RESUMEN
BACKGROUND: The estimated prevalence of lumbar radiculopathy has been described as 9.8 per 1,000 cases of low back pain. There are various surgical and nonsurgical modalities for treating lumbar disc herniation or radicular pain, including epidural injections. Epidural injection administration routes include transforaminal, interlaminar, and caudal approaches. The transforaminal approach requires the smallest volume to reach the primary site of pathology. Systematic reviews have yielded highly variable results, but a recent systematic review showed no significant difference among the 3 approaches. STUDY DESIGN: A randomized, controlled, double blind, active control trial. SETTING: An interventional pain management practice, a private specialty referral center in the United States. OBJECTIVES: To assess the effectiveness of transforaminal epidural injections of local anesthetic with or without steroids in managing chronic low back and lower extremity pain in patients with disc herniation and radiculitis. METHODS: One hundred twenty patients were randomly assigned to 2 groups: Group I received 1.5 mL of 1% preservative-free lidocaine, followed by 0.5 mL of sodium chloride solution. Group II received 1% lidocaine, followed by 3 mg, or 0.5 mL of betamethasone. The sodium chloride solution and betamethasone were either clear liquids or were provided in opaque-covered syringes. OUTCOMES ASSESSMENT: The primary outcome measure was significant improvement (at least 50%) measured by the average Numeric Rating Scale (NRS) and the Oswestry Disability Index 2.0 (ODI). Secondary outcome measures were employment status and opioid intake. RESULTS: At 2 years there was significant improvement in all participants in 65% who received local anesthetic alone and 57% who received local anesthetic and steroid. When separated into non-responsive and responsive categories based on initial relief of at least 3 weeks with 2 procedures, significant improvement (at least 50% improvement in pain and function) was seen in 80% in the local anesthetic group and 73% in the local anesthetic with steroid group. LIMITATIONS: Presumed limitations of this evaluation include the lack of a placebo group. CONCLUSION: Transforaminal epidural injections of local anesthetic with or without steroids might be an effective therapy for patients with disc herniation or radiculitis. The present evidence illustrates the lack of superiority of steroids compared with local anesthetic at 2-year follow-up.
Asunto(s)
Anestésicos Locales/administración & dosificación , Glucocorticoides/administración & dosificación , Inyecciones Epidurales/métodos , Desplazamiento del Disco Intervertebral/complicaciones , Dolor de la Región Lumbar/tratamiento farmacológico , Adulto , Betametasona/administración & dosificación , Dolor Crónico , Método Doble Ciego , Femenino , Estudios de Seguimiento , Humanos , Lidocaína/administración & dosificación , Dolor de la Región Lumbar/etiología , Extremidad Inferior/inervación , Vértebras Lumbares , Masculino , Persona de Mediana Edad , Radiculopatía/tratamiento farmacológico , Radiculopatía/etiologíaRESUMEN
BACKGROUND: Among the multiple nonsurgical modalities, epidural injections are one of the most commonly utilized treatment modalities in managing chronic low back and lower extremity pain due to disc herniation and radiculitis. There is a paucity of randomized trials from contemporary interventional pain management settings utilizing fluoroscopy with long-term follow-up. STUDY DESIGN: Randomized, double-blind, active-controlled trial with 2-year follow-up. SETTING: An interventional pain management practice in the United States. OBJECTIVE: The objective was to assess the effectiveness of lumbar interlaminar epidural injections of local anesthetic with or without steroids for managing chronic low back pain of disc herniation or radiculitis. METHODS: Two groups of patients were studied, with 60 patients in each group receiving either local anesthetic only or local anesthetic mixed with betamethasone. OUTCOME MEASURES: The primary outcome measure was defined as pain relief and functional status improvement of 50%. The outcomes were assessed by numeric rating scale (NRS) of pain and functional status with Oswestry Disability Index (ODI). Secondary outcome measures included employment status and opioid intake. RESULTS: Results showed significant improvement in 60% of patients in Group I and 70% of patients in Group II at the end of 2 years. In addition, in the successful groups, those with at least 3 weeks of relief (with the first 2 procedures), the improvement was 72% in Group I and 71% in Group II. Results were somewhat superior for pain relief at 6 months and functional status at 12 months in the steroid group. Thus, the results indicate that a patient's failure to respond to local anesthetic alone, may be treated with addition of steroids. LIMITATIONS: The results of the study are limited by the lack of a placebo group. CONCLUSION: Lumbar interlaminar epidural injections of local anesthetic with or without steroids is an effective modality, in patients with chronic function limiting low back and lower extremity pain secondary to disc herniation after failure of conservative modalities.