Effect Of Epidural Steroid Injection Research Articles

Therapeutic Effect of Epidural Steroid Injection in Patients Suspected of having an Internal Disc Disruption: A Prospective Case Study

Purpose: To assess the effect of the epidural steroid injection for patients suspected of having an internal disc disruption. Materials and Methods: Thirteen patients at the pain intervention clinic that received a lumbar interlaminar epidural steroid injection and were suspected of having an internal disc disruption were prospectively enrolled in this study. The treatment outcome was assessed using a 5-point patient satisfaction scale (no pain, improved, slightly improved, effect, aggravated) two weeks after injection. A successful outcome required a patient satisfaction scale of much improved or no pain. All patients received follow-up for two months. Two radiologists evaluated the presence of HIZ (high intensity zone), a dark disc by MR (n = 10) and a diffuse bulging disc by CT (n = 3). Results: Nine (69%) of the 13 patients achieved a successful outcome two weeks after injection. These nine patients showed recurrence during the two months months follow-up. Of the 22 abnormal discs demonstrated by MRI and CT, MRI showed a dark disc in six patients and HIZ in 13 patients. CT showed diffuse bulging in three discs. Nine of 10 patients showed at least one HIZ. Conclusion: An lumbar interlaminar epidural steroid injection might be an effective tool for managing patients suspected of having an internal disc disruption.

Cost-effectiveness and safety of epidural steroids in the management of sciatica

To investigate the clinical effectiveness of epidural steroid injections (ESIs) in the treatment of sciatica with an adequately powered study and to identify potential predictors of response to ESIs. Also, to investigate the safety and cost-effectiveness of lumbar ESIs in patients with sciatica. A pragmatic, prospective, multicentre, double-blind, randomised, placebo-controlled trial with 12-month follow-up was performed. Patients were stratified according to acute (<4 months since onset) versus chronic (4-18 months) presentation. All analyses were performed on an intention-to-treat basis with last observation carried forward used to impute missing data. Rheumatology, orthopaedic and pain clinics in four participating centres: three district hospitals and one teaching hospital in the south of England. Total of 228 patients listed for ESI with clinically diagnosed unilateral sciatica, aged between 18 and 70 years, who had a duration of symptoms between 4 weeks and 18 months. Patients received up to three injections of epidural steroid and local anaesthetic (active), or an injection of normal saline into the interspinous ligament (placebo). The primary outcome measure was the Oswestry Disability Questionnaire (ODQ); measures of pain relief and psychological and physical function were collected. Health economic data on return to work, analgesia use and other interventions were also measured. Quality-adjusted life-years (QALYs) were calculated using the SF-6D, calculated from the Short Form (SF-36). Costs per patient were derived from figures supplied by the centres' finance departments and a costings exercise performed as part of the study. A cost-utility analysis was performed using the SF-36 to calculate costs per QALY. ESI led to a transient benefit in ODQ and pain relief, compared with placebo at 3 weeks (p = 0.017, number needed to treat = 11.4). There was no benefit over placebo between weeks 6 and 52. Using incremental QALYs, this equates to and additional 2.2 days of full health. Acute sciatica seemed to respond no differently to chronic sciatica. There were no significant differences in any other indices, including objective tests of function, return to work or need for surgery at any time-points. There were no clinical predictors of response, although the trial lacked sufficient power to be confident of this. Adverse events were uncommon, with no difference between groups. Costs per QALY to providers under the trial protocol were 44,701 pounds sterling. Costs to the purchaser per QALY were 354,171 pounds sterling. If only one ESI was provided then costs per QALY fell to 25,745 pounds sterling to the provider and 167,145 pounds sterling to the purchaser. ESIs thus failed the QALY threshold recommended by the National Institute for Health and Clinical Excellence (NICE). Although ESIs appear relatively safe, it was found that they confer only transient benefit in symptoms and self-reported function in a small group of patients with sciatica at substantial costs. ESIs do not provide good value for money if NICE recommendations are followed. Additional research is suggested into the epidemiology of radicular pain, producing a register of all ESIs, possible subgroups who may benefit from ESIs, the use of radiological imaging, optimal early interventions, analgesic agents and nerve root injections, the use of cognitive behavioural therapy in rehabilitation, improved methods of assessment, a comparative cost-utility analysis between various treatment strategies, and methods to reduce the effect of scarring and inflammation.

Prospective randomised single blind study of epidural steroid injection comparing triamcinalone acetonide with methylprednisolone acetate

AbstractAim: This study aims to assess the effectiveness of epidural steroid injection as well as comparing two agents commonly used in these procedures, namely triamcinalone acetonide and methylprednisolone acetate.Method: Twenty subjects were recruited into each group receiving either agent.Results: Overall result showed that there were marked improvement in symptoms in both agents but there were no differences in terms of superiority from one agent to another.Conclusion: Epidural steroid injection is effective and both agents are equipotent.

The effect of spinal steroid injections for degenerative disc disease

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.

MULTIDISCIPLINARY PAIN ABSTRACTS: 12 . Anesthesia (12)

The purpose of this study was to investigate whether selective nerve fiber dysfunction, as assessed by quantitative sensory testing (QST), correlates with the effectiveness of epidural steroid injections (ESI) in patients with lumbar radiculopathy. Twenty patients with unilateral painful sciatica caused by disc herniation participated in this open study. Before ESI, quantitative thermal and mechanical sensory testing was conducted at the most painful dermatome and the contralateral dermatome. The primary outcome measure used was the self‐recording of pain intensity twice daily with a 0–10 numerical pain scale (NPS). Secondary efficacy measures included the Short Form of the McGill Pain Questionnaire, the straight leg raising test, and the lumbar range of motion. A significant difference in all types of sensory thresholds between the affected and the contralateral dermatomes was detected at baseline. All outcome measures improved subsequent to the ESI. A significant positive correlation was found between the increase in cold sensation thresholds of the affected dermatome (Adelta‐fiber dysfunction) and the improvement in NPS. The increase in touch and vibration thresholds (Abeta‐fiber dysfunction) was found to be inversely correlated with the improvement in NPS. No correlation was found between heat sensation thresholds and any of the outcome measures. These results suggest that QST has the potential to be an important tool in the selection of the appropriate treatment for patients with sciatica and may assist in identifying the mechanisms of pain generation in these patients.

The effect of epidural steroid injection on the natural history of lumbar disc herniation

Glenn R. Buttermann, MD, Stillwater, MN, USAIntroduction: The natural history of lumbar herniated nucleus pulposus (HNP) is that most decrease in size. Prior computed tomography and magnetic resonance imaging (MRI) studies have found that most HNPs resorb with time on serial scans. Furthermore, patients' symptoms typically improve as a disc herniation regresses. The effect of epidural steroid injection (ESI) in treating pain resulting from HNP has been studied by numerous authors, and a recent meta-analysis suggests that ESIs are effective in a small proportion of patients. A recent study by the author evaluated 169 patients with symptomatic HNP in which the size was greater than 25% of the spinal canal. During the study period, 69 patients improved without invasive treatment during the first 6 weeks after the onset of their symptoms. Another 100 patients, whose symptoms did not improve, were randomized to treatment: of these, 50 patients underwent discectomy and another 50 patients underwent lumbar ESI. For the ESI group, 23 patients (46%) had a successful result; the rest then had discectomy. Follow-up MRI scans were obtained in patients who had a successful ESI as well as in those 69 patients who improved without invasive treatment at an average of 18 months after the onset of their symptoms. This forms the basis of this study with the purpose of determining whether ESI-treated patients improve because of steroid effect and/or resorption of the HNP.Methods: Patients who underwent successful ESI for lumbar HNP had follow-up MRI scans in 20 of 23 cases. In the patients who had spontaneous improvement in symptoms, follow-up MRI scans were randomly obtained in 37 of 69 patients. Follow-up MRI scans were compared with the initial MRIs obtained at the onset of symptoms. Axial MRI images of the involved disc as well as adjacent normal levels were scanned and digitized on a personal computer. The area encompassed by the disc herniation within the spinal canal was determined for all patients on the initial and follow-up scans.Results: The average area of the initial disc herniation for the ESI-treated patients was 42%±8% of the spinal canal. The average area of the HNP on follow-up MRI scan was 15±10% of the spinal canal. The average decrease in size was 27%. Five HNP (25%) resorbed entirely (less than 10% of initial size), 12 HNP were smaller in area and 3 (15%) were unchanged. In the ESI group, two of three patients who did not have a decrease in the size of the HNP were improved on their outcomes survey. In the group who had improvement without invasive treatment, the initial size of the HNP was 42%±10%. On follow-up MRI, the size of was 17%±11%, an average decrease of 25%. Seventeen patients (46%) had resorption of their HNP, 16 patients had a decrease in size of their HNP and 4 (11%) were unchanged. Of the four without regression of their HNP, two of them improved substantially and two only minimally. For this group, sequestered and extruded disc herniations were the most likely to resorb. In the ESI group, 11 patients (55%) had sequestered and/or extruded disc herniations of which three resorbed entirely. In the spontaneously improving group, 21 patients (57%) had sequestered and/or extruded disc herniations of which 14 resorbed entirely. Outcome surveys at 1 year (visual analog scale, pain drawing, Oswestry disability scale) were similarly improved for both groups.A similar decrease in HNP size was found whether or not a patient received lumbar ESI at 1- to 2-year follow-up.Discussion: In patients treated nonoperatively for lumbar disc herniation, we could not find a significant effect of ESI on the size or extent of HNP resorbtion. Epidural steroid injection was effective in many patients in decreasing symptoms, but in terms of actually altering the natural history of HNP morphology, we could not detect a significant difference in the two groups. Epidural steroids may be useful in treating pain during the period required for the natural history of disc herniation to decrease or resorb.

Effectiveness of Caudal Epidural Injections in Discogram Positive and Negative Chronic Low Back Pain

Epidural steroid injections are the most commonly used procedures to manage chronic low back pain in interventional pain management settings. The overall effectiveness of epidural steroid injections has been highly variable, and in the role has not been evaluated in patients discographically evaluated. One hundred consecutive patients, without evidence of disc herniation or radiculitis, who had failed to respond to conservative management with physical therapy, chiropractic and/or medical therapy, underwent discography utilizing strict criteria of concordant pain, and negative adjacent discs, after being judged to be negative for facet joint and/or sacroiliac joint pain utilizing comparative local anesthetic blocks. Any other type of response was considered negative. This study included 62 patients, who underwent caudal epidural steroid injections with Sarapin. They included Group I, comprised of 45 of 55 patients negative on provocative discography; and Group II, with 17 of 45 patients with positive provocative discography. Results showed that there was significant improvement in patients receiving caudal epidural injections, with a decrease in pain associated with improved physical, functional, and mental status; decreased narcotic intake, and increased return to work. The study showed that at 1 month, 100% of the patients evaluated showed significant improvement in both groups; this declined to 86% at 3 months in Group I, but remained at 100% in Group II, declining to 60% and 64% at 6 months in Group I and Group II, respectfully, with administration of one to three injections. Analysis with one to three injections, which included all (62) patients showed significant relief in 71% and 65% of the patients at 1 month, in 67% and 65% at 3 months, and in 47% and 41% at 6 months, in Group I and Group II, respectively. In conclusion, caudal epidural injections with or without steroids is an effective modality of treatment in managing chronic, persistent low back pain failing to respond to conservative modalities of treatments, in patients negative for facet joint and sacroiliac joint pain, whether positive or negative, on evaluation with provocative discography.

Caudal Epidural Injections with Sarapin or Steroids in Chronic Low Back Pain

Epidural steroid injections are the most commonly used procedures to manage chronic low back pain in interventional pain management settings. Approaches available to access the epidural space in the lumbosacral spine include the interlaminar, transforaminal, and caudal. The overall effectiveness of epidural steroid injections has been highly variable. This study included 65 patients who underwent diagnostic facet joint nerve blocks utilizing comparative local anesthetic blocks and were shown to be negative for facet joint pain and other problems such as sacroiliac joint pain before enrollment into the study. They were randomly selected from 105 patients negative for facet joint pain allocated into three groups, with Group I consisting of 15 patients comprising a convenience control sample treated conservatively; Group II, consisting of 22 patients treated with caudal epidural with local anesthetic and Sarapin(R); and Group III, consisting of 33 patients treated with caudal epidural with a mixture of local anesthetic, and betamethasone. The study period lasted for 3 years. Results showed that there was significant improvement in patients receiving caudal epidural injections, with a decrease in pain associated with improved physical, functional and mental status; and decreased narcotic intake combined with return to work. The study showed that at 1 month 96% of the patients evaluated showed significant improvement, which declined to 56% at 3 months and 16% at 6 months, with administration of 1 to 3 injections. Cumulative relief with 1 to 12 injections was noted in 96% of the patients at 1 month, 95% at 3 months, 85% at 6 months, and 67% at 1 year. The study also showed cost effectiveness of this treatment, with a cost of $ 2550 for 1-year improvement of quality of life . In conclusion, caudal epidural injections with steroids or Sarapin are an effective modality of treatment in managing chronic, persistent low back pain that fails to respond to conservative modalities of treatments and is also negative for facet joint pain. The treatment is not only effective clinically but also is cost effective.

Transforaminal Ventral Epidural Adhesiolysis

Epidural fibrosis with chronic low back pain, nonresponsive to traditional measures of treatment including surgery, is a common entity in modern medicine. Traditionally, epidural steroid injections have been employed to treat chronic low back pain and radiculopathy associated with failed back surgery. Due to the poor effectiveness of epidural steroid injections in post lumbar laminectomy syndrome, epidural adhesiolysis was introduced in the early 1980s. Caudal epidural adhesiolysis with hypertonic saline neurolysis has been described extensively in the literature and has been proven to be relatively successful and safe. To improve the results and reach the target area with steroid, transforaminal ventral epidural adhesiolysis has been utilized. This retrospective case analysis included 14 patients. Transforaminal ventral epidural adhesiolysis was performed on an outpatient basis in all patients. The results showed 93% improvement initially, which decreased to 71% at 1 month, 57% at 3 months, 43% at 6 months and 21% at 1 year. The results of this case study show that ventral epidural lysis of adhesions with hypertonic saline neurolysis is safe and effective in managing chronic low back and lower extremity pain in patients who failed to respond to other conservative modalities of treatments, including fluoroscopically directed transforaminal epidural steroid injections.

Treatment of lumbosacral radiculopathy with epidural steroids.

Treatment of lumbosacral radiculopathy with epidural steroids.

Effect of Epidural Steroid Injections on Sciatica Underwhelming

Effect of Epidural Steroid Injections on Sciatica Underwhelming

A Retrospective Analysis of the Efficacy of Epidural Steroid Injections

Forty patients were studied retrospectively to evaluate the effect of epidural steroid injections on low back pain and sciatica characteristic of spinal stenosis or a herniated lumbar disc. All but one of these patients had radicular symptoms. The average age was 55 years, and the average follow-up time was eight months. All patients were injected by the same anesthesiologist with 2 cc of Depomedrol-40. Thirty-six patients received either one, two, or three injections. Four patients received either four or five injections. The overall results were poor, with about 60% of patients reporting varying degrees of relief from leg and back pain immediately after injection. However, at follow-up examination, only 24% were asymptomatic; 40% reported no change in preinjection numbness, weakness, or pain; and approximately 35% had varying degrees of relief with no consistent pattern. Of those who had complete relief, there was no correlation between relief of pain, age, or number of injections. From this study, it appears that approximately 50% of patients with radicular symptoms may receive temporary relief with steroid injection. However, long-term relief occurs in less than 25% of patients.