Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA.
University of Illinois at Urbana-Champaign, College of Liberal Arts and Sciences, Champaign, IL.
Pain Physician. 2021 Aug;24(5):E539-E554.
Epidural injections are one of the commonly performed procedures in managing low back and lower extremity pain. In the past, Pinto et al and Chou et al performed systematic reviews and meta-analyses with a recent update from Oliveira et al showing lack of effectiveness of epidural steroid injections in managing lumbar radiculopathy. In contrast, multiple other systematic reviews and meta-analyses have supported the efficacy and use of epidural injections utilizing fluoroscopic guidance.
A systematic review and meta-analysis of randomized controlled trials (RCTs) of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy.
To assess the efficacy of 3 categories of epidural injections for lumbar radiculopathy or sciatica performed utilizing saline with steroids, local anesthetic alone, or steroids with local anesthetic.
In this systematic review and meta-analysis, RCTs with a placebo control or an active control design, performed under fluoroscopic guidance, with at least 6 months of followed-up were included. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Literature search was performed through January 2021. Methodological quality assessments were performed. Evidence was summarized utilizing principles of best evidence synthesis.
In this analysis, a total of 21 RCTs were utilized with at least 6 months of follow-up and performed under fluoroscopic guidance. However, only 6 of 25 trials from Cochrane review met inclusion criteria for this review. Based on qualitative analysis, of the 21 trials included in the present analysis, there was only one placebo-controlled trial found to be negative. With conventional meta-analysis, there was no significant difference among the studies because all of the studies were active control with local anesthetic or local anesthetic and steroids. Further, with single-arm analysis, of the 5 trials included in that portion of the study, significant improvement was seen with local anesthetic alone compared to local anesthetic and steroids. There was a tendency for better improvement with steroids in terms of both pain relief and functional status. The level of evidence is Level I or strong for local anesthetic with steroids and Level I to II or moderate to strong for local anesthetic as a single agent based on multiple relevant high quality RCTs.
Despite multiple trials available, there is a paucity of true RCTs performed under fluoroscopic guidance with any of the approaches.
Epidural injections with or without steroids for radiculopathy showed significant effectiveness with Level I or strong evidence for local anesthetic with steroids and Level II to I or moderate to strong evidence with local anesthetic alone.
硬膜外注射是治疗下腰痛和下肢疼痛的常用方法之一。过去，Pinto 等人和 Chou 等人进行了系统评价和荟萃分析，最近 Oliveira 等人的研究表明硬膜外类固醇注射治疗腰椎神经根病无效。相比之下，其他多项系统评价和荟萃分析支持在透视引导下使用硬膜外注射的有效性和用途。
一项针对慢性下腰痛和下肢疼痛伴坐骨神经痛或腰椎神经根病的硬膜外注射的随机对照试验（RCT）的系统评价和荟萃分析。
评估在透视引导下使用生理盐水加类固醇、局部麻醉剂或类固醇加局部麻醉剂进行 3 类硬膜外注射治疗腰椎神经根病或坐骨神经痛的疗效。
在这项系统评价和荟萃分析中，纳入了至少 6 个月随访的、采用安慰剂对照或阳性对照设计、在透视引导下进行的 RCT。结局指标为疼痛缓解和功能状态改善。显著改善定义为疼痛缓解 50%或以上，功能状态改善。文献检索截至 2021 年 1 月。进行了方法学质量评估。利用最佳证据综合原则总结证据。
本分析共纳入 21 项 RCT，随访时间至少 6 个月，并在透视引导下进行。然而，仅 Cochrane 综述中 25 项试验中的 6 项符合本综述的纳入标准。基于定性分析，在本分析中纳入的 21 项试验中，只有一项安慰剂对照试验结果为阴性。采用常规荟萃分析，由于所有研究均为局部麻醉剂或局部麻醉剂加类固醇的阳性对照，因此研究之间没有显著差异。此外，在单臂分析中，在该部分研究中纳入的 5 项试验中，与局部麻醉剂加类固醇相比，单独使用局部麻醉剂可显著改善。在疼痛缓解和功能状态方面，类固醇的改善趋势更好。基于多项相关高质量 RCT，局部麻醉加类固醇的证据水平为 I 级或强，单独使用局部麻醉的证据水平为 I 级至 II 级或中至强。
尽管有多项试验可用，但在透视引导下使用任何方法进行的真正 RCT 仍然很少。
对于神经根病，硬膜外注射加或不加类固醇均有效，且局部麻醉加类固醇的证据水平为 I 级或强，单独使用局部麻醉的证据水平为 II 级至 I 级或中至强。
