Epidural Steroid Injections Wilkinson, Indy M.; Cohen, Steven P.
Current pain and headache reports,
02/2012, Letnik:
16, Številka:
1
Journal Article
Recenzirano
Epidural steroid injection (ESI) is the most commonly performed intervention in pain clinics across the United States. This article provides an evidence-based review of ESI, including data on ...efficacy, patient selection, comparison of types, and complications. The data strongly suggest that ESI can provide short-term relief for radicular symptoms but are less compelling for long-term effects or relief of back pain. Although it has been asserted that transforaminal ESIs are more efficacious than interlaminar injections, the evidence supporting this is limited.
Epidural steroid injections (ESIs) are the most widely utilized pain management procedure in the world, their use supported by more than 45 placebo-controlled studies and dozens of systematic ...reviews. Despite the extensive literature on the subject, there continues to be considerable controversy surrounding their safety and efficacy. The results of clinical trials and review articles are heavily influenced by specialty, with those done by interventional pain physicians more likely to yield positive findings. Overall, more than half of controlled studies have demonstrated positive findings, suggesting a modest effect size lasting less than 3 months in well-selected individuals. Transforaminal injections are more likely to yield positive results than interlaminar or caudal injections, and subgroup analyses indicate a slightly greater likelihood for a positive response for lumbar herniated disk, compared with spinal stenosis or axial spinal pain. Other factors that may increase the likelihood of a positive outcome in clinical trials include the use of a nonepidural (eg, intramuscular) control group, higher volumes in the treatment group, and the use of depo-steroid. Serious complications are rare following ESIs, provided proper precautions are taken. Although there are no clinical trials comparing different numbers of injections, guidelines suggest that the number of injections should be tailored to individual response, rather than a set series. Most subgroup analyses of controlled studies show no difference in surgical rates between ESI and control patients; however, randomized studies conducted by spine surgeons, in surgically amenable patients with standardized operative criteria, indicate that in some patients the strategic use of ESI may prevent surgery.
Epidural steroid injections (ESIs) are the most commonly performed intervention in pain clinics across the USA and worldwide. In light of the growing use of ESIs, a recent spate of highly publicized ...infectious complications, and increasing emphasis on cost-effectiveness, the utility of ESI has recently come under intense scrutiny. This article provides an evidence-based review of ESIs, including the most up-to-date information on patient selection, comparison of techniques, efficacy, and complications.
The data strongly suggest that ESIs can provide short-term relief of radicular symptoms but are less convincing for long-term relief, and mixed regarding cost-effectiveness. Although some assert that transforaminal ESIs are more efficacious than interlaminar ESIs, and that fluoroscopy can improve treatment outcomes, the evidence to support these assertions is limited.
The cost-effectiveness of ESI is the subject of great debate, and similar to efficacy, the conclusions one draws appear to be influenced by specialty. Because of the wide disparities regarding indications and utilization, it is likely that indiscriminate use is cost-ineffective, but that judicious use in well-selected patients can decrease healthcare utilization. More research is needed to better refine selection criteria for ESI, and to determine which approach, what dose, and how many injections are optimal.
Abstract
Objective
Low back pain is the leading cause of worldwide disability, with lumbosacral radiculopathy accounting for over one-third of these cases. There are limited data on the relationship ...between etiologies and lumbosacral radiculopathy, and it is unknown whether specific causes predict treatment outcomes.
Design, Setting, and Subjects
This study explores patient-reported etiologies for lumbosacral radiculopathy in a chronic pain clinic between January 2007 and December 2015 and examines whether these causes affected epidural steroid injection outcomes.
Methods
We reviewed the medical records of 1,242 patients with lumbosacral radiculopathy who received epidural steroid injections. The recording of an inciting event was done contemporaneously based on note templates. A positive outcome following an epidural steroid injection was defined as ≥30% pain relief sustained for six or more weeks without additional intervention. Factors associated with epidural steroid injection outcome were analyzed by multivariable logistic regression.
Results
Fifty point seven percent reported an inciting event, and 59.9% of patients experienced a positive epidural steroid injection outcome. The most commonly reported causes were falls (13.1%), motor vehicle collisions (10.7%), and lifting (7.8%). Individuals with a herniated disc (56.3%) were more likely to report a precipitating cause than those with stenosis (44.7%) or degenerative discs (47.8%, P = 0.012). An inciting event did not predict treatment outcome. Factors associated with negative treatment outcome included opioid consumption (odds ratio OR = 0.61, 95% confidence interval CI = 0.39–0.95, P = 0.027), secondary gain (OR = 0.69, 95% CI = 0.50–0.96, P = 0.030), and baseline pain score (OR = 0.90, 95% CI = 0.84–0.97, P = 0.006). The number of levels injected was associated with a positive outcome (OR = 2.72, 95% CI = 1.28–6.47, P = 0.008).
Conclusions
Reported inciting events are common in patients with lumbosacral radiculopathy but are not associated with outcome following epidural steroid injection, and their occurrence is not always consistent with the purported mechanism of injury.
Acupuncture is characterized as an alternative or complementary medicine with a low complication rate and minimal side effects. There is a lack of robust evidence that shows acupuncture is an ...effective treatment for chronic pain. The purpose of this study was to determine which (if any) characteristics can predict successful response to acupuncture in chronic pain patients treated at military treatment facilities.
Data from 222 patients who received treatment for a chronic pain condition were collected from 2 medical centers. The patients underwent at least 4 acupuncture treatments and had an average pain score of 4 or higher on a 0- to 10-point numerical rating scale or visual analog scale in the week before treatment initiation. A successful outcome was defined to be a 2-point or greater reduction on the numerical rating scale or visual analog scale 12 weeks postinitial treatment.
The overall treatment success rate was 42.3%. Multivariate logistic regression found a higher baseline pain rating and the use of stimulation needles to be associated with a positive outcome (odds ratio OR=1.26; 95% confidence interval CI, 1.03-1.55; P=0.02 and OR=2.73; 95% CI, 1.39-5.32; P=0.03, respectively). Only the presence of one or more psychological comorbidities was found to be associated with treatment failure (OR=0.67; 95% CI, 0.49-0.92; P=0.01).
The use of electrical stimulation and higher baseline pain score were associated with a positive treatment outcome, while the presence of a psychological comorbidity diminished the likelihood of treatment success. Practitioners should consider using electrical stimulation more frequently, and addressing psychopathology before or concurrent to treatment, when initiating acupuncture.
Objective. Occipital neuralgia (ON) is a challenging condition for which there is no reference standard for treatment. The purpose of this study was to provide outcome data on the largest study to ...date evaluating pulsed radiofrequency (PRF) for ON and to determine whether any demographic, clinical, or treatment characteristics are associated with success.
Design. Retrospective data analysis was conducted in 102 subjects evaluating the effect of myriad factors on treatment success.
Setting. This study was conducted in academic civilian and military pain treatment centers.
Patients. One hundred and two consecutive patients with a primary diagnosis of ON were treated with PRF of the greater and/or lesser occipital nerve.
Outcome Measures. A positive primary outcome was predefined as ≥50% pain relief lasting at least 3 months. The secondary outcome measure was procedural satisfaction.
Results. Fifty‐two (51%) patients experienced ≥50% pain relief and satisfaction with treatment lasting at least 3 months. Variables associated with a positive outcome included a traumatic inciting event (65.7% success rate; P = 0.03), lower diagnostic block volumes (odds ratio OR: 0.72; 95% confidence interval CI: 0.62–0.82; P < 0.0001), and employment of multiple rounds of PRF (OR: 2.95; 95% CI: 1.77–4.92; P < 0.0001). Factors correlating with treatment failure included extension of pain anterior to the scalp apex (OR: 0.32; 95% CI: 0.14–0.73; P = 0.006) and ongoing secondary gain issues (OR: 0.19; 95% CI: 0.11–0.33; P < 0.0001).
Conclusion. PRF may provide intermediate‐term benefit in ON to a significant proportion of refractory cases. Careful attention to selection criteria and treatment parameters may further improve treatment outcomes.
Background: Headache is often associated with physical trauma and psychological stress. The aim of this study is to evaluate the impact of headache on personnel deployed in war zones and to identify ...factors associated with return to duty (RTD).
Methods: Outcome data were prospectively collected on 985 personnel medically evacuated out of Operations Iraqi and Enduring Freedom for a primary diagnosis of headache between 2004 and 2009. Electronic medical records were reviewed to examine clinical and treatment patterns and the effect that myriad factors had on RTD.
Results: 33.6% of evacuees returned to duty. The most common headaches were post-concussion (34.1%) and migraine (30.0%). Headaches typically associated with trauma such as post-concussion (18.7%), occipital neuralgia (23.1%), and cervicogenic headache (29.7%) had the lowest RTD rates, whereas tension headache (49.6%) was associated with the best outcome. Other variables associated with negative outcome included presence of aura (OR 0.51, 95% CI 0.30–0.88; p = 0.02), traumatic brain injury (OR 0.50, 95% CI 0.29–0.87; p = 0.01), opioid (OR 0.41, 95% CI 0.26–0.63; p < 0.001), and beta-blocker (OR 0.26, 95% CI 0.12–0.61; p = 0.002) use, and co-existing psychopathology (p < 0.001 in univariable analysis).
Conclusion: Headaches represent a significant cause of unit attrition in personnel deployed in military operations, with physical trauma and co-existing psychopathology associated with poorer outcomes.
Background. In addition to its conventional use as a treatment for refractory neuropathic extremity pain, spinal cord stimulation (SCS) has recently emerged as a possible treatment for visceral and ...arthritic pain. But concurrent with the expansion of possible conditions amenable to SCS, other studies have questioned the long‐term efficacy of SCS for traditional indications. These disparate findings argue strongly for the refinement of selection criteria. The purpose of this study is to identify correlates of outcome for SCS.
Methods. Data were retrospectively collected on 244 patients who underwent a SCS trial at two academic medical centers. Success was predefined as ≥50% pain relief sustained for ≥6 months. Variables analyzed for their association with outcome included demographics, location of pain, diagnosis, presence of coexisting diseases, pain descriptors, opioid and adjuvant medication use, duration and pain relief during trial, and complications.
Results. The presence of allodynia and/or hyperalgesia correlated with both a positive SCS trial (P = 0.01) and long‐term implantation outcome (P = 0.05). History of substance abuse was associated with a negative permanent SCS outcome (P = 0.05) but bore no relationship to trial results. The variable most strongly associated with an SCS outcome was experiencing <50% pain relief during the trial, which strongly presaged a negative result (P < 0.001).
Conclusions. Although weak associations with outcome were noted for several clinical variables, none was strongly associated with trial and permanent implantation results. The strongest predictor of a negative SCS outcome was obtaining <50% pain relief during the trial period.
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