Epidural Corticosteroid Injections for Sciatica Due to Herniated Nucleus Pulposus

Carette, Simon; Leclaire, Richard; Marcoux, Sylvie; Morín, Fernando de la Torre; Ga, Blaise; St-Pierre, André; R, Truchon; Parent, F. Noel; Lévesque, Julie; Bergeron,; Montminy, P.; Blanchette, Caty

doi:10.1056/nejm199706053362303

Cited by 556 publications

(386 citation statements)

References 26 publications

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“…The magnitude of the effect is considered as moderate by Chou et al [19], who have noted inconsistency between studies. In a higher quality trial, Carette et al [16] found that during the first 6 weeks of the trial, patients reported less leg pain than those receiving the placebo consisting of 1 ml of saline compared with 80 mg of methyl prednisolone acetate in 8 ml of saline. To evaluate the magnitude of the benefit, Carette et al, calculated the effect size and found 0.50 for the radicular pain.…”

Section: Discussionmentioning

confidence: 99%

Epidural steroid injections in the management of low-back pain with radiculopathy: an update of their efficacy and safety

2011

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Introduction Epidural steroid injections (ESIs) have been widely used for over 50 years in the treatment of low-back pain with radiculopathy. Most interventional pain physicians strongly believe in their efficacy and safety. Recent Cochrane systematic reviews have disclosed controversial results and have questioned the effectiveness of ESIs. Moreover, a few neurological adverse events have been reported recently. Methods A literature search of systematic reviews analysing the effectiveness and complications of ESIs was carried out. The scientific quality of the reviews was assessed using the validated index of Oxman and Guyatt. We relied on data abstraction and quality ratings of the placebo-controlled trials as reported by high-quality systematic reviews. Results Two types of systematic reviews were found. The Cochrane high-quality systematic reviews combining the three approaches and different pathologies were predominantly non-conclusive. The second type of review, emanating from the US Evidence-based Practice Centers, distinguishing between the routes of administration and between the principal pathologies found a moderate shortterm benefit of ESIs versus placebo in patients with disc herniation and radiculitis, in keeping with the clinical experience. ESIs are generally well tolerated and most complications are related to technical problems. Cases of paraplegia, complicating the foraminal route and related to the violation of a radiculomedullary artery, have been recently reported. They are predominantly observed in previously operated patients. Conclusions Epidural steroid injections have a moderate short-term effect in the management of low-back pain with radiculopathy. Severe neurological complications are exceptional, but call for research for alternative approaches to the foramen as well as for means to detect an eventual arterial injury.

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Section: Discussionmentioning

confidence: 99%

Epidural steroid injections in the management of low-back pain with radiculopathy: an update of their efficacy and safety

2011

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“…It has since been used widely in many countries and all continents with varying success as reported in the United Kingdom 3,18 , America 10,15,20 , India 36 , Australia 13,39,48 , New Zealand 24 and Europe 32 . It has also been included as an often-used orthodox therapy in an orthopaedic text of the gold standard class 9 .…”

Section: Introductionmentioning

confidence: 99%

“…Other rare forms such as retinal haemorrhage, myopathy and lipomatosis associated with Cushing's syndrome have also been reported. 1,33,47 The present paper is aimed to present a single operator's experience with measurable parameters (straight leg raising test, spinal flexion and extension, percentage of improvement), which is believed to be uncommon 2,7,39 in the literature 10,15,49 A new test, the Whistle Test, is also described.…”

Section: Introductionmentioning

confidence: 99%

Epidural Steroid Injection for Sciatica: An Analysis of 526 Consecutive Cases with Measurements and the Whistle Test

Loy

2000

J Orthop Surg (Hong Kong)

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The effects of epidural injections of triamcinolone acetonide and bupivacaine in the treatment of sciatica were analyzed in a retrospective series of 526 consecutive cases with measurements. A new test (the whistle test) is described. There is a paucity of measureable parameters in reports on the subject in the literature, and many are not specific or symptomoriented to sciatica. The procedure was performed by the same operator and reviewed one week postoperatively with measurements. 491 patients (93.35%) achieved excellent to good pain relief, backed by appropriate increases of straight-leg-raise measurements. But 17 patients (3.46%) of this group required surgery later. It is concluded that epidural steroid injection is a simple, cost-effective and minimally invasive treatment for sciatica, especially in the acute. It also serves as a method for crisis intervention and as a prognosticator.

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“…In the literature, caudal epidural is a useful and relatively safe procedure for the treatment of radicular low back pain [16][17][18][19], as well as a potential treatment in the setting of non radicular low back pain [13,14]. Pathology at L3/4 and L4/5 and L5/S1 can be approached by this technique.…”

Section: Resultsmentioning

confidence: 99%

The flow patterns of caudal epidural in upper lumbar spinal pathology

2010

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Epidural steroid injections are an important therapeutic modality employed by spinal surgeons in the treatment of patients with chronic low back pain with or without lumbar radiculopathy. The caudal epidural is a commonly used and well-established technique; however, little is known about the segmental level of pathology that may be addressed by this intervention. This prospective study of over 50 patients aimed to examine the spreading pattern of this technique using epidurography. The effect of variation in Trendelenburg tilt and the eradication of lumbar lordosis on the cephalic distribution of the injectate were investigated. 52 patients with low back pain and radiculopathy underwent caudal epidural. All had 20 ml volume injected, comprised of 5 ml contrast (Ultravist TM Schering) 2 ml Triamcinolone (Adcortyl TM Squibb) and 13 ml local anaesthetic (1% lignocaine). Patients were randomised to either 0°or 30°of Trendelenburg tilt, as referenced from the lumbar spine. Patients were further randomised to presence or absence of lumbar lordosis, which was eradicated using a flexion device placed beneath the prone patient. A lateral image of each sacrum was obtained, to identify variations in sacral geometry particularly resistant to cephalic spread of injectate. The highest segment reached on fluoroscopy was recorded post injection. Fifty-two patients with a mean age of 50 years underwent caudal epidural. Thirty-one were in 0°head tilt, with 21 in 30°of head tilt. In each of these groups, 50% had their lumbar lordosis flattened prior to caudal injection.The median segmental level reached was L3, with a range from T9 to L5. Eradication of lumbar lordosis did not significantly alter cephalic spread of injectate. There was a trend for 30°tilt to extend the upper level reached by caudal injection (p = 0.08). There were no adverse events in this series. Caudal epidural is a reliable and relatively safe procedure for the treatment of low back pain. Pathology at L3/4 and L4/5 and L5/S1 can be approached by this technique. Although in selected cases thoracic and high lumbar levels can be reached, this is variable. If pathology at levels above L3 needs to be addressed, we propose a 30°head tilt may improve cephalic drug delivery. The caudal route is best reserved for pathology below L3.

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Epidural Corticosteroid Injections for Sciatica Due to Herniated Nucleus Pulposus

Abstract: Although epidural injections of methylprednisolone may afford short-term improvement in leg pain and sensory deficits in patients with sciatica due to a herniated nucleus pulposus, this treatment offers no significant functional benefit, nor does it reduce the need for surgery.

Cited by 556 publications

References 26 publications

Epidural steroid injections in the management of low-back pain with radiculopathy: an update of their efficacy and safety

Epidural steroid injections in the management of low-back pain with radiculopathy: an update of their efficacy and safety

Epidural Steroid Injection for Sciatica: An Analysis of 526 Consecutive Cases with Measurements and the Whistle Test

The flow patterns of caudal epidural in upper lumbar spinal pathology

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