Do Corticosteroids Still Have a Place in the Treatment of Chronic Pain?

Knezevic, Nebojsa Nick; Jovanovic, Filip; Voronov, Dimitry; Candido, Kenneth D.

doi:10.3389/fphar.2018.01229

Cited by 21 publications

(14 citation statements)

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“…Exposure to nucleus pulposus tissue is assumed to cause an auto-immune response leading to cytokine production and involvement of pro-inflammatory cells. Additionally, vertebral end plate devascularization may strengthen this response [8][9][10][11][12].…”

Section: Introductionmentioning

confidence: 99%

Epidural steroid compared to placebo injection in sciatica: a systematic review and meta-analysis

et al. 2021

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Purpose The purpose of this systematic review and meta-analysis was to determine whether epidural steroid injections (ESI) are superior to epidural or non-epidural placebo injections in sciatica patients. Methods The PubMed, Embase, Cochrane Library, and Web of science databases were searched for trials comparing ESI to epidural or non-epidural placebo. Risk of bias was assessed using the Cochrane RoB 2 tool. The primary outcome measures were pooled using a random-effects model for 6-week, 3-month, and 6-month follow-up. Secondary outcomes were described qualitatively. Quality of evidence was graded using GRADE classification. Results Seventeen out of 732 articles were included. ESI was superior compared to epidural placebo at 6 weeks (− 8.6 [− 13.4; − 3.9]) and 3 months (− 5.2 [− 10.1; − 0.2]) for leg pain and at 6 weeks for functional status (− 4.1 [− 6.5; − 1.6]), though the minimally clinical important difference (MCID) was not met. There was no difference in ESI and placebo for back pain, except for non-epidural placebo at 3 months (6.9 [1.3; 12.5]). Proportions of treatment success were not different. ESI reduced analgesic intake in some studies and complication rates are low. Conclusion The literature indicates that ESI induces larger improvements in pain and disability on the short term compared to epidural placebo, though evidence is of low to moderate quality and MCID is not met. Strong conclusions for longer follow-up or for comparisons with non-epidural placebo cannot be drawn due to general low quality of evidence and limited number of studies. Epidural injections can be considered a safe therapy.

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Section: Introductionmentioning

confidence: 99%

Epidural steroid compared to placebo injection in sciatica: a systematic review and meta-analysis

et al. 2021

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“…This hypothesis is supported by many studies showing that corticosteroids have an immediate effect on pain by inhibiting the synthesis of proinflammatory cytokines that are released locally at the injury site [ 26 ]. For these reasons, corticosteroids, in association with local anaesthetics, are actually still considered as a treatment of choice in the pain management of chronic spinal pain (cervical and lumbar) [ 27 ].…”

Section: Discussionmentioning

confidence: 99%

Comparison of Pulsed Radiofrequency, Oxygen-Ozone Therapy and Epidural Steroid Injections for the Treatment of Chronic Unilateral Radicular Syndrome

et al. 2021

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Background and objectives: For the treatment of chronic unilateral radicular syndrome, there are various methods including three minimally invasive computed tomography (CT)-guided methods, namely, pulsed radiofrequency (PRF), transforaminal oxygen ozone therapy (TFOOT), and transforaminal epidural steroid injection (TFESI). Despite this, it is still unclear which of these methods is the best in terms of pain reduction and disability improvement. Therefore, the purpose of this study was to evaluate the short and long-term effectiveness of these methods by measuring pain relief using the visual analogue scale (VAS) and improvement in disability (per the Oswestry disability index (ODI)) in patients with chronic unilateral radicular syndrome at L5 or S1 that do not respond to conservative treatment. Materials and Methods: After screening 692 patients, we enrolled 178 subjects, each of whom underwent one of the above CT-guided procedures. The PRF settings were as follows: pulse width = 20 ms, f = 2 Hz, U = 45 V, Z ˂ 500 Ω, and interval = 2 × 120 s. For TFOOT, an injection of 4–5 mL of an O2-O3 mixture (24 μg/mL) was administered. For the TFESI, 1 mL of a corticosteroid (betamethasone dipropionate), 3 mL of an anaesthetic (bupivacaine hydrochloride), and a 0.5 mL mixture of a non-ionic contrast agent (Iomeron 300) were administered. Pain intensity was assessed with a questionnaire. Results: The data from 178 patients (PRF, n = 57; TFOOT, n = 69; TFESI, n = 52) who submitted correctly completed questionnaires in the third month of the follow-up period were used for statistical analysis. The median pre-treatment visual analogue scale (VAS) score in all groups was six points. Immediately after treatment, the largest decrease in the median VAS score was observed in the TFESI group, with a score of 3.5 points (a decrease of 41.7%). In the PRF and TFOOT groups, the median VAS score decreased to 4 and 5 points (decreases of 33% and 16.7%, respectively). The difference in the early (immediately after) post-treatment VAS score between the TFESI and TFOOT groups was statistically significant (p = 0.0152). At the third and sixth months after treatment, the median VAS score was five points in all groups, without a statistically significant difference (p > 0.05). Additionally, there were no significant differences in the Oswestry disability index (ODI) values among the groups at any of the follow-up visits. Finally, there were no significant effects of age or body mass index (BMI) on both treatment outcomes (maximum absolute value of Spearman’s rank correlation coefficient = 0.193). Conclusions: Although the three methods are equally efficient in reducing pain over the entire follow-up, we observed that TFESI (a corticosteroid with a local anaesthetic) proved to be the most effective method for early post-treatment pain relief.

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“…Corticosteroids have both direct and indirect roles, decreasing the production and release of multiple pro-inflammatory cytokines, and inhibiting phospholipase A2 and the arachidonic acid pathway (4,9,10). Steroids also inhibit the transcription of inflammatory genes, such as nuclear factor kappa-light-chain-enhancer of activated B cells (NF-kB), and, upon binding to glucocorticoid-responsive elements (GREs), can increase the production of anti-inflammatory genes (11).…”

Section: Introductionmentioning

confidence: 99%

“…The use of these injections has historically been controversial, and multiple studies have shown variable results, both supporting and discouraging this management (12)(13)(14)(15). However, as multiple studies associate steroids with higher pain relief scores compared with local anesthetics alone, there is an increasing interest in assessing this topic and promoting their use (7,11). To determine the real effect of epidural steroid injections (ESIs), researchers have focused not only on the types of drugs used but also on the other factors that affect their efficacy, such as the different existing injection approaches and the performance technique (4).…”

Section: Introductionmentioning

confidence: 99%

Parasagittal Approach of Epidural Steroid Injection as a Treatment for Chronic Low Back Pain: A Systematic Review and Meta-Analysis

et al. 2021

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Background: Epidural steroid injection (ESI) has proven benefits in controlling chronic low back pain and can be performed via the midline interlaminar (MIL) or transforaminal (TF) approach. A modified interlaminar approach, the parasagittal interlaminar (PIL), has surfaced as a more reliable, safe, and suitable approach to minimize complications related to MIL and TF.Objective: To conduct a systematic review and meta-analysis to assess and compare the effectiveness and safety of PIL with both MIL and TF approaches in adult patients with a history of chronic low back pain.Methods: A literature search was conducted using major electronic databases, such as PubMed, EMBASE, and Cochrane. Selected studies included patients with unilateral radicular symptoms, secondary to lumbar intervertebral disc hernias or degenerative lumbar disc disease, that, additionally, received ESIs via PIL or either MIL or TF under fluoroscopic guidance. Randomized and observational studies with pain relief score and/or functional disability assessment and at least a 2-week follow-up were included.Results: The search led to the initial identification of 174 studies. Following the screening, eight studies were included in the qualitative analysis and seven randomized controlled trials (RCTs) were included in the statistical analysis. PIL showed statistically significantly more pain relief and functional improvement than MIL at 1-, 3-, and 6-month post-procedure. Compared to TF, PIL showed statistically significantly more pain relief at 3- and 6-month after the procedure. Additionally, PIL showed benefits in terms of lower mean fluoroscopy time, less radiation exposure, zero adverse events in all the included studies, no cases of intravascular spread compared with the TF approach, and a higher anterior epidural spread (AES) of PIL compared with TF.Conclusions: Our systematic review and meta-analysis suggest that the PIL approach is an effective and safe alternative to the MIL and TF approaches in patients presenting with chronic low back pain when epidural injections are indicated, demonstrating a higher level of pain relief and a stronger improvement in functionality post-procedure.

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Do Corticosteroids Still Have a Place in the Treatment of Chronic Pain?

Cited by 21 publications

References 30 publications

Epidural steroid compared to placebo injection in sciatica: a systematic review and meta-analysis

Epidural steroid compared to placebo injection in sciatica: a systematic review and meta-analysis

Comparison of Pulsed Radiofrequency, Oxygen-Ozone Therapy and Epidural Steroid Injections for the Treatment of Chronic Unilateral Radicular Syndrome

Parasagittal Approach of Epidural Steroid Injection as a Treatment for Chronic Low Back Pain: A Systematic Review and Meta-Analysis

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