ASIPP Practice Guidelines - Pain Physician

Manchikanti et al • ASIPP Practice Guidelines
56
study (564). Carette et al (258) also failed to include local
anesthetic in the injection. In addition, Carette et al (258)
used the same target level of epidural injection in all patients
irrespective of location or pathology and discounted
the short term facilitating effects of epidural steroid injections.
There were also no structured co-interventions (258).
Cuckler et al (560) included patients with prior surgery.
They also evaluated responses at 24 hours which was felt
to be inappropriate as it was quite a short period over which
to evaluate the effectiveness of an invasive procedure and
the anti-inflammatory effect of long-acting steroid preparation.
In addition, they also made injections at the L3/4
level in all of the patients rather than injecting close to the
site of pathology. Bush and Hillier (571) study was not
randomized and there were no outcome parameters.
Fukusaki et al (580) utilized three epidural injections in a
one week period with no pharmacologic basis, and failed
to enter the epidural space in a significant number of patients.
Interestingly none of the controlled studies were
performed under fluoroscopic visualization.
Numerous uncontrolled trials reported good results in 18%
to 90% of patients receiving lumbar epidural steroid injections.
Berman et al (583) reported good to excellent results
at three months, six months, and one year in 87%,
77% and 69% of patients, respectively. Brown (572) reported
even better results with 80% relief at one year. Other
selective uncontrolled trials also reported six months of
relief in approximately 60% of the patients, and 1 year
relief in 36% of the patients (573-578). Pawl et al (588),
in evaluating the records of 136 patients with typical radicular
symptoms reported that 29 patients or 80% indicated
that the relief of pain from epidural steroid injection was
50% or more, and 50% of the patients were able to avoid
surgery with the help of epidural injections. Various other
evaluations have shown success rates with cervical epidural
injections varying from 64% to 79% for less than three
months, 50% to 68% for 3 to 6 months, and 25%-68% for
over 6 months (584-586, 591). Manchikanti et al (553)
compared blind lumbar interlaminar epidural steroid injections
with fluoroscopically directed caudal and transforaminal
injections and concluded that blind interlaminar
epidural injections were not cost effective.
In terms of quality of the 13 studies considered in the
interlaminar lumbar and cervical epidural steroid injections,
two were of high quality (258, 567); six were of moderate
quality (560, 561-563, 566, 568), whereas remaining five
were of low quality (564, 565, 569-571). Of the 13 studies,
three of nine interlaminar lumbar epidural steroid injections
and three of three cervical epidural steroid injections
were judged to be positive, while the remaining were
considered negative (Table 11). Thus, evidence from controlled
studies is predominantly negative for lumbar
interlaminar and positive for cervical interlaminar epidural
injections. However, multiple observational studies
showed positive results. Hence, type and strength of efficacy
evidence is level III to IV moderate to limited. Level
III - moderate is defined as evidence from well-designed
trials without randomization, single group pre-post, cohort,
time series, or matched case controlled studies. Level IV
- limited is defined as evidence from well-designed nonexperimental
studies from more than one center or research
group.
Transforaminal Epidural Injections: Caudal epidural
injection of drugs was introduced as the first type of entry
into the epidural space in 1901, and transforaminal epidural
injection was introduced as the first and earliest use of
epidural steroids (315, 316). In 1952, Robechhi and Capra
(315) administered periradicular injection of hydrocortisone
into the first sacral nerve root and reported relief of
lumbar and sciatic pain in a woman in the Italian literature.
Subsequently, Lievre and colleagues (316) also reported
transforaminal injection of steroids into the first
sacral nerve root, in the French literature. The sacral transforaminal
epidural injection of steroids was popularized
largely in the Italian literature (315, 613-618), and to a
lesser extent, in the French literature (316, 619-621). There
were no significant American reports until 1971, when
McNab described the diagnostic value of selective nerve
root infiltration in patients with suspected radicular etiology
of pain (405). In contrast to reports of caudal and
interlaminar epidural injections, reports of transforaminal
injections are sparse in the literature (622-631). Review
of the literature showed three prospective, randomized
controlled, trials (622-624); two prospective evaluations
(571, 625); and multiple retrospective studies (415, 553,
609, 626-628) (Table 12).
Riew et al (622), in a prospective, randomized, controlled,
double-blinded study, evaluated the effectiveness of transforaminal
epidural cortical steroids in subjects with disc
herniations and/or spinal stenosis. The study included 55
patients with disc herniations or spinal stenosis referred
for surgical evaluation. All subjects had clinical indications
for surgery, and radiographic confirmation of nerve
root compression. All had failed a minimum of 6 weeks of
conservative care or had unrelenting pain. Exclusion criteria
consisted of patients who had sustained trauma, patients
with evidence of other serious diseases, patients demonstrating
adverse reactions to the medications employed
Pain Physician Vol. 4, No. 1, 2001