fusion candidates, underwent discography with or without intradiscal steroid in a randomized fashion. Pain and function were prospectively determined by a self-administered outcomes survey (VAS pain, Oswestry Disability index [ODI], pain diagram [PD] and opinion of success) before and after the patients' injection for a 2-year follow-up period. MRI and discography results were correlated with patient outcomes scores.
RESULTS: ESI was effective in improving pain and function, as assessed by outcomes scores at short-term follow-up. However, at 2 years, less than one-third had not had additional invasive treatment. Patients with inflammatory end-plate changes had greater improvement in ODI and PD scores in the first 6 months than did those patients without the end-plate changes. Intradiscal steroid injections into discs with concordant pain at the time of discography led to significant improvement in patients with inflammatory end-plate changes in all outcomes scales, but only minimal temporary improvement in patients without the end-plate changes. Disc pressure manometry at the time of discography found that discs with adjacent inflammatory end-plate changes reproduced symptoms at pressures significantly lower than those in other types of discs.
CONCLUSIONS: Spinal steroid injections, both ESI and ISI, are beneficial for a small number of patients with advanced DDD and chronic low back pain. For those patients in whom a beneficial effect is found, spinal steroid injection is a low-risk and rapid treatment option. Spinal steroid injections are more effective in patients with MRI findings of discogenic inflammation, specifically adjacent inflammatory end-plate changes.
BACKGROUND: Although epidural corticosteroid injections are commonly used for sciatica, their efficacy has not been established.
METHODS: 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).
RESULTS: 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).
CONCLUSIONS: 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 value of epidural injections of corticosteroid as an outpatient treatment of sciatica has been hitherto uncertain. An epidural injection of 80 mg methylprednisolone in 10 ml physiological saline was compared with an interspinous injection of 2 ml physiological saline in a double blind fashion amongst 39 outpatients. Significant differences of pain relief were seen between the two groups within 2 weeks. This benefit disappeared for six (35%) patients within 6 months of treatment although 11 (65%) successfully treated subjects had sustained improvement up to this time. Outpatient epidural injections of corticosteroid are thus a useful short-term means of relieving pain in sciatica but probably have little effect on the long-term natural history of symptoms. Factors associated with a failure to respond to epidural steroid injections are discussed.
Seventy-three patients with lumbar radicular pain syndromes were treated in a prospective, randomized, double-blind fashion with either seven milliliters of methylprednisolone acetate and procaine or seven milliliters of physiological saline solution and procaine. All patients had radiographic confirmation of lumbar nerve-root compression, consistent with the clinical diagnosis of either an acute herniated nucleus pulposus or spinal stenosis. No statistically significant difference was observed between the control and experimental patients with either acute disc herniation or spinal stenosis. Long-term follow-up, averaging twenty months, failed to demonstrate the efficacy of a second injection of epidural steroids administered to the patients whose pain did not respond within twenty-four hours to an injection of either eighty milligrams of methylprednisolone acetate combined with five milliliters of 1 per cent procaine or two milliliters of sterile saline combined with five milliliters of 1 per cent procaine. Therefore, a decision to use epidural steroids must be made with the realization that we failed to demonstrate its clinical efficacy in this study and that reports of serious complications of this procedure have been published.
A double blind study was carried out in 51 patients suffering from lumbar root compression syndrome of 12 days to 36 weeks duration. All patients had signs, symptoms and radiological abnormalities related to a herniated lumbar disc. Each patient received an extradural injection of either 2 ml (80 mg) methyl prednisolone or 2 ml normal saline solution. Neurological examination and interview of the patients with the aid of a questionnaire before and after extradural injection failed to demonstrate any statistically significant difference in outcome between the two groups. At follow-up 14 +/- 6 months after extradural injection 58.3 per cent of the patients in the control group and 51.9 per cent of the patients in the treatment group had undergone surgical treatment with laminectomy. Our results indicate that a single extradural injection of methyl prednisolone (80 mg) is no more effective than a placebo injection in relieving chronic symptoms due to myelographically demonstrable lumbar disc herniation.
To determine a critical canal dimension in patients with spinal stenosis that predicts response to epidural steroid injections (ESI).
METHODS:
Lumbar spinal stenosis patients with a computed tomography scan before ESI were identified through ICD-9/CPT codes. Using a digital caliper, canal dimensions on axial cuts of each lumbar intervertebral level were recorded: the transverse canal diameter in line with the facets including the soft tissues, TC; the transverse osseous canal diameter, OS; and the mid-sagittal anteroposterior diameter, MS. Minimum and maximum measurements were determined. Patients who improved after ESI and those that required a decompression after ESI were differentiated.
RESULTS:
Eighty-four patients were included in the study. Fifty required surgical decompression after ESI and 34 patients improved after ESI. There were no statistically significant differences in the demographics between the 2 groups. Mean minimum dimensions in the surgical group were 9.47 mm (TC), 16.53 mm (OS), and 12.40 mm (MS); and 9.75 mm (TC), 16.65 mm (OS), and 12.39 mm (MS) in the nonsurgical group. Mean ratio between the maximum and minimum dimensions in the surgical group was 1.76 (TC), 1.35 (OS), and 1.57 (MS); and 1.86 (TC), 1.47 (OS), and 1.63 (MS) in the nonsurgical group. There was no statistically significant difference in the minimum measurement in any dimension between the surgical and the nonsurgical group. There was also no statistically significant difference in the ratio between the minimum and maximum measurement in any dimension between the surgical and the nonsurgical group.
CONCLUSIONS:
Spinal canal dimension is not predictive of success or failure of ESI in patients with spinal stenosis.
