L/S ESIs: Caudal vs TF vs IL

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ampaphb

Interventional Spine
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[URL='http://www.ncbi.nlm.nih.gov/pubmed/27630917#']J Clin Diagn Res. 2016 Jul;10(7):RC05-11. doi: 10.7860/JCDR/2016/18208.8127. Epub 2016 Jul 1.
Efficacy of Epidural Steroid Injection in Management of Lumbar Prolapsed Intervertebral Disc: A Comparison of Caudal, Transforaminal and Interlaminar Routes.
Pandey RA1.
Author information

Abstract
INTRODUCTION:

Epidural steroid is an important modality in the conservative management of prolapsed lumbar disc and is being used for over 50 years. However, controversy still persists regarding their effectiveness in reducing the pain and improving the function with literature both supporting and opposing them are available.

AIM:
To study the efficacy of epidural steroid injection in the management of pain due to prolapsed lumbar intervertebral disc and to compare the effectiveness between caudal, transforaminal and interlaminar routes of injection.

MATERIALS AND METHODS:
A total of 152 patients with back pain with or without radiculopathy with a lumbar disc prolapse confirmed on MRI, were included in the study and their pre injection Japanese Orthopaedic Association (JOA) Score was calculated. By simple randomization method (picking a card), patients were enrolled into one of the three groups and then injected methyl prednisone in the epidural space by one of the techniques of injection i.e. caudal, transforaminal and interlaminar. Twelve patients didn't turn up for the treatment and hence were excluded from the study. Remaining 140 patients were treated and were included for the analysis of the results. Eighty two patients received injection by caudal route, 40 by transforaminal route and 18 by interlaminar route. Post injection JOA Score was calculated at six month and one year and effectiveness of the medication was calculated for each route. The data was compared by LSD and ANOVA method to prove the significance. Average follow-up was one year.

RESULTS:
At one year after injecting the steroid, all three routes were found to be effective in improving the JOA Score (Caudal route in 74.3%, transforaminal in 90% and interlaminar in 77.7%). Transforaminal route was significantly more effective than caudal (p=0.00) and interlaminar route (p=0.03) at both 6 months and one year after injection. No significant difference was seen between the caudal and interlaminar route (p=0.36).

CONCLUSION:
The management of low back pain and radicular pain due to a prolapsed lumbar intervertebral disc by injecting methyl prednisone in epidural space is satisfactory in the current study. All three injection techniques are effective with the best result obtained by transforaminal route.

http://www.ncbi.nlm.nih.gov/pubmed/27630917
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Last edited:
The Spine Journal
Volume 16, Issue 8, August 2016, Pages 928–934


10208||
Clinical Study

Predictors of the efficacy of epidural steroid injections for structural lumbar degenerative pathology
Abstract

Background
Lumbar epidural steroid injection (LESI) is a valuable therapeutic option when administered to the appropriate patient, for the appropriate disease process, at the appropriate time. There is considerable variability in patient-reported outcomes (PROs) after LESI, creating uncertainty as to who will benefit from the therapy and who will not.

Purpose
We set out to identify patient attributes, which are important predictors for the achievement of a minimum clinically important difference (MCID) in the Oswestry Disability Index (ODI) after LESI.

Study Design
A prospective cohort study was carried out.

Patient Sample
A total of 239 consecutive patients undergoing LESI for back-related disability, back pain (BP), and leg pain (LP) associated with degenerative pathology comprised the patient sample.

Outcome Measures
Baseline and 3-month patient self-reported ODI, numeric rating scale-BP and LP, Euro-Qol-5D, and Short Form (SF)-12 scores were recorded.

Methods
A total of 239 consecutive patients undergoing LESI for degenerative pathology over a period of 2 years who were enrolled into a prospective web-based registry were included in the study. Using the previously reported anchor-based approach, an MCID threshold of 7.1% was established for ODI after LESI. Each enrolled patient was then dichotomized as a “responder” (achieving MCID) or a “non-responder.” Multiple logistic regression analysis was then performed, with the achievement of MCID serving as the outcome of interest. Candidate variables included in the regression analyses were age, gender, employment, insurance type, smoking status, preoperative ambulation, preinjection narcotic use, comorbidities, predominant LP or BP symptoms, symptom duration, diagnosis, number of levels, prior surgery, baseline PROs, type of stenosis (central, lateral recesses, or foraminal), injection route (transforaminal, interlaminar, or caudal), and number of injections. Subsequently, we also randomly selected 80% of the patients to serve as the training data for a multiple logistic regression model. Once this predictive model was built, it was validated using the remaining 20% of patients.

Results
There were 124 (62%) patients who achieved MCID for ODI. The existence of central stenosis (p=.006), TF or IL injection route (p=.02) compared with caudal epidural steroid injection, higher baseline ODI (p=.00001), and a diagnosis of disc herniation (p=.02) increase the odds of achieving MCID for ODI at 3 months. Symptom duration for over a year (p=.006), prior surgery (p=.08), and preinjection anxiety (p=.001) decrease the odds of achieving MCID. The area under the curve (AUC) for our predictive model's receiver-operator characteristic was 0.81 when using the 80% training data set, and the AUC was 0.72 when using the 20% validation data.

Conclusion
We have identified patient attributes that are important predictors for the achievement of MCID in ODI 3 months after LESI. The use of these attributes, in the form of a predictive model for LESI efficacy, has the potential to improve decision making around LESI. Spine care providers can use the information to gain insight into the likelihood that a particular patient will experience a meaningful benefit from LESI.


Article mentions central stenosis, ODI, and TFESI/LESI are better than caudal.
 
Interesting.

Questions:
1. What is the actual JOA score?
It doesn't correlate well with the Roland-Morris disability index
http://www.ncbi.nlm.nih.gov/m/pubmed/19662468/?i=3&from=/20151256/related

2. Why so many Caudals vs TF and IL? (40 TF and 18 IL), and were any of IL parasagittal?

3. The study might not be "appropriate" in the US. Who routinely now uses methylprenisolone via TF route now?


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//Article mentions central stenosis, ODI, and TFESI/LESI are better than caudal.//
how could central stenosis be better than a caudal?
 
He's talking about predictive factors for benefit with injections... Central stenosis responds better, TF/lesi work better than Caudals...


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