Spinal Injections: A Narrative Review from a Surgeon’s Perspective
Abstract
:1. Introduction
2. Increase in Spinal Surgeries
3. Questions Arising Concerning the Necessity of Spinal Surgery
4. Spinal Surgery Outcomes
5. Efficacy of Injection Treatments
6. Spinal Injection Treatment
6.1. Diagnostic Blocks
6.1.1. Diagnostic Selective Nerve Root Blocks
6.1.2. Disc Simulation Tests
6.1.3. Diagnostic Medial Branch Blocks (MBBs)
6.2. Therapeutic Blocks
6.2.1. Transforaminal Nerve Root Injections
6.2.2. Therapeutic MBBs
6.2.3. Percutaneous Epidural Neuroplasty (PEN)
6.2.4. Radiofrequency Nucleoplasty
7. Changes in How Pain Is Viewed
8. Patients Requiring Surgery
9. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Study | Study Design | Participants | Interventions | Outcome Measurement | Summary of Outcomes |
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Devulder et al., 1999 [89] | Randomized controlled trial | n = 60 (three treatment groups with 20 participants each) | Group I with 1 mL bupivacaine 0.5% combined with 1500 units hyaluronidase and 1 mL saline per nerve root sleeve. Group II with 1 mL bupivacaine 0.5% combined with 40 mg methylprednisolone solution per nerve root. Group III with bupivacaine 0.5% combined with 1500 units hyaluronidase and 40 mg methylprednisolone solution. | Verbal pain rating scale at 1, 3, and 6 months | Three treatment methods provided pain relief at the 1-month follow-up, but these effects diminished during the 3- and 6-month follow-ups. Ultimately, none of the three injected solutions demonstrated satisfactory outcome in terms of pain relief. |
Karppinen et al., 2001 [94] | Randomized controlled trial | n = 160 (two treatment groups with 80 participants each) | Group I: periradicular infiltration with Methylprednisolone-Bupivacaine. Group II: periradicular infiltration with saline. | VAS and Nottingham health profile at 2 weeks, and 1, 3, 6, and 12 months | At the 2-week follow-up, the steroid injection exhibited superior recovery in terms of leg pain, straight leg raising, lumbar flexion, and patient satisfaction. However, the saline infiltration was significantly lower in back pain at 3 and 6 months, as well as lower in leg pain at 6 months. The combination of methylprednisolone and bupivacaine appeared to have a positive short-term effect. However, at 3 and 6 months, the steroid injection showed a “rebound” phenomenon. |
Bonetti et al., 2005 [85] | Randomized controlled trial | n = 306 (80 in group I, 86 in group II, 70 group III, 70 in group IV) | Group I, including patients with disc disease: 2 mL steroid injection. Group II, including patients with disc disease: infiltration of 3 mL O(2)-O(3) gas mixture. Group III, including patients without disc disease: 2 mL steroid injection. Group IV, including patients without disc disease: infiltration of 3 mL O(2)-O(3) gas mixture. | Modified version of the McNab method at 1 week, and 3 and 6 months | Both treatment methods demonstrated excellent pain reduction effects throughout all follow-up periods, regardless of the presence or absence of disc disease, with the most favorable outcomes observed in the short-term follow-up. The O(2)-O(3) gas mixture provided significantly greater pain relief compared to steroid injections, making it a potential first-line alternative to epidural steroids. |
Ackerman et al., 2007 [84] | Randomized controlled trial | n = 90 (three treatment groups with 30 participants each) | Group I: lumbar epidural steroid injection using caudal approach with 3 mL of isohexol 300 and 4 mL of preservative-free saline with 40 mg of triamincolone. Group II: lumbar epidural steroid injection using interlaminar approach with 3 mL of isohexol 300 and 19 mL of preservative-free saline with 40 mg of triamcinolone. Group III: lumbar epidural steroid injection using transforaminal approach with 3 mL of isohexol 300 and 40 mg of triamcinolone in 4 mL of preservative-free saline. | VAS at 12 and 24 weeks | During the evaluation period, a significantly higher number of patients who underwent the transforaminal approach reported overall or partial pain relief. The transforaminal route for epidural steroid placement was found to be more effective than the caudal or interlaminar routes. |
Jeong et al., 2007 [92] | Randomized controlled trial | n = 239 (112 in group I, 127 in group II) | Group I with transforaminal epidural steroid injection using a preganglionic approach. Group II with transforaminal epidural steroid injection using a ganglionic approach. | VAS at 1 and 6 months | In the short-term follow-up, the preganglionic group exhibited superior treatment outcomes compared to the ganglionic group. No significant difference was identified at the medium-term follow-up. These findings suggest that utilizing transforaminal epidural steroid injection with a preganglionic approach is more effective than a ganglionic approach in the short term, and it demonstrates comparable effectiveness to the ganglionic approach in the medium term. |
Tafazal et al., 2009 [100] | Randomized controlled trial | n = 150 (76 in group I, 74 in group II) | Group I: local anesthetic injection with 2 mL of 0.25% bupivacaine, Group II: peri-radicular infiltration of corticosteroids with 2 mL of 0.25% bupivacaine and 40 mg of methylprednisolone. | VAS and ODI at 6 and 12 weeks, and 12 months | After a 3-month follow-up, there were no statistically significant distinctions in pain relief and functional improvement between the two treatment approaches. Similarly, at a minimum of 1 year following the injection, no variation was observed in the necessity for subsequent interventions between the two methods. The peri-radicular infiltration of corticosteroids for sciatica does not confer any additional advantages when compared to the administration of local anesthetic injection alone. |
Ghahreman et al., 2010 [90] | Randomized controlled trial | n = 150 (28 in group I, 27 in group II, 37 in group III, 28 in group IV, 30 in group V) | Group I: transforaminal steroid injection with 0.75 mL of 0.5% bupivacaine followed by 1.75 mL of triamcinolone in a concentration of 40 mg/mL. Group II: transforaminal injection of local anesthetic with 2 mL of 0.5% bupivacaine. Group III: transforaminal injection of 2 mL normal saline. Group IV: intramuscular steroid injection with 1.75 mL of triamcinolone (40 mg/mL). Group V: intramuscular normal saline injection with 1.75 mL of triamcinolone (40 mg/mL). | NRS at 3, 6, and 12 months | A notable increase in the number of patients experiencing pain relief was observed with transforaminal injection of steroids compared to those who received transforaminal injection of local anesthetic or saline, intramuscular steroids, or intramuscular saline. However, it is important to note that the proportion of patients with sustained pain relief decreases over time, and only a few patients maintain relief beyond 12 months. The transforaminal injection of steroids is considered to be effective for pain relief in a subset of patients. |
Rados et al., 2011 [99] | Randomized controlled trial | n = 64 (32 in group I, 32 in group II) | Group I with transforaminal epidural steroid injection of 40 mg methylprednisolone, 3 mL of 0.5% lidocaine. Group II with interlaminar epidural steroid injection of 80 mg of methylprednisolone mixed with 8 mL of 0.5% lidocaine. | VAS and ODI at 3 and 6 months | During the 6-month follow-up period, the outcomes of pain relief and functional improvement were positive for both transforaminal and interlaminar epidural steroid injections. When using the transforaminal approach, it provided slightly better long-term pain relief and functional improvement. However, there was no statistically significant difference between the two treatment methods. |
Cohen et al., 2012 [86] | Randomized controlled trial | n = 84 (30 in group I, 28 in group II, 26 in group III) | Group I with saline. Group II with corticosteroid. Group III with etanercept. | NRS and ODI at 1, 3, and 6 months | After one month of treatment, overall positive effects were reported, and epidural steroid therapy showed greater efficacy in functional improvement and pain reduction compared to saline or etanercept treatment. Epidural steroid injections have the advantage of providing short-term pain relief for patients with lumbosacral radiculopathy. |
Ghai et al., 2014 [91] | Randomized controlled trial | n = 62 (32 in group I, 30 in group II) | Group I with fluoroscopically guided epidural injection of methylprednisolone (80 mg) through parasagittal interlaminar approach. Group II with fluoroscopically guided epidural injection of methylprednisolone (80 mg) through transforaminal approach. | VAS and ODI at 2 weeks, and 1, 2, 3, 6, 9, and 12 months | Significant pain relief and function improvement were observed at all time points post-intervention compared to baseline in both groups. The parasagittal interlaminar and transforaminal approach for low back pain yield similar pain relief and functional improvement. The parasagittal interlaminar approach can be considered as a suitable alternative, for equivalent efficiency, better safety profile, and technical ease, to the transforaminal approach. |
Kennedy et al., 2014 [95] | Randomized controlled trial | n = 78 (41 in group I, 37 in group II) | Group I with dexamethasone. Group II with triamcinolone. | NRS and ODI at 2 weeks, and 3 and 6 months | Both triamcinolone and dexamethasone demonstrated significant improvements in pain and function at 2 weeks, 3 months, and 6 months, with no distinct disparities between the two treatments. Dexamethasone seems to be equally effective as triamcinolone in managing the condition. |
Manchikanti et al., 2014 [97] | Randomized controlled trial | n = 120 (two treatment groups with 60 participants each) | Group I with 1.5 mL of 1% preservative-free lidocaine, followed by 0.5 mL of sodium chloride solution. Group II with 1% lidocaine, followed by 3 mg, or 0.5 mL of betamethasone. | NRS and ODI at 3, 6, 12, 18, and 24 months | The two-year follow-up results of local anesthesia alone or in combination with steroid therapy are positive. Both local anesthesia with or without steroids in epidural injections can be effective treatments for patients with disc herniation or radiculopathy. These findings indicate that the superiority of steroids over local anesthesia is insufficient in the two-year follow-up survey. |
Denis et al., 2015 [88] | Randomized controlled trial | n = 56 (29 in group I, 27 in group II) | Group I with lumbar transforaminal injection of dexamethasone 7.5 mg, Group II with lumbar transforaminal injection of betamethasone 6.0 mg, | VAS and ODI at 1, 3, and 6 months | At 3 months, there was no significant difference between the two treatments in terms of pain relief and functional improvement. However, at 6 months, the dexamethasone treatment showed better effects in terms of functional improvement. |
Kamble et al., 2016 [93] | Randomized controlled trial | n = 90 (three treatment groups with 30 participants each) | Group I with transforaminal steroid injection. Group II with caudal steroid injection. Group III with epidural steroid. | VAS and ODI at 1, 6, and 12 months | The transforaminal route showed greater improvements in pain relief and functional improvement compared to the interlaminar and caudal routes. However, there was no significant difference between the interlaminar and caudal routes. Overall, the transforaminal steroid injection group demonstrated better symptomatic improvement in both the short and long term compared to the interlaminar and caudal steroid injection groups. |
Pandey, 2016 [98] | Randomized controlled trial | n = 140 (82 in group I, 40 in group II, 18 in group III) | Group I with injection by caudal route. Group II with injection by transforaminal route. Group III with injection by interlaminar route. | JOA at 6 and 12 months | After 12 months of administering steroid injections, all three routes showed effectiveness in improving the JOA score. However, the transforaminal route was significantly more effective than the caudal and interlaminar routes at both 6 and 12 months after the injection. There was no significant difference observed between the caudal and interlaminar routes in terms of their effectiveness. |
Makkar et al., 2019 [96] | Randomized controlled trial | n = 61 (21 in group I, 20 in group II, 20 in group III) | Group I with epidural steroid injection using midline interlaminar approach. Group II with epidural steroid injection using parasagittal interlaminar approach. Group III with epidural steroid injection using transforaminal approach. | VAS and ODI at 2 and 4 weeks, and 3 and 6 months | The parasagittal interlaminar approach and transforaminal approach had significantly higher rates of effective pain relief compared to the midline interlaminar approach at 3 and 6 months. ODI scores were significantly lower in the parasagittal interlaminar approach and transforaminal approach compared to the midline interlaminar approach, but there was no significant difference between parasagittal interlaminar approach and transforaminal approach. |
De et al., 2020 [87] | Randomized controlled trial | n = 50 (two treatment groups with 25 participants each) | Group I with transforaminal epidural local anesthetic injection of 1 mL 0.5% bupivacaine. Group II with transforaminal epidural injection of 1 mL 0.5% bupivacaine with 3 cycles of pulsed radiofrequency of the dorsal root ganglion for 180 s. | VAS and ODI at 2 weeks and 1, 2, 3, and 6 months | The lumbar pulsed radiofrequency group showed statistically significant reductions in both pain and functional improvement compared to the transforaminal epidural local anesthetic injection group from 2 weeks to 6 months. The application of pulsed radiofrequency to the DRG for an extended period provides long-term pain relief and improves the functional quality of life in patients with chronic lower back pain. |
Wei et al., 2020 [101] | Randomized controlled trial | n = 90 (three treatment groups with 30 participants each) | Group I with TNF-α inhibitor. Group II with steroids. Group III with lidocaine-only. | VAS and modified ODI at 6 months | The TNF-α inhibitor showed significantly greater pain relief and improvement in movement function compared to steroids and lidocaine. There was no significant difference between the effects of steroids and lidocaine. |
Study | Study Design | Participants | Interventions | Outcome Measurement | Summary of Outcomes |
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Manchikanti et al. 2001 [110] | Randomized controlled trial | n = 73 (32 in group I and 41 in group II) | Group I with local anesthetic and Sarapin. Group II with local anesthetic, Sarapin, and methyl prednisolone. | Pain relief, physical health, psychological status, narcotic intake, and employment status at 1, 3, 6, 12,18, 24, and 32 months. | Relief from one to three injections decreased with time, with the highest relief in the first 3 months. The treatment showed significant improvements in overall health status, including pain relief, physical, functional, and psychological status, as well as the ability to return to work. In conclusion, medial branch blocks with local anesthetic and Sarapin, with or without steroids, proved to be a cost-effective and beneficial treatment option for improving pain status, physical and psychological well-being, functional status, and the ability to return to work. |
Manchikanti et al. 2007 [111] | Randomized controlled trial | n = 60 (four treatment groups with 15 participants each) | Group I with bupivacaine only. Group II with bupivacaine and Sarapin. Group III with bupivacaine and steroids. Group IV with bupivacaine, Sarapin, and steroids. | NRS, ODI, opioid intake, and employment status at 3, 6, and 12 months. | Significant pain relief and functional improvement were observed at 3, 6, and 12 months. No significant difference was found between steroid and non-steroid treatment groups. The treatment of lumbar facet joint nerve block using local anesthesia, with or without Sarapin or steroids, may be effective for chronic lower back pain originating from the facet joint. |
Study | Study Design | Participants | Interventions | Outcome Measurement | Summary of Outcomes |
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Gerdesmeyer et al., 2013 [120] | Randomized controlled trial | n = 90 (44 in group I and 46 in group II) | Group I: The caudal approach involved the intentional insertion of a needle and catheter without penetrating the spinal canal. The catheter was placed into the subcutaneous tissue above the affected area, and for three days, 10 mL of preservative-free sodium chloride solution was administered through the catheter before its removal. Group II: The Tun-L catheter was positioned through the sacral canal with injection of 10 mL of contrast. Local anesthetic, 10 mL, 0.25% bupivacaine was administered through the catheter, followed by 10 mL of preservative-free sodium chloride solution infused with 150 units per mL of hyaluronidase. Slow injections of sodium chloride solution, 10 mL, 10%, containing 40 mg of triamcinolone, along with 2 mL of 0.25% bupivacaine. On the 2nd and 3rd days, 10 mL of 0.25% bupivacaine was injected through the catheter, followed by slow injection of 10 mL of 10% sodium chloride solution and 2 mL, 0.25% bupivacaine. | VAS and ODI at 3, 6, and 12 months | In the lysis group, pain relief and functional improvement were significantly greater at 3, 6, and 12 months compared to the placebo group. The minimally invasive percutaneous adhesiolysis procedure could be considered as the first treatment option for patients with chronic lumbosacral radicular pain. |
Ji et al., 2015 [116] | Retrospective | n = 363 | Catheterization was performed with a caudal approach. After final positioning of the Racz catheter, 6 mL of 0.2% preservative free ropivacaine containing 1500 units of hyaluronidase and 4 mL of 40% triamcinolone acetate was injected. An hour later, 6 mL of 8% sodium chloride solution was infused over 30 min in the recovery room while being monitored. | VAS and Odom’s criteria at 3, 6, 12, and 24 months | Percutaneous epidural neuroplasty proves to be an effective intervention for managing lumbar disc herniation at a single level without affecting the dural sac cross-sectional area. |
Moon et al., 2017 [121] | Retrospective | n = 407 | The percutaneous epidural adhesiolysis was performed using an RK needle and Racz catheter through the caudal approach. Following the accurate placement of the catheter in the anterior epidural space at the target site, a test dose of 3–5 mL of 1% lidocaine was administered. Subsequently, 10 mL of 0.9% sodium chloride solution was injected, followed by a mixture of 0.125% bupivacaine and 5 mg of dexamethasone. After 5 min, under real-time fluoroscopic guidance, 10 mL of 10% sodium chloride solution was slowly injected. | NRS and GPES at 1 and 12 months | After 12 months of percutaneous epidural adhesiolysis, a highly effective pain reduction was observed in 72.2% of patients. Those who experienced pain relief reported a high level of treatment satisfaction. |
Cho et al., 2019 [113] | Retrospective | n = 430 | The treatment involved percutaneous adhesiolysis or neuroplasty through a caudal approach, with catheter placement ventrally and laterally. After ensuring proper catheter positioning, and contrast injection, a mixture of 6 mL of 0.2% preservative-free ropivacaine with 1500 units of hyaluronidase and 4 mL of betamethasone sodium phosphate was injected. An hour later, 6 mL of 8% sodium chloride solution was infused over 30 min in the recovery room while being monitored, and finally, the epidural catheter was removed. | VAS and Odom’s criteria at 1, 3, 6, and 12 months | The back and leg pain significantly decreased during the entire follow-up period after percutaneous epidural neuroplasty. Both short-term and long-term outcomes were positive. These results indicate that percutaneous epidural neuroplasty is an effective treatment for pain in the back and legs caused by a single-level lumbar disc herniation, and the outcomes are not influenced by the type of lumbar disc herniation. |
Park et al., 2018 [114] | Retrospective | n = 78 | The procedure was performed using a caudal entry approach. After placing the catheter in the appropriate position, a mixture of 10 mL of 0.9% sodium chloride solution and 300 units of hyaluronidase was injected. Another epidurogram was performed, followed by the slow injection of 8 mL of 0.2% ropivacaine and 40 mg of triamcinolone. | VAS, ODI, and SF-12 at 1, 3, 6, and 12 months | During the follow-up period, there was a notable improvement in back and leg pain relief, functional improvement, and overall health. It is possible that extraforaminal contrast distribution during lumbar percutaneous epidural neuroplasty could be linked to enhanced functional outcomes. |
Choi et al., 2017 [119] | Retrospective | n = 543 (333 in group I and 210 in group II) | Group I: 5% hypertonic sodium chloride solution injection. Group II: 10% hypertonic sodium chloride solution injection. The caudal approach was used for the procedure, and catheterization was performed after reaching the final catheter position. A total of 5 mL of 0.25% ropivacaine, along with 1500 units of hyaluronidase was injected. Following the confirmation of no complications, 6 mL of 10% or 5% sodium chloride solution was injected, at a rate of 1 mL every 15 min. Subsequently, 2 mL of 0.9% sodium chloride solution containing 40 mg of triamcinolone was injected. | NRS at 1, 3, and 6 months | Both 5% and 10% hypertonic sodium chloride solution injections significantly reduced pain at 1, 3, and 6 months after percutaneous epidural adhesiolysis when compared to pre-procedure levels. However, no significant differences were observed between the 5% and 10% groups during the follow-up period at any point. For patients with concerns about cytotoxic side effects or infusion-related pain, the use of 5% hypertonic saline could be considered as an alternative to the 10% hypertonic saline. |
Study | Study Design | Participants | Interventions | Outcome Measurement | Summary of Outcomes |
---|---|---|---|---|---|
Adakli et al., 2015 [122] | Retrospective | n = 73 (36 in group I and 37 in group II) | Group I with lumbar radiofrequency thermocoagulation nucleoplasty. Group II with targeted disc decompression. | VAS and FRI at 1, 6, and 12 months | A significant improvement was observed in all pain relief and improvement of function when compared with the preprocedure values, in both methods. The degree of pain relief after 1, 6 and 12 months was significantly lower in the decompression compared to nucleoplasty, but there was no statistically significant difference in function improvement. These results indicate that radiofrequency thermocoagulation nucleoplasty and targeted disc decompression could be effective and safe alternatives to surgery for the treatment of hernia nucleus pulposus. |
Nie et al., 2018 [126] | Retrospective | n = 260 (113 in group I and 147 in group II) | Group I with nucleoplasty. Group II with targeted disc decompression. | VAS and FRI at 1, 3, 6, 12, 24, and 60 months | The findings from a 5-year follow-up study revealed that both targeted disc decompression and nucleoplasty effectively reduced pain caused by disc herniation and improved the patients’ quality of life. Furthermore, there was no statistically significant difference in therapeutic efficacy between these two treatment methods. |
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Shin, D.A.; Choo, Y.J.; Chang, M.C. Spinal Injections: A Narrative Review from a Surgeon’s Perspective. Healthcare 2023, 11, 2355. https://doi.org/10.3390/healthcare11162355
Shin DA, Choo YJ, Chang MC. Spinal Injections: A Narrative Review from a Surgeon’s Perspective. Healthcare. 2023; 11(16):2355. https://doi.org/10.3390/healthcare11162355
Chicago/Turabian StyleShin, Dong Ah, Yoo Jin Choo, and Min Cheol Chang. 2023. "Spinal Injections: A Narrative Review from a Surgeon’s Perspective" Healthcare 11, no. 16: 2355. https://doi.org/10.3390/healthcare11162355