Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY.
The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
J Bone Joint Surg Am. 2020 Aug 5;102(15):1297-1304. doi: 10.2106/JBJS.19.00596.
Although epidural steroid injection (ESI) may provide pain relief for patients with degenerative spondylolisthesis in treatment regimens of up to 4 months, it remains unclear whether ESI affects crossover from nonoperative to operative management.
This retrospective cohort study analyzed 2 groups of surgical candidates with degenerative spondylolisthesis: those who received ESI within 3 months after enrollment (ESI group) and those who did not (no-ESI group). Annual outcomes following enrollment were assessed within operative and nonoperative groups (patients who initially chose or were assigned to surgery or nonoperative treatment) by using longitudinal mixed-effect models with a random subject intercept term accounting for correlations between repeated measurements. Treatment comparisons were performed at follow-up intervals. Area-under-the-curve analysis for all time points assessed the global significance of treatment.
The study included 192 patients in the no-ESI group and 74 in the ESI group. The no-ESI group had greater baseline Short Form-36 (SF-36) Bodily Pain scores (median, 35 versus 32) and self-reported preference for surgery (38% versus 11%). There were no differences in surgical rates within 4 years after enrollment between the no-ESI and ESI groups (61% versus 62%). The surgical ESI and no-ESI groups also showed no differences in changes in patient-reported outcomes at any follow-up interval or in the 4-year average. Compared with the nonoperative ESI group, the nonoperative no-ESI group showed greater improvements in SF-36 scores for Bodily Pain (p = 0.004) and Physical Function (p = 0.005) at 4 years, Bodily Pain at 1 year (p = 0.002) and 3 years (p = 0.005), and Physical Function at 1 year (p = 0.030) and 2 years (p = 0.002). Of the patients who were initially treated nonsurgically, those who received ESI and those who did not receive ESI did not differ with regard to surgical crossover rates. The rates of crossover to nonoperative treatment by patients who initially chose or were assigned to surgery also did not differ between the ESI and no-ESI groups.
There was no relationship between ESI and improved clinical outcomes over a 4-year study period for patients who chose or were assigned to receive surgery for degenerative spondylolisthesis. In the nonsurgical group, ESI was associated with inferior pain reduction through 3 years, although this was confounded by greater baseline pain. ESI showed little relationship with surgical crossover.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
硬膜外类固醇注射（ESI）可能为退行性脊椎滑脱患者的治疗方案提供长达 4 个月的疼痛缓解，但仍不清楚 ESI 是否会影响从非手术到手术治疗的转变。
本回顾性队列研究分析了两组退行性脊椎滑脱的手术候选者：在入组后 3 个月内接受 ESI 的患者（ESI 组）和未接受 ESI 的患者（非 ESI 组）。通过使用具有随机主体截距项的纵向混合效应模型评估入组后每年的手术和非手术组的结果（最初选择或被分配手术或非手术治疗的患者），以解释重复测量之间的相关性。在随访间隔进行治疗比较。所有时间点的曲线下面积分析评估了治疗的整体意义。
非 ESI 组纳入 192 例患者，ESI 组纳入 74 例患者。非 ESI 组基线下的简明健康调查问卷 36 项（SF-36）躯体疼痛评分（中位数 35 分比 32 分）和自我报告手术偏好（38%比 11%）更高。在入组后 4 年内，非 ESI 组和 ESI 组之间的手术率没有差异（61%比 62%）。在任何随访间隔或 4 年平均水平上，接受手术的 ESI 和非 ESI 组患者的患者报告结局变化也没有差异。与非手术 ESI 组相比，非手术非 ESI 组在 4 年时 SF-36 躯体疼痛评分（p = 0.004）和身体功能评分（p = 0.005）、1 年时躯体疼痛评分（p = 0.002）和 3 年时躯体疼痛评分（p = 0.005）以及 1 年时身体功能评分（p = 0.030）和 2 年时身体功能评分（p = 0.002）均有更大的改善。在最初接受非手术治疗的患者中，接受 ESI 和未接受 ESI 的患者在手术交叉率方面没有差异。最初选择或被分配手术的患者向非手术治疗的交叉率在 ESI 和非 ESI 组之间也没有差异。
对于选择或被分配手术治疗退行性脊椎滑脱的患者，在 4 年的研究期间，ESI 与临床结局的改善之间没有关系。在非手术组中，尽管存在基线疼痛更高的混杂因素，但 ESI 在 3 年内与疼痛减轻有关。ESI 与手术交叉关系不大。
治疗性 III 级。有关证据水平的完整说明，请参见作者指南。
