Epidural Steroid InjectionsColleague's E-mail is Invalid. Your message has been successfully sent to your colleague. Epidural steroid injection ESI is one of sterroid most commonly used treatments for radiculopathy. Previous studies have described the effectiveness of ESI in the management of anabolicos extremos. However, controversy caudal epidural steroid injection volume regarding the route that is most beneficial caudal epidural steroid injection volume effective with respect to the administration of epidural steroids, as both transforaminal TF and caudal C routes are commonly used.
The Effectiveness of Transforaminal Versus Caudal Routes for : Medicine
Colleague's E-mail is Invalid. Your message has been successfully sent to your colleague. Epidural steroid injection ESI is one of the most commonly used treatments for radiculopathy. Previous studies have described the effectiveness of ESI in the management of radiculopathy. However, controversy exists regarding the route that is most beneficial and effective with respect to the administration of epidural steroids, as both transforaminal TF and caudal C routes are commonly used.
This analysis reviewed studies comparing the effectiveness of TF-ESIs with that of C-ESIs in the treatment of radiculopathy as a means of providing pain relief and improving functionality.
This meta-analysis was performed to guide clinical decision-making. The randomized trials and observational studies that met our inclusion criteria were subsequently included.
Two reviewers, respectively, extracted data and estimated the risk of bias. All statistical analyses were performed using Review Manager 5.
Six prospective and 2 retrospective studies involving patients were included. Statistical analysis was performed utilizing only the 6 prospective studies. Although slight pain and functional improvements were noted in the TF-ESI groups compared with the C-ESI groups, these improvements were neither clinically nor statistically significant. The limitations of this meta-analysis resulted primarily from the weaknesses of the comparative studies and the relative paucity of patients included in each study.
Both the TF and C approaches are effective in reducing pain and improving functional scores, and they demonstrated similar efficacies in the management of lumbosacral radicular pain. The authors wish to disclose and thank the sponsor of the study.
None of the authors of the manuscript received any remuneration. Further, the authors have not received any reimbursement or honorarium in any other manner. This is an open access article distributed under the Creative Commons Attribution License 4.
Radicular pain secondary to spinal disease is one of the most challenging medical problems faced by clinicians with respect to therapeutic management.
The chemical mediators originating from either a ruptured disc or from neighboring structures, and the mechanical deformation caused by either a herniated disc or excessive tissue proliferation, which results in both nerve root compression and nerve irritation, represent 2 crucial factors that provoke inflammatory responses and increase sensory neuron susceptibility, resulting in radicular pain. Lumbar epidural steroid injection LESI was first suggested as a conservative treatment for radicular pain in by Robecchi and Capra, 4 and it has since become one of the most commonly utilized conservative interventions for radiculopathy.
However, this approach requires relatively large volumes of medication and is less specific to the site of pathology. Transforaminal ESI seems to be more effective at reducing pain, improving functionality, and preventing spinal surgery, based on the data reported in previous studies and systematic reviews. However, it remains debatable whether TF or C approaches should be utilized in clinical practice, and no definitive standards pertaining to LESI exist.
It is therefore necessary to compare the clinical efficacies of different procedures to generate data that can be used to formulate clinical guidelines. Our goal was to systematically review, grade, and perform meta-analysis of existing comparative studies. Ethical approval of this study was not necessary, as systematic review and meta-analyses do not involve patients.
References from each article directly comparing the 2 approaches, in addition to review articles discussing the efficacies of the 2 approaches, were cross-referenced to identify additional relevant studies. For inclusion in the systematic review, the articles were required to meet the following eligibility criteria: Randomized controlled trials RCTs were identified as the primary studies for analysis.
For inclusion in statistical analysis, the patients in a particular study must have been randomized to either TF or C groups. Studies were excluded from the analysis if they did not include standardized pain scores within specific follow-up periods or perform statistical analyses of their results. The inclusion criteria for each study are listed in Table 1. The included RCTs were evaluated for the risk of bias, which included assessments of adequate sequence generation, allocation of concealment, blinding, incomplete outcome data, and freedom from other biases, using the Cochrane Risk of Bias Tool.
Two reviewers independently assessed each RCT, and any disagreements were resolved by discussion and consensus. The data were extracted independently by 2 authors LL and HZ. The characteristics of each study were extracted, including the last name of the first author, publication year, study design, number of patients, mean age, baseline pain and functional scores, duration of symptoms, injection level Table 2 , and pain and functional improvement Table 3.
The data were collected and analyzed using Review Manager 5. Differences in pain and functional improvement between the TF and C groups were analyzed using the independent-samples t test under a random-effects model. The differences were displayed using a forest plot. Heterogeneity was interpreted via 8 statistics, which are used to analyze pain relief and functional improvement at 2 weeks, 3 months, 6 months, and 12 months, and the results are presented in forest plots Figures 1 and 2.
After the exclusion of duplicate items, articles were screened for review, and 20 that met the inclusion criteria were selected. Eight studies 2,29—37 were ultimately included in the meta-analysis Figure 3. Six 2,30,32—34,37 of the 8 studies were prospective studies, and two 29,31 were retrospective studies. These studies included patients, of whom were included in the prospective studies and of whom were included in the retrospective studies.
Statistical analysis involving the 6 prospective studies was performed. Differences in age, sex, and injection level Table 2 were noted; however, these differences were not statistically significant.
Follow-up periods ranged from 2 weeks to 24 months in duration. Different types of corticosteroids were used in the studies, including triamcinolone, betamethasone, and depo-medrol Table 3. The outcomes and clinical significance of the 6 prospective studies are summarized below and in Table 3 , respectively. We used the risk of bias tool implemented in Review Manager 5.
The particular information of the risk of bias of the included articles is demonstrated in Figure 4. Four 2,30,33—34 of the 6 studies comprehensively described the generation of a randomized sequence, and the remaining studies 32,37 did not demonstrate the randomization method. The patients were not blinded to treatment allocation in 1 study.
All of the included studies displayed a low risk of bias for the incomplete outcomes, selective outcome reporting, and other biases. Meta-analyses were performed at 2 weeks, 3 months, 6 months, and 12 months after the injections.
Ploumis et al 30 followed their patients for 6 months and reported pain scores at 2 weeks, 3 months, and 6 months. The patients in the TF groups experienced superior pain relief at 2 weeks, although this improvement was not statistically significant. Five prospective studies 30,32—34,37 documented pain scores at 6 months. Three 30,32,37 of the 5 studies demonstrated that the TF groups experienced significantly better pain relief than the C groups.
The remaining study 33,34 observed no difference between the 2 groups. Ackerman and Ahmad 2 observed better pain relief in the TF group at 24 weeks. In their study, 30 patients received C-ESI; 1 patient 3. Galhom and al-Shatouri 32 and Manchikanti et al 34 followed their patients for 12 months and provided data regarding pain relief. The pain level reported in these studies was 2.
No statistically significant differences in pain scores between the treatment groups were noted. Five 2,30,32,34,37 of the 6 prospective studies reported data on functional level rise.
All 5 studies measured functional level using the ODI. Meta-analyses were performed at 2 weeks, 3 months, 6 months, and 12 months after the injections Figure 2 A—D. Two studies 2,30 reported data only for the 2-week time point, but noted significantly different outcomes after the injections. Ackerman and Ahmad 2 observed that the C group experienced better functional improvement than the TF group, whereas Ploumis et al 30 observed the opposite.
Two prospective studies 30,32 provided functional score data at 3 months after the injections, with differing results. Four studies 30,32,34,37 recorded data at 6 months, and 2 studies 30,37 observed slightly better functional improvement in the TF groups. No significant differences were noted among the groups after the injections were administered at the different time points.
Few of the studies included in this meta-analysis recorded the occurrence of complications. Ackerman and Ahmad 2 reported that no patients in their study presented with infection, headache, intravascular injection, and so on. In addition, no major complications were observed after administration of injections in the study conducted by Ploumis et al. Karamouzian et al 33 found that only 1 patient suffered temporary paraparesis in the C group.
Mendoza-Lattes et al 29 did not observe the occurrence of complications; however, they reported that 10 of 39 patients required reinjection in the C group, in addition to 10 of 54 in the TF group. We included 6 prospective studies and 2 retrospective studies involving patients in our analysis. The TF approach seemed to facilitate slight improvements in pain relief within a short time period no more than 6 months ; however, no clinically or statistically significant differences in efficacy between TF-ESIs and C-ESIs were noted over longer periods of time.
However, no significant differences were observed between the 2 types of injections. Previous studies and systematic reviews of ESIs have been hampered by their designs, baseline differences between the treatment groups, inadequate sample sizes, and an inability to confirm the location of the injection because fluoroscopy was not used.
Several factors may clinically influence the outcomes of ESIs, thereby influencing the choice of the route of administration. With increasing age, the risk of developing radicular pain is higher. Older patients also tend to experience worse outcomes.
And these may be the reasons why these included prospective studies generated different outcomes. Most ESIs are used combining with local anesthetics. The local anesthetics are thought to have analgesic effects during the process of injection, which is beneficial for patients to relax. In these days, some researches 46—48 show that ESIs combined with local anesthetics get a better effect on pain relief and functional level in managing chronic low back pain.
Therefore, it is necessary to add the local anesthetic during the injections. The 2 most common causes of complications of ESIs are related to inaccurate needle placement and medicine administration. Both types of injections may cause complications such as headache, soreness at the injection site, and toxicity.
For the C route, there may be an increased risk of needle tip placement anterior to the sacrum or into the rectum, whereas TF-ESI carries an increased risk of trauma to the nerve root during needle placement, which may result in paraplegia in rare instances. Therefore, clinicians should pay attention and use caution when performing ESIs. Although no significant differences were noted with respect to either pain or functional improvement, TF-ESI was slightly more effective with respect to radicular pain management over a short duration no more than 6 months.
However, over 12 months a longer time period , C-ESIs exhibited a slightly better impact on both pain and functionality. Ackerman and Ahmad 2 documented both change of pain score and functional score after only 2 weeks, although their patients were followed for 24 weeks.