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Comparison of transforaminal verse interlaminar epidural steroid injection in low back pain with lumbosacral radicular pain: a meta-analysis of the literature

International Orthopaedics Aims and scope Submit manuscript

Abstract

Objective

The object of the present meta-analysis is to compare the effectiveness of transforaminal epidural steroid injection (TFESI) and interlaminar epidural steroid injection (ILESI) for treating patients with low back pain (LBP) secondary to lumbosacral radicular pain.

Methods

A systematic search was performed in the PubMed and Embase databases and the Cochrane Library for relevant literature published through January 2016. The randomized controlled trials (RCTs) and controlled observational studies were selected, which did not only compare TFESI with ILESI but also reported the available data. The Cochrane Collaboration’s Handbook and Newcastle-Ottawa Scale (NOS) were used for the methodological quality assessments of the RCTs and observational studies respectively. The meta-analysis was performed using the Revman 5.2 software.

Results

A total of 931 patients from nine RCTs and four observational studies were subjected to meta-analysis. In primary outcomes, the TFESI patients experienced superior pain relief compared with the TFESI patients in RCTs (P = 0.01), but not in observational studies (p = 0.63). The pooled data of RCTs showed that the TFESI group presented superior clinical results in terms of visual analogue scale (VAS) than the ILESI group (p = 0.0005). Moreover, the numeric rating scale (NRS) specifically favored TFESI in the RCTs (p < 0000.1). Similar functional improvement and oswentry disability index (ODI) score were observed between TFESI and ILESI in RCTs (P = 0.62). In secondary outcomes, meta-analysis of RCTs and observational studies revealed that there were no statistically significant differences between both groups in regard to procedure frequency, surgery rate, and ventral epidural spread.

Conclusions

According to the results of meta-analysis, TFESI to manage LBP provides superior short term pain relief and equal functional improvement when compared to ILESI. It has not shown a statistically significant difference between both groups with regard to procedure frequency, surgery rate, and ventral epidural spread.

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References

  1. Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, Williams G, Smith E, Vos T, Barendregt J, Murray C, Burstein R, Buchbinder R (2014) The global burden of low back pain: estimates from the global burden of disease 2010 study. Ann Rheum Dis 73:968–974. doi:10.1136/annrheumdis-2013-204428

    Article  PubMed  Google Scholar 

  2. Manchikanti L, Abdi S, Atluri S, Benyamin RM, Boswell MV, Buenaventura RM, Bryce DA, Burks PA, Caraway DL, Calodney AK, Cash KA, Christo PJ, Cohen SP, Colson J, Conn A, Cordner H, Coubarous S, Datta S, Deer TR, Diwan S, Falco FJ, Fellows B, Geffert S, Grider JS, Gupta S, Hameed H, Hameed M, Hansen H, Helm S, Janata JW 2nd, Justiz R, Kaye AD, Lee M, Manchikanti KN, McManus CD, Onyewu O, Parr AT, Patel VB, Racz GB, Sehgal N, Sharma ML, Simopoulos TT, Singh V, Smith HS, Snook LT, Swicegood JR, Vallejo R, Ward SP, Wargo BW, Zhu J, Hirsch JA (2013) An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Phys 16:S49–S283

    Google Scholar 

  3. Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R (2003) Lost productive time and cost due to common pain conditions in the US workforce. JAMA 290:2443–2454. doi:10.1001/jama.290.18.2443

    Article  CAS  PubMed  Google Scholar 

  4. Cooper G, Lutz GE, Boachie-Adjei O, Lin J (2004) Effectiveness of transforaminal epidural steroid injections in patients with degenerative lumbar scoliotic stenosis and radiculopathy. Pain Phys 7:311–317

    Google Scholar 

  5. Pearson AM, Blood EA, Frymoyer JW, Herkowitz H, Abdu WA, Woodward R, Longley M, Emery SE, Lurie JD, Tosteson TD, Weinstein JN (2008) SPORT lumbar intervertebral disk herniation and back pain: does treatment, location, or morphology matter? Spine 33:428–435. doi:10.1097/BRS.0b013e31816469de

    Article  PubMed  PubMed Central  Google Scholar 

  6. Ng L, Chaudhary N, Sell P (2005) The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double-blind, controlled trial. Spine 30:857–862

    Article  PubMed  Google Scholar 

  7. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG (2010) Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 303:1259–1265. doi:10.1001/jama.2010.338

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Manchikanti L, Falco FJ, Singh V, Pampati V, Parr AT, Benyamin RM, Fellows B, Hirsch JA (2012) Utilization of interventional techniques in managing chronic pain in the Medicare population: analysis of growth patterns from 2000 to 2011. Pain Phys 15:E969–E982

    Google Scholar 

  9. Manchikanti L, Helm Ii S, Singh V, Hirsch JA (2013) Accountable interventional pain management: a collaboration among practitioners, patients, payers, and government. Pain Phys 16:E635–E670

    Google Scholar 

  10. Manchikanti L, Pampati V, Falco FJ, Hirsch JA (2013) Growth of spinal interventional pain management techniques: analysis of utilization trends and Medicare expenditures 2000 to 2008. Spine 38:157–168. doi:10.1097/BRS.0b013e318267f463

    Article  PubMed  Google Scholar 

  11. Bicket MC, Horowitz JM, Benzon HT, Cohen SP (2015) Epidural injections in prevention of surgery for spinal pain: systematic review and meta-analysis of randomized controlled trials. Spine J: Off J North Am Spine Soc 15:348–362. doi:10.1016/j.spinee.2014.10.011

    Article  Google Scholar 

  12. Lee JH, Moon J, Lee SH (2009) Comparison of effectiveness according to different approaches of epidural steroid injection in lumbosacral herniated disk and spinal stenosis. J Back Musculoskelet Rehab 22:83–89. doi:10.3233/bmr-2009-0220

    Article  Google Scholar 

  13. Manchikanti L, Buenaventura RM, Manchikanti KN, Ruan X, Gupta S, Smith HS, Christo PJ, Ward SP (2012) Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Phys 15:E199–E245

    Google Scholar 

  14. Boswell MV, Hansen HC, Trescot AM, Hirsch JA (2003) Epidural steroids in the management of chronic spinal pain and radiculopathy. Pain Phys 6:319–334

    Google Scholar 

  15. Kaye AD, Manchikanti L, Abdi S, Atluri S, Bakshi S, Benyamin RM, Boswell MV, Buenaventura RM, Candido KD, Cordner H, Datta S, Doulatram G, Gharibo CG, Grami V, Gupta S, Jha SS, Kaplan ED, Malla Y, Mann DP, Nampiaparampil DE, Racz GB, Raj PP, Rana MV, Sharma ML, Singh V, Soin A, Staats PS, Vallejo R, Wargo BW, Hirsch JA (2015) Efficacy of epidural injections in managing chronic spinal pain: a best evidence synthesis. Pain Phys 18:E939–e1004

    Google Scholar 

  16. Manchikanti L, Benyamin RM, Falco FJ, Kaye AD, Hirsch JA (2015) Do epidural injections provide short- and long-term relief for lumbar disc herniation? A systematic review. Clin Orthop Relat Res 473:1940–1956. doi:10.1007/s11999-014-3490-4

    Article  PubMed  Google Scholar 

  17. Meng H, Fei Q, Wang B, Yang Y, Li D, Li J, Su N (2015) Epidural injections with or without steroids in managing chronic low back pain secondary to lumbar spinal stenosis: a meta-analysis of 13 randomized controlled trials. Drug Des Dev Ther 9:4657–4667. doi:10.2147/dddt.s85524

    Google Scholar 

  18. Zhai J, Zhang L, Li M, Tian Y, Zheng W, Chen J, Huang T, Li X, Tian Z (2015) Epidural injection with or without steroid in managing chronic low back and lower extremity pain: ameta-analysis of ten randomized controlled trials. Int J Clin Exp Med 8:8304–8316

    CAS  PubMed  PubMed Central  Google Scholar 

  19. Bicket MC, Gupta A, Brown CH, Cohen SP (2013) Epidural injections for spinal pain: a systematic review and meta-analysis evaluating the “control” injections in randomized controlled trials. Anesthesiology 119:907–931. doi:10.1097/ALN.0b013e31829c2ddd

    Article  PubMed  Google Scholar 

  20. Parr AT, Diwan S, Abdi S (2009) Lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain: a systematic review. Pain Phys 12:163–188

    Google Scholar 

  21. Gupta R, Singh S, Kaur S, Singh K, Aujla K (2014) Correlation between epidurographic contrast flow patterns and clinical effectiveness in chronic lumbar discogenic radicular pain treated with epidural steroid injections Via different approaches. Korean J Pain 27:353–359. doi:10.3344/kjp.2014.27.4.353

    Article  PubMed  PubMed Central  Google Scholar 

  22. Kawu AA (2012) Epidural steroid injection in patients with lumbosacral radiculopathy in Abuja, Nigeria. J Neurosci Rural Pract 3:121–125. doi:10.4103/0976-3147.98206

    Article  PubMed  PubMed Central  Google Scholar 

  23. Lee JH, An JH, Lee SH (2009) Comparison of the effectiveness of interlaminar and bilateral transforaminal epidural steroid injections in treatment of patients with lumbosacral disc herniation and spinal stenosis. Clin J Pain 25:206–210. doi:10.1097/AJP.0b013e3181878f9e

    Article  PubMed  Google Scholar 

  24. Rezende R, Jacob Junior C, da Silva CK, de Barcellos ZI, Cardoso IM, Batista Junior JL (2015) Comparison of the efficacy of transforaminal and interlaminar radicular block techniques for treating lumbar disk hernia. Rev Bras Ortop 50:220–225. doi:10.1016/j.rboe.2015.02.016

    Article  PubMed  PubMed Central  Google Scholar 

  25. Schaufele MK, Hatch L, Jones W (2006) Interlaminar versus transforaminal epidural injections for the treatment of symptomatic lumbar intervertebral disc herniations. Pain Phys 9:361–366

    Google Scholar 

  26. Gharibo CG, Varlotta GP, Rhame EE, Liu EC, Bendo JA, Perloff MD (2011) Interlaminar versus transforaminal epidural steroids for the treatment of subacute lumbar radicular pain: a randomized, blinded, prospective outcome study. Pain Phys 14:499–511

    Google Scholar 

  27. Ackerman WE 3rd, Ahmad M (2007) The efficacy of lumbar epidural steroid injections in patients with lumbar disc herniations. Anesth Analg 104:1217–1222. doi:10.1213/01.ane.0000260307.16555.7f, tables of contents

    Article  PubMed  Google Scholar 

  28. Kamble PC, Sharma A, Singh V, Natraj B, Devani D, Khapane V (2015) Outcome of single level disc prolapse treated with transforaminal steroid versus epidural steroid versus caudal steroids. Eur Spine J: Off Publ Eur Spine Soc, Eur Spinal Deformity Soc, Eur Sec Cervical Spine Res Soc. doi:10.1007/s00586-015-3996-9

    Google Scholar 

  29. Buenaventura RM, Datta S, Abdi S, Smith HS (2009) Systematic review of therapeutic lumbar transforaminal epidural steroid injections. Pain Phys 12:233–251

    Google Scholar 

  30. Ghai B, Bansal D, Kay JP, Vadaje KS, Wig J (2014) Transforaminal versus parasagittal interlaminar epidural steroid injection in low back pain with radicular pain: a randomized, double-blind, active-control trial. Pain Phys 17:277–290

    Google Scholar 

  31. Hashemi SM, Aryani MR, Momenzadeh S, Razavi SS, Mohseni G, Mohajerani SA, Esmilijah AA (2015) Comparison of transforaminal and parasagittal epidural steroid injections in patients with radicular low back pain. Anesthesiol Pain Med 5, e26652. doi:10.5812/aapm.26652v2

    Google Scholar 

  32. Rados I, Sakic K, Fingler M, Kapural L (2011) Efficacy of interlaminar vs transforaminal epidural steroid injection for the treatment of chronic unilateral radicular pain: prospective, randomized study. Pain Med (Malden, Mass) 12:1316–1321. doi:10.1111/j.1526-4637.2011.01213.x

    Article  Google Scholar 

  33. Smith CC, Booker T, Schaufele MK, Weiss P (2010) Interlaminar versus transforaminal epidural steroid injections for the treatment of symptomatic lumbar spinal stenosis. Pain Med (Malden, Mass) 11:1511–1515. doi:10.1111/j.1526-4637.2010.00932.x

    Article  Google Scholar 

  34. Benyamin RM, Wang VC, Vallejo R, Singh V, Helm Ii S (2012) A systematic evaluation of thoracic interlaminar epidural injections. Pain Phys 15:E497–E514

    Google Scholar 

  35. Chang-Chien GC, Knezevic NN, McCormick Z, Chu SK, Trescot AM, Candido KD (2014) Transforaminal versus interlaminar approaches to epidural steroid injections: a systematic review of comparative studies for lumbosacral radicular pain. Pain Phys 17:E509–E524

    Google Scholar 

  36. Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6, e1000097. doi:10.1371/journal.pmed.1000097

    Article  PubMed  PubMed Central  Google Scholar 

  37. Higgins JP, Green S ([updated March 2011]) Conchrane Handbook for Systematic Reviews of Interventions 5.1.0. The Cochrane Collaboration:Available: www.cochrane-handbook.org

  38. Ottawa Hospital Research Institute. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses.Available: http://www.ohri.ca/programs/clinicalepidemiology/oxford.asp

  39. Candido KD, Raghavendra MS, Chinthagada M, Badiee S, Trepashko DW (2008) A prospective evaluation of iodinated contrast flow patterns with fluoroscopically guided lumbar epidural steroid injections: the lateral parasagittal interlaminar epidural approach versus the transforaminal epidural approach. Anesth Analg 106:638–644. doi:10.1213/ane.0b013e3181605e9b, table of contents

    Article  PubMed  Google Scholar 

  40. Whitlock EL, Bridwell KH, Gilula LA (2007) Influence of needle tip position on injectate spread in 406 interlaminar lumbar epidural steroid injections. Radiology 243:804–811. doi:10.1148/radiol.2433060983

    Article  PubMed  Google Scholar 

  41. Andreisek G, Jenni M, Klingler D, Wertli M, Elliott M, Ulbrich EJ, Winklhofer S, Steurer J (2013) Access routes and reported decision criteria for lumbar epidural drug injections: a systematic literature review. Skelet Radiol 42:1683–1692. doi:10.1007/s00256-013-1713-5

    Article  Google Scholar 

  42. Rosenberg SK, Grabinsky A, Kooser C, Boswell MV (2002) Effectiveness of transforaminal epidural steroid injections in low back pain: a one year experience. Pain Phys 5:266–270

    Google Scholar 

  43. Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Sanelli JT, Freeman ED, Slaten WK, Rao S (2002) Fluoroscopically guided lumbar transformational epidural steroid injections in degenerative lumbar stenosis: an outcome study. Am J Phys Med Rehab / Assoc Acad Phys 81:898–905. doi:10.1097/01.phm.0000034953.43372.72

    Article  Google Scholar 

  44. Riew KD, Yin Y, Gilula L, Bridwell KH, Lenke LG, Lauryssen C, Goette K (2000) The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, double-blind study. J Bone Joint Surg Am 82-a:1589–1593

    Article  CAS  PubMed  Google Scholar 

  45. Riew KD, Park JB, Cho YS, Gilula L, Patel A, Lenke LG, Bridwell KH (2006) Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year follow-up. J Bone Joint Surg Am Vol 88:1722–1725. doi:10.2106/jbjs.e.00278

    Google Scholar 

  46. Yang SC, Fu TS, Lai PL, Niu CC, Chen LH, Chen WJ (2006) Transforaminal epidural steroid injection for discectomy candidates: an outcome study with a minimum of two-year follow-up. Chang Gung Med J 29:93–99

    PubMed  Google Scholar 

  47. Ploumis A, Christodoulou P, Wood KB, Varvarousis D, Sarni JL, Beris A (2014) Caudal vs transforaminal epidural steroid injections as short-term (6 months) pain relief in lumbar spinal stenosis patients with sciatica. Pain Med (Malden, Mass) 15:379–385. doi:10.1111/pme.12318

    Article  Google Scholar 

  48. Kozlov N, Benzon HT, Malik K (2015) Epidural steroid injections: update on efficacy, safety, and newer medications for injection. Minerva Anestesiol 81:901–909

    CAS  PubMed  Google Scholar 

  49. El-Yahchouchi CA, Plastaras CT, Maus TP, Carr CM, McCormick ZL, Geske JR, Smuck M, Pingree MJ, Kennedy DJ (2015) Adverse event rates associated with transforaminal and interlaminar epidural steroid injections: a multi-institutional study. Pain medicine, Malden. doi:10.1111/pme.12896

    Google Scholar 

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Correspondence to Jie Liang.

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Wei, G., Liang, J., Chen, B. et al. Comparison of transforaminal verse interlaminar epidural steroid injection in low back pain with lumbosacral radicular pain: a meta-analysis of the literature. International Orthopaedics (SICOT) 40, 2533–2545 (2016). https://doi.org/10.1007/s00264-016-3220-5

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