Habib George, Jabbour Adel, Salman Jameel, Hakim Geries, Haddad Henry
Rheumatology Clinic, Nazareth Hospital, Nazareth 16000, Israel; Deputy, Department of Medicine, Carmel Medical Center, Haifa, Technion Faculty of Medicine, Haifa 34362, Israel.
Central Laboratory, Nazareth Hospital, Nazareth 16000, Israel.
J Clin Anesth. 2013 Dec;25(8):629-33. doi: 10.1016/j.jclinane.2013.07.002. Epub 2013 Aug 27.
To evaluate the effect of an epidural corticosteroid injection of 80 mg and 40 mg of methylprednisolone acetate on the hypothalamic-pituitary-adrenal axis and on back pain.
Randomized, single-blinded prospective study.
Operating room of a university-affiliated hospital.
42 patients with low back pain due to radiculopathy.
Group 1 received an epidural corticosteroid injection of 80 mg of methylprednisolone acetate, and Group 2 received an epidural corticosteroid injection of 40 mg of methylprednisolone acetate. All study patients underwent a stimulation test of one μg of adrenocorticotropin hormone (ACTH), and their pain levels were graded just prior to and following the epidural corticosteroid injection on weeks one, 3, and 4.
Serum cortisol of the ACTH stimulation tests and back pain levels were rated using a visual analog scale (VAS). Serum cortisol levels lower than 18 ng/mL 30 minutes following the ACTH stimulation test were considered to be secondary adrenal insufficiency.
21 patients were enrolled in each group. The rate of secondary adrenal insufficiency in Group 1 was ~86%, ~ 22%, and ~17% of patients versus ~53% (P = 0.024), 15% (P = 0.874), and ~12% (P = 0.715) of Group 2 patients at weeks one, 3, and 4, respectively. About 62%, 56%, and 39% of Group 1 patients had a favorable clinical response as opposed to ~47% (P = 0362), 35% (P = 0.21), and ~6% (P = 0.049) of Group 2 patients at weeks one, 3, and 4, respectively.
Epidural corticosteroid injection of methylprednisolone acetate in both groups was associated with very high rates of secondary adrenal insufficiency, but significantly more so in Group 1 at week one. This suppression was transient, with recovery of the gland in most patients noted over the ensuing weeks. An epidural corticosteroid injection of 80 mg had higher rates of favorable clinical response than a 40 mg injection, but significantly more so at week 4 only. This favorable response waned over a few weeks in both groups.
评估80毫克和40毫克醋酸甲泼尼龙硬膜外注射对下丘脑 - 垂体 - 肾上腺轴及背痛的影响。
随机、单盲前瞻性研究。
大学附属医院手术室。
42例因神经根病导致腰痛的患者。
第1组接受80毫克醋酸甲泼尼龙硬膜外注射，第2组接受40毫克醋酸甲泼尼龙硬膜外注射。所有研究患者均接受1微克促肾上腺皮质激素（ACTH）刺激试验，并在硬膜外注射皮质类固醇前以及第1、3和4周注射后对疼痛程度进行分级。
使用视觉模拟量表（VAS）对ACTH刺激试验的血清皮质醇和背痛水平进行评分。ACTH刺激试验后30分钟血清皮质醇水平低于18纳克/毫升被认为是继发性肾上腺功能不全。
每组纳入21例患者。第1组继发性肾上腺功能不全的发生率在第1、3和4周分别约为患者的86%、22%和17%，而第2组分别约为53%（P = 0.024）、15%（P = 0.874）和12%（P = 0.715）。第1组分别约62%、56%和39%的患者有良好的临床反应，而第2组在第1、3和4周分别约为47%（P = 0.362）、35%（P = 0.21）和6%（P = 0.049）。
两组醋酸甲泼尼龙硬膜外注射均与非常高的继发性肾上腺功能不全发生率相关，但第1组在第1周时更为显著。这种抑制是短暂的，在随后几周大多数患者的肾上腺功能恢复。80毫克硬膜外注射皮质类固醇的良好临床反应率高于40毫克注射，但仅在第4周时显著更高。两组的这种良好反应在几周内均有所减弱。
