Neurological

Epidural injections with and without steroids effective in lumbar radiculopathy

Epidural injections of local anesthetics, with or without steroids, can effectively treat lumbar radiculopathy, with moderate to strong evidence available, according to a systematic review and meta-analysis of the results of randomized controlled trials published in Pain Physician. 1

In the current review, researchers sought to evaluate the effectiveness – or lack of it – of epidural injections of saline, a local anesthetic alone, or a local anesthetic with steroids, and compared these results with the results of a recently published Cochrane review.2,3

Literature published by January 2021 was eligible for inclusion. Predefined inclusion criteria included fluoroscopic guidance and results reported for at least 6 months, epidural injections of sodium chloride solution, local anesthetic, or steroids via caudal, interlaminar, or transforaminal approaches.

Continue reading

The predefined endpoints were pain and function measurements with a description of composite endpoints with significant pain and an improvement in functional status of 50% or more.

A total of 21 studies met the inclusion criteria, of which 7 assessed caudal epidural injections, 10 of which assessed interlaminar epidural injections, and 12 of which assessed transforaminal epidural injections.

The original Cochrane review included 25 studies, several of which did not meet the currently pre-defined inclusion criteria. Of the 21 studies in the current review, 15 were not included in the Cochrane review, which corresponds to an overlap of 6 studies.

According to the researchers, the current assessment showed the importance of an interventional pain therapy-specific assessment that uses the criteria of interventional pain therapy – quality assessment of reliability and risk of bias (IPM-QRB). These criteria have led to evaluation results that differ from the data derived from Cochrane reviews. In 19 of 21 studies, there was a match between the Cochrane review and the IPM QRB scoring.

Among the studies included, there was a placebo-controlled study and a study comparing conservative treatment; 7 studies compared local anesthetics alone with local anesthetics plus steroids and the remaining studies compared technical aspects or dose responses.

In 5 studies, including 527 patients, local anesthetics were compared with steroids with local anesthetics alone in a two-arm meta-analysis. The results of this review showed no statistically significant difference between these two groups (standardized mean difference 0.19; 95% CI -0.49 to 0.87).

Five studies rated the pain score at 6 months using the numerical rating scale (NRS) in patients who received epidural local anesthetic injections. The pooled mean difference in pain scores from baseline to 6 months of follow-up decreased by 3.637 points (95% CI, -3.787 to -3.487).

Another 5 studies assessed the pain score at 6 months using the NRS in patients receiving epidural steroid injections. The pooled mean difference in pain scores between baseline and 6-month follow-up decreased by 4.105 points (95% CI, -4.2024 to -4.005).

The results of a conventional two-armed analysis indicated that although there was no significant difference between local anesthetic and local anesthetic plus steroids, there was a “slight advantage” in favor of local anesthesia with steroids (pain reduction, 3.637 vs. 4.015 points).

Five studies with 527 patients compared local anesthetics with combined local anesthetics and steroids. There was no statistically significant difference between these groups (standardized mean difference 0.70; 95% CI -0.11 to 1.51).

The researchers also performed a one-arm analysis of 5 local anesthetic studies that assessed the functional value after 6 months. The pooled mean difference in pain score decreased by 13.697 points (95% CI, -13.785 to -13.609). Functional analyzes show statistically similar results in those who received a local anesthetic alone versus a local anesthetic with steroids, although there was a trend towards greater improvement with local anesthetic plus steroids.

In a conventional two-arm analysis, the 1-year follow-up showed results with no significant difference between local anesthesia alone and local anesthesia with steroids. No tendency for either treatment to be superior was found. In a one-arm analysis with local anesthetic alone, however, the difference in pain scores from baseline up to month 12 was 3.773 points lower.

Changes in functionality after 1 year were also examined from 5 studies with 527 patients comparing local anesthetics with steroids versus local anesthetics alone. No statistically significant difference was found between the groups (standardized mean difference 0.61; 95% CI, -0.14 to 1.35).

“The qualitative and quantitative synthesis of evidence showed level I or strong evidence for the effectiveness of lumbar epidural injections with local anesthetics and steroids and levels II to I or moderate to strong evidence for local anesthesia alone in the treatment of lumbar radiculopathy or sciatica as a result of a lumbar disc herniation, “Concluded the researchers.

Disclosure: Study authors stated links with the pharmaceutical industry. For a full list of the author’s disclosures, see the original reference.

References

  1. Manchikanti L, Knezevic E, Knezevic NN, et al. Epidural Injections for Lumbar Radiculopathy or Sciatica: A Comparative Systematic Review and Meta-Analysis of the Cochrane Review. Pain doctor. 2021; 24 (5): E539-E554.
  2. Oliveira CB, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev. 2021; 4 (4): CD013577. doi: 10.1002 / 14651858.CD013577
  3. Oliveira CB, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections for sciatica: an abbreviated systematic review and meta-analysis by Cochrane. Spine. 2021; 45 (21): E1405-E1415. doi: 10.1097 / BRS.0000000000003651

This article originally appeared on Clinical Pain Advisor

Related Articles