Department of Anesthesiology and Perioperative Medicine, University of Louisville.
Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Pain Physician. 2016 Mar;19(3):E365-410.
The prevalence of chronic low back pain and related disability is rapidly increasing as are the myriad treatments, including epidural injections. Even though epidural injections are one of the most commonly performed procedures in managing low back and lower extremity pain, starting in 1901 with local anesthetic alone, conflicting recommendations have been provided, despite the extensive literature. Recently Chou et al performed a technology assessment review for Agency for Healthcare Research and Quality (AHRQ) part of which was published in Annals of Internal Medicine showing lack of effectiveness of epidural steroid injections in managing lumbar radiculopathy and spinal stenosis. In contrast, multiple other publications have supported the efficacy and use of epidural injections.
To assess the efficacy of 3 categories of epidural injections for lumbar and spinal stenosis: performed with saline with steroids, local anesthetic alone, or steroids with local anesthetic and separate facts from opinions.
PubMed, Cochrane Library, US National Guideline Clearinghouse, prior systematic reviews, and reference lists. The literature search was performed through August 2015.
Randomized trials, either placebo or active control, of epidural injections for lumbar radiculopathy and spinal stenosis.
Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Evidence was summarized utilizing principles of best evidence synthesis.
Thirty-nine randomized controlled trials met inclusion criteria. There were 9 placebo-controlled trials evaluating epidural corticosteroid injections, either with sodium chloride solution or bupivacaine, compared to placebo injections. There were 12 studies comparing local anesthetic alone to local anesthetic with steroid.
A meta-analysis of 5 studies utilizing sodium chloride or bupivacaine with steroid showed a lack of efficacy.A comparison of lidocaine to lidocaine with steroids in 7 studies showed significant effectiveness from baseline to long-term follow-up periods. Meta-analysis showed a similar effectiveness for pain and function without non-inferiority of lidocaine compared to lidocaine with steroid at 3 months and 12 months.
The review was restricted to the data available with at least 3 months of follow-up, which excluded some studies. The inclusion criteria were restricted to English language studies.
Epidural corticosteroid injections for radiculopathy or spinal stenosis with sodium chloride solution or bupivacaine were shown to be ineffective. Lidocaine alone or lidocaine in conjunction with steroids were significantly effective.
随着慢性腰痛及其相关残疾的患病率迅速上升，治疗方法也层出不穷，包括硬膜外注射。尽管硬膜外注射是治疗下腰痛和下肢痛最常用的方法之一，但自 1901 年首次使用局部麻醉剂以来，尽管文献丰富，但仍存在相互矛盾的建议。最近，Chou 等人对医疗保健研究和质量局（AHRQ）进行了技术评估审查，其中一部分发表在《内科医学年鉴》上，表明硬膜外皮质类固醇注射在治疗腰椎神经根病和椎管狭窄方面无效。相比之下，其他许多出版物都支持硬膜外注射的疗效和使用。
评估 3 类硬膜外注射治疗腰椎和椎管狭窄的疗效：用生理盐水加类固醇、单独使用局部麻醉剂或类固醇加局部麻醉剂，并将事实与观点区分开来。
PubMed、Cochrane 图书馆、美国国家指南清除中心、先前的系统评价和参考文献列表。文献检索截止到 2015 年 8 月。
随机试验，无论是安慰剂还是活性对照，用于治疗腰椎神经根病和椎管狭窄的硬膜外注射。
利用 Cochrane 综述方法学质量评估和介入性疼痛管理技术-可靠性和偏倚评估的质量评估（IPM-QRB），进行数据提取和方法学质量评估。利用最佳证据综合的原则总结证据。
39 项随机对照试验符合纳入标准。有 9 项安慰剂对照试验评估了硬膜外皮质类固醇注射，分别使用生理盐水或布比卡因，与安慰剂注射相比。有 12 项研究比较了单独使用局部麻醉剂与局部麻醉剂加类固醇。
5 项研究的荟萃分析显示，使用生理盐水或布比卡因加类固醇缺乏疗效。7 项研究中比较利多卡因与利多卡因加类固醇的研究显示，从基线到长期随访期间，疼痛和功能均有显著改善。荟萃分析显示，疼痛和功能无差异，利多卡因与类固醇在 3 个月和 12 个月时无非劣效性。
该综述仅限于至少有 3 个月随访数据的研究，这排除了一些研究。纳入标准仅限于英语语言研究。
在腰椎神经根病或椎管狭窄症中，硬膜外注射生理盐水或布比卡因加皮质类固醇无效。单独使用利多卡因或利多卡因加类固醇均有显著疗效。
