Manchikanti Laxmaiah, Benyamin Ramsin M, Falco Frank J E, Kaye Alan D, Hirsch Joshua A
Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA,
Clin Orthop Relat Res. 2015 Jun;473(6):1940-56. doi: 10.1007/s11999-014-3490-4.
As part of a comprehensive nonsurgical approach, epidural injections often are used in the management of lumbar disc herniation. Recent guidelines and systematic reviews have reached different conclusions about the efficacy of epidural injections in managing lumbar disc herniation.
QUESTIONS/PURPOSES: In this systematic review, we determined the efficacy (pain relief and functional improvement) of the three anatomic approaches (caudal, lumbar interlaminar, and transforaminal) for epidural injections in the treatment of disc herniation.
We performed a literature search from 1966 to June 2013 in PubMed, Cochrane library, US National Guideline Clearinghouse, previous systematic reviews, and cross-references for trials studying all types of epidural injections in managing chronic or chronic and subacute lumbar disc herniation. We wanted only randomized controlled trials (RCTs) (either placebo or active controlled) to be included in our analysis, and 66 studies found in our search fulfilled these criteria. We then assessed the methodologic quality of these 66 studies using the Cochrane review criteria for RCTs. Thirty-nine studies were excluded, leaving 23 RCTs of high and moderate methodologic quality for analysis. Evidence for the efficacy of all three approaches for epidural injection under fluoroscopy was strong for short-term (< 6 months) and moderate for long-term (≥ 6 months) based on the Cochrane rating system with five levels of evidence (best evidence synthesis), with strong evidence denoting consistent findings among multiple high-quality RCTs and moderate evidence denoting consistent findings among multiple low-quality RCTs or one high-quality RCT. The primary outcome measure was pain relief, defined as at least 50% improvement in pain or 3-point improvement in pain scores in at least 50% of the patients. The secondary outcome measure was functional improvement, defined as 50% reduction in disability or 30% reduction in the disability scores.
Based on strong evidence for short-term efficacy from multiple high-quality trials and moderate evidence for long-term efficacy from at least one high quality trial, we found that fluoroscopic caudal, lumbar interlaminar, and transforaminal epidural injections were efficacious at managing lumbar disc herniation in terms of pain relief and functional improvement.
The available evidence suggests that epidural injections performed under fluoroscopy by trained physicians offer improvement in pain and function in well-selected patients with lumbar disc herniation.
作为综合非手术治疗方法的一部分，硬膜外注射常用于腰椎间盘突出症的治疗。最近的指南和系统评价对于硬膜外注射治疗腰椎间盘突出症的疗效得出了不同结论。
问题/目的：在本系统评价中，我们确定了硬膜外注射的三种解剖学入路（骶管、腰椎椎板间和经椎间孔）在治疗椎间盘突出症方面的疗效（缓解疼痛和改善功能）。
我们在PubMed、Cochrane图书馆、美国国家指南资料库、既往系统评价以及研究各种硬膜外注射治疗慢性或慢性及亚急性腰椎间盘突出症的试验的交叉参考文献中进行了1966年至2013年6月的文献检索。我们仅希望将随机对照试验（RCT）（安慰剂对照或活性对照）纳入分析，在检索中发现的66项研究符合这些标准。然后，我们使用Cochrane随机对照试验评价标准评估这66项研究的方法学质量。39项研究被排除，剩下23项方法学质量高和中等的随机对照试验进行分析。根据具有五个证据水平（最佳证据综合）的Cochrane评级系统，对于透视下硬膜外注射的所有三种入路，短期（<6个月）疗效证据强，长期（≥6个月）疗效证据中等，强证据表示多个高质量随机对照试验结果一致，中等证据表示多个低质量随机对照试验或一个高质量随机对照试验结果一致。主要结局指标为疼痛缓解，定义为至少50%的患者疼痛改善至少50%或疼痛评分提高3分。次要结局指标为功能改善，定义为残疾程度降低50%或残疾评分降低30%。
基于多个高质量试验的短期疗效强证据和至少一项高质量试验的长期疗效中等证据，我们发现透视下骶管、腰椎椎板间和经椎间孔硬膜外注射在缓解疼痛和改善功能方面对治疗腰椎间盘突出症有效。
现有证据表明，由训练有素的医生在透视下进行硬膜外注射可使精心挑选的腰椎间盘突出症患者的疼痛和功能得到改善。
