Volume 88, Issue 5 , Page 687, May 2007
Do We Really Want to Suggest 4 Transforaminal Epidural Steroid Injections Prior to Surgery?
Article Outline
In their review of the evidence for transforaminal epidural steroid injections (TFESIs) in the treatment of lumbosacral radiculopathy, DePalma et al1 emphasized the need to repeat these injections prior to referral for surgical intervention. They referenced in particular a 2000 study by Riew et al,2 which states that 13 of 19 patients who underwent more than 1 injection were able to avoid surgery.
A close review of the Riew article brings up several important points in terms of DePalma’s conclusions. Fifty-five patients in the Riew study received TFESIs—27 with bupivacaine only and 28 with bupivacaine and betamethasone (the experimental group). Patients were allowed to choose to receive as many as 4 injections at any time during the follow-up period. This was consistent with standard treatment in this setting.
The 19 patients who received multiple injections came from the overall sample of 55 patients, not from the group that only received bupivacaine and betamethasone. While there were 13 patients in the multiple-injection group who avoided surgery, the study did not allow for differentiation between the 2 study cohorts in terms of success.
Making a statement as strong as suggesting at least 4 TFESIs prior to a surgical procedure based on the Riew study does not follow the basic tenants of evidence-based medicine. The protocol in the Riew study appears to allow the patient to choose whether to repeat an injection, regardless of effect. This type of protocol does not allow for any definition of when a repeat injection should be made based on clinical evidence. The lack of breakdown between the treatment groups in terms of repeat injections allows for no conclusions to be made in terms of suggestions for frequency of TFESIs.
Of even greater interest is the 5-year follow-up of the original Riew study published in 2006.3 Of the patients available for follow-up who avoided surgery (21/29, with 9 from the group that received bupivacaine only and 12 from the bupivacaine and steroid group), there was no statistical difference between the groups with regard to the avoidance of surgery. These results emphasize the statement made by DePalma that definitive conclusions on the role of TFESIs in treating lumbosacral radiculopathy cannot be made due to the lack of a true placebo-control group.1 These findings also appear to be consistent with the statement that “The true utility of TFESIs may lie in the their value to lessen lumbosacral radicular pain earlier than its natural progression without changing the chronology of complete resolution.”1(p1481)
Additional research is needed to determine the appropriate number of epidural steroid injections (regardless of approach), efficacy guidelines to help to determine when a repeat injection should be performed, and the role of injectate in overall treatment. In addition, we must continue to investigate the most appropriate placebo treatment to use as a control in these studies.
References
- . A critical appraisal of the evidence for selective nerve root injection in the treatment of lumbosacral radiculopathy. Arch Phys Med Rehabil. 2005;86:1477–1483
- 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. 2000;82:1589–1593
- Nerve root blocks in the treatment of lumbar radicular pain (A minimum five-year follow-up). J Bone Joint Surg Am. 2006;88:1722–1725
PII: S0003-9993(07)00199-2
doi:10.1016/j.apmr.2007.03.006
© 2007 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
Volume 88, Issue 5 , Page 687, May 2007
