Fang Zeyu, Yuan Chenghua, Cheng Lei, Yao Qingyu, Zhang Can, Wang Xinyu, Guan Jian, Jian Fengzeng
Department of Neurosurgery, Division of Spine, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, Beijing, People's Republic of China.
Pain Physician. 2022 Mar;25(2):145-160.
Selective nerve root block has been widely used to treat degenerative disc disease (DDD), but no detailed research data is provided to compare the efficacy of epidural injection of anesthetics with or without steroids on the DDD treatment.
This study aimed to provide the first comparison of steroids + local anesthetic (LA) or LA alone for the treatment of DDD.
We systematically searched PubMed, Medline, Embase, and Cochrane. A systemic review and meta-analysis were performed to assess the clinical efficacy of both the steroids + LA group and the LA alone group, and subgroup analysis was also adopted.
A systematic review and meta-analysis using a random effects model on randomized controlled studies (RCTs).
After reviewing titles, abstracts, risk of bias, and full texts of 15,889 studies that were chosen following removal of duplicates after the initial database search, finally, 19 RCTs were included. Pain rating, functional score, follow-up period, and other-related data were extracted from these included works, and the effect size and statistical significance were calculated by the random effects model. The quality and level of the derived evidence were assessed by means of the Grading of Recommendations Assessment, Development and Evaluation method.
In terms of the Numeric Rating Scale (NRS-11) and Oswestry Disability Index (ODI) at one year, the combination of steroids + LA was obviously superior to LA. Subgroup analysis suggested that the combination of steroids + LA was more effective than LA alone in regard to the ODI in the lumbar group within 2 years. The opioids intake of patients treated by LA alone was less than that of the steroids + LA group within 3 months, and LA alone was more effective in pain score reduction, with more than 50% within 6 months in the interlaminar injection group. However, the combination of steroids + LA was more effective when alleviating the NRS-11 within 18 months in the caudal injection group.
Firstly, this analysis was inconsistent in technique, dosage, injection frequency, and follow-up period of epidural injections. Such differences may compromise the reported efficacy. Secondly, adverse reactions arising out of the 2 groups were not examined in that the included RCTs did not provide the data. Thirdly, different injection methods would compromise the outcomes, and no subgroup analysis was performed on different injection methods. Finally, these included articles that were mainly sourced from Manchikanti's team, and thus biased to some extent.
The addition of steroids to anesthetic injectates was associated with a better NRS-11 and ODI compared with LA alone within one year in patients with DDD. Furthermore, the improvement of the ODI was observed within 2 years in patients with lumbar DDD.
选择性神经根阻滞已广泛用于治疗椎间盘退变疾病（DDD），但尚无详细研究数据比较硬膜外注射麻醉剂加或不加类固醇对DDD治疗的疗效。
本研究旨在首次比较类固醇+局部麻醉剂（LA）或单纯LA治疗DDD的效果。
我们系统检索了PubMed、Medline、Embase和Cochrane数据库。进行系统评价和荟萃分析以评估类固醇+LA组和单纯LA组的临床疗效，并采用亚组分析。
对随机对照试验（RCT）采用随机效应模型进行系统评价和荟萃分析。
在对初始数据库检索后去除重复项后选择的15889项研究的标题、摘要、偏倚风险和全文进行审查后，最终纳入19项RCT。从这些纳入的研究中提取疼痛评分、功能评分、随访期和其他相关数据，并通过随机效应模型计算效应量和统计学意义。采用推荐分级评估、制定和评价方法评估所得证据的质量和级别。
在一年时的数字评分量表（NRS-11）和Oswestry功能障碍指数（ODI）方面，类固醇+LA的联合使用明显优于LA。亚组分析表明，在2年内，类固醇+LA联合使用在腰椎组的ODI方面比单纯LA更有效。在3个月内，单纯LA治疗的患者的阿片类药物摄入量低于类固醇+LA组，并且单纯LA在降低疼痛评分方面更有效，在椎板间注射组中6个月内超过50%。然而，在尾端注射组中，类固醇+LA联合使用在18个月内减轻NRS-11方面更有效。
首先，该分析在硬膜外注射的技术、剂量、注射频率和随访期方面不一致。这些差异可能会影响报告的疗效。其次，由于纳入的RCT未提供数据，未检查两组产生的不良反应。第三，不同的注射方法会影响结果，并且未对不同的注射方法进行亚组分析。最后，这些纳入的文章主要来自Manchikanti团队，因此在一定程度上存在偏倚。
与单纯LA相比，在DDD患者中，在麻醉剂注射中添加类固醇在一年内与更好的NRS-11和ODI相关。此外，在腰椎DDD患者中，在2年内观察到ODI有所改善。
