BACKGROUND: The efficacy of epidural steroid injection for sciatica due to herniated disc is controversial. This study evaluates the therapeutic effect of an alternative technique that uses a modified approach of epidural steroid injection for the above mentioned disease. The aim was to determine whether this procedure can reduce the need of surgery among discectomy candidates.
METHODS: Twenty-one eligible patients who had suffered from sciatica with unilateral symptoms for 2 to 24 months received injections of betamethasone in combination with xylocaine. The treatment outcome was evaluated by direct questioning and examination using the JOA score (the criteria for low back pain syndrome of Japanese Orthopaedic Association) before the procedure and at the final follow-up visit. The final analysis comprised 19 patients with a minimum of 24-month follow-up.
RESULTS: The overall JOA score increased significantly from 14.26 +/- 3.25 before injection to 23.38 +/- 4.46 after injection showing improvement. In terms of subcategories, the JOA score for sciatica increased significantly from 0.69 +/- 0.48 before infection to 2.13 +/- 0.72 after injection and the JOA score for daily activity increased significantly from 7.44 +/- 2.16 before injection to 12.19 +/- 2.23 after injection). In the end, three treated patients received surgical decompression for intractable recurrent pain.
CONCLUSIONS: Transforaminal epidural steroid injection is a relatively simple, effective and low-risk alternative to surgical decompression for the treatment of lumbar disc herniation in selected cases. The procedure significantly alleviates the severity of sciatica due to a herniated disc and improves the patient's daily activity; this reduces the need for surgical decompression.
OBJECTIVES: Cervical disc herniations are a common cause of radicular pain from nerve root impingement and may necessitate surgical decompression to alleviate symptoms. The use of cervical epidural injections has not been studied in detail. The objective of this retrospective study was to examine the efficacy of cervical epidural steroid injections for the treatment of symptomatic herniated cervical discs.
METHODS: Patients with herniated cervical discs without myelopathy that had failed conservative management and were otherwise surgical candidates were offered a trial of cervical epidural injections. The results and benefits of the injections were examined as well as the incidence of proceeding to surgical intervention.
RESULTS: Of the 70 treated patients, 44 (63%) had significant relief of their symptoms and did not wish to proceed with surgical treatment. Of the 26 patients who underwent surgical decompression, 92% had successful resolution of their symptoms. The nonsurgical and surgical groups were similar in terms of gender, preinjection symptoms, or number of injections. However, significant differences between the two groups were found with regard to age (P<0.05) and time from initial consultation to initial injection (P<0.05). With an average of 13-month follow-up, 45 (65.3%) patients reported a good/excellent result per Odom criteria. In addition, 53 (75%) would attempt cervical epidural steroid injections again in the future. No complications were noted in our series.
CONCLUSIONS: Cervical epidural injections are a reasonable part of the nonoperative treatment of patients with symptomatic cervical disc herniations. The success rates appear to be very similar to prior studies of lumbar epidural injections for symptomatic lumbar disc herniations. It appears that a large percentage of the patients may obtain relief from radicular symptoms and avoid surgery for the follow-up period up to 1 year. In addition, patients older than 50 years and those who received the injections earlier, less than 100 days from diagnosis, seemed to have a more favorable outcome.
BACKGROUND: In a previous prospective, randomized, controlled, double-blinded study on the effect of nerve root blocks on the need for operative treatment of lumbar radicular pain, we found that injections of corticosteroids were more effective than bupivacaine for up to thirteen to twenty-eight months. We performed a minimum five-year followup of those patients who had avoided surgery.
METHODS: All of the patients were considered to be operative candidates by the treating surgeon, and all had initially requested operative intervention. They had then been randomized to be treated with a selective nerve-root block with either bupivacaine or bupivacaine and betamethasone. Both the treating physician and the patient were blinded to the type of medication. Of fifty-five randomized patients, twenty-nine avoided an operation in the original study. Twenty-one of those twenty-nine patients were reevaluated with a follow-up questionnaire at a minimum of five years after the initial block.
RESULTS: Seventeen of the twenty-one patients still had not had operative intervention. There was no difference between the group treated with bupivacaine alone and the group treated with bupivacaine and betamethasone with regard to the avoidance of surgery for five years. At the five-year follow-up evaluation, all of the patients who had avoided operative treatment had significant decreases in neurological symptoms and back pain compared with the baseline values.
CONCLUSIONS: The majority of patients with lumbar radicular pain who avoid an operation for at least one year after receiving a nerve root injection with bupivacaine alone or in combination with betamethasone will continue to avoid operative intervention for a minimum of five years.
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.
STUDY DESIGN: A randomized, double-blind controlled trial.
OBJECTIVES: To determine the treatment effect of corticosteroids in periradicular infiltration for chronic radicular pain. We also examined prognostic factors in relation to the outcome of the procedure.
SUMMARY OF BACKGROUND DATA: Various studies have examined the therapeutic value of periradicular infiltration using treatment agents consisting of local anesthetic and corticosteroids for radicular pain, secondary to lumbar disc herniation and spinal stenosis. There is currently no randomized trial to determine the efficacy of a single injection of corticosteroids for chronic radicular pain.
METHODS: Eligible patients with radicular pain who had unilateral symptoms who failed conservative management were randomized for a single injection with bupivacaine and methylprednisolone or bupivacaine only. Outcome measures included the Oswestry Disability Index, visual analogue score for back pain and leg pain, claudication walking distance, and the patient's subjective level of satisfaction of the outcome.
RESULTS: We recruited 43 patients in the bupivacaine and methylprednisolone group and 43 patients in the bupivacaine only group. The follow-up rate is 100%. Five patients had early termination of the trial for discectomy and further root block. There is no statistically significant difference in the outcome measures between the groups at 3 months (change of the Oswestry Disability Index [P = 0.68], change in visual analogue score [back pain, P = 0.68; leg pain, P = 0.94], change in walking distance [P = 0.7]). Duration of symptoms has a statistically significant negative association with the change in Oswestry Disability Index (P = 0.03).
CONCLUSION: Clinical improvement occurred in both groups of patients. Corticosteroids did not provide additional benefit.
BACKGROUND: Chronic sciatica can be managed by caudal steroid epidural or by targeted steroid placement during spinal endoscopy. Spinal endoscopy is a new unproven procedure. We aimed to compare the two pain management techniques and to investigate whether the site of steroid placement within the epidural space was significant.
METHODS: We randomized 60 patients with a 6-18 months history of sciatica to either targeted epidural local anaesthetic and steroid placement with a spinal endoscope or caudal epidural local anaesthetic and steroid treatment. Pre-treatment and 6-week, 3-month, and 6-month SF-MPQ and HAD scores were recorded.
RESULTS: No significant differences were found between the groups for any of the measures at any time. However, there were significant differences within both groups compared with pre-treatment values. For the caudal group, significant improvements were found for descriptive pain at 6 months (P=0.031), VAS at 6 weeks (P=0.036), 3 months (P=0.026), and 6 months (P=0.003), present pain intensity (PPI) at 3 months (P=0.013) and 6 months (P=0.01); anxiety at 6 weeks (P=0.008), 3 months (P=0.004), and 6 months (P=0.001) and depression at 6 months only (P=0.037). For the epiduroscopy group there were fewer significant changes. PPI was significantly reduced at 6 weeks (P=0.004) and at 6 months (P=0.02). Anxiety was reduced at 6 months only (P=0.03).
CONCLUSION: The targeted placement of epidural steroid onto the affected nerve root causing sciatica does not significantly reduce pain intensity and anxiety and depression compared with untargeted caudal epidural steroid injection. When analysed individually, both techniques benefited patients.
BACKGROUND: The aim of this study was to assess if transforaminal steroid injections applied to cohort of patients waiting for cervical disc surgery, reduce the pain of cervical radiculopathy and hence reduce the need for surgical intervention. Cervical radiculopathy due to cervical disc herniation or spondylosis is a common indication for cervical disc surgery. Surgery is however not always successful, and is not done without risk of complications. Transforaminal injection of steroids has gained popularity due to the rationale that inflammation of the spinal nerve roots causes radicular pain, and therefore steroids placed locally should relieve symptoms.
METHODS: During a 12-month period, 21 secondary referral patients with unilateral cervical radiculopathy entered the study. Cervical disc herniation or spondylosis affecting the corresponding nerve root was demonstrated by appropriate investigation (MRI or myelography). The patients then received 2 transforaminal steroid injections, at 2 weeks interval, while waiting for operative treatment. The pain intensity (VAS), Odom's criteria and operative indications were registered at 6 weeks and 4 months.
FINDINGS: After receiving injection treatment 5 of the 21 patients decided to cancel the operation due to clinical improvement. A statistically significant reduction (0.02) in radicular pain score was simultaneously measured. This corresponds well with the reduction in operative requirements since radicular pain is the main indication for operative treatment. The responders experienced a long-lasting effect. Those responding positively however improved neck pain to the same extent as radicular pain, and patients with cervical spondylosis responded as positively as those with disc herniation.
INTERPRETATION: This prospective cohort study indicates a reduction in the need for operative treatment due to injection treatment. The clinical effect is measurable, and a statistically significant improvement of the radicular pain is registered. Routine transforaminal injection treatment prior to surgery seems rewarding, but the complication risk must be taken into consideration.
BACKGROUND AND PURPOSE: Cervical radiculopathy is a common entity that can become unremitting, seriously disrupting the patient's work and social activities. The purpose of our study was to evaluate the feasibility, tolerance, and efficacy of transforaminal periganglionic steroid infiltration under CT control.
METHODS: Thirty patients with cervical radiculopathy, despite at least 1 month of appropriate medical treatment, underwent percutaneous periradicular foraminal steroid infiltration under CT control. Sixteen patients had foraminal degenerative stenosis, and 14 patients had disk herniation. The intensity of radicular pain was scored on an analogic visual scale (AVS). Pain relief was classified as excellent when the pain had diminished by 75% or more; good, by 50%-74%; fair by 25%-49%; or poor, by less than 25%. The patients were followed up at 2 weeks and at 6 months.
RESULTS: No local complications occurred after the procedure. The mean AVS pain scores were 6.5 points before the procedure and 3.3 points 2 weeks after, with significant pain relief (P <.001). Pain relief was excellent in 11 patients (37%) and good in seven patients (23%). There was no rebound of pain at the 6-month follow-up. The duration of symptoms before infiltration and the intensity and cause of radiculalgia were not predictive of radicular pain relief.
CONCLUSION: Intraforaminal cervical infiltration produced substantial sustained pain relief, whatever the cause of the radiculalgia. The CT approach ensures the safety of vital structures and allows the precise injection of a steroid specifically targeted to the ganglia.
BACKGROUND: Epidural steroid injection is a low-risk alternative to surgical intervention in the treatment of lumbar disc herniation. The objective of this study was to determine the efficacy of epidural steroid injection in the treatment of patients with a large, symptomatic lumbar herniated nucleus pulposus who are surgical candidates. METHODS: One hundred and sixty-nine patients with a large herniation of the lumbar nucleus pulposus (a herniation of >25% of the cross-sectional area of the spinal canal) were followed over a three-year period. One hundred patients who had no improvement after a minimum of six weeks of noninvasive treatment were enrolled in a prospective, non-blinded study and were randomly assigned to receive either epidural steroid injection or discectomy. Evaluation was performed with the use of outcomes scales and neurological examination. RESULTS: Patients who had undergone discectomy had the most rapid decrease in symptoms, with 92% to 98% of the patients reporting that the treatment had been successful over the various follow-up periods. Only 42% to 56% of the fifty patients who had undergone the epidural steroid injection reported that the treatment had been effective. Those who did not obtain relief from the injection had a subsequent discectomy, and their outcomes did not appear to have been adversely affected by the delay in surgery resulting from the trial of epidural steroid injection. CONCLUSIONS: Epidural steroid injection was not as effective as discectomy with regard to reducing symptoms and disability associated with a large herniation of the lumbar disc. However, epidural steroid injection did have a role: it was found to be effective for up to three years by nearly one-half of the patients who had not had improvement with six or more weeks of noninvasive care.
The efficacy of epidural steroid injection for sciatica due to herniated disc is controversial. This study evaluates the therapeutic effect of an alternative technique that uses a modified approach of epidural steroid injection for the above mentioned disease. The aim was to determine whether this procedure can reduce the need of surgery among discectomy candidates.
METHODS:
Twenty-one eligible patients who had suffered from sciatica with unilateral symptoms for 2 to 24 months received injections of betamethasone in combination with xylocaine. The treatment outcome was evaluated by direct questioning and examination using the JOA score (the criteria for low back pain syndrome of Japanese Orthopaedic Association) before the procedure and at the final follow-up visit. The final analysis comprised 19 patients with a minimum of 24-month follow-up.
RESULTS:
The overall JOA score increased significantly from 14.26 +/- 3.25 before injection to 23.38 +/- 4.46 after injection showing improvement. In terms of subcategories, the JOA score for sciatica increased significantly from 0.69 +/- 0.48 before infection to 2.13 +/- 0.72 after injection and the JOA score for daily activity increased significantly from 7.44 +/- 2.16 before injection to 12.19 +/- 2.23 after injection). In the end, three treated patients received surgical decompression for intractable recurrent pain.
CONCLUSIONS:
Transforaminal epidural steroid injection is a relatively simple, effective and low-risk alternative to surgical decompression for the treatment of lumbar disc herniation in selected cases. The procedure significantly alleviates the severity of sciatica due to a herniated disc and improves the patient's daily activity; this reduces the need for surgical decompression.
