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

Abstract

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.

Ligamentum Flavum Rupture by Epidural Injection Using Ultrasound with SMI Method

“…However, the LOR method cannot accurately identify the epidural space if there is a false lumen with the LOR outside the epidural space, as it only uses a decrease in pressure as an indicator. Efforts have been made to improve the success rate by measuring the distance from the epidermis in advance using MRI, CT, or sonography to avoid mistaking the false lumen for the epidural space [ 4 , 5 , 6 ]. Imaging procedures have been used to enhance the safety and efficacy of epidural injection by providing anatomical precision and accurate needle placement (angle and distance) [ 9 , 10 ], with fluoroscopy recommended for all interlaminar and transforaminal injections by a multispecialty working group sponsored by the United States Food and Drug Administration [ 11 ].…”

“…However, a lumbar epidural block, such as a trigger point injection performed in an outpatient department, cannot be easily performed due to complications [ 2 , 3 ]. Needle guidance using fluoroscopy, computed tomography (CT), sonography [ 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ], and special devices to increase the sensitivity of the LOR method have been used to minimize these complications. Since the epidural fat layer varies in thickness from patient to patient, the placement of the needle tip in the same area cannot completely avoid the risk of complications.…”

Parasagittal Interlaminar and Transforaminal Epidural Steroid Injections for Radicular Low Back Pain; Which is More Comfortable?

“… 6 , 9 , 10 , 11 However, in a meta-analysis comparing the two methods, the PS approach was found to be superior for pain relief, but no difference was found in terms of functionality. 18 In the results of studies comparing midline, PS and TF approaches are conflicting. 6 , 19 , 20 …”

Recent Advancements in Epidural Etanercept for Pain Management in Radiculopathy: A Literature Review

“…The VAS utilized is a tool to quantify pain intensity [ 14 ]. One meta-analysis showed no significant difference in lumbar disc herniation and spinal stenosis in patients who received lidocaine alone versus lidocaine with steroids for one to two years [ 14 , 15 ]. Epidural steroids with anesthetic resulted in significantly more Numeric Rating Scale (NRS-11) and Oswestry Disability Index (ODI) improvement than epidural anesthetics alone after one year for Degenerative Disc Disease (DDD).…”

“…Epidural steroids with anesthetic resulted in significantly more Numeric Rating Scale (NRS-11) and Oswestry Disability Index (ODI) improvement than epidural anesthetics alone after one year for Degenerative Disc Disease (DDD). More specifically, ODI improvement has been demonstrated for two years in patients with lumbar DDD treated with epidural steroids and anesthetics [ 15 , 16 , 17 , 18 ].…”