Background: Intervertebral disc herniation, spinal stenosis, intervertebral disc degeneration
without disc herniation, and post lumbar surgery syndrome are the most common diagnoses of
chronic persistent low back and lower extremity symptoms, resulting in significant economic,
societal, and health care impact. Epidural injections are one of the most commonly performed
interventions in the United States in managing chronic low back pain. However the evidence
is highly variable among different techniques utilized – namely interlaminar, caudal, and
transforaminal – and for various conditions, namely – intervertebral disc herniation, spinal
stenosis, and discogenic pain without disc herniation or radiculitis. Multiple systematic reviews
conducted in the evaluation of the effectiveness of interlaminar epidural injections have been
marred with controversy. Consequently, the debate continues with regards to the effectiveness,
indications, and medical necessity of interlaminar epidural injections.
Study Design: A systematic review of lumbar interlaminar epidural injections with or without
steroids.
Objective: To evaluate the effect of lumbar interlaminar epidural injections with or without
steroids in managing various types of chronic low back and lower extremity pain emanating as a
result of disc herniation or radiculitis, spinal stenosis, and chronic discogenic pain.
Methods: The available literature on lumbar interlaminar epidural injections with or without
steroids in managing various types of chronic low back pain with or without lower extremity pain
was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane
Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized
trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies.
The level of evidence was classified as good, fair, or limited based on the quality of evidence
developed by the U.S. Preventive Services Task Force (USPSTF).
Data sources included relevant literature identified through searches of PubMed and EMBASE
from 1966 to December 2011, and manual searches of the bibliographies of known primary
and review articles.
Outcome Measures: The primary outcome measure was pain relief (short-term relief = up
to 6 months and long-term > 6 months). Secondary outcome measures were improvement in
functional status, psychological status, return to work, and reduction in opioid intake.
Results: Overall, 82 lumbar interlaminar trials were identified. All non-randomized studies
without fluoroscopy and randomized trials not meeting the inclusion criteria were excluded.
Overall, 15 randomized trials and 11 non-randomized studies were included in the analysis.
Analysis was derived mainly from fluoroscopically-guided randomized trials and non-randomized
studies.
The evidence is good for radiculitis secondary to disc herniation with local anesthetics and
steroids, fair with local anesthetic only; whereas it is fair for radiculitis secondary to spinal
stenosis with local anesthetic and steroids, and fair for axial pain without disc herniation with
local anesthetic with or without steroids, with fluoroscopically-guided epidural injections.
Limitations: The limitations of this study include that we were unable to perform meta-analysis for disc herniation, and the paucity of evidence for discogenic pain and spinal stenosis. Further, methodological criteria
have been highly variable along with sample sizes. The studies were heterogenous.
Conclusion: The evidence based on this systematic review is good for lumbar epidural injections under fluoroscopy for radiculitis
secondary to disc herniation with local anesthetic and steroids, fair with local anesthetic only; whereas it is fair for radiculitis
secondary to spinal stenosis with local anesthetic and steroids, and fair for axial pain without disc herniation with local anesthetic
with or without steroids.
Key words: Chronic low back pain, lower extremity pain, disc herniation, radiculitis, spinal stenosis, discogenic pain, lumbar
interlaminar epidural injections, fluoroscopy
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