A recent study from Australian researchers determined that transforaminal injection of steroids was a viable alternative to surgery for lumbar radicular pain due to disc herniation.
Full details of the study appear in the August issue of Pain Medicine, a journal published by Wiley-Blackwell on behalf of the American Academy of Pain Medicine, the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists, and the International Spine Intervention Society.
Lumbar radicular pain (sciatica) is most commonly caused by lumbar disc herniation and inflammation of the affected nerve roots. Injections of steroids by various routes are used as an alternative to surgery to reduce the inflammation and relieve the pain. Epidural steroid injection, by either the interlaminar or caudal route, is the most widely used steroid treatment for pain relief. However, studies indicate that interlaminar injections are no more effective than normal saline injections into an interspinous ligament, while caudal epidural injections of steroids have failed to prove superior to local anaesthetic alone.
Transforaminal injection—the injection of steroids directly and accurately onto the affected spinal nerve under radiologic guidance—has proved more effective than interlaminar injection of steroids with respect to pain relief and improvement of disability. However, controlled studies of this method of administration produce conflicting results.
The present study examined whether the transforaminal route of injection or the agent injected is the critical element in determining successful pain relief. Study participants were randomized into one of five groups: Transforaminal injection of steroids (TFST) to test its effectiveness; transforaminal injection of normal saline (TFNS) to test for an irrigation effect; transforaminal injection of local anesthetic (TFLA) to test the effect of a local anesthetic; intramuscular injection of steroids (IMST) to test for a systemic effect; or intramuscular injection of normal saline (IMNS) to test for non-specific (placebo) effects.
A total of 150 patients were enrolled in the study. The inclusion criteria were adult patients, capable of providing consent and capable of complying with the outcome instruments used, with pain radiating into the lower limb of a lancinating, burning, stabbing, or electric quality, limitation of straight-leg-raise to less than 30 degrees, and demonstration of a disc herniation by CT or MRI at a segmental level consistent with the clinical features. Pain of the appropriate quality was the primary indication for treatment. Neurological signs of radiculopathy were not required, but served to consolidate the diagnosis when they were present. All patients were classified as eligible for surgery, meaning that surgery would be the next intervention if injections did not relieve the pain.
Exclusion criteria were foraminal stenosis, severe motor deficit, a history of substance abuse, previous surgery at the affected segmental level, or conditions that rendered an injection unsafe, such as pregnancy, recent infection, or spinal deformity. Patients were not excluded on the basis of duration of pain.
After randomization, the five treatment-groups showed no statistically significant differences in demographic features such as age, gender balance, segmental levels treated, or the proportion of acute or chronic cases.
A standard volume and dose were used for each patient for each type of injection. Patients allocated for TFST received 0.75ml of 0.5% bupivacaine followed by 1.75ml of triamcinalone in a concentration of 40mg/ml. The TFLA group received 2 ml of 0.5% bupivacaine. The TFNS group received 2 ml of the saline agent. Patients in the IMST received 1.75 ml of triamcinolone (40mg/ml). Patients allocated for IMNS received a volume of 2 ml.
The primary outcome measure was the proportion of patients who achieved complete relief of pain or at least 50% relief, at one month after treatment. Secondary outcome measures were function, disability, patient-specified functional outcomes, and use of other health care, and duration of relief beyond one month.
A significantly greater proportion of patients treated with transforaminal injection of steroid (54%) achieved relief of pain than did patients treated with transforaminal injection of local anaesthetic (7%) or transforaminal injection of saline (19%), intramuscular steroids (21%) or intramuscular saline (13%). Relief of pain was corroborated by clinically significant improvements in function and disability, and reductions in use of other health care. Outcomes were equivalent for patients with acute or chronic radicular pain. Twenty-five percent maintained relief beyond 12 months.
Study leader Dr. Bogduk concludes, "In essence, transforaminal injection of steroids is a viable alternative to surgery for lumbar radicular pain due to disc herniation. Its immediate yield is modest, but substantial, and is not simply a placebo effect. For long-term efficacy, proof beyond reasonable doubt would require prohibitively large studies."
Editorial author Dr. Ray Baker concurs. "The study results are particularly impressive given the stringent study design." Dr. Baker also praises the team's method of analysis, the number needed to treat (NNT) measure of treatment effect, stating, "From Bogduk's analysis, one can easily grasp that every third patient will be significantly improved beyond what an intramuscular injection of steroid or a transforaminal injection of normal saline can offer. More to the point, one can observe that one in four patients will retain significant benefit with transforaminal injection of steroids at 12 months, while avoiding the cost of surgery. In the end, this landmark study has vindicated transforaminal steroid injection for lumbar radicular pain as superior to placebo. Further studies are now needed."
Article: "The Efficacy of Transforaminal Injection of Steroids for the Treatment of Lumbar Radicular Pain." Ali Ghahreman, Richard Ferch and Nikolai Bogduk. Pain Medicine; Published Online: July 30, 2010 (DOI: 10.1111/j.1526-4637.2010.00908.x); Print Issue Date: August 2010.
Editorial: "Demystifying Lumbar Transforaminal Epidural Steroids: A Seminal Efficacy Study of a Specific Spinal Injection." Ray Baker. Pain Medicine; Published Online: July 30, 2010 (DOI: 10.1111/j.1526-4637.2010.00920.x); Print Issue Date: August 2010.
This study is published in Pain Medicine. Media wishing to receive a PDF of this article may contact firstname.lastname@example.org
Pain Medicine is a multi-disciplinary journal dedicated to the pain clinician, teacher and researcher. It is the Official Journal of the American Academy of Pain Medicine, the International Spine Intervention Society, and of the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists. The journal is devoted to the advancement of pain management, education and research.
Wiley-Blackwell is the international scientific, technical, medical, and scholarly publishing business of John Wiley & Sons, Inc., with strengths in every major academic and professional field and partnerships with many of the world's leading societies. Wiley-Blackwell publishes nearly 1,500 peer-reviewed journals and 1,500+ new books annually in print and online, as well as databases, major reference works and laboratory protocols. For more information, please visit www.wileyblackwell.com.
Dawn Peters | EurekAlert!
Study relating to materials testing Detecting damages in non-magnetic steel through magnetism
23.07.2018 | Technische Universität Kaiserslautern
Innovative genetic tests for children with developmental disorders and epilepsy
11.07.2018 | Christian-Albrechts-Universität zu Kiel
Scientists develop first tool to use machine learning methods to compute flow around interactively designable 3D objects. Tool will be presented at this year’s prestigious SIGGRAPH conference.
When engineers or designers want to test the aerodynamic properties of the newly designed shape of a car, airplane, or other object, they would normally model...
Researchers from TU Graz and their industry partners have unveiled a world first: the prototype of a robot-controlled, high-speed combined charging system (CCS) for electric vehicles that enables series charging of cars in various parking positions.
Global demand for electric vehicles is forecast to rise sharply: by 2025, the number of new vehicle registrations is expected to reach 25 million per year....
Proteins must be folded correctly to fulfill their molecular functions in cells. Molecular assistants called chaperones help proteins exploit their inbuilt folding potential and reach the correct three-dimensional structure. Researchers at the Max Planck Institute of Biochemistry (MPIB) have demonstrated that actin, the most abundant protein in higher developed cells, does not have the inbuilt potential to fold and instead requires special assistance to fold into its active state. The chaperone TRiC uses a previously undescribed mechanism to perform actin folding. The study was recently published in the journal Cell.
Actin is the most abundant protein in highly developed cells and has diverse functions in processes like cell stabilization, cell division and muscle...
Scientists have discovered that the electrical resistance of a copper-oxide compound depends on the magnetic field in a very unusual way -- a finding that could help direct the search for materials that can perfectly conduct electricity at room temperatur
What happens when really powerful magnets--capable of producing magnetic fields nearly two million times stronger than Earth's--are applied to materials that...
The quality of materials often depends on the manufacturing process. In casting and welding, for example, the rate at which melts solidify and the resulting microstructure of the alloy is important. With metallic foams as well, it depends on exactly how the foaming process takes place. To understand these processes fully requires fast sensing capability. The fastest 3D tomographic images to date have now been achieved at the BESSY II X-ray source operated by the Helmholtz-Zentrum Berlin.
Dr. Francisco Garcia-Moreno and his team have designed a turntable that rotates ultra-stably about its axis at a constant rotational speed. This really depends...
08.08.2018 | Event News
27.07.2018 | Event News
25.07.2018 | Event News
14.08.2018 | Information Technology
14.08.2018 | Life Sciences
14.08.2018 | Life Sciences