Department of Physical Medicine and Rehabilitation, Wooridul Spine Hospital, Seoul.
Heal & Teun Rehabilitation & Pain Clinic, Bundang, South Korea.
Pain Physician. 2018 Sep;21(5):433-448.
Epidural injection (EI) is used to treat back or radicular pain from lumbosacral disc herniation (LDH). Although several reports have stated that the transforaminal approach in EI (TFEI) has an advantage in target specificity and yields better clinical efficacy than the interlaminar approach in EI (ILEI), other studies have indicated that the clinical efficacy of ILEI was not inferior to that of TFEI and that ILEI also has the ability to spread medication into the ventral space to a degree similar to that of TFEI. There has been controversy about whether TFEI is superior to ILEI in clinical efficacy.
This systematic review and meta-analysis aimed to investigate whether TFEI is more useful than ILEI for achieving clinical outcomes in patients with LDH.
A systematic review and meta-analysis using a random effects model on randomized controlled studies (RCT).
A literature search was performed in MEDLINE, EMBASE, Cochrane review, and KoreaMed for studies published from January 1996 until July 2017. From those found fulfilling the search criteria, manuscripts that compared the clinical efficacy of steroids and control agents, such as local anesthetics or saline, in terms of pain control and functional improvement were included in this study. Exclusion criteria included a previous history of lumbosacral surgery, non-specific low back pain, severe spinal stenosis, and severe disc degeneration. After reviewing titles, abstracts, and the full text of 6,711 studies; 12 studies were included in the qualitative synthesis. Data including pain scores, functional scores, and follow-up period were extracted from 10 studies and analyzed using a random effects model to obtain effect size and its statistical significance. The quality and level of evidence were analyzed in accordance with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.
In terms of pain control, TFEI showed significantly better short-term (2 weeks to 1 month) outcomes and slightly favorable long-term (4 - 6 month) outcomes, but without significance, in comparison with ILEI. In terms of functional improvement, TFEI also showed favorable short- and long-term outcomes, but without significance, in comparison with ILEI. TFEI had target specificity, required no additional cost and resources, and had equal applicability to ILEI. However, TFEI was more associated with a higher frequency of discomfort or adverse events during the procedure. Overall, better results were reported with TFEI over ILEI, but with low-grade evidence due to the inconsistency and imprecision of the selected studies.
Analyses of safety or adverse effects could not be performed due to a lack of available data from the included studies.
Based on low-grade evidence, TFEI showed significantly better short-term pain control and slightly favorable outcomes in long-term pain reduction and short- and long-term functional improvement in comparison with ILEI.
Epidural injection, interlaminar, transforaminal, meta-analysis, systemic review, pain, function.
硬膜外注射（EI）用于治疗腰骶椎间盘突出症（LDH）引起的背部或神经根疼痛。尽管有几项报告表明，经椎间孔入路 EI（TFEI）在目标特异性方面具有优势，并且在临床疗效方面优于 EI 的经椎间孔入路（ILEI），但其他研究表明 ILEI 的临床疗效并不逊于 TFEI，并且 ILEI 也有能力将药物扩散到腹侧空间，程度类似于 TFEI。关于 TFEI 是否在临床疗效方面优于 ILEI 存在争议。
本系统评价和荟萃分析旨在探讨 TFEI 是否比 ILEI 更能在 LDH 患者中获得临床结果。
一项系统评价和荟萃分析，采用随机效应模型对随机对照研究（RCT）进行分析。
在 MEDLINE、EMBASE、Cochrane 综述和 KoreaMed 中进行文献检索，检索自 1996 年 1 月至 2017 年 7 月发表的研究。从符合搜索标准的研究中，纳入了比较类固醇和对照剂（如局部麻醉剂或生理盐水）在疼痛控制和功能改善方面临床疗效的研究。排除标准包括腰骶部手术史、非特异性腰痛、严重的椎管狭窄和严重的椎间盘退变。在回顾了 6711 项研究的标题、摘要和全文后；12 项研究被纳入定性综合分析。从 10 项研究中提取疼痛评分、功能评分和随访时间等数据，并采用随机效应模型进行分析，以获得效应大小及其统计学意义。根据推荐评估、制定和评估（GRADE）方法学对质量和证据水平进行了分析。
在疼痛控制方面，与 ILEI 相比，TFEI 在短期（2 周至 1 个月）结果方面表现出明显更好的结果，在长期（4-6 个月）结果方面也有稍微有利的结果，但无统计学意义。在功能改善方面，TFEI 也表现出短期和长期结果有利，但无统计学意义。TFEI 具有靶向特异性，无需额外的成本和资源，并且与 ILEI 具有同等的适用性。然而，TFEI 与手术过程中更频繁的不适或不良事件相关。总体而言，TFEI 比 ILEI 报告了更好的结果，但由于所选研究的不一致性和不精确性，证据水平较低。
由于纳入研究缺乏可用数据，因此无法进行安全性或不良影响的分析。
基于低质量证据，与 ILEI 相比，TFEI 在短期疼痛控制方面表现出明显更好的结果，在长期疼痛缓解和短期及长期功能改善方面也有稍微有利的结果。
硬膜外注射、经椎间孔入路、经椎间孔入路、荟萃分析、系统评价、疼痛、功能。
