Effectiveness of parasagittal interlaminar epidural local anesthetic with or without steroid in chronic lumbosacral pain

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SCIENCE
Effectiveness of parasagittal interlaminar epidural local anesthetic with or without steroid in chronic lumbosacral pain
Key Take-Away: 

Using a parasaggital interlaminar (PIL) approach and the addition of steroid to local anesthetic (LA) for epidural injections (EI) may provide superior effectiveness in terms of extent and duration of pain relief for managing chronic low back pain (CLBP) with unilateral lumbosacral radicular pain (LRP), even though, local anesthetic alone was also effective.

Low back pain (LBP) with or without LRP is the most common of all spinal and chronic pain problems. It is among the most common chronic disorders with the longest number of years lived with disability in the US. LRP is most commonly caused by a protrusion of a lumbar intervertebral disc resulting in an inflammatory response around its nerve root. 

ABSTRACT: 
Background: 

Low back pain (LBP) with or without LRP is the most common of all spinal and chronic pain problems. It is among the most common chronic disorders with the longest number of years lived with disability in the US. LRP is most commonly caused by a protrusion of a lumbar intervertebral disc resulting in an inflammatory response around its nerve root.

Epidural injections (EI) are the most commonly performed minimally invasive intervention to manage CLBP with LRP. LA and/or steroids are frequently used injectates for EI and are reported with variable effectiveness. The majority of earlier studies have used either caudal, transforaminal (TF), or undefined interlaminar approaches for EI. The PIL approach route is reported to have good ventral epidural spread and effectiveness to the TF route.

Rationale behind research

There is a lack of head-to-head comparative study which has evaluated the effectiveness of EI of LA, with or without steroid for CLBP with LRP using a PIL approach.

  • Objective

To evaluate the effectiveness of PIL EI of LA alone as compared to LA and steroid in managing patients with CLBP and LRP

Methods: 

 

Study outcomes

  • Primary outcomes: Proportion of patients achieving effective pain relief (EPR) at 3 months. EPR was 50% reduction from baseline on NRS
  • Secondary outcomes: Mean NRS and Modified Oswestry Disability Questionnaire (MODQ) index at various time points, ventral and perineural spread, number of injections required, TEAE, and possibly neurological complications
  • Time Points
  • Primary outcomes: baseline, 2 weeks, 1 month and up to 12 months post-intervention
  • Secondary outcomes: baseline, 2 weeks, 1 month and up to 12 months post-intervention
Results: 

 

Outcomes

  • Baseline: Overall characteristics between the randomized groups were similar.
  • Primary outcome: A significantly higher proportion of patients achieved effective pain relief (EPR) at 3 months in group LS [30 (86%, 95% CI 71% – 94%)] as compared to group L [17 (50%, 95% CI 34% – 66%)] (- 0.002). Similar results are obtained at 6, 9, and 12 months, respectively
  •  At one year of follow-up, a significantly higher relative success of EPR was noted in LS group 89% as compared to 59% in group L and the absolute risk reduction (pain relief) at one year of follow-up was found to be 36% (95% CI 14 – 53) with LS injections and number needed to treat was calculated to be 3 (95% CI 2 – 7). At one year follow-up, a significantly higher relative success of EPR was noted in group LS, relative risk = 1.5 (95% CI 1.11 – 2.04), P = 0.006
  • Secondary outcome: A significant reduction in NRS and improvement in MODQ were seen at all time-points post-intervention than baseline (P < 0.001) in both groups. NRS and MODQ scores were significantly lower in group LS than group L at all time intervals post baseline. On an average, patients in group L received 2.0 (0.85) and group LS received 1.7 (0.71) injections annually (P = 0.07)
  • Ventral epidural spread was comparable in both groups (97%)
  • No major complications were seen in groups; however, intravascular spread of contrast was noted during 2 injections (one in each group) requiring relocation.Figure 1: Effective pain relief (EPR) incidence over 1 year follow-up
Conclusion: 

The study shows that using PIL and addition of steroid to LA for EI may provide superior effectiveness in terms of extent and duration of pain relief for managing CLBP with unilateral LRP, even though, local anesthetic alone was not effective.

Our results are in accordance with the one-year follow-up results of Manchikanti et al where significant superior pain relief at 6 months and better functional improvement at 6 and 12 months were observed with lidocaine plus steroid than lidocaine alone. More patients failed in the lidocaine group (n = 6/35) than lidocaine with steroid group (n = 1/35). However, the average annual procedures required in our study (2.0 in group L and 1.7 in Group LS) are less than reported by them (4.3 in group L and 4.2 in group LS). This might be because of the difference in study patients’ clinical and ethnic characteristics or the use of the PIL approach in our study.

Pain Physician. 2015; 18:237-248
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