Single Epidural Steroid Injection Research Articles

Comparing clinical outcomes of dogs suffering from degenerative lumbosacral stenosis upon surgical or nonsurgical treatment

PICO question In dogs suffering from degenerative lumbosacral stenosis (DLSS), is surgical treatment more effective than nonsurgical therapy in reducing lumbosacral pain and neurological dysfunction in the long-term? Clinical bottom line Category of research Treatment. Number and type of study designs reviewed Two papers were critically reviewed. They were prospective and retrospective studies. Strength of evidence Weak. Outcomes reported Besides the two studies, there are no other studies currently available that directly compare long-term clinical outcome of patients that have undergone nonsurgical and surgical treatment respectively. In the study comparing clinical outcome of nonsurgical treatment by epidural steroid injection (ESI) and surgical treatment of degenerative lumbosacral stenosis, dogs were classified into clinical severity groups ranging from mild to moderate to severe. Mild cases demonstrated degenerative lumbosacral stenosis (DLSS) compatible clinical signs such as lumbosacral pain, reluctance to climb stairs / jump / raise up, lameness and muscle atrophy but no neurological deficits. Moderate cases presented DLSS compatible clinical signs in combination with neurological deficits such as reduced flexor withdrawal, proprioceptive deficits and nerve root signature. Severe cases demonstrated DLSS compatible clinical signs with more severe neurological deficits such as tail paresis and absent perineal reflex. Clinical outcomes were considered complete if clinical signs had resolved at follow-up consultations, partial if there was substantial but incomplete improvement in clinical signs and failed if the dog did not improve or deteriorated further. Improvements in patient condition were measured in terms of clinical outcome grading which is in relation to the initial clinical severity group assigned to each dog. Improvement after single dose of ESI was seen in 27/32 dogs, with 17/22 (after accounting for four dogs whose owners have refused further treatment, five dogs lost to follow-up after re-check as well as one dog whose owners have opted for repeated ESI instillations) relapsing within 6 months. All 17 of these dogs that suffered a relapse after single ESI subsequently underwent surgical treatment and demonstrated improvement in clinical signs, with a complete response seen in eight dogs and a partial response seen in nine dogs. In the study comparing clinical outcome of conservative treatment of exercise restriction with phenylbutazone administration and surgical treatment of degenerative lumbosacral stenosis, outcomes were classified as good in dogs that regained preoperative activity levels; acceptable in dogs with persistent abnormality or requiring continued medication though otherwise active, and poor in all other cases. Out of 16 dogs treated surgically, 11 were treated by dorsal lumbosacral laminectomy and excision of the dorsal portion of the lumbosacral disc, while the other five had additional unilateral facetectomy to decompress the seventh lumbar nerve. Out of the 11 dogs treated with dorsal lumbosacral laminectomy and excision of the dorsal portion of the lumbosacral disc, 6/11 (54.5%) of dogs were deemed to have a good outcome, while 3/11 (27.3%) of dogs were deemed to have an acceptable outcome. Out of the five dogs treated with dorsal lumbosacral laminectomy and excision of the dorsal portion of the lumbosacral disc with additional unilateral facetectomy, 3/5 (60%) of dogs were deemed to have an acceptable outcome. The outcome of conservative treatment was deemed good in 8/16 (50%) of dogs in the conservative treatment group. Conclusion There is evidence suggesting that both nonsurgical and surgical treatments can improve clinical outcomes and reduce lower back pain and neurological deficits. However, based on the current limited literature, it cannot be ascertained whether surgical treatments are more effective than nonsurgical treatments in improving long-term clinical outcomes and vice versa. In the study that tested the efficacy of epidural steroid injection, only a single dose of steroids was given in this study, making it a potential reason for the high rate of relapse following nonsurgical treatment. For surgical treatment of DLSS, the type of surgical procedure chosen would also depend on the part of the lumbosacral region which fails and leads to compression. In conclusion, randomised controlled trials that compare different forms of nonsurgical treatment with surgical treatment for dogs with DLSS caused by different underlying factors need to be conducted to properly address the PICO question. How to apply this evidence in practice The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources. Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

Effectiveness of epidural steroid injection in patients with lumbar herniated intervertebral disc under a "wait-and-see" policy.

There are no consensus and guidelines on the optimal interval of repeat epidural steroid injections (ESI) for patients with lumbar herniated intervertebral disc (HIVD) who respond to initial ESI. To evaluate the effectiveness of ESI in patients with HIVD under a "wait-and-see" policy, i.e. as-needed injections not on a predetermined schedule. A total of 592 patients with lumbar HIVD received spine injections between January and December 2017. After excluding patients with excellent (no pain) or poor (>70% residual symptoms) response in the two- or three-week pain assessment, the data of 141 responders were analyzed (60 men, 73 women; age = 50.55±17.25 years). We divided patients into wait-and-see (n=124) and early repeat-ESI (n=17) groups, who received repeat ESIs within three weeks. Evaluations of characteristics and outcomes were performed with the chi-square test or independent Student's t-test. Six patients (4.8%) in the wait-and-see group and 1 (5.9%) in the early repeat-ESI group underwent operation within one year (P=0.85). A mean of 1.52±0.82 ESIs was performed in the wait-and-see and a mean of 2.29±0.47 ESIs in the early repeat-ESI group over one year (P<0.001). The time interval between the first and second ESIs was longer in the wait-and-see group than in the early repeat-ESI group (97.15 vs. 15.47 days, P<0.001). Seventy-eight patients (62.9%) in the wait-and-see group could control their pain with a single ESI. A "wait-and-see" policy could be an effective pain management option for patients with lumbar HIVD who respond to initial ESI.

Conus Medullaris Syndrome Days After A Single Epidural Steroid Injection

Background: Epidural steroid injections (ESI) are commonly used in treatment of chronic lower back pain. Conus medullaris and cauda equina syndromes are rare complications of ESI. However, these typically occur after multiple injections within a few minutes to hours. Some reported cases are also transient, with patients completely regaining neurological function. We discuss a unique case of a patient developing conus medullaris syndrome over 24 hours after a single epidural steroid injection without resolution of symptoms.

Can High-Sensitivity C-Reactive Protein Levels Predict Functional Outcome Following Epidural Steroid Injection in Patients with Lumbar Disc Disease?

Study DesignProspective cohort study.PurposeInflammatory cytokines produced at the site of disc herniation are considered as pain generators in patients with lumbar disc disease. Whether a high-sensitivity C-reactive protein (hs-CRP) assay can be used in order to predict the quantum of inflammation surrounding nerve roots is a matter of investigation. This study aimed to evaluate the association of hs-CRP level and functional outcomes measured by the Modified Oswestry Low Back Pain Disability Questionnaire (MODY) before and after epidural steroid injection (ESI) in patients with lumbar disc disease.Overview of LiteratureAlthough many studies examining the role of hs-CRP levels and lumbar pain have been published previously, the results are equivocal, and there is no clear consensus regarding which patients will benefit from an ESI.MethodsThis was a prospective study, with 77 patients in the study group and 23 participants in the control group. Baseline hs-CRP levels were obtained for both groups. Study group patients received a single ESI and were subjected to detailed pre- and post-procedure evaluation using MODY scores. For this group, hs-CRP levels were measured at 1 and 2 months after injection.ResultsOut of 77 patients, 52 had acute and 25 had chronic low back pain. Thirty-six patients with acute pain obtained significant improvement, while 16 had an insignificant response to the ESI. None of the chronic cases had a significant response. The mean baseline hs-CRP (mg/L) among the study group (29.83±10.43) was significantly higher than for the controls (10.26±2.783). The baseline hs-CRP among acute cases, where post ESI MODY score at 2 months had significant reduction, was 32.19±5.126, and those with insignificant reduction was 18.13±7.949 (p<0.001).ConclusionsBaseline hs-CRP levels can be used to prognosticate the outcome following ESI in patients with acute lumbar disc disease, with radicular pain refractory to physiotherapy and analgesics.

Fluoroscopic Epidural Steroid Injection: Pain Relief in Discogenic Sciatica Versus Lumbar Spinal Stenosis. A Study on Middle Eastern Patients.

To compare the effect of epidural steroid injections (ESI) in patients with discogenic sciatica (Sci) versus patients with lumbar canal stenosis (LSS), not controlled by conservative treatment. In our study, 80 patients with Sci and 66 with LSS were included. A single ESI (10 mg dexamethasone in 3 cc 0.25% bupivacaine) was applied under fluoroscopic control: one level above the highest stenotic level, in the posterior epidural space, via interlaminar approach in LSS and at the prolapse level, in the anterior epidural space, via transforaminal route in Sci. Pain intensity was assessed by VAS at baseline and on days 1, 15 and 30 after intervention. The procedure was successful in 78 Sci and 63 LSS patients. Patients with Sci responded significantly better. At one month, pain reduction over 50% was achieved in 63% (52.3-73.7% at p = 0.95) of Sci but only in 35% (23.2-46.8%) of LSS (p = 0.03). Return to pre-intervention level happened in 47% (34.7-59.3%) of LSS versus 14% (6.3-21.7%) of Sci patients (p = 0.01). In 5 patients the procedure failed, without resulting morbidity. ESI are more effective in patients with Sci than in single level LSS. In multiple level LSS, results are disappointing.

Can repeat injection provide clinical benefit in patients with cervical disc herniation and stenosis when the first epidural injection results only in partial response?

Epidural steroid injection (ESI) is known to be an effective treatment for neck or radicular pain due to herniated intervertebral disc (HIVD) and spinal stenosis (SS). Although repeat ESI has generally been indicated to provide more pain relief in partial responders after single ESI, there has been little evidence supporting the usefulness of this procedure. The purpose of this study, therefore, was to determine whether repeat ESI at a prescribed interval of 2 to 3 weeks after the first injection would provide greater clinical benefit in patients with partial pain reduction than intermittent ESI performed only when pain was aggravated. One hundred eighty-four patients who underwent transforaminal ESI (TFESI) for treatment of axial neck and radicular arm pain due to HIVD or SS and could be followed up for 1 year were enrolled. We divided the patients into 2 groups. Group A (N = 108) comprised partial responders (numeric rating scale (NRS) ≥ 3 after the first injection) who underwent repeat injection at a prescribed interval of 2 to 3 weeks after the first injection. Group B (N = 76) comprised partial responders who did not receive repeat injection at the prescribed interval, but received intermittent injections only for aggravation of pain. Various clinical data were assessed, including total number of injections during 1 year, NRS duration of <3 during 1 year (NRS < 3 duration), and time interval until pain was increased to require additional injections after repeat injection in Group A, or after first injection in Group B (time to reinjection). Groups A and B were compared in terms of total population, HIVD, and SS. In the whole population, HIVD subgroup, and SS subgroup, patients in Group A required significantly fewer injections to obtain satisfactory pain relief during the 1-year follow-up period. Group A showed a significantly longer time to reinjection and longer NRS < 3 than Group B did. Repeat TFESI conducted at 2- to 3-week intervals after the first injection in partial responders contributed to greater clinical benefit compared with intermittent TFESI performed only upon pain aggravation, with fewer TFESI sessions.

Exploratory Study for Identifying Systemic Biomarkers that Correlate with Pain Response in Patients with Intervertebral Disc Disorders

Introduction Molecular events that drive disc damage and low back pain (LBP) may precede clinical manifestation of disease onset and can cause detrimental long-term effects such as disability. Biomarkers serve as objective molecular indicators of pathological processes. The goal of this study is to identify systemic biochemical factors as predictors of response to treatment of LBP with epidural steroid injection (ESI). Since inflammation plays a pivotal role in LBP, this pilot study investigates the effect of ESI on systemic levels of 51 inflammatory biochemical factors (cytokines, chemokines, and growth factors) and examines the relationship between biochemical factor levels and pain or disability in patients with disc herniation (DH), or other diagnoses (Other Dx) leading to low back pain, which included spinal stenosis (SS) and degenerative disc disease (DDD). Material and Methods Study participants ( n = 16) were recruited from a Back Pain Management practice. Pain numerical rating score (NRS), Oswestry Disability Index (ODI), and blood samples were collected pre- and at 7 to 10 days post treatment. Samples were assayed for inflammatory mediators using commercial multiplex assays. Mediator levels were compared pre- and post-treatment to investigate the potential correlations between clinical and biochemical outcomes. Results Our results indicate that a single ESI significantly decreased systemic SCGF-β and IL-2 levels and increased levels of MMP3. Improvement in pain in all subjects was correlated with changes in chemokines (MCP-1, MIG), hematopoietic progenitor factors (SCGF-β), and factors that participate in angiogenesis/fibrosis (HGF), nociception (SCF, IFN-a2), and inflammation (IL-6, IL-10, IL-18, TRAIL). Levels of biochemical mediators varied based on diagnosis of LBP, and changes in pain responses and systemic mediators from pre- to post treatment were dependent on the diagnosis cohort. In the DH cohort, levels of IL-17 and VEGF significantly decreased and levels of MMP-3 and MMP-9 significantly increased post treatment. In the Other Dx cohort, levels of IL-2Ra, IL-3 and SCGF-β significantly decreased post treatment. To determine if mediator changes were related to pain, correlations between change in pain scores and change in mediator levels were performed. Conclusion Subjects with DH demonstrated a profile signature that implicated hematopoiesis factors (SCGF-β, GM-CSF) in pain response, while subjects with Other Dx demonstrated a biomarker profile that implicated chemokines (MCP-1, MIG) and angiogenic factors (HGF, VEGF) in pain response. Our findings provide evidence that systemic biochemical factors in patients with LBP vary by diagnosis, and pain response to treatment is associated with a unique profile of biochemical responses in each diagnosis group. Future hypothesis-based studies with larger subject cohorts are warranted to confirm the findings of this pilot exploratory study.

Can Repeat Injection Provide Clinical Benefit in Patients with Lumbosacral Diseases When First Epidural Injection Results Only in Partial Response?

Epidural steroid injection (ESI) is known to be an effective treatment for lower back or radicular pain due to herniated intervertebral disc (HIVD) and spinal stenosis (SS). Although repeat ESI has generally been indicated to provide more pain relief in partial responders after a single ESI, there has been little evidence supporting the usefulness of repeat injections in cumulative clinical pain reduction. The purpose of this study was to determine whether repeat ESI at a prescribed interval of 2 to 3 weeks after the first injection would provide greater clinical benefit in patients with partial pain reduction than that provided by intermittent injection performed only when pain was aggravated. An Institutional Review Board (IRB)-approved retrospective chart review. Spine hospital. Two hundred and four patients who had underwent transforaminal ESI (TFESI) for treatment of lower back and radicular pain due to HIVD or SS and could be followed-up for one year were enrolled. We divided the patients into 2 groups. Group A (N = 108) comprised partial responders (NRS = 3 after first injection) who underwent repeat injection at a prescribed interval of 2 to 3 weeks after the first injection. Group B (N = 96) comprised partial responders who did not receive a repeat injection at the prescribed interval, but received repeat injections only for aggravation of pain. Various clinical data including total number of injections during one year, duration of NRS < 3 during one year (NRS < 3 duration), and time interval until aggravation of pain required additional injections after repeat injection in group A, or after first injection in group B (time to reinjection), were assessed. These data were compared between groups A and B in terms of total population, HIVD, and SS. In the whole population, the mean time to reinjection was 6.09 ± 3.02 months in group A and 3.69 ± 2.07 months in group B. The NRS < 3 duration was 9.72 ± 2.86 months and 6.2 ± 2.61 months in groups A and B, respectively. In HIVD patients, the mean time to reinjection was 5.82 ± 3.23 months in group A and 3.84 ± 2.34 months in group B, and NRS < 3 duration was 9.40 ± 3.34 months and 7.15 ± 2.40 months in groups A and B, respectively. In SS patients, the mean time to reinjection was 6.40 ± 2.85 months in group A and 3.59 ± 1.88 months in group B, and NRS < 3 duration was 9.98 ± 2.41 months and 5.52 ± 2.55 months in groups A and B, respectively. Group A had a significantly longer time to reinjection and longer NRS < 3 duration than group B in the whole population, HIVD, and SS. Retrospective design. Repeat TFESI conducted at 2- to 3-week intervals after the first injection in partial responders contributed to greater clinical benefit compared to intermittent TFESI performed only upon pain aggravation. These benefits were observed in patients with HIVD and in those with SS, irrespective of severity or location of disease.

Exploratory study for identifying systemic biomarkers that correlate with pain response in patients with intervertebral disc disorders.

Molecular events that drive disc damage and low back pain (LBP) may precede clinical manifestation of disease onset and can cause detrimental long-term effects such as disability. Biomarkers serve as objective molecular indicators of pathological processes. The goal of this study is to identify systemic biochemical factors as predictors of response to treatment of LBP with epidural steroid injection (ESI). Since inflammation plays a pivotal role in LBP, this pilot study investigates the effect of ESI on systemic levels of 48 inflammatory biochemical factors (cytokines, chemokines, and growth factors) and examines the relationship between biochemical factor levels and pain or disability in patients with disc herniation (DH), or other diagnoses (Other Dx) leading to low back pain, which included spinal stenosis (SS) and degenerative disc disease (DDD). Study participants (n = 16) were recruited from a back pain management practice. Pain numerical rating score (NRS), Oswestry Disability Index (ODI), and blood samples were collected pre- and at 7 to 10 days post-treatment. Blood samples were assayed for inflammatory mediators using commercial multiplex assays. Mediator levels were compared pre- and post-treatment to investigate the potential correlations between clinical and biochemical outcomes. Our results indicate that a single ESI significantly decreased systemic levels of SCGF-β and IL-2. Improvement in pain in all subjects was correlated with changes in chemokines (MCP-1, MIG), hematopoietic progenitor factors (SCGF-β), and factors that participate in angiogenesis/fibrosis (HGF), nociception (SCF, IFN-α2), and inflammation (IL-6, IL-10, IL-18, TRAIL). Levels of biochemical mediators varied based on diagnosis of LBP, and changes in pain responses and systemic mediators from pre- to post-treatment were dependent on the diagnosis cohort. In the DH cohort, levels of IL-17 and VEGF significantly decreased post-treatment. In the Other Dx cohort, levels of IL-2Rα, IL-3, and SCGF-β significantly decreased post-treatment. In order to determine whether mediator changes were related to pain, correlations between change in pain scores and change in mediator levels were performed. Subjects with DH demonstrated a profile signature that implicated hematopoiesis factors (SCGF-β, GM-CSF) in pain response, while subjects with Other Dx demonstrated a biomarker profile that implicated chemokines (MCP-1, MIG) and angiogenic factors (HGF, VEGF) in pain response. Our findings provide evidence that systemic biochemical factors in patients with LBP vary by diagnosis, and pain response to treatment is associated with a unique profile of biochemical responses in each diagnosis group. Future hypothesis-based studies with larger subject cohorts are warranted to confirm the findings of this pilot exploratory study.

Is there a decrease in opioid use after a single epidural steroid injection in LBP: a pilot study

Is there a decrease in opioid use after a single epidural steroid injection in LBP: a pilot study

Effect of Epidural Steroid Injection on Bone Mineral Density and Markers of Bone Turnover in Postmenopausal Women

A prospective, observational study. To evaluate the effect of epidural steroid injection (ESI) on bone mineral density (BMD) in postmenopausal women. ESIs are used to treat the pain associated with radiculopathy. Although it is known that exogenous steroid use can disrupt skeletal architecture, it is less clear whether ESIs result in a decrease of BMD. Twenty-eight postmenopausal women experiencing radiculopathy elected L4-L5 ESI treatment. We had a 50% dropout rate due to noncompliance with study requirements. BMD of the hip, femoral neck, and spine along with markers of bone turnover, bone specific-alkaline phosphatase and serum C-telopeptide of collagen I (CTX), was evaluated at baseline preinjection and 3 and 6 months postinjection. There was a significant decline in the hip BMD of 0.018 g/cm (0.028 ± 0.007, P = 0.002) at 6 months compared with baseline. We compared this decline with an age-matched control population that exhibited a decline of 0.003 g/cm(2), significantly less than our study population (P = 0.007). Bone-specific alkaline phosphatase increased significantly by 2.33 U/L from 3 to 6 months (P = 0.012), but the rise of CTX was not significant. A single ESI in postmenopausal women adversely affects BMD of the hip. This is in conjunction with a rise in bone remodeling activity, as evidenced by an increase in bone-specific alkaline phosphatase and CTX. In addition, when compared with an age-matched control population, our study population exhibited a greater decline in BMD. Our findings show that epidural administration of corticosteroids has a deleterious effect on bone, which should be considered when contemplating treatment options for radiculopathy. The resulting decrease in BMD, while slight, suggests that ESIs should be used with caution in those at a risk for fracture.

Focal Spinal Epidural Lipomatosis After a Single Epidural Steroid Injection

Spinal epidural steroid injections (ESIs) are commonly used as a treatment option in patients who present with significant radicular symptoms due to a spinal etiology. The possible adverse effects and complications of these procedures are rare but need to be considered. These adverse effects include infection, hematoma, dural puncture with spinal headache, air embolism, vasovagal syncope, allergic reaction, spinal cord infarction, as well as spinal epidural lipomatosis (SEL). SEL is a rare condition of hypertrophied adipose tissue within the epidural space that can cause spinal cord or nerve root compromise. Most cases of epidural lipomatosis have been associated with long-term use of systemic exogenous steroids, but they also can be caused by endogenous steroid overproduction, obesity, or an idiopathic process [1,2]. In addition, 3 prior case reports have described multiple ESIs as the causative agent of SEL [3-5]. This case presentation represents the first report, to our knowledge, to describe the development of focal SEL following a single ESI.

(735): Epidural steroid injection efficacy is a function of the contrast dispersion pattern

Epidural steroid injections (ESI) may provide relief of radicular pain associated with lumbar disc herniations. Inflammation from a disc herniation occurs primarily in the ventral epidural space at the site of the disc injury. Epidural steroids should therefore, be deposited at the level of the disc lesion in the ventral epidural space. Epidural needle placement can be accomplished by one of three methods: caudal (C), translaminar (TL) or transforaminal (TF). The purpose of this study is to analyze epidurogram contrast dispersion patterns in the epidural space using the three routes of epidural needle placement. After patient informed consent and IRB approval, 60 patients with L5-S1 disc herniations were randomly assigned to have epidural steroid injections by one of three methods for epidural needle placement; caudal (n=20), translaminar (n=20) and transforaminal (n=20). Each procedure was performed with fluoroscopy using a 22 gauge Tuohoy needle. Each patient received 3 ml of iohexol 300 with 5 ml preservative saline with 40 mg of triamincolone in Groups TL and TF and 20 ml preservative saline with 40 mg steroid in Group C after proper needle placement was ascertained by epidurogram observation. Fluoroscopy was repeated at 30 min post injection. Statistical analysis was done using the Fisher Exact test with p <0.05 to reject the null hypothesis. Observed epidural contrast dispersion patterns were; V=ventral, AP =anterior-posterior and P= posterior; Caudal (n=20), V=0/20 (0%), AP=11/20(55%), P=9/20, (45%); Translaminar (n=20) V=2/20 (10%), AP= 8/20 (40%), P=10/20 (50%) and Transforaminal (n=20), V=18/20 (90%), AP, 2/20 (10%), P=0/20 (20%). Pain relief two weeks following the ESI was as follows: C, 9/20 (45%), TL, 10/20 (50%), TF, 15/20 (75%). Transforaminal ESI resulted in significantly (p<0.05) greater pain relief with a single epidural steroid injection which is attributed to a higher incidence of steroid placement within the ventral epidural space.