What is the Role of Epidural Injections in the Treatment of Lumbar Discogenic Pain: A Systematic Review of Comparative Analysis with Fusion

Abstract

BackgroundLumbar discogenic pain without pain mediated by a disc herniation, facet joints, or the sacroiliac joints, is common and often results in chronic, persistent pain and disability. After conservative treatment failure, injection therapy, such as an epidural injection, is frequently the next step considered in managing discogenic pain. The objective of this systematic review is to determine the efficacy of lumbar epidural injections in managing discogenic pain without radiculopathy, and compare this approach to lumbar fusion or disc arthroplasty surgery.MethodsA systematic review of randomized trials published from 1966 through October 2014 of all types of epidural injections and lumbar fusion or disc arthroplasty in managing lumbar discogenic pain was performed with methodological quality assessment and grading of evidence. The level of evidence was based on the grading of evidence criteria which, was conducted using 5 levels of evidence ranging from levels I to V.ResultsBased on a qualitative assessment of the evidence for both approaches, there is Level II evidence for epidural injections, either caudal or lumbar interlaminar.ConclusionsThe available evidence suggests fluoroscopically directed epidural injections provide long-term improvement in back and lower extremity pain for patients with lumbar discogenic pain. There is also limited evidence showing the potential effectiveness of surgical interventions compared to nonsurgical treatments.

Responsible, Safe, and Effective Prescription of Opioids for Chronic Non-Cancer Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines

“…They included various types of drug therapies including nonsteroidal anti-inflammatory agents, acetaminophen, and anticonvulsants. However, they have not included multiple interventional techniques which have been shown to be significantly effective based on high quality RCTs and appropriately conducted systematic reviews (82,414,(487)(488)(489)(490)(491)(492)(493)(494)(495)(496)(497)(498)(499)(500)(501)(502)(503)(504)(505)(506). However, there also have been multiple discordant opinions with lack of efficacy (507-510).…”

“…As a composite analysis of multiple systematic reviews, most interventional techniques have been shown to be with at least moderate evidence. Multiple systematic reviews assessing the effectiveness of epidural injections in managing chronic spinal pain with RCTs (487)(488)(489)(490)(491)(492)(493)(494)(495)(496) have shown significant effectiveness of epidural injections in managing spinal pain. The evidence has been variable with somewhat of a stronger evidence for disc herniation and radiculopathy compared to spinal stenosis.…”

“…However, these 2 opposing facts may be reconciled based on the fact that 70% of long-term opioid users were disabled or suffered from a handicap or chronic disease which kept them from participating fully in work, school, housework, or other activities. Consequently, clinical effectiveness, cost utility, and cost effectiveness studies have shown interventional therapies to be more economical than many of the drug therapies described in CDC guidelines (42), with interventional therapies showing clinically significant improvement utilizing criterion standards of > 50% improvement (487)(488)(489)(490)(491)(492)(493)(494)(495)(496)(499)(500)(501)(502)(503)(504)(505)(506)521,525,(531)(532)(533). Fifty-eight percent of the patients agreed that opioids are prescribed appropriately, 67% agreed that opioids are a preferred treatment, and an overwhelming 89% were worried that they would not be able to get opioid pain medication.…”

An Update of the Systematic Appraisal of the Accuracy and Utility of Discography in Chronic Spinal Pain

“…Disc herniation has been well described in the literature. However, the pain emanating from pathologic changes within the disc itself, without disc herniation (1,34,35,(88)(89)(90)(91)(92)(93)(94)(95)(96)(97)(98)(99), was described before the classic description of disc herniation. Mixter and Barr described lumbar discectomy in 1934 (100).…”

Alternatives to Opiates in the Management of Non-cancer-related Pain

“…One of the classic interventional or minimally invasive approaches is epidural steroids or the application of small amounts of steroids to specific sites within the epidural space [15]. It is thought to decrease inflammation reduce nociceptive input from neural structures, resulting in improved pain scores, function and decrease opiate consumption in patients with acute radiculopathies secondary to disk herniations.…”