Rationing by assumption: De-implementation of spinal injections requires rigorous comparative evidence.

The aim of this retrospective study was to investigate the therapeutic effect of transforaminal epidural steroid injection in patients with chronic low back pain and radicular leg pain due to lumbar disc herniation. This study included 80 patients (32 female and 48 male; mean age: 45.8 years [range: 25-65 years]) that received fluoroscopically guided transforaminal epidural steroid injections for chronic radicular low back pain due to lumbar disc herniation. All of the patients had diagnostic MRI findings and did not respond to conservative treatment. All injections were performed by the same physician at the interventional pain unit of a tertiary hospital. The effectiveness of transforaminal epidural steroid injections was assessed via a standardized telephone questionnaire administered 2 years after the first injection. Mean duration of radicular low back pain was 24.50 ± 18.25 months. Most of the epidural injections were administered at the L5 and S1 levels. The most effective post-injection period was the first 5.11 ± 3.07 months. Mean duration of injection effect was 12.46 ± 7.24 months. The response rate to the epidural steroid injections was 72%. There was negative correlation between the duration of treatment effect and the duration of pre-treatment symptoms. Additionally, clinical improvement of radicular low back pain increased significantly as the duration of pre-treatment symptoms decreased. Based on the present findings, we think that transforaminal epidural steroid injections can be used as an alternative treatment for managing chronic radicular low back pain.

Incidence of intravascular penetration in transforaminal cervical epidural steroid injections

Low back pain is a widespread medical condition seen in middle-aged and elderly individuals, causing labor loss, high treatment costs, depression, and poor life quality. This study aimed to investigate pain levels, life quality, and depression in patients undergoing facet radiofrequency (RF) and/or transforaminal epidural steroid injection (TFESI) for the treatment of chronic low back pain (CLBP). The records of 51 patients with low back pain lasting more than three months who underwent interventional procedures for pain management were reviewed retrospectively. Patient data including age, sex, type of interventional treatment, visual analog scale (VAS) scores before and after the procedure, SF-36 life quality scores, and Beck Depression Scale (BDS) scores were obtained from patient tracking forms and the hospital information system. A total of 51 patients (35 males, 16 females) who received interventional treatment were included in the study. The mean age of the patients was 48.37±13 years. Patients underwent facet RF (n=14), TFESI (n=23), or both procedures combined (n=14). Compared to pre-procedure values, VAS and BDS scores at the third and sixth months were significantly lower (p<0.05), while SF-36 life quality scores were significantly higher (p<0.05). No significant difference was observed between the third and sixth months (p>0.05). In chronic low back pain, interventional treatments such as facet RF and/or TFESI were found to reduce pain and depression levels and improve life quality.

Chronic low back pain (CLBP) affects millions of people worldwide, and appears to be increasing in prevalence. It is associated not only with pain, but also with increased disability, psychological symptoms, and reduced quality of life. There are various treatment options for CLBP, but no single therapy stands out as being the most effective. In the past 10 years, yoga interventions have been studied as a CLBP treatment approach. The objective of this paper is to review the current literature supporting the efficacy of yoga for CLBP. In nations with abundant resources, more than 70% of people eventually have low back pain (CLBP). However, recuperation is not always successful; 82 percent of non-recent-onset patients are still in pain after a year. Many chronic patients, whose natural histories were previously deemed to be favourable, spend months or years looking for treatment. We carried out a systematic review with the following clinical inquiries in mind: What results do oral medication treatments produce? What results does injectable therapy produce? What outcomes might non-drug therapies expect? Up until May 2007, we conducted searches in Medline, Embassy, The Cochrane Library, and other significant databases. (BMJ Clinical Evidence reviews are updated on a regular basis; for the most recent version of this review. We incorporated hazards warnings from pertinent agencies as the UK Medicines and Healthcare products Regulatory Agency and the US Food and Drug Administration (FDA) (MHRA). Our inclusion criteria were satisfied by 74 systematic reviews, RCTs, or observational studies. We graded the strength of the interventional evidence using the GRADE system. The effectiveness and safety of the following interventions are discussed in this systematic review: acupuncture, analgesics, antidepressants, back schools, behavioural therapy, electromyography biofeedback, exercise, injections (epidural steroid injections, facet joint injections, local injections), intensive multidisciplinary treatment programmes, lumbar supports, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), and spinal manipulation (TENS).

ObjectiveWith the advance of the internet, social media platforms have become a major source of medical information. We assessed the reliability, quality, and usefulness of the most-viewed YouTube videos of epidural steroid injection (ESI).MethodsA search was conducted on YouTube on February 13, 2020, using the keywords “epidural injection,” “epidural steroid injection,” “epidural transforaminal injection,” and “epidural transforaminal steroid injection.” The top 50 most-viewed videos were assessed with a modified DISCERN scale (mDISCERN) and a Global Quality Scale (GQS). Further, the usefulness of information in each video was evaluated.ResultsOnly 22% of videos contained information with high reliability, and these were produced by hospitals or physicians. None of the videos provided by media organizations and patients were reliable. As for information quality, only 34% were moderate to excellent quality. Even of the videos produced by hospitals or physicians, approximately half were of generally poor or poor quality. Regarding the usefulness of information, although 76% were assessed to contain useful information, 8% had misleading information. Particularly, four of these videos contained misleading information, and three were provided by patients who experienced ESI.ConclusionYouTube is a platform where medical information is actively shared and widespread. Here, we found that the reliability and quality of videos were low even when these were produced by hospitals or physicians. Further, the quality tended to be much lower when it was provided by media organizations or patients. Future efforts by physicians and professional societies to improve the reliability and quality of medical content are necessary.

Background:Chronic low back pain (LBP) is highly prevalent and costly in our society. The use of epidural steroid injections (ESIs) for the treatment of radicular LBP is very widespread and continues to rise. The most popular injection is the lumbar/sacral transforaminal epidural steroid injection (TFESI). Here, we present a serious neurological complication resulting from such a TFESI that was only reversed by timely neurosurgical intervention.Case Description:A 49-year-old male presented with a 5-year history of progressive neurogenic claudication and right lower extremity pain/radiculopathy. He had previously received multiple lumbar ESIs and other conservative therapy. Due to a recent exacerbation of his radiculopathy associated with MRI-documented lumbosacral spondylosis, he underwent a right L5/S1 TFESI under fluoroscopic guidance. This resulted in acute right lower extremity weakness accompanied by a right-sided foot drop and sphincter dysfunction. Although the follow-up MRI was noncontributory, the EMG showed L5/S1 denervation, and the patient underwent an L4–5, L5–S1 laminectomy with discectomies at the L4–5 and L5–S1 levels. Immediately after the surgery, the patient's weakness and sensory deficits improved. Two years later, the patient continued to do well without evidence of recurrence of signs or symptoms of lumbosacral radiculopathy.Conclusion:Patients should be counseled about the risk and benefits of TFESI. Surgical treatment may be warranted in patients who develop acutely progressive worsening following these non-FDA (Food/Drug Administration) approved injections.

BackgroundChronic low back pain without disc herniation is common. Various modalities of treatments are utilized in managing this condition, including epidural injections. However, there is continued debate on the effectiveness, indications, and medical necessity of any treatment modality utilized for managing axial or discogenic pain, including epidural injections.MethodsA randomized, double-blind, actively controlled trial was conducted. The objective was to evaluate the ability to assess the effectiveness of caudal epidural injections of local anesthetic with or without steroids for managing chronic low back pain not caused by disc herniation, radiculitis, facet joints, or sacroiliac joints. A total of 120 patients were randomized to two groups; one group did not receive steroids (group 1) and the other group did (group 2). There were 60 patients in each group. The primary outcome measure was at least 50% improvement in Numeric Rating Scale and Oswestry Disability Index. Secondary outcome measures were employment status and opioid intake. These measures were assessed at 3, 6, 12, 18, and 24 months after treatment.ResultsSignificant pain relief and functional status improvement (primary outcome) defined as a 50% or more reduction in scores from baseline, were observed in 54% of patients in group 1 and 60% of patients in group 2 at 24 months. In contrast, 84% of patients in group 1 and 73% in group 2 saw significant pain relief and functional status improvement in the successful groups at 24 months.ConclusionCaudal epidural injections of local anesthetic with or without steroids are effective in patients with chronic axial low back pain of discogenic origin without facet joint pain, disc herniation, and/or radiculitis.

Background: Low back pain (LBP) is a prevalent musculoskeletal disorder that significantly affects quality of life and incurs considerable costs. Transforaminal epidural steroid injections (TFESI) and trigger point injections (TPI) are widely utilised in interventional pain management treatments. Nonetheless, their relative efficacy for sustained pain relief is not well comprehended. Aim: This research assesses the efficacy of TFESI compared to TPI in managing chronic LBP by analysing pain alleviation and functional outcomes at a six-month follow-up. Methodology: A prospective, comparative interventional study was undertaken at Aditi mother and Child Care Centre, Patna, Bihar, India, involving 96 patients with chronic low back pain. Patients were randomly assigned to two groups: Group A (n=48) underwent transforaminal epidural steroid injection (TFESI), and Group B (n=48) received trigger point injection (TPI). Pain intensity was evaluated using the Visual Analogue Scale (VAS) during the initial consultation and at follow-up appointments at 1, 3, and 6 months. The Mann-Whitney U test was employed for statistical analysis, with p&lt;0.05 indicating statistical significance. Results: Both therapies considerably decreased pain scores over time. TFESI provide more substantial alleviation in the long term. The mean VAS score for Group A at 3 months (3.2 ± 1.1) was considerably lower than that of Group B (3.8 ± 1.3, p=0.04). Group A (2.9 ± 1.0) exhibited superior pain management compared to Group B (3.6 ± 1.2, p=0.02) at the six-month mark. Conclusion: Although both TFESI and TPI effectively mitigate LBP, TFESI provides longer prolonged pain relief, making it preferable for long-term application.

ObjectiveChronic low back pain is very common and often treated with epidural steroid injections (ESIs). As ESI referrals had been rapidly increasing at our Veterans’ Administration hospital, we were concerned...

Epidural steroid injection has been used to treat low back pain for many decades. Numerous randomized trials have examined the efficacy of this approach. This review details the findings of older systematic reviews, newer randomized controlled trials, and two recent systematic reviews that examine the effectiveness of this treatment. Collectively, studies in acute radicular pain due to herniated nucleus pulposus have failed to show that epidural steroid injection reduces long-term pain or obviates the need for surgery. Similarly, there is scant evidence that epidural steroids have any beneficial effect in those with acute low back pain without leg pain or in those with chronic low back or leg pain. However, most studies have demonstrated more rapid resolution of leg pain in those who received epidural steroid injections versus those who did not. The role of epidural steroid injections in the management of acute radicular pain due to herniated nucleus pulposus is simply to provide earlier pain relief.

To determine if the timing of a lumbar epidural steroid injection (LESI) effects rates of post-operative infection in patients receiving a non-fusion lumbar decompression (LDC) due to degenerative disc disease (DDD). Lumbar pain due to DDD can frequently be temporized or definitively treated with epidural injections. While there is ample literature regarding the infection risks associated with corticosteroid injections prior to hip/knee replacements, there are few studies relating to the spine. A nationwide insurance database was queried to identify those who underwent LDC for DDD without instrumentation [2005-2014]. Lumbar fusion procedures were excluded. From this group those with a history of a LESI were identified and matched to a control group without a history of LESI. Four separate cohorts were examined: (I) LDC and no LESI within 6 months (control); (II) LDC performed within 0-1 month after LESI; (III) LDC between 1 and 3 months after LESI; (IV) LDC performed between 3 and 6 months after LESI. There was an increased odds of a 90-day postoperative infection if the LESI was within the 1-3 months (OR =4.69; P<0.001) and 3-6 months (OR =5.33; P<0.001) interval prior to the LDC. While LESI is helpful for possibly delaying or avoid lumbar surgery, it may predispose patients to higher infection rates following lumbar decompressions without fusion. Surgeons and pain management specialist should counsel patients on these risks and.

Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines

Background: Chronic radicular low back pain is a common disease that limits patient’s daily activity. Epidural steroid injection is becoming the mainstay of therapies for radicular low back pain due to contained bulged disc. Purpose: To determine the effect of adding hypertonic saline to epidural steroid injections to provide pain relief for chronic radiculopathy back pain secondary to foraminal stenosis. Methods: In a randomized clinical trial, 50 patients with unilateral radicular low back pain due to unilateral foraminal stenosis were enrolled. Epidural steroid injections were performed using transforminal approach. In hypertonic saline group 80 mg of triamcinolone plus 2 ml of 10% hypertonic saline, and in control group 80 mg of triamcinolone plus 2 ml of normal saline were injected. Outcome measures were numerical rating scale (NRS), Oswestry disability index, and proportion of responder patients (NRS<3) were measured at baseline, 1, 3, and 6 months post-procedure. Results: Comparison of pain score between two groups showed that pain score was not significantly different at 1 (p=0.24), 3 (p=0.31) and 6 month (p=0.38). Significant pain relief (NRS<3) in 76% of patients within 1 months. Percent of patient with NRS<3 was 48% and 32% in hypertonic and 40% and 32% in steroid group at 3 and 6 month, respectively. Conclusion: Hypertonic saline added to steroid did not significantly increase pain relief effect of epidural steroid injection.

Background: Low back pain without disc herniation is the most common problem among chronic pain disorders. Epidural injections are commonly used interventions in managing chronic low back pain without disc herniation. However, little evidence exists regarding the effectiveness, indications, and medical necessity of lumbar epidural injections in managing axial low back pain without disc herniation or radiculitis. Study Design: A randomized, double-blind, controlled trial. Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objectives: To evaluate the ability to provide effective and long-lasting pain relief with lumbar interlaminar epidural injections with local anesthetic with or without steroids in managing chronic low back pain not caused by disc herniation or radiculitis. Methods: Patients were randomly assigned to one of 2 groups with Group I patients receiving local anesthetic only, whereas Group II patients received local anesthetic mixed with non-particulate betamethasone. Seventy patients were included in this analysis. Randomization was performed by computer-generated random allocation sequence by simple randomization. Outcomes Assessment: Outcome measures included the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake. The assessments were done at baseline, 3 months, 6 months, and 12 months post-treatment. Significant pain relief and/or improvement in disability were defined as at least 50% improvement. Results: Significant pain relief (≥ 50%) was demonstrated in 74% of patients in Group I and 63% in Group II. Functional status improvement (reduction of ≥ 50%) in the ODI scores was seen in 71% of patients in Group I and 60% of patients in Group II. The overall average procedures per year were approximately 4. Limitations: The results of this study are limited by the lack of a placebo group and that it is a preliminary report of 35 patients in each group with a total of 70 patients. Conclusion: Lumbar interlaminar epidural injections of local anesthetic with or without steroids was effective in 63% and 74% of patients with chronic function-limiting low back pain without facet joint pain, disc herniation, and/or radiculitis. Key words: Chronic low back pain, lumbar interlaminar epidural injections, discogenic pain, disc herniation, radiculitis, local anesthetic, steroids, controlled comparative local anesthetic blocks

Excessive spine operations is an economic and social problem today in Korea. Proper conservative treatment can reduce the need for surgical treatment by relieving the pain during the acute phase of spinal disease. Epidural steroid injection and a selective nerve root block are relatively safer and easier than other treatments. They may have many advantages such as relief of neck and back pain and of radicular pain, and reducing the gastrointestinal adverse effects caused by long-term NSAID medication or injection. Furthermore, patients in an inoperable state due to old age or other comorbidities and outpatients who want conservative treatment may benefit from epidural steroid injection and a nerve root block. The treatment outcomes differ among reports. The efficacy of temporary pain relief has been described to be excellent, but it gradually decreases as time passes. Recently, transforaminal epidural steroid injection has been widely performed. Epidural steroid injection should be performed for temporary pain relief due to its limited efficacy. In addition, an overuse of epidural and selective nerve root steroid injection can cause serious side effects. Therefore, this procedure should be done with caution, taking into account the technical risks and side effects.