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European Spine Journal

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01-02-2012 | Review Article

Transforaminal injection of corticosteroids for lumbar radiculopathy: systematic review and meta-analysis

Author: Nasir A. Quraishi

Published in: European Spine Journal | Issue 2/2012

Abstract

Background

Transforaminal epidural injection of steroids is used to treat lumbar radicular pain. However, there are only a few well-designed randomized, controlled studies on the effectiveness of steroid injection.

Study design

Hence, this study aims to assess the effectiveness of steroid injection to treat lumbar radicular pain using a meta-analysis of transforaminal epidural injection therapy for low back and lumbar radicular pain. The comparison was based on the mean difference in the Visual Analogue Score (VAS) and Oswestry Disability Index (ODI) from baseline to the specified followed up.

Methods

The available literature of lumbar transforaminal epidural injections in managing low back and radicular pain was reviewed. Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to 2009, and manual searches of the bibliographies of known primary and review articles. Finally, the search included the Current Controlled Trials Register and the Cochrane Database of Controlled Trials.

Results

The initial search identified 126 papers. After screening, five randomised controlled trials (RCTs) were studied for analysis and only three of these had followed-up patients systematically with pain and disability outcome scores to 3 months and of these, only one had follow up to 12 months. A total of 187 patients (‘treatment group’ receiving local anaesthetic/steroid injection) were compared with 181 patients (‘control’ group, receiving local anaesthetic only or saline injection). Improvement in pain (standardised mean difference in VAS 0.2 in favour of ‘treatment’; 95%CI: −0.41 to 0.00, p = 0.05, I squared 0%) but not disability (standardised mean difference in ODI 0; 95%CI: −0.21 to 0.20, p = 0.99, I squared 0%) was observed between ‘treatment’ and ‘control’ groups; these differences were not significant. Additionally, the one study following patients to 12 months did not find any significant difference in VAS and ODI between treatment and control groups.

Conclusion

The current meta-analysis shows that transforaminal epidural steroid injections, when appropriately performed, should result in an improvement in pain, but not disability. The three RCTs that followed patients to 3 months (and the single study to 12 months) have found no benefit by the addition of steroids. The limitations of this study include the paucity of the available literature.

Frymoyer JW (1988) Back pain and sciatica. N Engl J Med 318:291–300PubMedCrossRef

Muramoto T, Atsuta Y, Iwahara T et al (1997) The action of prostaglandin E2 and triamcinolone acetonide on the firing activity of lumbar nerve roots. Int Orthop 21:172–175PubMedCrossRef

Saal JS (1995) The role of inflammation in lumbar pain. Spine 20:1821–1827PubMedCrossRef

Olmarker K, Størkson R, Berge OG (2002) Pathogenesis of sciatic pain: a study of spontaneous behaviour in rats exposed to experimental disc herniation. Spine 27:1312–1317PubMedCrossRef

Koes BW, Scholten RJ, Mens JM et al (1995) Efficacy of epidural steroid injections for low-back pain and sciatica: a systematic review of randomized clinical trials. Pain 63:279–288PubMedCrossRef

Bogduk N (1995) Epidural steroids. Spine 20:845–848PubMedCrossRef

Weinstein SM, Herring SA, Derby R (1995) Contemporary concepts in spine care: epidural steroid injections. Spine 20:1842–1846PubMedCrossRef

O’Neill C, Derby R, Knederes L (1999) Precision injection techniques for the diagnosis and treatment of lumbar disc disease. Semin Spine Surg 11:104–118

Derby R, Kine G, Saal JA et al (1992) Response to steroid and duration of radicular pain as predictors of surgical outcome. Spine 17:S176–S183PubMedCrossRef

10.

Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. Br Med J 327:557–560CrossRef

11.

Riew KD, Yin Y, Gilula L, Bridwell KH, Lenke LG, Lauryssen C, Goette K (2000) The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, double-blind study. J Bone Jt Surg Am 82-A(11):1589–1593

12.

Karppinen J, Malmivaara A, Kurunlahti M, Kyllönen E, Pienimäki T, Nieminen P, Ohinmaa A, Tervonen O, Vanharanta H (2001) Periradicular infiltration for sciatica: a randomized controlled trial. Spine 26(9):1059–1067PubMedCrossRef

13.

Vad VB, Bhat AL, Lutz GE, Cammisa F (2002) Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Spine 27(1):11–16PubMedCrossRef

14.

Ng L, Chaudhary N, Sell P (2005) The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double-blind, controlled trial. Spine 30(8):857–862PubMedCrossRef

15.

Tafazal S, Ng L, Chaudhary N, Sell P (2009) Corticosteroids in periradicular infiltration for radicular pain: a randomised double blind controlled trial. One year results and subgroup analysis. Eur Spine J 8:1220–1225CrossRef

16.

Riew KD, Park JB, Cho YS, Gilula L, Patel A, Lenke LG, Bridwell KH (2006) Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year follow-up. J Bone Jt Surg Am 88:1722–1725CrossRef

17.

Karppinen J, Ohinmaa A, Malmivaara A, Kurunlahti M, Kyllönen E, Pienimäki T, Nieminen P, Tervonen O, Vanharanta H (2001) Cost effectiveness of periradicular infiltration for sciatica: subgroup analysis of a randomized controlled trial. Spine 26:2587–2595PubMedCrossRef

18.

Manchikanti L (2002) Role of neuraxial steroids in interventional pain management. Pain Physician 5:182–199PubMed

19.

Dietrich CL, Smith CE (2004) Epidural granuloma and intracranial hypotension resulting from cervical epidural steroid injection. Anesthesiology 100:445–447PubMedCrossRef

20.

Tachihara H, Sekiguchi M, Kikuchi S, Konno S (2008) Do corticosteroids produce additional benefit in nerve root infiltration for lumbar disc herniation. Spine 33:743–747PubMedCrossRef

21.

Katz WA, Rothenberg R (2005) The nature of pain: pathophysiology. J Clin Rheumatol 11(Suppl 2):S11–S15PubMedCrossRef

22.

Mao J, Chen LL (2000) Systemic lidocaine for neuropathic pain relief. Pain 87:7–17PubMedCrossRef

23.

Arner S, Lindblom U, Meyerson BA, Molander C (1990) Prolonged relief of neuralgia after regional anesthetic block. A call for further experimental and systematic clinical studies. Pain 43:287–297PubMedCrossRef

24.

Manchikanti L, Singh V, Rivera JJ, Pampati V, Beyer CD, Damron KS, Barnhill RC (2002) Effectiveness of caudal epidural injections in discogram positive and negative chronic low back pain. Pain Physician 5:18–29PubMed

25.

Manchikanti L, Singh V, Falco FJ, Cash KA, Pampati V (2008) Lumbar facet joint nerve blocks in managing chronic facet joint pain: one-year follow-up of a randomized, double-blind controlled trial: clinical trial NCT00355914. Pain Physician 11:121–132PubMed

26.

Manchikanti L, Singh V, Falco FJ, Cash KA, Fellows B (2008) Cervical medial branch blocks for chronic cervical facet joint pain: a randomized double-blind, controlled trial with one-year follow-up. Spine 33:1813–1820PubMedCrossRef

27.

Manchikanti L, Singh V, Falco FJE, Cash KA, Pampati V (2008) Effectiveness of thoracic medial branch blocks in managing chronic pain: a preliminary report of a randomized, double-blind controlled trial; clinical trial NCT00355706. Pain Physician 11:491–504PubMed

28.

Kawakami M, Weinstein JN, Chatani K, Spratt KF, Meller ST, Gebhart GF (1994) Experimental lumbar radiculopathy. Behavioral and histologic changes in a model of radicular pain after spinal nerve root irritation with chromic gut ligatures in the rat. Spine 19:1795–1802PubMedCrossRef

29.

Manchikanti L (2000) Transforaminal lumbar epidural steroid injections. Pain Physician 3:374–398PubMed

30.

Manchikanti L, Cash KA, McManus CD, Pampati V, Smith HS (2008) Preliminary results of randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 1. Discogenic pain without disc herniation or radiculitis. Pain Physician 11:785–800PubMed

31.

Huntoon MC, Burgher AH (2008) Back to the future: the end of the steroid century. Pain Physician 11:713–716PubMed

32.

Manchikanti L, Singh V, Cash KA, Pampati V, Datta S (2008) Preliminary results of randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 3. Post surgery syndrome. Pain Physician 11:817–831PubMed

33.

Manchikanti L, Cash KA, McManus CD, Pampati V, Abdi S (2008) Preliminary results of randomized, equivalence trial of flu oroscopic caudal epidural injections in managing chronic low back pain: Part 4. Spinal stenosis. Pain Physician 11:833–848PubMed

34.

Manchikanti L, Pampati V, Rivera JJ, Beyer CD, Damron KS, Barnhill RC (2001) Caudal epidural injections with Sarapin steroids in chronic low back pain. Pain Physician 4:322–335PubMed

35.

Manchikanti KN, Pampati V, Damron KS, McManus CD (2004) A double-blind, controlled evaluation of the value of Sarapin in neural blockade. Pain Physician 7:59–62PubMed

36.

Manchikanti L, Damron KS, Cash KA, Manchukonda R, Pampati V (2006) Therapeutic medial branch blocks in managing chronic neck pain: a preliminary report of a randomized, double-blind, controlled trial: clinical trial CT0033272. Pain Physician 9:333–346PubMed

37.

Manchikanti L, Manchikanti KN, Manchukonda R, Pampati V, Cash KA (2006) Evaluation of therapeutic thoracic medial branch block effectiveness in chronic thoracic pain: a prospective outcome study with minimum 1-year follow up. Pain Physician 9:97–105PubMed

38.

Manchikanti L, Manchikanti K, Manchukonda R, Cash KA, Damron KS, Pampati V, McManus CD (2007) Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain: a preliminary report of a randomized, double-blind controlled trial: clinical trial NCT000355914. Pain Physician 10:425–440PubMed

39.

Conn A, Buenaventura R, Datta S, Abdi S, Diwan S (2009) Systematic review of caudal epidurals injections in the management of chronic low back pain. Pain Physician 12:109–135PubMed

40.

Bogduk N (2007) Complications associated with transforaminal injections. In: Neal JM, Rathmell JP (eds) Complications in regional anesthesia and pain medicine. Saunders Elsevier, PA, pp 259–265CrossRef

41.

Bogduk N, Dreyfuss P, Baker R et al (2008) Complications of spinal diagnostic and treatment procedures. Pain Med 6:S11–S34CrossRef

42.

Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N (2009) Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports. Pain Med 10:1389–1394PubMedCrossRef

43.

Society International Spinal Intervention (2004) Lumbar transforaminal injections. In: Bogduk N (ed) Practice guidelines for spinal diagnostic and treatment procedures. International Spinal Intervention Society, San Francisco, CA, pp 163–187

44.

Fredman B, Nun MB, Zohar E, Iraqi G, Shapiro M, Gepstein R, Jedeikin R (1999) Epidural steroids for treating “failed back surgery syndrome”: is fluoroscopy really necessary? Anesth Analg 88:367–372PubMed

45.

Mehta M, Salmon N (1985) Extradural block. Confirmation of the injection site by X-ray monitoring. Anaesthesia 40:1009–1012PubMedCrossRef

46.

Bartynski WS, Grahovac SZ, Rothfus WE (2005) Incorrect needle position during lumbar epidural steroid administration: Inaccuracy of loss of air pressure resistance and requirement of fluoroscopy and epidurography during needle insertion. Am J Neuroradiol 26:502–505PubMed

47.

Botwin KP, Natalicchio J, Hanna A (2004) Fluoroscopic guided lumbar interlaminar epidural injections: a prospective evaluation of epidurography contrast patterns and anatomical review of the epidural space. Pain Physician 7:77–80PubMed

48.

Weil L, Frauwirth NH, Amirdelfan K, Grant D, Rosenberg JA (2008) Fluoroscopic analysis of lumbar epidural contrast spread after lumbar interlaminar injection. Arch Phys Med Rehabil 89:413–416PubMedCrossRef

49.

Parr AT, Diwan S, Abdi S (2009) Lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain: a systematic review. Pain Physician 12:163–188PubMed

50.

Buenaventura RM, Datta S, Abdi S, Smith HS (2009) Systematic review of therapeutic lumbar transforaminal epidural steroid injections. Pain Physician 12:233–251PubMed

Title: Transforaminal injection of corticosteroids for lumbar radiculopathy: systematic review and meta-analysis
Author: Nasir A. Quraishi
Publication date: 01-02-2012
Publisher: Springer-Verlag
Published in: European Spine Journal / Issue 2/2012
Print ISSN: 0940-6719
Electronic ISSN: 1432-0932
DOI: https://doi.org/10.1007/s00586-011-2008-y

At a glance: The STEP trials

Springer Medicine

Transforaminal injection of corticosteroids for lumbar radiculopathy: systematic review and meta-analysis

Abstract

Background

Study design

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Study design

Methods

Results

Conclusion

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