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Facet vs. Epidural Injection - Spinal Injections
The efficacy of epidural and facet joint injections has been assessed utilizing multiple solutions including saline, local anesthetic, steroids, and others. The responses to these various solutions have been variable and have not been systematically assessed with long-term follow-ups.
Randomized trials utilizing a true active control design were included. The primary outcome measure was pain relief and the secondary outcome measure was functional improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the criteria developed by the American Society of Interventional Pain Physicians ASIPP for assessing interventional techniques. An evidence analysis was conducted based on the qualitative level of evidence Level I to IV.
A total of 31 trials met the inclusion criteria. There was Level I evidence that local anesthetic with steroids was effective in managing chronic spinal pain based on multiple high-quality randomized controlled trials. The evidence also showed that local anesthetic with steroids and local anesthetic alone were equally effective except in disc herniation, where the superiority of local anesthetic with steroids was demonstrated over local anesthetic alone.
This systematic review showed equal efficacy for local anesthetic with steroids and local anesthetic alone in multiple spinal conditions except for disc herniation where the superiority of local anesthetic with steroids was seen over local anesthetic alone. The increasing prevalence of spinal pain and disability, and the explosion of health care costs are major issues for the US and the world. A study of US Burden of Disease Collaborators showed spinal pain occupying three of the first five categories of disability.
In addition, the prevalence of persistent pain is high, especially in the elderly and it is closely associated with functional limitations.
Various diagnostic and treatment modalities have been increasingly utilized including surgery, imaging, physical therapy, drugs, and interventional techniques, and have been increasing rapidly.
They reported that Medicare recipients who received spinal interventional techniques increased The overall number of spinal interventional techniques performed increased by In another manuscript, Manchikanti et al.
An increase in interventional techniques along with geographic variability and variability among specialities has been demonstrated. Epidural injections are used in managing spinal pain secondary to disc herniation, spinal stenosis, postsurgery syndrome, discogenic pain not from facet or sacroiliac joints, and multiple other conditions. Facet joint injections are administered by intraarticular injections or facet joint nerve blocks.
The efficacy of epidural injections and facet joint injections has been assessed utilizing multiple solutions including saline, local anesthetics, steroids, and other drugs such as clonidine, ketamine, hypertonic sodium chloride solution, and amitriptyline. This evidence ranged from good to limited based on the pathology and treatment. The evidence from multiple assessments appears to be similar for local anesthetics alone compared with local anesthetic with steroids.
Steroids and local anesthetics have multiple mechanisms of action when injected into the epidural space; antiinflammatory effects are predominantly seen with steroids and other effects are seen with local anesthetics. The objective of this review is to characterize the role of saline and local anesthetic in these procedures and to compare their effects to those of steroids in the long-term.
The methodology for this systematic review was derived from evidence-based systematic reviews and meta-analyses of randomized trials. Furthermore, included trials had at least 25 patients in each group or described appropriate sample size calculation, enrolled patients with pain duration of at least 3 months, and followed-up for at least 1 month after treatment. Only randomized trials utilizing a true active control design with injection of either sodium chloride solution or local anesthetic or steroid into the epidural space, on the nerve root, in the joint, or facet joint nerves were included.
True placebo injections, that is, injections of inactive solutions into inactive structures, were not included. In active control trials, two different procedures or drugs are compared. For this assessment, only the trials comparing sodium chloride solution, local anesthetic, or steroids were utilized.
The rationale for assessing only the aforementioned agents is that they are the most clinically relevant medications. Further, trials where a drug was injected outside the epidural space, nerve root, or joint were excluded. This evidence will address the misconception concerning local anesthetic as a placebo or even sodium chloride solution as a pure placebo.
The interventions evaluated were caudal and interlaminar epidural injections in the cervical, thoracic, and lumbar regions; transforaminal epidural injections in the cervical, thoracic, and lumbar regions; and facet joint injections and nerve blocks in the cervical, thoracic, and lumbar regions. The primary outcome measure was pain relief; the secondary outcome measure was functional improvement. The search strategy emphasized chronic neck, thoracic, low back, and upper extremity pain; lower extremity pain; and chest wall pain treated with epidural or facet joint interventions.
Chronic low back pain or chronic back pain or chronic neck pain or disc herniation or discogenic pain or facet joint pain or herniated lumbar discs or nerve root compression or lumbosciatic pain or postlaminectomy or lumbar surgery syndrome or radicular pain or radiculitis or sciatica or spinal fibrosis or spinal stenosis or zygapophyseal and epidural injection or epidural steroid or epidural perineural injection or interlaminar epidural or intraarticular corticosteroid or nerve root blocks or intraarticular injection or periradicular infiltration or saline injection or transforaminal injection or corticosteroid or methylprednisolone or facet joint or medial branch block ; Sort by: The literature search, selection of trials, and methodological quality assessment were performed by at least two authors for each task.
The allocation of trials for methodological quality assessment was distributed among the authors. Any discrepancies were resolved by consensus and the primary LM and senior JH authors.
Trials scoring 8—12 on Cochrane review criteria or 32—48 on ASIPP criteria were considered high quality, trials scoring 4—7 on Cochrane review criteria or 20—31 on ASIPP criteria were considered moderate quality, and studies scoring less than 4 on Cochrane review criteria or less than 20 on ASIPP criteria were considered low quality.
A meta-analysis was conducted if there were more than two trials that were condition-specific and homogeneous. Analysis of the evidence was based on the condition, region, and modality e. In another trial,[ ] forceful injection was assessed.
One facet joint nerve block trial compared two different modalities. The primary authors of manuscripts being assessed were not involved in the methodological quality assessment. All disagreements between reviewers were resolved by the primary and senior authors LM and JH. The flow diagram illustrating published literature evaluating various solutions in epidural and facet joint injections. Methodological quality assessment of randomized trials utilizing Cochrane review criteria. There was no homogeneity among the 31 trials meeting the inclusion criteria for methodological quality assessment when the region, technique, solutions injected, and use of fluoroscopy were considered.
Of the 31 trials, 13 trials by Manchikanti et al. Thus, a meta-analysis was not feasible. Furthermore, the trials were all performed by one group of authors in the same setting with similar protocols. Similarly, four facet joint nerve block manuscripts also had similarities;[ , , , ] they were performed in the same setting, but for different regions, by the same group of authors.
Consequently, none of them met the criteria for homogeneity so as to be included in a meta-analysis. Study characteristics and outcomes are described in Table 4. Study characteristics and outcomes of randomized epidural and facet joint injection trials. Among those trials meeting the inclusion criteria, there were six examining the efficacy of caudal epidural injections with multiple solutions.
Four of these studies were conducted by Manchikanti et al. These studies were rated as high quality on Cochrane review criteria, with scores ranging from 10 to 11 out of 12 and IPM-QRB scores of 44 out of All patients were grouped into successful responsive or nonresponsive categories accordingly. We then calculated the number of patients with disc herniation, discogenic pain, spinal stenosis, or postsurgery syndrome who were nonresponsive to local anesthetic alone or local anesthetic with steroid.
We observed no significant differences in the patients who did not respond to either injection for any of the spinal conditions. This suggests that none of the spinal conditions influenced the response to either type of injection.
Table 4 shows the results were superior in the responsive groups in all four diagnostic categories. A limitation of these trials was that none of them included placebo controls. The authors discussed potential pathophysiologic mechanisms for the efficacy of local anesthetic with steroids. Long-term improvement seen with both types of injections and may be attributed to previously described mechanisms of action. The study by Sayegh et al. This trial showed significant improvement for both local anesthetic, and local anesthetic plus steroids; however, steroids were shown to be superior, in that they provided faster, higher quality, and longer-lasting relief compared with local anesthetic alone.
This study included patients with acute and subacute sciatica. The trial was criticized for flaws in its design and conduct. In conclusion, there was Level I evidence supported by multiple, relevant high-quality randomized controlled trials[ , , , ] and one moderate to high-quality trial[ ] reporting the efficacy of local anesthetics with steroids in managing chronic low back and lower extremity pain with a caudal approach.
There was also Level I evidence, based on multiple, relevant high-quality randomized controlled trials,[ , , ] showing equal effectiveness for local anesthetic alone or local anesthetic with steroids, with one high-quality trial showing that local anesthetic alone or local anesthetic with steroids are equally effective[ ] and one moderate to high-quality trial[ ] reporting the superiority of local anesthetic with steroids.
There were eight randomized controlled trials assessing the efficacy of multiple solutions used in lumbar transforaminal administration. The characteristics of these studies were considerably different with varying protocols, multiple injections of solutions, and follow-up periods ranging from 1 month to 2 years.
The study included patients with acute and subacute disc herniations and was rather small, with just 30 patients in the local anesthetic alone group and 28 patients in the local anesthetic with steroids group. However, the follow-up period was just one month.
This trial also showed a lack of effectiveness for sodium chloride solution when it was utilized as a true placebo injected away from the nerve root, and a significant effect when sodium chloride solution was injected transforaminally, even though this was still much inferior to local anesthetic with steroids. In a large trial, Karppinen et al.
This trial showed rather surprising effects in favor of sodium chloride solution at 3 and 6 months, with no significant difference noted at one year. In a subgroup analysis, the authors reported the efficacy of transforaminal steroids with local anesthetic compared with sodium chloride solution in disc protrusions. Nam and Park[ ] conducted a small study assessing the role of transforaminal epidural injections in lumbar spinal stenosis in 36 patients, with 19 receiving lidocaine and 17 receiving lidocaine with steroids with a short-term follow-up of 3 months.
This study showed positive results for local anesthetic with steroids and local anesthetic alone but a superiority for local anesthetic with steroids. These patients with disc herniation had improvement in all parameters: Pain intensity, function, and medication reduction.
Overall this trial showed both local anesthetic alone and local anesthetic with steroid were effective; however, local anesthetic with steroid was superior. They reported superior results for sciatica with similar efficacy for local anesthetic alone or with steroids. There was Level I evidence, based on multiple, relevant high-quality randomized controlled trials,[ 27 , , , ] that local anesthetic with steroids provides significant improvement in transforaminal epidural injections, and that local anesthetic alone and local anesthetic with steroids are equally effective.
There was also Level III evidence that local anesthetic with steroids was superior to local anesthetic alone based on one high-quality randomized trial[ 52 ] with short-term follow-up and one moderate- to high-quality randomized trial. There were six randomized controlled trials assessing the efficacy of multiple solutions used in lumbar interlaminar epidurals.
Three of these studies were conducted by Manchikanti et al. The studies included a total of patients to assess the efficacy of local anesthetic alone or local anesthetic with steroids in lumbar disc herniation, lumbar discogenic pain without facet joint or sacroiliac joint pain, and lumbar central spinal stenosis.
The study period for each was 2 years. These studies were rated as high quality based on Cochrane review criteria, with all of them scoring 10 out of In these manuscripts, the study subcategories were identified as responsive and nonresponsive groups. The number of patients in the nonresponsive category who received interlaminar epidural injections of local anesthetic only included 10 who had disc herniation, five who had discogenic pain, and nine patients who had central stenosis.
In the corresponding nonresponsive local anesthetic with steroids category, the number of patients were: