Systematic Review of the Efficacy of Particulate Versus Nonparticulate Corticosteroids in Epidural Injections

Mehta, Priyesh; Syrop, Isaac P.; Singh, Jaspal; Kirschner, Jonathan S.

doi:10.1016/j.pmrj.2016.11.008

Cited by 57 publications

(38 citation statements)

References 57 publications

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“…Regarding particulate vs nonparticulate steroids, a recent systematic review has found no evidence of a significant difference in efficacy. On the basis of potential catastrophic complications with particulate steroids, nonparticulate steroids are recommended [89].…”

Section: Resultsmentioning

confidence: 99%

A Comprehensive Algorithm for Management of Neuropathic Pain

Bates

Schultheis

Hanes³

et al. 2019

Pain Medicine

265

208

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Background The objective of this review was to merge current treatment guidelines and best practice recommendations for management of neuropathic pain into a comprehensive algorithm for primary physicians. The algorithm covers assessment, multidisciplinary conservative care, nonopioid pharmacological management, interventional therapies, neurostimulation, low-dose opioid treatment, and targeted drug delivery therapy. Methods Available literature was identified through a search of the US National Library of Medicine’s Medline database, PubMed.gov. References from identified published articles also were reviewed for relevant citations. Results The algorithm provides a comprehensive treatment pathway from assessment to the provision of first- through sixth-line therapies for primary care physicians. Clear indicators for progression of therapy from firstline to sixth-line are provided. Multidisciplinary conservative care and nonopioid medications (tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, gabapentanoids, topicals, and transdermal substances) are recommended as firstline therapy; combination therapy (firstline medications) and tramadol and tapentadol are recommended as secondline; serotonin-specific reuptake inhibitors/anticonvulsants/NMDA antagonists and interventional therapies as third-line; neurostimulation as a fourth-line treatment; low-dose opioids (no greater than 90 morphine equivalent units) are fifth-line; and finally, targeted drug delivery is the last-line therapy for patients with refractory pain. Conclusions The presented treatment algorithm provides clear-cut tools for the assessment and treatment of neuropathic pain based on international guidelines, published data, and best practice recommendations. It defines the benefits and limitations of the current treatments at our disposal. Additionally, it provides an easy-to-follow visual guide of the recommended steps in the algorithm for primary care and family practitioners to utilize.

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Section: Resultsmentioning

confidence: 99%

A Comprehensive Algorithm for Management of Neuropathic Pain

Bates

Schultheis

Hanes³

et al. 2019

Pain Medicine

265

208

View full text Add to dashboard Cite

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“…But these adverse effects occurred mainly in cases in which particulate steroid was administered, and its replacement with a non-particulate steroid could reduce serious side effects (50)(51)(52)(53). A Soluble non-particulate steroid reportedly showed comparable and non-inferior clinical outcomes to those of particulate steroid (50,54,55). Thus injection of soluble nonparticulate steroid could reduce the fear or concerns of serious side effects and consequently prevent unnecessary avoidance of TFEI (36,37).…”

Section: Discussionmentioning

confidence: 99%

Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis

Lee

2018

Pain Phys

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Background: Epidural injection (EI) is used to treat back or radicular pain from lumbosacral disc herniation (LDH). Although several reports have stated that the transforaminal approach in EI (TFEI) has an advantage in target specificity and yields better clinical efficacy than the interlaminar approach in EI (ILEI), other studies have indicated that the clinical efficacy of ILEI was not inferior to that of TFEI and that ILEI also has the ability to spread medication into the ventral space to a degree similar to that of TFEI. There has been controversy about whether TFEI is superior to ILEI in clinical efficacy. Objectives: This systematic review and meta-analysis aimed to investigate whether TFEI is more useful than ILEI for achieving clinical outcomes in patients with LDH. Study design: A systematic review and meta-analysis using a random effects model on randomized controlled studies (RCT). Methods: A literature search was performed in MEDLINE, EMBASE, Cochrane review, and KoreaMed for studies published from January 1996 until July 2017. From those found fulfilling the search criteria, manuscripts that compared the clinical efficacy of steroids and control agents, such as local anesthetics or saline, in terms of pain control and functional improvement were included in this study. Exclusion criteria included a previous history of lumbosacral surgery, nonspecific low back pain, severe spinal stenosis, and severe disc degeneration. After reviewing titles, abstracts, and the full text of 6,711 studies; 12 studies were included in the qualitative synthesis. Data including pain scores, functional scores, and follow-up period were extracted from 10 studies and analyzed using a random effects model to obtain effect size and its statistical significance. The quality and level of evidence were analyzed in accordance with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Results: In terms of pain control, TFEI showed significantly better short-term (2 weeks to 1 month) outcomes and slightly favorable long-term (4 - 6 month) outcomes, but without significance, in comparison with ILEI. In terms of functional improvement, TFEI also showed favorable short- and long-term outcomes, but without significance, in comparison with ILEI. TFEI had target specificity, required no additional cost and resources, and had equal applicability to ILEI. However, TFEI was more associated with a higher frequency of discomfort or adverse events during the procedure. Overall, better results were reported with TFEI over ILEI, but with low-grade evidence due to the inconsistency and imprecision of the selected studies. Limitation: Analyses of safety or adverse effects could not be performed due to a lack of available data from the included studies. Conclusions: Based on low-grade evidence, TFEI showed significantly better short-term pain control and slightly favorable outcomes in long-term pain reduction and short- and long-term functional improvement in comparison with ILEI. Key words: Epidural injection, interlaminar, transforaminal, meta-analysis, systemic review, pain, function

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“…There is currently limited evidence to support particulate vs. nonparticulate steroids for epidural injections in improving pain or function in the nononcologic population. 18 It is notable that the practitioner should be cautious when using particulate steroids, especially for TFESI, given the increased risk of spinal ischemia and in the case of cervical ESI, an added potential risk of posterior circulation infarction due to embolization. 19 A couple proposed mechanisms of spinal cord infarction involve direct injury to or embolization of particulate steroids through the artery of Adamkiewicz or other radiculomedullary arteries in the intervertebral foramen.…”

Section: Discussionmentioning

confidence: 99%

“…19 A couple proposed mechanisms of spinal cord infarction involve direct injury to or embolization of particulate steroids through the artery of Adamkiewicz or other radiculomedullary arteries in the intervertebral foramen. 18 This adverse effect may be pronounced in the oncologic population, in which ESI may be performed close to neovascularized tissue. Nevertheless, no patients in this study suffered from such complications.…”

Section: Discussionmentioning

confidence: 99%

Epidural Steroid Injections for the Management of Spinal Malignancy‐Related Pain: A Pragmatic Review and Retrospective Study

Rispoli

Ghosh

et al. 2020

Pain Practice

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Background: Spinal malignancy-related pain results from tumor, fracture, instability, inflammation, and/or nerve root/ spinal cord compression. Systemic corticosteroids are commonly used but have many undesirable adverse effects that impact quality of life and continuation of cancer treatments. Epidural steroid injections (ESIs) may be a viable alternative pain treatment. Objectives: This study starts with a pragmatic review on the efficacy of ESIs to treat spinal malignancy-related pain. Given the limited evidence, we supplement the study with a singlecenter, retrospective review. Methods: A pragmatic review using PRISMA guidelines was conducted in MEDLINE, EMBASE, SCOPUS, and Cochrane Review. Then, a retrospective chart review was performed. Results: A pragmatic review yielded 10 patients who underwent ESI for spinal malignancy-related pain. Three patients had "excellent" relief (≥ 50% relief), who all received thoracic injections. This amounted to level IV evidence and an inconclusive recommendation (Grade C) as per Wright's criteria. In our retrospective review, all thoracic cases achieved at least "moderate" pain improvement (30% to 49% relief). 55.6% had "excellent" relief. Lumbosacral injections resulted in 86.0% with at least "moderate" relief and 69.8% with "excellent" relief. Caudal injections were less likely to benefit than lumbosacral injections (P = 0.02). The transforaminal approach resulted in the best relief. There were no adverse events. Conclusions: There is inconclusive evidence to use ESIs to treat spinal malignancy-related pain in the current literature. Our retrospective review provides level III evidence for our conclusion that ESIs are safe and efficacious to treat spinal malignancy-related pain. Thoracic/lumbosacral injections led to significantly better pain relief compared with caudal injections. &

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Systematic Review of the Efficacy of Particulate Versus Nonparticulate Corticosteroids in Epidural Injections

Abstract: III.

Cited by 57 publications

References 57 publications

A Comprehensive Algorithm for Management of Neuropathic Pain

A Comprehensive Algorithm for Management of Neuropathic Pain

Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis

Epidural Steroid Injections for the Management of Spinal Malignancy‐Related Pain: A Pragmatic Review and Retrospective Study

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