Wirbelsäulennahe Injektionstherapie im Sport

Zusammenfassung

Wirbelsäulennahe Injektionen werden bei unterschiedlichen spezifischen Ursachen für akuten oder auch chronischen Rücken- und/oder Beinschmerz beim Sportler durchgeführt. Auch wenn diese Injektionen in zahlreichen Leitlinien als Teil der konservativen Therapie implementiert sind, werden diese nach wie vor kontrovers diskutiert. Gerade im Sport rückt die konservative Therapie inklusive wirbelsäulennahe Injektionen in den Focus von Wissenschaft und Forschung. In diesem Artikel werden die unterschiedlichen Formen der bildgesteuerten Injektionstechniken an der Wirbelsäule als schmerztherapeutische Maßnahmen beschrieben und in ihrer Wirksamkeit beleuchtet. Lokale Injektionen der Facettengelenke beim Facettensyndrom und der Bandscheiben beim diskogenen Schmerz scheinen einen eher kurzfristigen Effekt zu haben, während epidurale Injektionen bei Diskusprolaps und/oder epiduraler Fibrose nach Wirbelsäulenoperationen (Postnukleotomie-Syndrom) eine sinnvolle Unterstützung bei der konservativen Therapie sein können. Beim Facettensyndrom scheint die Denervation mittels Radiofrequenz eine effektive Behandlungsmethode für eine kurz- bis mittelfristige Besserung darzustellen. Daneben haben auch Pars-Injektionen beim Pars-interarticularis-Ödem sowie Injektionen beim Sakroiliakalgelenks-Syndrom ihren Stellenwert. Die Medikamente und das Steroidpräparat für wirbelsäulennahe Injektionen müssen sorgfältig ausgewählt werden und werden in Deutschland teilweise als off-label-use eingesetzt, worüber der Patient aufgeklärt werden muss und nicht zu Lasten der gesetzlichen Krankenkassen abgerechnet werden darf.

Abstract

A major proportion of athletes have intermittent acute low back pain at some stage of their sport life. Some athletes develop chronic low back pain, which may be a major source of failing in sports. Facet, epidural and intradiscal steroid injections for specific pain generators in the spine show different short- and long-term results. They can improve low back pain for specific pain generators experienced by back pain patients and might be able to help some of these athletes to avoid open surgery and shorten the time until return to sports (RTS). Facet and intradiscal steroid injections provide only short-term effects in axial low back pain and should therefore be considered with caution, whereas the different forms of epidural steroid injections for sciatica caused by radicular compression seem to be a well-proven adjuvant treatment option within a conservative therapeutic regimen. An overview of the literature related to the use of different steroids has shown that non-particulate steroids provide better results regarding safety and avoidance of major complications, especially when used at the cervical spine. However, in Germany the use of these steroids is still off-label and patients have to provide their informed consent prior to injection. In summary, careful use of spinal injections within a conservative physiotherapeutic regimen seems to improve chronic back pain and, in turn, reduce the time of RTS.

Schlüsselwörter

Wirbelsäulennahe Injektionen - Sportler - spezifischer Rückenschmerz

Key word

spinal/epidural steroid injection - specific low back pain - athlete

• Literatur

• 1 Videman T, Sarna S, Battie MC. et al. The long-term effects of physical loading and exercise lifestyles on back-related symptoms, disability, and spinal pathology among men. Spine 1995; 20: 699-709
• 2 Lawrence JP, Greene HS, Grauer JN. Back pain in athletes. J Am Acad Orthop Surg 2006; 14: 726-735
• 3 Abdi S, Datta S, Trescot AM. et al. Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician 2007; 10: 185-212
• 4 Manchikanti L, Abdi S, Atluri S. et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician 2013; 16: S49-S283
• 5 Benyamin RM, Manchikanti L, Parr AT. et al. The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician 2012; 15: E363-E404
• 6 Parr AT, Manchikanti L, Hameed H. et al. Caudal epidural injections in the management of chronic low back pain: a systematic appraisal of the literature. Pain Physician 2012; 15: E159-E198
• 7 Manchikanti L, Singh V, Cash KA. et al. Effect of fluoroscopically guided caudal epidural steroid or local anesthetic injections in the treatment of lumbar disc herniation and radiculitis: a randomized, controlled, double blind trial with a two-year follow-up. Pain Physician 2012; 15: 273-286
• 8 Manchikanti L, Singh V, Cash KA. et al. A randomized, double-blind, active-control trial of the effectiveness of lumbar interlaminar epidural injections in disc herniation. Pain Physician 2014; 17: E61-E74
• 9 Manchikanti L, Cash KA, Pampati V. et al. Transforaminal epidural injections in chronic lumbar disc herniation: a randomized, double-blind, active-control trial. Pain Physician 2014; 17: E489-E501
• 10 Vad VB, Bhat AL, Lutz GE. et al. Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Spine (Phila Pa 1976) 2002; 27: 11-16
• 11 Riew KD, Yin Y, Gilula L. et al. The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, double-blind study. J Bone Joint Surg Am 2000; 82: 1589-1593
• 12 Radcliff K, Hilibrand A, Lurie JD. et al. The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation: a subgroup analysis of the SPORT trial. J Bone Joint Surg Am 2013; 38: 279-291
• 13 Hsu WK, McCarthy KJ, Savage JW. et al. The professional athlete spine initiative: outcomes after lumbar disc herniation in 342 elite professional athletes. Spine J 2011; 11: 180-186
• 14 Earhart JS, Roberts D, Roc G. et al. Effects of lumbar disk herniation on the careers of professional baseball players. Orthopedics 2012; 35: 43-49
• 15 Krych AJ, Richman D, Drakos M. et al. Epidural steroid injection for lumbar disc herniation in NFL athletes. Med Sci Sports Exerc 2012; 44: 193-198
• 16 Jackson DW, Rettig A, Wiltse LL. Epidural cortisone injections in the young athletic adult. Am J Sports Med 1980; 8: 239-243
• 17 Ackerman WE, Ahmad M. The efficacy of lumbar epidural steroid injections in patients with lumbar disc herniations. AnesthesAnalges 2007; 104: 1217-1222
• 18 Schaufele MK, Hatch L, Jones W. Interlaminar versus transforaminal dural injections for the treatment of symptomatic lumbar intervertebral disc herniations. Pain Physician 2006; 9: 361-366
• 19 Dreyfuss P, Halbrook B, Pauza K. et al. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine (Phila Pa 1976) 2000; 25: 1270-1277
• 20 Bogduk N, Dreyfuss P, Govind J. A narrative review of lumbar medial branch neurotomy for the treatment of back pain. Pain Med 2009; 10: 1035-1045
• 21 Slipman CW, Issac Z. et al. The role of diagnostic selective nerve root blocks in the management of spinal pain. Pain Physician 2001; 4: 214-226
• 22 Boswell MV, Trescot AM, Datta S. et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007; 10: 7-111
• 23 Birkenmaier C, Veihelmann A, Trouillier HH. et al. Medial branch blocks versus pericapsular blocks in selecting patients for percutaneous cryodenervation of lumbar facet joints. Reg Anesth Pain Med 2007; 32: 27-33
• 24 Carette S, Marcoux S, Truchon R. et al. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. N Engl J Med  1991; 325: 1002-1007
• 25 Binder DS, Nampiaparampil DE. The provocative lumbar facet joint. Curr Rev Musculoskelet Med 2009; 2: 15-24
• 26 Falco FJ, Manchikanti L, Datta S. et al. An update of the effectiveness of therapeutic lumbar facet joint interventions. Pain Physician 2012; 15: E909-E953
• 27 Birkenmaier C, Veihelmann A, Trouillier HH. et al. Percutaneous cryodenervation of lumbar facet joints: a prospective clinical trial. Int Orthop 2007; 31: 525-530
• 28 Cohen SP, Williams KA, Kurihara C. et al. Multicenter, randomized, comparative cost-effectiveness study comparing 0, 1, and 2 diagnostic medial branch (facet joint nerve) block treatment paradigms before lumbar facet radiofrequency denervation. Anesthesiology 2010; 113: 395-405
• 29 van Kleef M, Barendse GA, Kessels A. et al. Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. Spine (Phila Pa 1976)  1999; 24: 1937-1942
• 30 Lee CH, Chung CK, Kim CH. The efficacy of conventional radiofrequency denervation in patients with chronic low back pain originating from the facet joints: a meta-analysis of randomized controlled trials. Spine J 2017; 17: 1770-1780
• 31 Vad VB, Cano WG, Basrai D. et al. Role of radiofrequency denervation in lumbar zygapophyseal joint synovitis in baseball pitchers: a clinical experience. Pain Physician 2003; 6: 307-312
• 32 Micheli LJ, Wood R. Back pain in young athletes. Arch Pediatr Adolesc Med 1995; 149: 15-18
• 33 Seitsalo S, Osterman K, Hyvarinen H. et al. Progression of spondylolisthesis in children and adolescents. A long-term follow-up of 272 patients. Spine 1991; 16: 417-421
• 34 Iwamoto J, Takeda T, Wakano K. Returning athletes with severe low back pain and spondylolysis to original sporting activities with conservative treatment. Scand J Med Sci Sports 2004; 14: 346-351
• 35 Debnath UK, Freeman BJ, Grevitt MP. et al. Clinical outcome of symptomatic unilateral stress injuries of the lumbar pars interarticularis. Spine 2007; 32: 995-1000
• 36 McCormick CC, Taylor JR, Twomey LT. Facet joint arthrography in lumbar spondylolysis: anatomic basis for spread of contrast medium. Radiology 1989; 171: 193-196
• 37 Chaturvedi A, Chaturvedi S, Sivasankar R. Image-guided lumbar facet joint infiltration in nonradicular low back pain. Indian J Radiol Imaging 2009; 19: 29-34
• 38 Timm KE. Sacroiliac joint dysfunction in elite rowers. J Orthop Sports Phys Ther 1999; 29: 288-293
• 39 Lindsay DM, Meeuwisse WH, Vyse A. et al. Lumbosacral dysfunctions in elite cross-country skiers. J Orthop Sports Phys Ther 1993; 18: 580-585
• 40 Hansen HC, McKenzie-Brown AM, Cohen SP. et al. Sacroiliac joint interventions: systematic review. Pain Physician 2007; 10: 165-184
• 41 Aoki Y, Nakajima A, Ohtori S. et al. Increase of nerve growth factor levels in the human herniated intervertebral disc: can annular rupture trigger discogenic back pain?. Arthritis Res Ther 2014; 16: R159
• 42 Cuellar JM, Stauff MP, Herzog RJ. et al. Does provocative discography cause clinically important injury to the lumbar intervertebral disc?. A 10-year matched cohort study. Spine J 2016; 16: 273-280
• 43 Khot A, Bowditch M, Powell J. et al. The use of intradiscal steroid therapy for lumbar spinal discogenic pain: a randomized controlled trial. Spine (Phila Pa 1976) 2004; 29: 833-836
• 44 Nguyen C, Boutron I, Baron G. et al. Intradiscal Glucocorticoid Injection for Patients With Chronic Low Back Pain Associated With Active Discopathy: A Randomized Trial. Ann Intern Med 2017; 166: 547-556
• 45 Comella K, Silbert R, Parlo M. Effects of the intradiscal implantation of stromal vascular fraction plus platelet rich plasma in patients with degenerative disc disease. J Transl Med 2017; 15: 12
• 46 Tuakli-Wosornu YA, Terry A, Boachie-Adjei K. et al. Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study. PM R 2016; 8: 1-10
• 47 Buenaventra RM, Datta S, Abdi S. et al. Systematic Review of therapeutic lumbar transforminal epidural steroid injections. Pain Physician 2009; 12: 233-251
• 48 Jablawi F, Schoeller K. Spinal steroid injections (periarticular, periradicular, epidural). Die Wirbelsäule 2018; 02: 111-118
• 49 Manchikanti L, Malla Y, Wargo BW. et al. A retrospective evaluation of complications of 10000 fluoroscopically guided epidural injections. Pain Physician 2012; 15: 131-140
• 50 Rozin L, Rozin R, Koehler SA. et al. Death during transforaminal epidural steroid nerve root block (C7) due to perforation oft he left vertebral artery. Am J Forensic Med Pathol 2003; 24: 351-355