Lumbar radiculopathy

Summary

Epidural steroid injections for treatment of sciatica did not confer significant additional benefit over placebo injection in patients who had had symptoms for less than one year. While steroid injections may afford short-term improvements in pain and movement, this beneficial effect was transient, and there was no statistical difference between active and placebo treatments after 4 weeks of follow-up. Treatment of sciatica with epidural steroids has exhibited no significant functional benefit, nor does it reduce the need for surgery. Outcomes varied minimally by injection site across studies, not based on direct comparisons.

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