Review article
A Critical Appraisal of the Evidence for Selective Nerve Root Injection in the Treatment of Lumbosacral Radiculopathy

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Abstract

DePalma MJ, Bhargava A, Slipman CW. A critical appraisal of the evidence for selective nerve root injection in the treatment of lumbosacral radiculopathy.

Objective

To critically review the best available trials of the utility of transforaminal epidural steroid injections (TFESIs) or selective nerve root blocks (SNRBs) to treat lumbosacral radiculopathy.

Data Sources

MEDLINE (PubMed, Ovid, MDConsult), EMBASE, and the Cochrane database. Databases were searched from inception through 2003.

Study Selection

A database search was conducted by using the following key words: prospective, transforaminal and foraminal epidural steroid injections, selective nerve root block and injection, and periradicular and nerve root injection. We included English-language, prospective, randomized studies of patients with lower-limb radicular symptoms treated with fluoroscopically guided nerve root or transforaminal epidural injections.

Data Extraction

Data were compiled for each of the following categories: inclusion criteria, randomization protocol, total number of subjects enrolled initially and at final analysis, statistical analysis utilized, documentation of technique, outcome measures, follow-up intervals and results (positive or negative), and reported complications. These data were abstracted by 1 reviewer and reviewed by a second. Study quality was assessed with the system developed by the Agency for Health Care and Policy Research.

Data Synthesis

We selected 6 articles for review. Our analysis identified a single article as the highest quality study addressing the appropriate use of TFESIs or therapeutic SNRBs. Coupled with the evidence provided by 4 other articles (1 article was excluded because its patients were not truly randomized), our review of the evidence for TFESIs found level III (moderate) evidence in support of these minimally invasive and safe procedures in treating painful radicular symptoms. However, conclusive evidence (level I) is lacking.

Conclusions

The evidence for TFESIs reveals level III (moderate) evidence in support of these minimally invasive and safe procedures in treating painful lumbar radicular symptoms. Current studies support use of TFESIs as a safe and minimally invasive adjunct treatment for lumbar radicular symptoms. However, more prospective, randomized, placebo-controlled studies using sham procedures are needed to provide conclusive evidence for the efficacy of TFESIs in treating lumbar radicular symptoms.

Section snippets

Methods

We searched MEDLINE (PubMed, Ovid, MDConsult), EMBASE, and the Cochrane database for the period 1966 to 2003 using the following key words: prospective, transforaminal and foraminal epidural steroid injections, selective nerve root block and injection, and periradicular and nerve root injection. In addition, we examined the references cited in these studies for these key words. We did not review abstracts or unpublished studies. Selected studies had to fulfill the following criteria: (1)

Results

A total of 6 trials36, 39, 40, 41, 42, 44 satisfied the inclusion criteria and were evaluated in this review (table 1). All 6 were published between 1997 and 2003 in peer-reviewed journals. No non-English studies were identified. Five studies36, 39, 40, 41, 45 were prospective, randomized, and double-blinded. Three of these studies36, 39, 41 incorporated a placebo-control group. The other 2 trials40, 44 compared transforaminal with interlaminar corticosteroid injections without a

Methodology

In all 6 studies, the presenting complaint was leg pain equal to or greater than lumbar pain. The radicular pain was defined as pain referring from the back to below the knee,36, 44 extending to the knee,40 or simply as radicular limb pain.39, 42, 44 The required duration of symptoms before enrollment in the study varied from greater than 15 days,40 to 3 to 28 weeks,41 more than 6 weeks,42 or less than 3 months,44 or was not specified.36, 39 Evidence of disk herniation affecting the clinically

Discussion

Although the Kolsi40 and Thomas44 studies found positive results for the TFESIs, the difference may be artificial. Kolsi combined contrast (2mL), lidocaine (2mL), and corticosteroid (1.5mL) in 1 single TFESI. If the interventionalist needed to rearrange the needle tip after administering a portion of the contrast-medication mixture, a proportion of the steroid would have been misplaced. Kolsi commented that the patients who underwent selective nerve root injections had greater improvement than

Conclusions

Our analysis identified the article by Riew et al39 as the highest-quality study among those prospectively randomized investigations. This was because the investigators used an appropriate number of TFESIs or therapeutic SNRBs after a defined course of more conservative care had failed and used an objective clinical parameter as the endpoint. Coupled with the evidence provided by 4 other articles,36, 40, 41, 44 (1 article42 was excluded because its patients were not truly randomized), our

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