Header

UZH-Logo

Maintenance Infos

Repeat epidural steroid injections for radicular pain due to lumbar or cervical disc herniation


Joswig, H; Neff, A; Ruppert, C; Hildebrandt, G; Stienen, M N (2018). Repeat epidural steroid injections for radicular pain due to lumbar or cervical disc herniation. The Bone & Joint Journal, 100-B(10):1364-1371.

Abstract

Aims The aim of this study was to determine the efficacy of repeat epidural steroid injections as a form of treatment for patients with insufficiently controlled or recurrent radicular pain due to a lumbar or cervical disc herniation. Patients and Methods A cohort of 102 patients was prospectively followed, after an epidural steroid injection for radicular symptoms due to lumbar disc herniation, in 57 patients, and cervical disc herniation, in 45 patients. Those patients with persistent pain who requested a second injection were prospectively followed for one year. Radicular and local pain were assessed on a visual analogue scale (VAS), functional outcome with the Oswestry Disability Index (ODI) or the Neck Pain and Disability Index (NPAD), as well as health-related quality of life (HRQoL) using the 12-Item Short-Form Health Survey questionnaire (SF-12). Results A second injection was performed in 17 patients (29.8%) with lumbar herniation and seven (15.6%) with cervical herniation at a mean of 65.3 days (sd 46.5) and 47 days (sd 37.2), respectively, after the initial injection. All but one patient, who underwent lumbar microdiscectomy, responded satisfactorily with a mean VAS for leg pain of 8.8 mm (sd 10.3) and a mean VAS for arm pain of 6.3 mm (sd 9) one year after the second injection, respectively. Similarly, functional outcome and HRQoL were improved significantly from the baseline scores: mean ODI, 12.3 (sd 12.4; p < 0.001); mean NPAD, 19.3 (sd 24.3; p = 0.041); mean SF-12 physical component summary (PCS) in lumbar herniation, 46.8 (sd 7.7; p < 0.001); mean SF-12 PCS in cervical herniation, 43 (sd 6.8; p = 0.103). Conclusion Repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection. Cite this article: Bone Joint J 2018;100-B:1364–71. Physicians treating patients with radicular pain due to disc herniation frequently use epidural steroid injections. Establishing factors which predict outcome in these patients is difficult. We previously found that the outcome one month after the injection could be predicted by the course of the pain within the first days after a lumbar or cervical injection.1,2 However, predicting outcome, two years after the injection, based on clinical or radiological parameters, was not possible.3,4 Given the difficulties of prognostic modelling, the management of these patients largely remains guided by the experience of the physician and personal preference within the availability of institutional resources. This is especially true for patients who do not need immediate surgical treatment and in whom the first injection fails to give adequate pain relief or if the pain recurs. There is uncertainty about the management of these patients, as few studies5-11 have provided information about the role of repeat steroid injections. The main aim of this study was therefore to determine the effect of a second injection on pain relief in patients with lumbar and cervical disc herniation. Patients and Methods Within the framework of a prospective observational study performed at the Department of Radiology, Cantonal Hospital St. Gallen (St. Gallen, Switzerland), eligible consecutive patients with single-level lumbar or cervical disc herniation were enrolled. Surgery, a second injection and insufficiently controlled pain (> 80% of the baseline pain) were endpoints and these results have been published recently.1-4 A secondary aim was to assess prospectively whether those patients with insufficiently controlled or recurrent pain who reached the endpoint would benefit from a second injection. The study had local ethical approval (St. Gallen, Switzerland; EKSG 13/061) and was registered under ClinicalTrials.gov (Identifier: NCT01945554). All patients gave written informed consent. All data were collected by a nurse. In order to conceal the identity of the patients, unique patient identifiers for follow-up questionnaires and data management were assigned. Adult patients with clinical signs of radicular pain and lumbar or cervical disc herniation identified on MRI scans were included. Purely diagnostic blocks were not performed. Exclusion criteria were pre-procedural pain in the extremity of < 20 mm (out of 100 mm) on the visual analogue scale (VAS), red flags including severe motor deficit and cauda equina syndrome, and previous injections or spinal surgery. The baseline characteristics of the patients and clinical parameters are shown in Table I. The herniation was graded according to the simplified system of Ghahreman et al12 into low grade (0 and 1), high grade (2 and 3 for intraspinal herniations).

Abstract

Aims The aim of this study was to determine the efficacy of repeat epidural steroid injections as a form of treatment for patients with insufficiently controlled or recurrent radicular pain due to a lumbar or cervical disc herniation. Patients and Methods A cohort of 102 patients was prospectively followed, after an epidural steroid injection for radicular symptoms due to lumbar disc herniation, in 57 patients, and cervical disc herniation, in 45 patients. Those patients with persistent pain who requested a second injection were prospectively followed for one year. Radicular and local pain were assessed on a visual analogue scale (VAS), functional outcome with the Oswestry Disability Index (ODI) or the Neck Pain and Disability Index (NPAD), as well as health-related quality of life (HRQoL) using the 12-Item Short-Form Health Survey questionnaire (SF-12). Results A second injection was performed in 17 patients (29.8%) with lumbar herniation and seven (15.6%) with cervical herniation at a mean of 65.3 days (sd 46.5) and 47 days (sd 37.2), respectively, after the initial injection. All but one patient, who underwent lumbar microdiscectomy, responded satisfactorily with a mean VAS for leg pain of 8.8 mm (sd 10.3) and a mean VAS for arm pain of 6.3 mm (sd 9) one year after the second injection, respectively. Similarly, functional outcome and HRQoL were improved significantly from the baseline scores: mean ODI, 12.3 (sd 12.4; p < 0.001); mean NPAD, 19.3 (sd 24.3; p = 0.041); mean SF-12 physical component summary (PCS) in lumbar herniation, 46.8 (sd 7.7; p < 0.001); mean SF-12 PCS in cervical herniation, 43 (sd 6.8; p = 0.103). Conclusion Repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection. Cite this article: Bone Joint J 2018;100-B:1364–71. Physicians treating patients with radicular pain due to disc herniation frequently use epidural steroid injections. Establishing factors which predict outcome in these patients is difficult. We previously found that the outcome one month after the injection could be predicted by the course of the pain within the first days after a lumbar or cervical injection.1,2 However, predicting outcome, two years after the injection, based on clinical or radiological parameters, was not possible.3,4 Given the difficulties of prognostic modelling, the management of these patients largely remains guided by the experience of the physician and personal preference within the availability of institutional resources. This is especially true for patients who do not need immediate surgical treatment and in whom the first injection fails to give adequate pain relief or if the pain recurs. There is uncertainty about the management of these patients, as few studies5-11 have provided information about the role of repeat steroid injections. The main aim of this study was therefore to determine the effect of a second injection on pain relief in patients with lumbar and cervical disc herniation. Patients and Methods Within the framework of a prospective observational study performed at the Department of Radiology, Cantonal Hospital St. Gallen (St. Gallen, Switzerland), eligible consecutive patients with single-level lumbar or cervical disc herniation were enrolled. Surgery, a second injection and insufficiently controlled pain (> 80% of the baseline pain) were endpoints and these results have been published recently.1-4 A secondary aim was to assess prospectively whether those patients with insufficiently controlled or recurrent pain who reached the endpoint would benefit from a second injection. The study had local ethical approval (St. Gallen, Switzerland; EKSG 13/061) and was registered under ClinicalTrials.gov (Identifier: NCT01945554). All patients gave written informed consent. All data were collected by a nurse. In order to conceal the identity of the patients, unique patient identifiers for follow-up questionnaires and data management were assigned. Adult patients with clinical signs of radicular pain and lumbar or cervical disc herniation identified on MRI scans were included. Purely diagnostic blocks were not performed. Exclusion criteria were pre-procedural pain in the extremity of < 20 mm (out of 100 mm) on the visual analogue scale (VAS), red flags including severe motor deficit and cauda equina syndrome, and previous injections or spinal surgery. The baseline characteristics of the patients and clinical parameters are shown in Table I. The herniation was graded according to the simplified system of Ghahreman et al12 into low grade (0 and 1), high grade (2 and 3 for intraspinal herniations).

Statistics

Citations

Dimensions.ai Metrics
5 citations in Web of Science®
4 citations in Scopus®
Google Scholar™

Altmetrics

Downloads

1 download since deposited on 27 Nov 2018
0 downloads since 12 months
Detailed statistics

Additional indexing

Item Type:Journal Article, refereed, original work
Communities & Collections:04 Faculty of Medicine > University Hospital Zurich > Clinic for Neurosurgery
Dewey Decimal Classification:610 Medicine & health
Scopus Subject Areas:Health Sciences > Surgery
Health Sciences > Orthopedics and Sports Medicine
Uncontrolled Keywords:General Medicine
Language:English
Date:1 October 2018
Deposited On:27 Nov 2018 15:41
Last Modified:29 Jul 2020 08:07
Publisher:British Editorial Society of Bone and Joint Surgery
ISSN:2049-4394
OA Status:Closed
Free access at:Publisher DOI. An embargo period may apply.
Publisher DOI:https://doi.org/10.1302/0301-620x.100b10.bjj-2018-0461.r1
PubMed ID:30295524

Download

Closed Access: Download allowed only for UZH members