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Практична медицина I Practical Medicine
БШЬ.
СуГЛОБИ. JOINTS. I ХРЕБЕТ SPINE I
УДК616.8-085.2.3 DOI: 10.22141/2224-1507.9.1.2019.163059
V.I. Smolanka1, V.M. Fedurtsia2, B.B. Pavlov3
Uzhgorod National University, Uzhgorod, Ukraine
2Uzhgorod Regional Center of Neurosurgery and Neurology, Uzhgorod, Ukraine 3Neuromed Clinic, Kyiv, Ukraine
Epidural steroid injections in chronic discogenic low back pain treatment
For cite: Bol', sustavy, pozvonocnik. 2019;9(1):59-64. doi: 10.22141/2224-1507.9.1.2019.163059
Abstract. Background. Low back pain (LBP) remains one of the most common problems of the spinal column and chronic pain syndromes. It is a frequent cause of disability, and the treatment expense is quite high. Nowadays, there are three methods of treatment for discogenic pain: physiotherapy, drug therapy and surgery. Interventional treatment of discogenic pain by injecting drugs into the epidural space can equally be attributed to both minimally invasive surgery and active target therapy. The purpose of this study is to research the dynamic of pain among patients suffering from chronic discogenic low back pain taking epidural steroid injections as the treatment. Materials and methods. The retrospective study included 74 patients aged from 25 to 83 years (53.86 ± 14.27) treated from 2015 to 2017 in Neuromed Clinic and Uzhgorod Regional Center of Neurosurgery and Neurology. After a comprehensive examination, a therapeutically resistant chronic discogenic LBP was diagnosed in all patients. We applied interlaminar and transforaminal injections of corticosteroids under a radiological control of the C-arm. A total of 35 (47 %) transforaminal epidural injections, or blockades and 39 interlaminar epidural blocks were performed. Depending on the localization, the manipulations performed were distributed as follows: at L5-S1 level — 36 (48 %), at L4-L5 level — 17 (23 %), at L3-L4 level — 12 (16 %) and at L2-L3 level — 9 (12 %). Pain syndrome was assessed using a 10-point visual analogue scale (VAS) before manipulation, 7 and 30 days after treatment. Results. No complications were registered. All patients have reported a pain reduction. Most patients, right before the manipulation, complained about "a very strong or unbearable" pain (VAS 7.01 ± 0.86), and a week after the procedure, the majority of the patients confirmed that their pain turned to a "mild or sometimes moderate" (VAS 3.68 ± 0.87). A similar trend persisted a month after the manipulation (VAS 1.98 ± 1 01). Conclusions. Epidural injection of corticosteroids is a safe and effective way to treat a chronic lower back pain. This intervention technique can significantly reduce the intensity of suffering. Keywords: low back pain; discogenic pain; epidural corticosteroids
Introduction
Low back pain (LBP) remains one of the most common problems of the spinal column and chronic pain syndromes in general [1]. In the US, it's one of the prevalent causes of long-term disabilities [2]. In Ukraine, up to 20 % of the working population get permanently disabled due to this condition [3]. In the Great Britain, 37 % of insurance payments were LBP-associated, while in the Netherlands, the cumulative annual LBP costs make 4, 2 billion euros [4, 5]. Direct and indirect expenses incurred by the US due to LBS patients account for an astronomical annual amount of 200 billion dollars [6]. Nowadays, there are three methods
of treatment for discogenic pain: physiotherapy, medication and surgery. The firs one is usually performed at the early stage of degenerative-dystrophic spinal changes, and as a part of rehabilitative complex. A significant disadvantage of the conservative pharmacological therapy is an absence of direct influence on the pathological substrate, reducing its effectiveness and promoting the chronization. Moreover, pharmacological therapy is usually associated with serious side effects. Surgical methods, lacking the above-mentioned disadvantages, have a higher risk of intra- and post-operative complications, recurrences, aggravation of the condition and even disability [7]. Interventional treat-
© «Бшь. Суглоби. Хребет» / «Боль. Суставы. Позвоночник» / «Pain. Joints. Spine» (<ЯоГ, sustavy, pozvonocnik»), 2019 © Видавець Заславський О.Ю. / Издатель Заславский А.Ю. / Publisher Zaslavsky O.Yu., 2019
Для корреспонденции: Павлов Борис Борисович, врач-нейрохирург, клиника «Нейромед», ул. Енисейская, 8, г. Киев, 03028, Украина; е-mail: [email protected]; контактный телефон: +380976205257.
For correspondence: Borys Pavlov, neurosurgeon, "Neuromed" Clinic, Yenisyeyskaya st., 8, Kyiv, 03028, Ukraine; e-mail: [email protected]; phone: +380976205257.
ment of discogenic pain by injecting drugs into the epidural space can equally be attributed to both minimally invasive surgery and active targeted therapy.
Epidural steroid injections were first performed to treat the discogenic LBP and radiculopathies in the USA in 1950s, and since then are most often used to tackle pain [8, 9, 10, 11]. Corticosteroids suppress inflammatory mediators (Phospholipases A2 (PLA2s)) in the epidural space, prevent Group C unmyelinated fibers ectopic damage and reduced centralized sensitization [12, 13, 14]. In the clinical practice, there are three methods of epidural injection: interlaminar, transforaminal and caudal one. Axial and radicular pains originate in the dural funnel of the spinal nerve and posterior radix's ganglia. It is only logical to suggest that a transforaminal injection is preferable as the medication is delivered straight into the anterior epi-dural space, where the disc-radicular conflict occurs [15, 16]. However, the studies show a similar degree of efficacy for all three methods (Level of evidence: II) [17, 18]. The technical characteristics of manipulations vary in terms of their complexity and potential complications. Thus, a choice of method is up to the healthcare provider relying on the individual conditions. Among the essential requirements of the procedure there are an X-ray control (C-arch, Q-arch, CT), adequate venous access and vital function monitoring. It is necessary to provide at least an hour-long observation after the manipulation [12, 19]. For this procedure, several different corticosteroid types may be recommended [20]. Their combination with a local anesthetics is also up to the healthcare provider's decision [19].
The purpose of this study is to research the dynamic of pain among patients suffering from chronic disco-genic low back pain taking epidural steroid injections as the treatment.
Materials and methods
The retrospective study included 74 patients aged from 25 to 83 years (53.86±14,27) treated from 2015 to 2017 in "Neuromed" Clinic (Kyiv) and Uzhgorod Regional Center of Neurosurgery and Neurology. Among them 46 were female (62%) and 28 were male (37%). All the examined patients suffered from LBP irradiating into the lower limbs. The symptoms lasted over 6 weeks, i.e. the pain was chronic. During the pre-procedural period, the patients had undergone a conservative treatment with NSAIDs, Pregabalin Gabapentin, physiotherapeutic procedures with no apparent effect. All of the patients had had a complex standard examination: functional spondilography, MRI, X-ray densitometry, CT, neurological evaluation. Patients with lumbosacral disk extrusions up to 7 mm and minor spinal stenosis were included in the study. Among the exclusion criteria there were earlier operations of the respective spinal-locomotor segment; epidural steroid injections in the previous 2 months; a long-term corticosteroid therapy per os in case of concomitant
pathologies; pregnancy; cognitive disorders; anti-coagulant treatment; osteoporosis. Pain syndrome was assessed using a 10-point visual analogue scale (VAS) before manipulation, 7 and 30 days after it was carried out. Statistical analysis was performed using Statistica 10 software (StatSoft. Inc. USA). Before undergoing the procedure, all of the patients signed the Informed consent form №003-6/o. Epidural injections were made in the surgery with the patient lying prone. Flu-oroscopic control was carried out by means of C-arch. We applied interlaminar and transforaminal injections of corticosteroids. The method was chosen depending on the prevailing (either uni- or bilateral) root symptomatic complex and anatomical spinal features (interlaminar and intervertebral space sizes).
While performing the interlaminar injections, the following algorithm was adhered to. The patient was instructed to lie down at the X-ray-negative table. The primary fluoroscopic visualization detected the required interlaminar space. The patient's skin was treated with antiseptics while the manipulation area was demarcated with sterile films. The local anesthesia of skin and underlying tissues was performed with 1% lidocaine solution. After that, a Tuohy 18G needle for percutaneous injection was inserted along the medial line between two adjacent spinous processes in the direction of the above-located basis. As soon as the needle's point reached a yellow ligament, the mandarin was removed. Using the 'resistance loss' method, the healthcare provider used his/her syringe to penetrate the epidural space. After a negative aspirational test (no blood or spinal fluid), 0,5 — 1,0 ml of iohexol solution (350 mg/ml) were introduced to confirm epidural penetration. Control fluoroscopy was carried out both in the frontal and lateral projection (Fig. 1).
The medication contained 4 mg of dexamethasone and 4,0 ml of 0,25% lidocaine solution. After the manipulation was over, aseptic bandage was kept on the area for 4-6 hours. Post-procedural observation with an hour-long bed confinement included neurological evaluation, vital function control and awareness testing. All of the patients were recommended to keep exertions to a minimum for 3 days.
Preparation prior to a transforaminal injection of corticosteroids was similar, the only difference being a tunnel method of visualization. In this case, initial positioning is performed in the C-arch oblique projection with a 20-25° angle to the ipsilateral side. After a 1% lidocaine solution local anesthesia, a 22G needle is moved into a safe intervertebral space area. This area is a triangle with the following sides: the upper one is a vertebral arch root, the lateral one is a vertebral edge, the medial one is a spinal nerve edge. Aspirational test was performed to reveal any blood or spinal fluid. 0,5—1,0 ml of iohexol solution (350 mg/ml) were introduced to confirm epidural penetration. Control flu-oroscopy was carried out both in the frontal and lateral projection; however, the former was found more informative (Fig. 2).
Composition of medication was similar to the one used in the interlaminar injections. Post-procedural actions and recommendations did not differ either. A total of 35 (47%) transforaminal epidural injections, or blockades (TFEB) and 39 interlaminar epidural blocks (ILEB) were performed. In terms of localization, the performed manipulations were distributed as follows: at the L5S1 level - 36 (48%), at the L4L5 level - 17 (23%), at the L3L4 level - 12 (16%) and at the L2L3 level - 9 (12%) (Fig. 3).
Results and discussion
No septic or hemorrhagic complications were registered. There were no perforations of spinal cord sheath, or motor block reported in the examined group.
All patients reported a pain reduction. Atatistical data show that most patients, right before the manipulation, complained of a "very strong or unbearable" pain (VAS 7,01 ± 0,86), and a week after the procedure, the majority confirmed that their pain turned to a "light or sometimes moderate" (VAS 3,68 ± 0,87). This description often referred to an inevitable discomfort following the injection. A similar trend persisted a month after the manipulation (VAS 1,98 ± 1,01) though becoming less pronounced (Fig. 4).
In this regard, we need to emphasize the most pronounced pain reduction in the middle-aged and young patients. It is attributed to the more debilitating degenerative-dystrophic spinal changes in the elderly people and increased centralized sensitization
Fig. 1. Interlaminar epidural corticosteroid injection at the L5S1 level (on the left: Tuohy needle is introduced into the interlaminar space; on the right: X-ray control of contrasting agent spread in the epidural space, lateral projection)
Fig. 2. Transforaminal epidural corticosteroid injection at the left L4L5 level (on the left: 22G needle is introduced into the intervertebral space; on the right: X-ray control of contrasting agent spread in the epidural space, frontal projection)
Fig. 3. Distribution of patients according to the level of manipulation
□ Mean
□ Mean ± SD
I Mean ± 1,96*SD
before manipulation a month after manipulation 7 days after manipulation
level. All the employed patients returned to their jobs in due time.
Unfortunately, our study was not without limitations: first and foremost, absence of a placebo group which we considered unethical taking into account the pronounced pain syndrome. Secondly, medication spread in the epidural space was evaluated according to the contrasting agent, though their characteristics differ to a certain extent.
Conclusions
Epidural injection of corticosteroids is a safe and effective way to treat a chronic lower back pain. This intervention technique can significantly reduce the intensity of suffering. It is a reasonable alternative to a long-term NSAID treatment and to an early and unnecessary surgery.
Information of the authors' individual contributions.
Smolanka VI. Concept and design of the study.
Fedurtsia VM. Collection and processing of study materials.
Pavlov BB. Analysis of the data, writing of the text.
Conflicts of interests. Authors declare the absence of any conflicts of interests that might be construed to influence the results or interpretation of their manuscript.
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Fig. 4. Dynamics of pronounced pain syndrome: before
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(Mean ± 1,96*SD) presented according to a 10-point visual analogue scale (VAS)
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Received 01.02.2019 ■
Смоланка В.11, Федурця В.М2, Павлов Б.Б3 'Ужгородський нац'юнальний yHieepcumem, м. Ужгород, Украша 2Ужгородський обласний центр нейрох'рург'йта неврологи, м. Ужгород, Украна 3Кл'ш'!ка «Нейромед», м. Кив, Украна
Ешдуральне введення кортикостероВДв у лшуванж хрошчного дискогенного болю в нижнш частит спини
Резюме. Актуальтсть. Бшь у нижнш частит спини за-лишаеться одтею з найпоширетших проблем хребетного стовпа та хрошчних больових синдромiв взагаль Вона е частою причиною втрати працездатносл, а витрати на неГ вражають значтстю сум. На сьогодт юнують три на-прямки лжування дискогенного болю — фiзiотерапевтич-ний, медикаментозний i ирурпчний. Iнтервенцiйне лжу-вання дискогенного болю шляхом уведення лiкарських препаралв у епiдуральний простiр однаковою мiрою мож-на вщнести як до малошвазивно'Г хiрургii, так i до активно! таргетной терапи. Мета дослгдження — вивчити динамо больового синдрому в пацiентiв, яш страждають вщ хронiчного дискогенного болю в нижнш частиш спини, при використанш в Гх лiкуваннi етдуральних стероГдних iн'екцiй. Матерiали та методы. У ретроспективне досль дження включено 74 пащенти вiком вщ 25 до 83 ротв (се-реднш вiк — 53,86 ± 14,27 року), пролшованих iз 2015 по 2017 рж у клiнiцi «Нейромед» м. Киева та Ужгородсько-му обласному цен^ нейрохирурги та неврологи. У вск до-слiджуваних тсля комплексного обстеження дiагносто-вано терапевтично-резистентний хрошчний дискоген-ний бiль у нижнш частиш спини. Нами застосовувалося штерламшарне та трансфорамшальне введення кортико-
стерощв пiд радiологiчним контролем С-дуги. Всього бу-ло виконано 35 (47 %) трансфорамшальних епiдуральних ш'екцш, або блокад, i 39 штерламшарних епщуральних блокад. За локалiзацiею проведет маншуляци було роз-под1лено наступним чином: на рiвнi L5-S1 — 36 (48 %), на рiвнi L4-L5 — 17 (23 %), на рiвнi L3-L4 — 12 (16 %) i на рiвнi L2-L3 — 9 (12 %). Больовий синдром оцшювався за 10-бальною вiзуально-аналоговою шкалою (ВАШ) перед маншулящею, через 7 i 30 дшв пiсля Г! проведення. Результаты. Ускладнень не зареестровано. Абсолютно вс паць енти вщзначали зниження больового синдрому. Бiльшiсть пацiентiв до маншуляци характеризували свiй б1ль як «ду-же сильний, на межi з нестерпним» (7,01 ± 0,86 за ВАШ), а через тиждень тсля процедури бiльшiсть вже описували больовi вщчуття як «легы, часом помiрнi» (3,68 ± 0,87 за ВАШ). Така тенденц1я зберiгалася i через мюяць пiсля ма-нiпуляцii (1,98 ± 1,01 за ВАШ). Висновки. Епщуральне уведення кортикостерощв е безпечним i ефективним способом лжування хронiчного болю в нижнш частит спини. Ця штервенцшна методика дозволяе ютотно знизити ш-тенсившсть страждання.
Ключовi слова: б1ль у нижнш частит спини; дискоген-ний бшь; епщуральне введення кортикостеро'Гщв
Смоланка В.И.1, Федурця В.М.2, Павлов Б.Б.3
Ужгородский национальный университет, г. Ужгород, Украина
2Ужгородский областной центр нейрохирургии и неврологии, г. Ужгород, Украина
3Клиника «Нейромед», г. Киев, Украина
Эпидуральное введение кортикостероидов в лечении хронических дискогенных
болей в нижней части спины
Резюме. Актуальность. Боль в нижней части спины остается одной из самых распространенных проблем позвоночного столба и хронических болевых синдромов в целом. Она является частой причиной утраты трудоспособности, а затраты на ее лечение поражают внушительностью сумм. На сегодняшний день существуют три направления лечения дискогенной боли — физиотерапевтический, медикаментозный и хирургический. Интервенционное лечение дискогенной боли путем введения лекарственных препаратов в эпидуральное пространство в одинаковой степени можно отнести как к малоинвазивной хирургии, так и к активной таргетной терапии. Цель исследования — изучить динамику вертебрального болевого синдрома у пациентов, страдающих хроническими дискоген-ными болями в нижней части спины, при использовании в их лечении эпидуральных стероидных инъекций. Материалы и методы. В ретроспективное исследование включены 74 пациента в возрасте от 25 до 83 лет (средний возраст — 53,86 ± 14,27 года), пролеченных с 2015 по 2017 год в клинике «Нейромед» г. Киева и Ужгородском областном центре нейрохирургии и неврологии. У всех испытуемых после комплексного обследования диагностированы терапевтически резистентные хронические дискогенные боли в нижней части спины. Нами применялось интерламинарное и трансфораминальное введение кортикостеро-
идов под радиологическим контролем С-дуги. Всего было выполнено 35 (47 %) трансфораминальных эпидуральных инъекций, или блокад, и 39 интерламинарных эпидуральных блокад. По локализации проведенные манипуляции распределились следующим образом: на уровне L5-S1 — 36 (48 %), на уровне L4-L5 — 17 (23 %), на уровне L3-L4 — 12 (16 %) и на уровне L2-L3 — 9 (12 %). Болевой синдром оценивался по 10-балльной визуально-аналоговой шкале (ВАШ) перед манипуляцией, спустя 7 и 30 дней после ее проведения. Результаты. Осложнений не зарегистрировано. Абсолютно все пациенты отмечали снижение болевого синдрома. Большинство пациентов до манипуляции характеризовали свою боль как «очень сильную, на грани с невыносимой» (7,01 ± 0,86 по ВАШ), а спустя неделю после процедуры большинство уже описывало болевые ощущения как «легкие, временами умеренные» (3,68 ± 0,87 по ВАШ). Подобная тенденция сохранялась и через месяц после манипуляции (1,98 ± 1,01 по ВАШ). Выводы. Эпидуральное введение кортикостероидов является безопасным и эффективным способом лечения хронических болей в нижней части спины. Эта интервенционная методика позволяет существенно снизить интенсивность страдания.
Ключевые слова: боль в нижней части спины; дискогенная боль; эпидуральное введение кортикостероидов
