The acute lumbosacral radicular syndrome

Abstract

The lumbosacral radicular syndrome or sciatica is a common neurological problem characterized by pain radiating into the leg, following one of the lumbosacral nerve roots. There are several treatment options including medication, physiotherapy, transforaminal epidural steroid injections (TESIs) and disc surgery. This thesis, that was aimed to contribute to best clinical practice during the acute stage of the lumbosacral radicular syndrome and was subdivided into three themes. Theme 1: Diagnosis and treatment of acute lumbosacral radicular syndrome This theme contains an historical overview and a survey among 124 physicians. The results of this survey showed that 40-60% of neurologists think that TESIs are effective in 40% of injected patients and that 23/44(52%) of anesthesiologists think that TESIs are effective in 60-80% of the injected patients. We also found that neurologists treat patients with lumbosacral radicular syndrome initially with pain medication and physiotherapy, followed by epidural steroid injections and referral for surgery Anesthesiologists treat patients with lumbosacral radicular syndrome with one or more steroid injections or may perform a selective nerve root block. Theme 2: Inflammation This theme contained a systematic review that answers the following two questions: What inflammatory biomarkers have been identified in patients with sciatica in the literature so far, and is there an association between the level of inflammatory activity and clinical symptoms? Based on the results of the systematic review, we concluded that there was considerable heterogeneity in the type of biomarkers and in the clinical measurements in the included studies and that, taking into account the overall risk of bias, there is insufficient evidence to draw firm conclusions regarding the relationship between inflammation and clinical symptoms in patients with sciatica. Theme 3 (Cost-)effectiveness of transforaminal epidural steroid injections in patients with acute lumbosacral radicular syndrome This theme described the design, statistical analysis plan, and results of the STAR-trial. A total of 141 patients with acute lumbosacral radicular syndrome (due to a herniated disc) was included. Participants were randomly assigned to: 1) usual care and TESI of 1ml of 40mg/ml Methylprednisolone plus 1ml of 0.5% Levobupivacaine (intervention 1); 2) usual care and transforaminal epidural injection with 1 ml of 0.5% Levobupivacaine and 1ml NaCl 0.9% (intervention 2); or 3) usual care, consisting of oral pain medication with or without physiotherapy (control). Co-primary outcomes were back and leg pain intensity, physical functioning, and recovery measured during 6-month follow-up. Secondary outcomes included health-related quality of life, patient satisfaction, and surgery rate. There were no significant mean differences in co-primary outcomes between groups during follow-up, except (a not clinically relevant difference) for leg pain when comparing intervention group 1 with control (-0.96 95%CI:-1.83 to -0.09). For secondary outcomes, some significant between group differences were found for treatment satisfaction and surgery, but only when comparing intervention group 2 to control. There were no serious side effects. Based on these results, we do not recommend TESI as a standard treatment. Nonetheless, transforaminal epidural injections seem to be associated with less opioid use. After 6 months, no significant differences in costs between the three treatment groups were found. The adjusted mean difference in total societal costs was €1718 (95%CI:-3020 to 6052) for comparison 1 (intervention-group 1 versus control group), €1640 (95%CI:- 3354 to 6106) for comparison 2 (intervention group 1 versus intervention-group 2) and €770 (95%CI: -3758 to 5702) for comparison 3 (intervention group 2 versus control). The maximum probability of the interventions being cost-effective compared with control was low (<0.7) for all effect measures. These results suggest that adding TESI (or TEI) to usual care is not cost-effective compared with usual care in patients with acute sciatica.