Clinical notes
Abdulrazzaq Alobaid, Kuwait
Epidural steroid injections have long been endorsed as an integral part of nonsurgical
management of radicular pain from lumbar spine disorders.
Epidural steroid injections (ESI) can provide diagnostic and therapeutic benefits.
Diagnostically, it may help to identify the epidural space as the potential pain generator,
through pain relief after local anesthetic injection to the site of presumed anatomic
pathology. In addition, if the patient receives several weeks or more of pain relief,
then it may be reasonable to assume that an element of inflammation was involved in
his or her pathophysiology. Moreover, it helps control the symptoms in patients with
radicular symptoms on the waiting list for surgery, or patients with significant comorbid
history where surgical intervention carries a high risk.
Although many articles have supported the benefit of ESI for radiculopathy, other
studies have disputed the efficacy of these procedures. Unfortunately, most of the
earlier studies had significant limitations. Aside from employing a weak research
methodology, most of these studies did not use fluoroscopy and radiographic contrast
to document accurate placement of the injected substance into the epidural space.
Many also failed to demonstrate that injection was performed at a presumed level of
pathology, which has been shown to be critical to the success of ESI.
Epidural steroid injections have long been endorsed as an integral part of nonsurgical
management of radicular pain from lumbar spine disorders.
Epidural steroid injections (ESI) can provide diagnostic and therapeutic benefits.
Diagnostically, it may help to identify the epidural space as the potential pain generator,
through pain relief after local anesthetic injection to the site of presumed anatomic
pathology. In addition, if the patient receives several weeks or more of pain relief,
then it may be reasonable to assume that an element of inflammation was involved in
his or her pathophysiology. Moreover, it helps control the symptoms in patients with
radicular symptoms on the waiting list for surgery, or patients with significant comorbid
history where surgical intervention carries a high risk.
Although many articles have supported the benefit of ESI for radiculopathy, other
studies have disputed the efficacy of these procedures. Unfortunately, most of the
earlier studies had significant limitations. Aside from employing a weak research
methodology, most of these studies did not use fluoroscopy and radiographic contrast
to document accurate placement of the injected substance into the epidural space.
Many also failed to demonstrate that injection was performed at a presumed level of
pathology, which has been shown to be critical to the success of ESI.
The current concern is the stretched indications in which at some centers it is presented
as an alternative treatment option to surgery. At my own practice, we use ESI In selected
groups of patient as follows:
-
Symptomatic patients on the waiting list for surgery, where ESI can give temporary
relief. A follow-up study at 5 years found that 17 of 21 patients (81%) surveyed still
had still not opted for surgery [1]. This report demonstrated a benefit from lumbar ESIs in patients who had been diagnosed
with lumbar spinal stenosis or herniated nucleus pulposus, with the injections helping
to reduce the need for surgery.
-
Patients who are unable to do physiotherapy because of pain. In this group, the temporary
effect of ESI may help in giving the patients the best outcome with physiotherapy.
The judicial use of ESI in conjunction with a properly designed rehabilitation program
may play a very important role in the conservative management of patients with severe
radicular pain, improving their quality of life and function
-
Symptomatic spinal stenosis patients with contra-indications to surgery.
-
Transforaminal blocks for isolated nerve root radicular symptoms. In 2002, Vad and
colleagues reported a prospective randomized study comparing transforaminal ESI with
lumbar paraspinal trigger-point injection [2]. They randomized 48 patients with sciatica from herniated disk pulposus (confirmed
by lumbar spine magnetic resonance imaging [MRI]) into 2 groups. One group received
transforaminal ESI, and the other received a lumbar paraspinal intramuscular injection
with saline. The average follow-up period was 16 months. The authors used patient
satisfaction, the Rolland-Morris scale, and pain reduction extent as indices for efficacy.
The success rate in the transforaminal injection group was 84%, compared with 48%
in the saline group.
In comparing interlaminar Vs trans foraminal ESI, Rhee and colleagues found a difference
in patients undergoing interlaminar and transforaminal epidural injectons [3]. Those patients who underwent transforaminal injections had a 46% reduction in their
pain score, and 10% went on to need surgery. In contrast, patients who had interlaminar
injections had a 19% reduction in pain, and 25% required surgery
One recent systemic review has shown that the indicated evidence for transforaminal
ESI injections is Level II-1 for short-term relief and Level II-2 for long-term improvement
in the management of lumbar nerve root and low back pain [4].
In conclusion, although the literature reports conflicting results with variable techniques,
ESI plays a significant role in the management of radicular symptoms if utilized in
selected patients. However, timing and frequency of injections remains controversial
without solid evidence.
References
- 1
Riew K D, Park J B, Cho Y S. et al .
Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year follow-up.
J Bone Joint Surg Am.
2002;
88 (8)
1722-1725
- 2
Vad V B, Bhat A L, Lutz G E. et al .
Transforaminal Epidural Steroid Injections in Lumbosacral Radiculopathy: A Prospective
Randomized Study.
Spine.
2002;
27
11-15
- 3
Rhee J M, Schaufele M, Abdu W A.
Radiculopathy and the herniated lumbar disc. Controversies regarding pathophysiology
and management.
J Bone Joint Surg Am.
2006;
8
2070-2080
- 4
Buenaventura R M, Datta S, Abdi S. et al .
Systematic review of therapeutic lumbar transforaminal epidural steroid injections.
Pain Physician.
2009;
12
233-251
