Use Of Epidural Injections Research Articles

Современные стратегии лечения дегенеративно-дистрофических заболеваний позвоночника: Обзор литературы

Currently, there is a wide range of methods for the treatment of herniated intervertebral disc, such as: conservative treatment, the use of epidural injections, therapeutic spinal blockades, methods of molecular therapy and genetic engineering, various methods of surgical treatment.The purpose of this review is to study the currently existing treatment methods for degenerative diseases of the spine, including their advantages and disadvantages.Level I studies have shown the advantages of surgical treatment methods. In the application of the surgical approach, there is currently a wide range of techniques (minimally invasive surgeries using endoscopy, interbody spondylodesis using various grafts and cages, including those using cellular technologies), which also complicates the task of choosing a particular treatment tactic. Surgical treatment options for intervertebral disc disease are controversial, with a medium- to low-quality evidence base supporting each modality: decompression, discectomy, spondylodesis formation, and interbody disc replacement. Surgical interventions carry certain risks and complications and should be offered after conservative measures have failed to improve the patient's quality of life. In general, the goal of all types of spinal surgeries for the pathology under study is to provide definitive treatment to the patient for long-term pain relief, reduce the incidence of complications and reoperations, and ensure good patient satisfaction. Recent advances in regenerative and reconstructive treatment strategies for degenerative-dystrophic spine diseases in molecular science in the areas of cell, gene therapy and intervertebral disc growth factor therapy are evolving in the hope of disc repair and regeneration, have some challenges but also show promising results. Surgery is the last option, with the choice of surgical treatment tactics being a matter of debate among physicians.Keywords: degenerative-dystrophic diseases of the spine, interbody fusion, cage, lumbar spine, treatment.

The role of epidural steroid injections in the treatment of pain in patients with degenerative changes in the lumbar spine

Epidural steroid injections of the lumbar spine are a common interventional procedure that is used to alleviate radicular pain resulting from degenerative changes in the spine. Although several studies have compared epidural steroid injections with placebo with favorable outcomes, randomized controlled trials in this direction are needed. The purpose of the study was to evaluate the effectiveness of the use of epidural steroid injections in the treatment of pain in patients with degenerative lesions of the lumbar spine. During the study, 262 patients with degenerative lesions of the spine at one or two levels of the vertebral-motor segment (VMS) were selected. Epidurally transforaminally under fluoroscopic control all patients received steroid injections at the appropriate level (s) of VMS on the basis of the rehabilitation department of the Institute of Traumatology and Orthopedics of the National Academy of Medical Sciences of Ukraine during 2017-2019. Of the 262 patients who received epidural steroid injections, 204 were able to reduce pain and avoid surgery within one year. However, 58 patients experienced only slight pain relief and were recommended surgical treatment. In our study, patients with negative results were offered surgery after 1.98 ESI procedures with an interval of 3.7 months. In the group of operated patients, the preliminary use of steroid injections did not bring relief by the results of Oswestry Disability Index (ODI) and Visual Analog scale (VAS), however, the condition of these patients improved significantly after surgery (p<0.05). The use of epidural injections is possible as a first-line therapy in patients with moderate functional limitations, which can subsequently be directed to surgery in the absence of a positive result.

Epidural Injections for Lumbar Radiculopathy or Sciatica: A Comparative Systematic Review and Meta-Analysis of Cochrane Review

Epidural injections are one of the commonly performed procedures in managing low back and lower extremity pain. In the past, Pinto et al and Chou et al performed systematic reviews and meta-analyses with a recent update from Oliveira et al showing lack of effectiveness of epidural steroid injections in managing lumbar radiculopathy. In contrast, multiple other systematic reviews and meta-analyses have supported the efficacy and use of epidural injections utilizing fluoroscopic guidance. A systematic review and meta-analysis of randomized controlled trials (RCTs) of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy. To assess the efficacy of 3 categories of epidural injections for lumbar radiculopathy or sciatica performed utilizing saline with steroids, local anesthetic alone, or steroids with local anesthetic. In this systematic review and meta-analysis, RCTs with a placebo control or an active control design, performed under fluoroscopic guidance, with at least 6 months of followed-up were included. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Literature search was performed through January 2021. Methodological quality assessments were performed. Evidence was summarized utilizing principles of best evidence synthesis. In this analysis, a total of 21 RCTs were utilized with at least 6 months of follow-up and performed under fluoroscopic guidance. However, only 6 of 25 trials from Cochrane review met inclusion criteria for this review. Based on qualitative analysis, of the 21 trials included in the present analysis, there was only one placebo-controlled trial found to be negative. With conventional meta-analysis, there was no significant difference among the studies because all of the studies were active control with local anesthetic or local anesthetic and steroids. Further, with single-arm analysis, of the 5 trials included in that portion of the study, significant improvement was seen with local anesthetic alone compared to local anesthetic and steroids. There was a tendency for better improvement with steroids in terms of both pain relief and functional status. The level of evidence is Level I or strong for local anesthetic with steroids and Level I to II or moderate to strong for local anesthetic as a single agent based on multiple relevant high quality RCTs. Despite multiple trials available, there is a paucity of true RCTs performed under fluoroscopic guidance with any of the approaches. Epidural injections with or without steroids for radiculopathy showed significant effectiveness with Level I or strong evidence for local anesthetic with steroids and Level II to I or moderate to strong evidence with local anesthetic alone.

Therapeutic and diagnostic value of transforaminal epidural injections in patients with herniated disc and radicular pain: analytical literature review

The aim of the study is to analyze comprehensive information on the use of epidural injections in the treatment and diagnosis of patients with herniated intervertebral discs. Epidemiology and modern concepts of the pathogenesis of pain syndrome formation in patients with herniated intervertebral discs, algorithms and methods of conservative and surgical treatment of such patients are highlighted. Information on the methods and features of various routes of epidural injections used for these drugs is presented, as well as a comparative assessment of their effectiveness and safety. The diagnostic and prognostic significance of transforaminal epidural block is discussed separately.

Epidural Injections for Lumbar Radiculopathy and Spinal Stenosis: A Comparative Systematic Review and Meta-Analysis

Background: The prevalence of chronic low back pain and related disability is rapidly increasing as are the myriad treatments, including epidural injections. Even though epidural injections are one of the most commonly performed procedures in managing low back and lower extremity pain, starting in 1901 with local anesthetic alone, conflicting recommendations have been provided, despite the extensive literature. Recently Chou et al performed a technology assessment review for Agency for Healthcare Research and Quality (AHRQ) part of which was published in Annals of Internal Medicine showing lack of effectiveness of epidural steroid injections in managing lumbar radiculopathy and spinal stenosis. In contrast, multiple other publications have supported the efficacy and use of epidural injections. Purpose: To assess the efficacy of 3 categories of epidural injections for lumbar and spinal stenosis: performed with saline with steroids, local anesthetic alone, or steroids with local anesthetic and separate facts from opinions. Data Sources: PubMed, Cochrane Library, US National Guideline Clearinghouse, prior systematic reviews, and reference lists. The literature search was performed through August 2015. Study Selection: Randomized trials, either placebo or active control, of epidural injections for lumbar radiculopathy and spinal stenosis. Data Extraction: Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Evidence was summarized utilizing principles of best evidence synthesis. Data Synthesis: Thirty-nine randomized controlled trials met inclusion criteria. There were 9 placebo-controlled trials evaluating epidural corticosteroid injections, either with sodium chloride solution or bupivacaine, compared to placebo injections. There were 12 studies comparing local anesthetic alone to local anesthetic with steroid. Results A meta-analysis of 5 studies utilizing sodium chloride or bupivacaine with steroid showed a lack of efficacy. A comparison of lidocaine to lidocaine with steroids in 7 studies showed significant effectiveness from baseline to long-term follow-up periods. Meta-analysis showed a similar effectiveness for pain and function without non-inferiority of lidocaine compared to lidocaine with steroid at 3 months and 12 months. Limitations: The review was restricted to the data available with at least 3 months of followup, which excluded some studies. The inclusion criteria were restricted to English language studies. Conclusion: Epidural corticosteroid injections for radiculopathy or spinal stenosis with sodium chloride solution or bupivacaine were shown to be ineffective. Lidocaine alone or lidocaine in conjunction with steroids were significantly effective. Key Words: Epidural injections, epidural steroids, lumbar radiculopathy, spinal stenosis, lidocaine, steroids, bupivacaine

Guidance on the management of pain in older people

This guidance document reviews the epidemiology and management of pain in older people via a literature review of published research. The aim of this document is to inform health professionals in any care setting who work with older adults on best practice for the management of pain and to identify where there are gaps in the evidence that require further research. The assessment of pain in older people has not been covered within this guidance and can be found in a separate document (http://www.britishpainsociety.org/pub_professional.htm#assessmentpop). Substantial differences in the population, methods and definitions used in published research makes it difficult to compare across studies and impossible to determine the definitive prevalence of pain in older people. There are inconsistencies within the literature as to whether or not pain increases or decreases in this age group, and whether this is influenced by gender. There is, however, some evidence that the prevalence of pain is higher within residential care settings. The three most common sites of pain in older people are the back; leg/knee or hip and 'other' joints. In common with the working-age population, the attitudes and beliefs of older people influence all aspects of their pain experience. Stoicism is particularly evident within this cohort of people. Evidence from the literature search suggests that paracetamol should be considered as first-line treatment for the management of both acute and persistent pain, particularly that which is of musculoskeletal origin, due to its demonstrated efficacy and good safety profile. There are few absolute contraindications and relative cautions to prescribing paracetamol. It is, however, important that the maximum daily dose (4 g/24 h) is not exceeded. Non-selective non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution in older people after other safer treatments have not provided sufficient pain relief. The lowest dose should be provided, for the shortest duration. For older adults, an NSAID or cyclooxygenase-2 (COX-2) selective inhibitor should be co-prescribed with a proton pump inhibitor (PPI), and the one with the lowest acquisition cost should be chosen. All older people taking NSAIDs should be routinely monitored for gastrointestinal, renal and cardiovascular side effects, and drug–drug and drug–disease interactions. Opioid therapy may be considered for patients with moderate or severe pain, particularly if the pain is causing functional impairment or is reducing their quality of life. However, this must be individualised and carefully monitored. Opioid side effects including nausea and vomiting should be anticipated and suitable prophylaxis considered. Appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, should be prescribed throughout treatment for all older people who are prescribed opioid therapy. Tricyclic antidepressants and anti-epileptic drugs have demonstrated efficacy in several types of neuropathic pain. But, tolerability and adverse effects limit their use in an older population. Intra-articular corticosteroid injections in osteoarthritis of the knee are effective in relieving pain in the short term, with little risk of complications and/or joint damage. Intra-articular hyaluronic acid is effective and free of systemic adverse effects. It should be considered in patients who are intolerant to systemic therapy. Intra-articular hyaluronic acid appears to have a slower onset of action than intra-articular steroids, but the effects seem to last longer. The current evidence for the use of epidural steroid injections in the management of sciatica is conflicting and, until further larger studies become available, no firm recommendations can be made. There is, however, a limited body of evidence to support the use of epidural injections in spinal stenosis. The literature review suggests that assistive devices are widely used and that the ownership of devices increases with age. Such devices enable older people with chronic pain to live in the community. However, they do not necessarily reduce pain and can increase pain if used incorrectly. Increasing activity by way of exercise should be considered. This should involve strengthening, flexibility, endurance and balance, along with a programme of education. Patient preference should be given serious consideration. A number of complementary therapies have been found to have some efficacy among the older population, including acupuncture, transcutaneous electrical nerve stimulation (TENS) and massage. Such approaches can affect pain and anxiety and are worth further investigation. Some psychological approaches have been found to be useful for the older population, including guided imagery, biofeedback training and relaxation. There is also some evidence supporting the use of cognitive behavioural therapy (CBT) among nursing home populations, but of course these approaches require training and time. There are many areas that require further research, including pharmacological management where approaches are often tested in younger populations and then translated across. Prevalence studies need consistency in terms of age, diagnosis and terminology, and further work needs to be done on evaluating non-pharmacological approaches.

A Systematic Evaluation of Thoracic Interlaminar Epidural Injections

Background: There is a paucity of literature on the use of epidural injections for the treatment of chronic mid and upper back pain due to disc herniation and radiculitis, axial or discogenic pain, spinal stenosis, post surgery syndrome, and post thoracotomy pain syndrome. Study Design: A systematic review of therapeutic thoracic epidural injection therapy for chronic mid and upper back pain. Objective: The objective of this systematic review is to determine the effects of thoracic interlaminar epidural injections with or without steroids, with or without fluoroscopy, and for various conditions including disc herniation and radiculitis, axial or discogenic pain, spinal stenosis, post thoracic surgery syndrome, and post thoracotomy pain syndrome. Methods: The available literature on thoracic interlaminar epidural injections with or without steroids in managing various types of chronic mid and upper back pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, or limited (or poor) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to March 2012, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: For this review, 17 studies were identified, including studies examining adverse reactions. Only 2 studies were included: one randomized trial and one non-randomized or observational study. The results of this systematic review evaluating the effectiveness of thoracic epidural injections with or without steroids in managing chronic thoracic pain shows fair evidence with one randomized trial in patients with various causes; whereas the evidence is limited based on one non-randomized study evaluating chronic pain in post thoracotomy syndrome. Limitations: The limitations of this study include paucity of evidence. Conclusion: The evidence based on this systematic review for thoracic epidural injection in treating chronic thoracic pain is considered fair and limited for post thoracotomy pain. Key words: Spinal pain, chronic mid back pain, chronic upper back pain, post-thoracotomy pain, thoracic epidural injection, radiculopathy, herniation, steroids, local anesthetic, epidural steroid

Neuroarthropathy of the hip following spinal cord injury

We present the case of a 33-year-old male who sustained a burst fracture D12 vertebrae with spinal cord injury (ASIA impairment scale A) and a right mid-diaphysial femoral shaft fracture around 1.5 years back. The patient reported 1.5 years later with a swelling over the right buttock. Arthrotomy revealed serous fluid and fragmented bone debris. The biopsy showed a normal bony architecture with no evidence of infection and malignant cells. Hence, a diagnosis of Charcot’s hip was made. Charcot’s neuroarthropathy of the feet is a well-recognized entity in the setting of insensate feet resulting from causes such as diabetes or spina bifida. Although Charcot’s disease of the hips has been described, it is uncommon in association with spinal cord injury, syphilis and even with the use of epidural injection. The present case highlights the fact that neuroarthropathy of the hip can occur in isolation in the setting of a spinal cord injury, and this can lead to considerable morbidity.

Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low-back pain, and lumbar fusion

In summary, there is no meaningful evidence in the medical literature that the use of epidural injections is of any long-term value in the treatment of patients with chronic low-back pain. The literature does indicate that the use of lumbar epidural injections can provide short-term relief in selected patients with chronic low-back pain. There is evidence that suggests that facet joint injections can be used to predict outcome after RF ablation of a facet joint. The predictive ability of facet joint injections does not appear to apply to lumbar fusion surgery. No evidence exists to support the effectiveness of facet injections in the treatment of patients with chronic low-back pain. There is conflicting evidence suggesting that the use of local TPIs can be effective for the short-term relief of low-back pain. There are no data to suggest that TPIs with either steroids or anesthetics alone provide lasting benefit for patients suffering from chronic low-back pain.

An audit of the use of epidural injections for back pain and sciatica.

An audit was conducted to determine if epidural injections for back pain and sciatica were practised in accordance with guidelines prescribed by the National Health and Medical Research Council (NHMRC). More than 80% of injections were used for conditions for which they were not indicated, and which the NHMRC considers experimental. Most commonly, epidural injections afforded no benefit to the patients, yet were often repeated. In no instance was informed consent recorded as recommended by the NHMRC. The practice of epidural injections is dissonant both with the evidence-based literature and with recommended guidelines, and squanders both financial and professional resources.

Spinal Epidural Abscess After Corticosteroid Injections

Although spinal epidural abscess is uncommon, its incidence is likely to rise with increasing use of epidural injections for the control of lower back pain. We report a case of spinal epidural abscess after epidural steroid injection. The abscess resolved with conservative medical management.

Spinal Epidural Abscess After Corticosteroid Injections

Although spinal epidural abscess is uncommon, its incidence is likely to rise with increasing use of epidural injections for the control of lower back pain. We report a case of spinal epidural abscess after epidural steroid injection. The abscess resolved with conservative medical management.