Comparative Effectiveness of Lumbar Transforaminal Epidural Steroid Injections with Particulate Vers

oreosandsake

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http://onlinelibrary.wiley.com/doi/10.1111/pme.12325/abstract

David J. Kennedy MD1,*, Christopher Plastaras MD2, Ellen Casey MD3, Christopher J. Visco MD4, Joshua D. Rittenberg MD5, Bryan Conrad PhD6, James Sigler MD7, Paul Dreyfuss MD8Article first published online: 2 JAN 2014

Abstract
Background
Lumbar transforaminal epidural injections are commonly utilized to treat radicular pain due to intervertebral disc herniation.
Objective
This study aims to determine if there was a major difference in effectiveness between particulate and nonparticulate corticosteroids for acute radicular pain due to lumbar disc herniation.

Design
A multicenter, double blind, prospective, randomized trial on 78 consecutive subjects with acute uni-level disc herniation resulting in unilateral radicular pain. All subjects received a single level transforaminal epidural steroid injection with either dexamethasone or triamcinolone. Repeat injections were allowed as determined by the blinded physician and subjects. Primary outcomes included: number of injections received, surgical rates, and categorical pain scores at 2 weeks, 3 months, and 6 months. Secondary outcomes included mean Oswestry Disability Index.

Results
Both triamcinolone and dexamethasone resulted in statically significant improvements in pain and function at 2 weeks, 3 months, and 6 months, without clear differences between groups. The surgical rates were comparable with 14.6% of the dexamethasone group and 18.9% of the triamcinolone group receiving surgery. There was a statistically significant difference in the number of injections received, with 17.1% of the dexamethasone group receiving three injections vs only 2.7% of the triamcinolone group.

Conclusions
Transforaminal epidural corticosteroid injections are an effective treatment for acute radicular pain due to disc herniation, and frequently only require 1 or 2 injections for symptomatic relief. Dexamethasone appears to possess reasonably similar effectiveness when compared with triamcinolone. However, the dexamethasone group received slightly more injections than the triamcinolone group to achieve the same outcomes.
 

clubdeac

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Ahhh finally a study to show what we all knew. I'd be interested in the doses as well?
 

Taus

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How do you call it equivalent if you need additional injections?
Also, curious to read how "acute" the acute radics were... ie natural history occurring
 
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oreosandsake

oreosandsake

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How do you call it equivalent if you need additional injections?
Also, curious to read how "acute" the acute radics were... ie natural history occurring

I haven't pulled the paper, BUT from what i remember when i saw it presented, i think their % reduction in pain was similar... (80%?)

and the conclusion was that almost 1/5 needed/got a 3rd injection (with dex) within a 6 month f/u period to maintain that same level of continued pain relief
 

Ducttape

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assuming the "worst case" scenario -
120 mg triamcinolone is roughly 120 mg prednisone. 30 mg dexamethasone is roughly 200 mg prednisone, and 45 mg dexamethasone is roughly 300 mg prednisone.

balance out the increased amount of steroids and the extra injection with the probable decreased risk of catastrophic intravascular event (apparently the lower surgical rates for dex is not clinically significant).
 

clubdeac

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Not equivalent doses... 60mg kenalog is more like ~11mg dexamethasone. Why did they use nonequivalent doses?
 

DOctorJay

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They wanted to keep volume of injectate similar.
 
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lobelsteve

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With results that close in a group of only 78 patients, not much power to detect a difference can be had. The groups may not have been equal to start with, as 46% of triamc group had extrusions and 27% of dex group had extrusions. Outcome measures were NRS, ODI, 50% pain relief reported.