Manchikanti Laxmaiah, Falco Frank J E, Pampati Vidyasagar, Hirsch Joshua A
Pain Management Center of Paducah, Paducah, KY, and 2University of Louisville, Louisville, KY; Mid Atlantic Spine & Pain Physicians, Newark, DE, and Temple University Hospital, Philadelphia, PA; and Massachusetts General Hospital and Harvard Medical Schoo.
Pain Physician. 2014 Nov-Dec;17(6):E691-702.
Epidural injections are performed to manage lumbar central spinal stenosis pain utilizing caudal, interlaminar, and transforaminal approaches. The literature on the efficacy of epidural injections in managing lumbar central spinal stenosis pain is sparse; lacking multiple, high quality randomized trials with long-term follow-up.
Two randomized controlled trials of the caudal and lumbar interlaminar approaches that assessed 220 patients with lumbar central spinal stenosis were analyzed.
The analysis found efficacy for both caudal and interlaminar approaches in managing chronic pain and disability from central spinal stenosis was demonstrated. In the patients responsive to treatment, those with at least 3 weeks of improvement with the first 2 procedures, 51% reported significant improvement with caudal epidural injections, whereas it was 84% with local anesthetic only with interlaminar epidurals, 57% with caudal and 83% with lumbar interlaminar with local anesthetic with steroid. The response rate was 38% with caudal and 72% with lumbar interlaminar with local anesthetic only and 44% with caudal and 73% with lumbar interlaminar with local anesthetic with steroid when all patients were considered. In the interlaminar approach, results were superior for pain relief and functional status with fewer nonresponsive patients compared to the caudal approach.
The data was derived from 2 previously published randomized, controlled trials rather than comparing 2 techniques in one randomized controlled trial. Further, the randomized controlled trials were active control trials without a placebo.
The results of this assessment showed significant improvement in patients suffering with chronic lumbar spinal stenosis with caudal and interlaminar epidural approaches with local anesthetic only, or with steroids in a long-term follow-up of up to 2 years, in contemporary interventional pain management setting, with the interlaminar approach providing significantly better results.
硬膜外注射通过骶管、椎板间和经椎间孔途径来治疗腰椎中央管狭窄症引起的疼痛。关于硬膜外注射治疗腰椎中央管狭窄症疼痛疗效的文献较少；缺乏多项高质量的长期随访随机试验。
分析了两项评估220例腰椎中央管狭窄症患者的骶管和腰椎椎板间途径的随机对照试验。
分析发现骶管和椎板间途径在治疗中央管狭窄引起的慢性疼痛和功能障碍方面均有效。在对治疗有反应的患者中，在前两种治疗方法中至少有3周改善的患者中，51%报告骶管硬膜外注射有显著改善，而仅局部麻醉的椎板间硬膜外注射为84%，骶管联合局部麻醉加类固醇为57%，腰椎椎板间联合局部麻醉加类固醇为83%。当考虑所有患者时，仅局部麻醉的骶管注射反应率为38%，腰椎椎板间为72%；骶管联合局部麻醉加类固醇为44%，腰椎椎板间为73%。在椎板间途径中，与骶管途径相比，疼痛缓解和功能状态的结果更好，无反应患者更少。
数据来自两项先前发表的随机对照试验，而非在一项随机对照试验中比较两种技术。此外，随机对照试验为无安慰剂的活性对照试验。
在当代介入性疼痛管理环境中，这项评估结果显示，在长达2年的长期随访中，仅使用局部麻醉剂或联合类固醇的骶管和椎板间硬膜外途径，可使慢性腰椎管狭窄症患者有显著改善，其中椎板间途径效果更佳。
