Pain Management Injection Therapies for Low-back Pain [Entered Retrospectively]

Project Summary Title and Description

Title
Pain Management Injection Therapies for Low-back Pain [Entered Retrospectively]
Description
Structured Abstract Objectives. Low back pain is common and injections with corticosteroids are a frequently used treatment option. This report reviews the current evidence on effectiveness and harms of epidural, facet joint, and sacroiliac corticosteroid injections for low back pain conditions. Data Sources. A prior systematic review (searches through July 2008), electronic databases (Ovid MEDLINE, Scopus, and the Cochrane Libraries from January 2008 through October 2014), reference lists, and clinical trials registries. Review Methods. Using predefined criteria, we selected randomized trials of patients with lumbosacral radiculopathy, spinal stenosis, nonradicular back pain, or chronic postsurgical back pain that compared effectiveness or harms of epidural, facet joint, or sacroiliac corticosteroid injections versus placebo or other interventions. We also included randomized trials that compared different injection techniques and large (sample sizes >1000) observational studies of back injections that reported harms. The quality of included studies was assessed, data were extracted, and results were summarized qualitatively and using meta-analysis on outcomes stratified by immediate- (1 week to <2 weeks), short- (2 weeks to <3 months), intermediate- (3 months to <1 year), and long-term (>1 year) followup. Results. Seventy-eight randomized trials of epidural injections, 13 trials of facet joint injections, and one trial of sacroiliac injections were included. For epidural corticosteroid injections versus placebo interventions for radiculopathy, the only statistically significant effects were on mean improvement in pain at immediate-term followup (weighted mean difference [WMD] ‒7.55 on a 0 to 100 scale, 95% CI ‒11.4 to ‒3.74) (strength of evidence [SOE]: moderate), mean improvement in function at immediate-term followup when an outlier trial was excluded (standardized mean difference [SMD] ‒0.33, 95% CI ‒0.56 to ‒0.09) (SOE: low), and risk of surgery at short-term followup (relative risk [RR] 0.62, 95% CI 0.41 to 0.92) (SOE: low). The magnitude of effects on pain and function was small, did not meet predefined thresholds for minimum clinically important differences, and there were no differences on outcomes at longer-term followup. Evidence on effects of different injection techniques, patient characteristics, or comparator interventions estimates was limited and did not show clear effects. Trials of epidural corticosteroid injections for radiculopathy versus nonplacebo interventions did not clearly demonstrate effectiveness (SOE: insufficient to low). Evidence was limited for epidural corticosteroid injections versus placebo interventions for spinal stenosis (SOE: low to moderate) or nonradicular back pain (SOE: low), but showed no differences in pain, function, or likelihood of surgery. Studies found no clear differences between various facet joint corticosteroid injections (intra-articular, extra-articular [peri-capsular], or medial branch) and placebo interventions (SOE: low to moderate). There was insufficient evidence from one very small trial to determine effects of peri-articular sacroiliac joint corticosteroid injections injection (SOE: insufficient). Serious harms from injections were rare in randomized trials and observational studies, but harms reporting was suboptimal (SOE: low). Conclusions: Epidural corticosteroid injections for radiculopathy were associated with immediate improvements in pain and might be associated with immediate improvements in function, but benefits were small and not sustained, and there was no effect on long-term risk of surgery. Evidence did not suggest that effectiveness varies based on injection technique, corticosteroid, dose, or comparator. Limited evidence suggested that epidural corticosteroid injections are not effective for spinal stenosis or nonradicular back pain and that facet joint corticosteroid injections are not effective for presumed facet joint pain. There was insufficient evidence to evaluate effectiveness of sacroiliac joint corticosteroid injections.
Attribution
N/A
Authors of Report
N/A
Methodology description
Review Methods. Using predefined criteria, we selected randomized trials of patients with lumbosacral radiculopathy, spinal stenosis, nonradicular back pain, or chronic postsurgical back pain that compared effectiveness or harms of epidural, facet joint, or sacroiliac corticosteroid injections versus placebo or other interventions. We also included randomized trials that compared different injection techniques and large (sample sizes >1000) observational studies of back injections that reported harms. The quality of included studies was assessed, data were extracted, and results were summarized qualitatively and using meta-analysis on outcomes stratified by immediate- (1 week to <2 weeks), short- (2 weeks to <3 months), intermediate- (3 months to <1 year), and long-term (>1 year) followup.)
PROSPERO
N/A
DOI
10.7301/Z0KS6PHJ
Notes
The report files uploaded for this project include the following: Appendix E1. Data Abstraction: Epidural Steroid Injections for Radicular Pain; Appendix E2. Data Abstraction: Epidural Steroid Injections for Spinal Stenosis; Appendix E3. Data Abstraction: Epidural Steroid Injections for Nonradicular Pain; Appendix E4. Data Abstraction: Epidural Steroid Injections for Postsurgery Pain; Appendix E5. Data Abstraction: Epidural Steroid Injections for Facet Joint Pain; Appendix E6. Data Abstraction: Epidural Steroid Injections for Sacroiliac Pain; Appendix F1. Quality Assessment: Epidural Steroid Injections for Radicular Pain; Appendix F2. Quality Assessment: Epidural Steroid Injections for Spinal Stenosis; Appendix F3. Quality Assessment: Epidural Steroid Injections for Nonradicular Pain; Appendix F4. Quality Assessment: Epidural Steroid Injections for Postsurgery Pain; Appendix F5. Quality Assessment: Epidural Steroid Injections for Facet Joint Pain; Appendix F6. Quality Assessment: Epidural Steroid Injections for Sacroiliac Pain
Funding Source
Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. HHSA 290-2012-00014-I.) Rockville, MD: Agency for Healthcare Research and Quality; March 2015. www.effectivehealthcare.ahrq.gov/reports/final.cfm

Key Questions

1. Key Question 1. In patients with low back pain, what is the effectiveness of epidural corticosteroid injections, facet joint corticosteroid injections, medial branch blocks, and sacroiliac joint corticosteroid injections versus epidural nonsteroid injection, nonepidural injection, no injection, surgery or nonsurgical therapies on outcomes related to pain, function and quality of life?
2. Key Question 1a. How does effectiveness vary according to the medication (corticosteroid, local anesthetic) used, the dose or frequency of injections, the number of levels treated, or degree of provider experience?
3. Key Question 1b. How does effectiveness vary according to use of imaging guidance or route of administration (e.g., for epidural injections interlaminar, transforaminal, caudal for epidural injections and for facet joint injections intra-articular, extra-articular [peri-capsular] or medial branch injections)?
4. Key Question 2. In patients with low back pain, what patient characteristics predict responsiveness to injection therapies on outcomes related to pain, function, and quality of life?
5. Key Question 3. In randomized trials of low back pain injection therapies, how does effectiveness vary according to the comparator used (e.g., epidural nonsteroid injection, nonepidural injection, no injection, surgery, or nonsurgical therapies)?
6. Key Question 3a. How do response rates vary according to the specific comparator evaluated (e.g., saline epidural, epidural with local anesthetic, nonepidural injection, no injection, surgery, nonsurgical therapies)?
7. Key Question 4. What are the harms of epidural corticosteroid, facet joint corticosteroid injections, medial branch blocks, and sacroiliac joint corticosteroid injection compared to epidural nonsteroid injection, nonepidural injection, no injection, surgery, or nonsurgical therapies?

Associated Extraction Forms

Associated Studies (each link opens a new tab)

TitleAuthorsYear
The efficacy of lumbar epidural steroid injections in patients with lumbar disc herniations.
Pain relief with intraarticular or medial branch nerve blocks in patients with positive lumbar facet joint SPECT imaging: a 12-week outcome study.2008
Lumbar transforaminal epidural dexamethasone: a prospective, randomized, double-blind, dose-response trial.-- Not Found --
A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study.
Percutaneous microdiscectomy versus epidural injection for management of chronic spinal pain.2010
Efficacy of epidural perineural injections with autologous conditioned serum for lumbar radicular compression: an investigator-initiated, prospective, double-blind, reference-controlled study.2007
A comparison between epidural anaesthesia with and without corticosteroid in the treatment of sciatica.1971
A double-blind, randomized, prospective study of epidural steroid injection vs. the mild® procedure in patients with symptomatic lumbar spinal stenosis.2012
Epidural corticosteroid injection in the conservative management of sciatica.2000
Transforaminal epidural clonidine versus corticosteroid for acute lumbosacral radiculopathy due to intervertebral disc herniation.2011
A controlled study of caudal epidural injections of triamcinolone plus procaine for the management of intractable sciatica.1991
Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study.2004
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.2008
Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus.1997
A controlled trial of corticosteroid injections into facet joints for chronic low back pain.1991
Comparison of effectiveness of facet joint injection and radiofrequency denervation in chronic low back pain.2012
Effect of MRI on treatment results or decision making in patients with lumbosacral radiculopathy referred for epidural steroid injections: a multicenter, randomized controlled trial.2012
Epidural steroids, etanercept, or saline in subacute sciatica: a multicenter, randomized trial.2012
The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study.1985
Comparison of caudal steroid epidural with targeted steroid placement during spinal endoscopy for chronic sciatica: a prospective, randomized, double-blind trial.2005
Nerve root sleeve injections in patients with failed back surgery syndrome: a comparison of three solutions.1999
Extradural corticosteroid injection in management of lumbar nerve root compression.1973
Intraarticular hyaluronic acid versus glucocorticoid injections for nonradicular pain in the lumbar spine.
Symptoms of spinal stenosis do not improve after epidural steroid injection.1998
Ultrasound-guided versus computed tomography-controlled facet joint injections in the lumbar spine: a prospective randomized clinical trial.-- Not Found --
Plasma disc decompression compared with fluoroscopy-guided transforaminal epidural steroid injections for symptomatic contained lumbar disc herniation: a prospective, randomized, controlled trial.2010
The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain.2010
Lateral parasagittal versus midline interlaminar lumbar epidural steroid injection for management of low back pain with lumbosacral radicular pain: a double-blind, randomized study.
Interlaminar versus transforaminal epidural steroids for the treatment of subacute lumbar radicular pain: a randomized, blinded, prospective outcome study.2011
The effect of epidural methylprednisolone acetate injection on the hypothalamic-pituitary-adrenal axis.2013
Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial.
Effectiveness of transforaminal epidural steroid injection by using a preganglionic approach: a prospective randomized controlled study.2007
The dosages of corticosteroid in transforaminal epidural steroid injections for lumbar radicular pain due to a herniated disc.2011
Periradicular infiltration for sciatica: a randomized controlled trial.2001
Comparative effectiveness of lumbar transforaminal epidural steroid injections with particulate versus nonparticulate corticosteroids for lumbar radicular pain due to intervertebral disc herniation: a prospective, randomized, double-blind trial.2014
Efficacy and safety of lumbar epidural dexamethasone versus methylprednisolone in the treatment of lumbar radiculopathy: a comparison of soluble versus particulate steroids.2011
Lumbar epidural injections in the treatment of sciatica.1984
Effectiveness of physical therapy and epidural steroid injections in lumbar spinal stenosis.2009
Transforaminal hypertonic saline for the treatment of lumbar lateral canal stenosis: a double-blinded, randomized, active-control trial.2013
Efficacy of nerve root versus interspinous injections of glucocorticoids in the treatment of disk-related sciatica. A pilot, prospective, randomized, double-blind study.2000
Lumbar epidural perineural injection: a new technique.
Comparison of Epidural Steroid Injections with conservative management in patients with lumbar radiculopathy.2009
A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation in the treatment of low back pain: a randomized, controlled, double-blind trial.2013
Comparison of the effectiveness of interlaminar and bilateral transforaminal epidural steroid injections in treatment of patients with lumbosacral disc herniation and spinal stenosis.
Lumbar facet joint syndrome. A randomised clinical trial.1989
Efficacy of periarticular corticosteroid treatment of the sacroiliac joint in non-spondylarthropathic patients with chronic low back pain in the region of the sacroiliac joint.-- Not Found --
The preliminary results of a comparative effectiveness evaluation of adhesiolysis and caudal epidural injections in managing chronic low back pain secondary to spinal stenosis: a randomized, equivalence controlled trial.2009
Lumbar interlaminar epidural injections in central spinal stenosis: preliminary results of a randomized, double-blind, active control trial.2012
Fluoroscopic caudal epidural injections in managing chronic axial low back pain without disc herniation, radiculitis, or facet joint pain.
A randomized, double-blind, active-controlled trial of fluoroscopic lumbar interlaminar epidural injections in chronic axial or discogenic low back pain: results of 2-year follow-up.
Results of 2-year follow-up of a randomized, double-blind, controlled trial of fluoroscopic caudal epidural injections in central spinal stenosis.2012
Effectiveness of lumbar facet joint nerve blocks in chronic low back pain: a randomized clinical trial.2001
Assessment of effectiveness of percutaneous adhesiolysis and caudal epidural injections in managing post lumbar surgery syndrome: 2-year follow-up of a randomized, controlled trial.2012
Effect of fluoroscopically guided caudal epidural steroid or local anesthetic injections in the treatment of lumbar disc herniation and radiculitis: a randomized, controlled, double blind trial with a two-year follow-up.2012
A randomized, double-blind, active-control trial of the effectiveness of lumbar interlaminar epidural injections in disc herniation.-- Not Found --
Evaluation of lumbar facet joint nerve blocks in managing chronic low back pain: a randomized, double-blind, controlled trial with a 2-year follow-up.2010
Facet joint injection and facet nerve block: a randomised comparison in 86 patients with chronic low back pain.1992
Back pain and sciatica: controlled trials of manipulation, traction, sclerosant and epidural injections.1987
A pilot study of the dose-response of caudal methylprednisolone with levobupivacaine in chronic lower back pain.2011
Forceful sacrococcygeal injections in the treatment of postdiscectomy sciatica. A controlled study versus glucocorticoid injections.2001
Caudal epidural steroid injection: a randomized controlled trial.2011
Effects of transforaminal injection for degenerative lumbar scoliosis combined with spinal stenosis.2011
Epidural administration of spinal nerves with the tumor necrosis factor-alpha inhibitor, etanercept, compared with dexamethasone for treatment of sciatica in patients with lumbar spinal stenosis: a prospective randomized study.2012
Comparison of two doses of corticosteroid in epidural steroid injection for lumbar radicular pain.2007
Comparison of the effectiveness of lumbar transforaminal epidural injection with particulate and nonparticulate corticosteroids in lumbar radiating pain.2010
Ultrasound-guided vs. fluoroscopy-guided caudal epidural steroid injection for the treatment of unilateral lower lumbar radicular pain: a prospective, randomized, single-blind clinical study.2013
Low back pain: prediction of short-term outcome of facet joint injection with bone scintigraphy.2006
Efficacy of interlaminar vs transforaminal epidural steroid injection for the treatment of chronic unilateral radicular pain: prospective, randomized study.2011
Adjuvant hyaluronidase to epidural steroid improves the quality of analgesia in failed back surgery syndrome: a prospective randomized clinical trial.2014
Effect of facet joint injection versus systemic steroids in low back pain: a randomized controlled trial.2013
Outpatient lumbar epidural corticosteroid injection in the management of sciatica.1988
The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, double-blind study.2000
Epidural steroids, epidural morphine and epidural steroids combined with morphine in the treatment of post-laminectomy syndrome.1989
Efficacy of steroid and nonsteroid caudal epidural injections for low back pain and sciatica: a prospective, randomized, double-blind clinical trial.2009
Double blind evaluation of extradural methyl prednisolone for herniated lumbar discs.1977
Corticosteroids in peri-radicular infiltration for radicular pain: a randomised double blind controlled trial. One year results and subgroup analysis.2009
A comparison of the analgesic efficacy of transforaminal methylprednisolone alone and with low doses of clonidine in lumbo-sacral radiculopathy.2014
Efficacy of transforaminal versus interspinous corticosteroid injectionin discal radiculalgia - a prospective, randomised, double-blind study.2003
Epidural corticosteroid injections for sciatica: a randomised, double blind, controlled clinical trial.2003
Epidural steroid injection for nerve root compression. A randomised, controlled trial.2005
Concordant pressure paresthesia during interlaminar lumbar epidural steroid injections correlates with pain relief in patients with unilateral radicular pain.2013
A randomized trial of epidural glucocorticoid injections for spinal stenosis.2014
Transforaminal versus parasagittal interlaminar epidural steroid injection in low back pain with radicular pain: a randomized, double-blind, active-control trial.2014
Clinical comparison of effectiveness of epidural triamcinolone and betamethasone in discal radiculalgia: a prospective, randomized study2009
Treatment of chronic low back pain and sciatica. Comparison of caudal epidural injections of bupivacaine and methylprednisolone with bupivacaine followed by saline1976
A randomized clinical trial of three different steroid agents for treatment of low backache through the caudal route2011
The value of caudal epidural steroids in the treatment of lumbar neural compression syndromes1991
Outpatient treatment of low-back pain and sciatica by a single extradural corticosteroid injection1985
The efficacy of epidural depo-methylprednisolone and triamcinolone acetate in relieving the symptoms of lumbar anal stenosis: a comparative study2010
Facet joints-intra-articular steroids or nerve block1990
Epidural steroids for sciatica1992
Lumbar epidural perineural injection: a new technique.1997

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