Review articleA Critical Appraisal of the Evidence for Selective Nerve Root Injection in the Treatment of Lumbosacral Radiculopathy
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 We did not review abstracts or unpublished studies.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
References (53)
- et al.
Mechanosensitivity of dorsal root ganglia and chronically injured axonsa physiological basis for the radicular pain of nerve root compression
Pain
(1977) - et al.
Fluoroscopic transforaminal lumbar epidural steroidsan outcome study
Arch Phys Med Rehabil
(1998) - et al.
Incidence of vocal cord dysfunction after fluoroscopically guided steroid injections in the axial skeleton
Arch Phys Med Rehabil.
(2005) - et al.
Rupture of the intervertebral disc with involvement of the spinal canal
N Eng J Med
(1934) - et al.
Abnormal myelograms in asymptomatic patients
J Neurosurg
(1968) - et al.
The nonoperative treatment of herniated nucleus pulposus with radiculopathyan outcome study
Spine
(1989) - et al.
A study of computer-assisted tomography: I. The incidence of positive CAT scans in an asymptomatic group of patients
Spine
(1984) - et al.
Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjectsa prospective investigation
J Bone Joint Surg Am
(1990) - et al.
Computed tomographic follow-up study of forty-eight cases of nonoperatively treated lumbar intervertebral disc herniation
Spine
(1992) - et al.
Lumbar disc herniationcomputed tomography scan changes after conservative treatment of nerve root compression
Spine
(1992)
Herniation or rupture of the intervertebral disc into the spinal canal
N Engl J Med
High levels of inflammatory phospholipase A2 activity in lumbar disc herniations
Spine
Histologic changes in spinal nerve roots of operated cases of sciatica
Acta Orthop Scand
The inflammatory effects of nucleus pulposusa possible element in the pathogenesis of low-back pain
Spine
Incision of the annulus fibrosis induces nerve root morphologic, vascular, and functional changes. An experimental study
Spine
Effects of phospholipase A2 on lumbar nerve root structure and function
Spine
The role of inflammation in lumbar pain
Spine
Autologous nucleus pulposus induces neurophysiologic and histologic changes in porcine cauda equina nerve roots
Spine
The inflammatory properties of contained and noncontained lumbar disc herniation
Spine
Phospholipase A2-induced electrophysiologic and histologic changes in rabbit dorsal lumbar spine tissues
Spine
Pathoanatomy and pathophysiology of nerve root compression
Spine
[Hydrocortisone (compound F); first clinical experiments in the field of rheumatology] [undetermined language]
Minerva Med
L’hydrocortisone en injection locale
Rev Rhum
Negative disc explorationan analysis of the causes of nerve-root involvement in sixty-eight patients
J Bone Joint Surg Am
Nerve root injectiona method for evaluating the etiology of sciatica
J Bone Joint Surg Am
Selective lumbosacral radiculopathy and block
Spine
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