TY - JOUR
T1 - A comparative systematic review and meta-analysis of 3 routes of administration of epidural injections in lumbar disc herniation
AU - Manchikanti, Laxmaiah
AU - Knezevic, Emilija
AU - Knezevic, Nebojsa Nick
AU - Vangala, Bramha Prasad
AU - Sanapati, Mahendra R.
AU - Thota, Srinivasa
AU - Abdi, Salahadin
AU - Abd-Elsayed, Alaa
AU - Kaye, Alan D.
AU - Hirsch, Joshua A.
N1 - Publisher Copyright:
© 2021, American Society of Interventional Pain Physicians. All rights reserved.
PY - 2021
Y1 - 2021
N2 - Background: The Best Practices in Pain Management from the U.S. Department of Health and Human Services (HHS) describes interventional techniques as part of a continuum. Epidural injections are commonly utilized modalities in managing low back and lower extremity pain. Epidural injections were initially administered in 1901 where the first descriptions of caudal epidural with local anesthetic for low back pain appeared. Since then, multiple developments have occurred. Currently, epidural injections are provided by caudal, interlaminar, and transforaminal approaches. The comparative effectiveness of each modality has been studied. However, comparative assessment has been sparse. Objectives: To assess the efficacy of 3 routes of administration of epidural injections for lumbar disc herniation. Study Design: A systematic review and meta-analysis of randomized controlled trials (RCTs) of transforaminal, interlaminar and caudal epidural injections in managing chronic low back and lower extremity pain due to lumbar disc herniation. Methods: RCTs with a placebo control or an active control design, performed under fluoroscopic guidance, with at least 6 months of follow-up are included. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Data extraction and methodological quality assessment were performed. Evidence was summarized utilizing principles of best evidence synthesis. Results: A total of 21 trials were included. Of these, 7 studied caudal epidural injections, whereas transforaminal epidural injections were studied in 12 trials, and lumbar interlaminar epidural injections were studied in 10 trials, which all met inclusion criteria. Based on qualitative and quantitative analysis, which included conventional dual-arm and single-arm analysis for interlaminar epidural injections, and single-arm analysis for caudal and transforaminal epidural injections, and the approach to the epidural space, there is Level I evidence for local anesthetic and steroids, Level II for local anesthetic alone for transforaminal and interlaminar approaches, and Level II for the caudal approach with steroids or local anesthetic alone for short-and long-term relief. Limitations: There is a paucity of literature with intermediate or long-term relief of at least 6 months with appropriate outcome parameters. Conventional dual-arm meta-analysis was feasible only for interlaminar epidural injections. Conclusion: Epidural injections with local anesthetic and steroids showed Level I evidence for transforaminal and interlaminar approaches, whereas with local anesthetic alone Level II evidence was demonstrated. In contrast, caudal epidural injections showed Level II evidence with local anesthetic with steroids or local anesthetic alone.
AB - Background: The Best Practices in Pain Management from the U.S. Department of Health and Human Services (HHS) describes interventional techniques as part of a continuum. Epidural injections are commonly utilized modalities in managing low back and lower extremity pain. Epidural injections were initially administered in 1901 where the first descriptions of caudal epidural with local anesthetic for low back pain appeared. Since then, multiple developments have occurred. Currently, epidural injections are provided by caudal, interlaminar, and transforaminal approaches. The comparative effectiveness of each modality has been studied. However, comparative assessment has been sparse. Objectives: To assess the efficacy of 3 routes of administration of epidural injections for lumbar disc herniation. Study Design: A systematic review and meta-analysis of randomized controlled trials (RCTs) of transforaminal, interlaminar and caudal epidural injections in managing chronic low back and lower extremity pain due to lumbar disc herniation. Methods: RCTs with a placebo control or an active control design, performed under fluoroscopic guidance, with at least 6 months of follow-up are included. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Data extraction and methodological quality assessment were performed. Evidence was summarized utilizing principles of best evidence synthesis. Results: A total of 21 trials were included. Of these, 7 studied caudal epidural injections, whereas transforaminal epidural injections were studied in 12 trials, and lumbar interlaminar epidural injections were studied in 10 trials, which all met inclusion criteria. Based on qualitative and quantitative analysis, which included conventional dual-arm and single-arm analysis for interlaminar epidural injections, and single-arm analysis for caudal and transforaminal epidural injections, and the approach to the epidural space, there is Level I evidence for local anesthetic and steroids, Level II for local anesthetic alone for transforaminal and interlaminar approaches, and Level II for the caudal approach with steroids or local anesthetic alone for short-and long-term relief. Limitations: There is a paucity of literature with intermediate or long-term relief of at least 6 months with appropriate outcome parameters. Conventional dual-arm meta-analysis was feasible only for interlaminar epidural injections. Conclusion: Epidural injections with local anesthetic and steroids showed Level I evidence for transforaminal and interlaminar approaches, whereas with local anesthetic alone Level II evidence was demonstrated. In contrast, caudal epidural injections showed Level II evidence with local anesthetic with steroids or local anesthetic alone.
KW - Caudal epidural injections
KW - Chronic low back pain
KW - Epidural injections
KW - Interlaminar epidural injections
KW - Local anesthetic
KW - Lumbar disc herniation
KW - Lumbar radiculopathy
KW - Sciatica
KW - Steroids
KW - Transforaminal epidural injections
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U2 - 10.36076/ppj.2021.24.425
DO - 10.36076/ppj.2021.24.425
M3 - Review article
C2 - 34554683
AN - SCOPUS:85117008879
SN - 1533-3159
VL - 24
SP - 425
EP - 440
JO - Pain physician
JF - Pain physician
IS - 6
ER -