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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 4  |  Page : 184-187

Steroids versus pulsed radiofrequency in treatment of radicular pain due to lumbar disc prolapse: a randomized clinical trial


Department of Anesthesia, Zagazig Faculty of Medicine, Zagazig, Egypt

Date of Submission10-Jun-2016
Date of Acceptance01-Jun-2017
Date of Web Publication11-Oct-2017

Correspondence Address:
Osama Y.A. Khalifa
Department of Anesthesia, Zagazig Faculty of Medicine, Zagazig, 44519
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/roaic.roaic_54_16

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  Abstract 

Background
Both lumbar transforaminal epidural steroids (TESs) and dorsal root ganglion pulsed radiofrequency (PRF) are used in the treatment of radiculopathy after lumbar disc prolapse. We try to detect which is more effective.
Patients and methods
A total of 90 patients were randomly allocated into two groups: the TESs group, which comprised 45 patients, and the PRF group, also comprising 45 patients. In the first group, transforaminal epidural methylprednisolone was injected on the affected roots at a dose of 24 mg/root and in group PRF for 4 min was done and only 8 mg of methylprednisolone was injected after radiofrequency. Visual analog scale (VAS) was assessed by a blinded pain physician before intervention and 1 week, 4 weeks, 2 months, and 3 months after intervention through telephone calls.
Results
At 1 week the VAS was significantly reduced in both groups, and there was a nonsignificant difference between the two groups. At 4 weeks the VAS reduction was still significant in both groups but the reduction in group PRF was significant in comparison with the TES group. At 2 months there was a nonsignificant difference between VAS and preintervention value in group TES, whereas it was significant in group PRF either in comparison with preinterventional value or with the TES group. At 3 months, the VAS reduction was significant in group PRF in comparison with group TES.
Conclusion
PRF of lumbar dorsal root ganglia is more effective than lumbar TES injection up to 3 months of follow-up in patients with radiculopathy due to lumbar disc prolapse.

Keywords: lumbar disc, pulsed radiofrequency, radicular pain, steroids


How to cite this article:
Khalifa OY, Saadalla AE. Steroids versus pulsed radiofrequency in treatment of radicular pain due to lumbar disc prolapse: a randomized clinical trial. Res Opin Anesth Intensive Care 2017;4:184-7

How to cite this URL:
Khalifa OY, Saadalla AE. Steroids versus pulsed radiofrequency in treatment of radicular pain due to lumbar disc prolapse: a randomized clinical trial. Res Opin Anesth Intensive Care [serial online] 2017 [cited 2020 Jun 4];4:184-7. Available from: http://www.roaic.eg.net/text.asp?2017/4/4/184/216451


  Introduction Top


After a long experience of lumbar transforaminal epidural steroid (TES) injections and dorsal root ganglion (DRG) pulsed radiofrequency (PRF), we observe unsatisfactory outcome after steroids injection in so many cases, and this is not the case in DRG PRF. This observation pushes us to perform a comparative study between both interventional procedures.

Many approaches to lumbar epidural space and injection of steroids are described, including caudal, interlaminar, and transforaminal epidural approaches. The transforaminal epidural approach allows injection of the smallest volume at the anterior epidural space, which is the site of pathology in lumbar disc prolapse (LDP) with radiculopathy [1]. Although there is deficiency in well-designed randomized clinical trials to detect the evidence of effectiveness of different approaches of lumbar epidural steroids injection, a systematic review of these approaches finds that there is a limited evidence for long-term (>6 weeks) pain relief while there is a moderate evidence for lumbar TESs in managing lumbar radiculopathy regarding long-term improvement of pain, functional, psychological status, and return back to work [2].

To the best of our knowledge also there is no well-designed large randomized controlled trials to proof the efficacy of DRG PRF in the management of chronic lumbar radicular pain. Shanthanna et al. [3] reported that there is a nonsignificant difference between lumbar DRG PRF and control group regarding visual analog scale (VAS) and Oswestry disability index either at 4-week or 3-month intervals post intervention.

In the current study, we compare between the effect of lumbar TES injection and DRG PRF in the treatment of radicular pain due to LDP lasting more than 3 months with weak or no response to conservative measures.


  Patients and methods Top


A total of 100 patients were enrolled in the study; after an informed consent and IRB (ZU-IRB#2386-22-10-2015) approval from Zagazig medical faculty committee, they were randomly allocated through closed envelope into two groups. The first group was named TES or transforaminal epidural steroid group, which comprised 50 patients who were treated by TES injection. The second group was called PRF group, which comprised 50 patients who were treated by DRG PRF. In both groups, preprocedure VAS was assessed by a blinded pain physician and also assessed 1 week, 4 weeks, 2 months, and 3 months after the procedure by the same physician through a telephone call. Three patients of the TES group opted out of follow-up as they underwent spine surgery, and two others required tramadol before 3 months. Three patients of group PRF lost communication before 3 months and two others underwent surgery. Therefore, 45 patients completed the study in each group. Patients and the assessing physician were blinded while the two efficient interventionist were randomly distributed on the procedures performed to the study cases. In both groups, patients were lying prone sterilized and draped; midazolam and ketamine were used for sedation with local anesthetic infiltration before fluoroscopy-guided needle placement. In the TES group a 22 G spinal needle was introduced to the middle of the upper half of the intervertebral foramen, and after confirmation of the site through posteroanterior and lateral views and injection of 0.5 ml of nonionic contrast iohexol 300 mg/ml (Omnipaque, GE Healthcare Inc., Princeton, NJ, USA) we injected 3 ml of 8 mg/ml methylprednisolone solution in normal saline for each clinically affected lumbar root with positive MRI finding. In the PRF group we used 10 cm 20 G (NeuroTherm, Morgan Automation Ltd., Liss, Hants, UK) cannula with 10 mm curved active tip and NeuroTherm NT1100 generator to give 4 min of PRF at 42°C after positive sensory stimulation at 0.4–0.7 V and motor at 0.8–1.3 V on the affected nerve roots, after which we injected 2 ml of 4 mg/ml methylprednisolone solution in normal saline.

Inclusion criteria

Patients with lumbar radiculopathy with MRI-proved LDP for more than 3 months with weak or no response to conservative treatment were included. Radicular pain should be more than back pain if also associated.

Exclusion criteria

The exclusion criteria were as follows:
  1. Radiculopathy with irrelevant MRI finding.
  2. Back pain more than radicular pain.
  3. Spinal canal stenosis.
  4. Failed back surgery.
  5. Multiple disc degeneration.
  6. Presence of motor or sphincteric disorders.
  7. Patients with work troubles or psychological problems.
  8. Patients who decided to shift to either surgery or tramadol during the follow-up period.


Statistical analysis

Data were checked, entered, and analyzed by using statistical package for the social sciences (version 20, SPSS; SPSS Inc., Chicago, Illinois, USA). Data were expressed as number and percentage. χ2-test and Fischer’s exact test or t-test were used when appropriate. P less than 0.05 was considered statistically significant.


  Results Top


There was a nonsignificant difference between group TES and group PRF regarding the age, sex, and levels of root affection, as shown in [Table 1].
Table 1 Demographic and clinical data

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We notice from [Table 2] that in group TES the VAS values at 1 week (4±2) and at 4 weeks (5.9±0.7) after intervention were significantly lower than preinterventional value (7.5±0.5). At 2 months and at 3 months the VAS values (6.5±0.5 and 7.5±0.5) were non significantly different from preinterventional values (7.5±0.5).
Table 2 Visual analog scale changes

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Regarding the PRF group, it is shown in [Table 2] that the VAS values expressed as mean±SD at 1 week (3.2±1.6), 4 weeks (3.2±1.6), 2 months (3.2±1.6), and at 3 months (4±1.2) all were significantly lower than the preinterventional value (7.5±0.5).

The differences between VAS values in the PRF group at all times of postinterventional assessment and the corresponding values of the TES group were statistically significant, being lower in the PRF group.


  Discussion Top


There is much debate on the efficacy of either epidural steroids injection or DRG PRF in the management of radicular pain after LDP particularly in the long run.

In the current study, we notice that the differences in both groups are statistically nonsignificant regarding the age, sex, and level of root affection.

Regarding the effect of TESs injection, this study reports that there is a statistically significant reduction in the VAS values only after 1 week and at 4 weeks after intervention in group TES in comparison with preinterventional values. At 2 and 3 months of follow-up in comparison with the preprocedure VAS, the difference becomes nonsignificant. This result disagrees with those of Kennedy et al. [4], who reported that TES injection is an effective treatment for acute radicular pain due to disc herniation and frequently requires one or two more injections for symptomatic relief. This conflict may be because their study manages acute cases of lumbar radiculopathy and also they frequently use more than one steroid injection.

In addition, our results disagree with those of Manchikanti et al. [1], and this may also be because they use more than one single injection and their results may be attributed to the effect of local anesthetic they inject in the foramen not the steroids. The results of steroids injection in this study agree with the results of Schaufele et al. [5], who reported that 45% of patients who are improved after TES injection require one or two more injections in a period of 1 year of follow-up and the initial period of improvement in such patients occurs in a mean of 18.7 days.

Taskaynatan et al. [6] reported that there is a negative correlation between the duration of the effect of TES injection and the duration of the pretreatment symptoms, and this is concordant with our results as our patients are those with more than 3 months of symptoms.

Leslie et al. [7] found that there is no statistically significant difference in the VAS at 3 months between transforaminal local anesthetic injection alone and transforaminal steroid with local anesthetic. This finding agrees with the results of that study in which there is no local anesthetic injection, which may be the cause of long-term improvement after steroid injection in other studies.

Regarding the PRF group, the results of that study disagree with those of Shanthanna et al. [3], who reported that there is no statistically significant difference between the effect of PRF on DRG and the control group in treating radicular pain of LDP either at 4 weeks or 3 months after the procedure. This may be because we used PRF at 42°C for 240 s and not only for 120 s.

In the current study the results of the PRF group are concordant with the results of Simopoulos et al. [8], who reported that PRF is a successful treatment for radicular pain after LDP in the majority of cases up to 3 months after the procedure.

To the best of our knowledge, there is no randomized controlled study comparing the effect of TESs and PRF in the treatment of radiculopathy after LDP, and as the results have shown that there is a significant difference we recommend the use of PRF from the start to avoid unnecessary escape of the patients to the surgery side.


  Conclusion Top


PRF of lumbar DRG is more effective than lumbar TES injection up to 3 months of follow-up in patients with radiculopathy due to LDP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Manchikanti L, Cash KA, Pampati V, Falco FJ. Transforaminal epidural injections in chronic lumbar disc herniation: a randomized, double-blind, active-control trial. Pain Physician 2014; 17:E489–E501.  Back to cited text no. 1
    
2.
Abdi S, Datta S, Trescot AM, Schult DM, Adlaka R, Atluri SL et al. Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician 2007; 10:185–212.  Back to cited text no. 2
    
3.
Shanthanna H, Chan P, Mcchesney J, Thabane L, Paul J. Pulsed radiofrequency treatment of the lumbar dorsal root ganglion in patients with chronic lumbar radicular pain: a randomized, placebo-controlled pilot study. J Pain Res 2014; 7:47–55.  Back to cited text no. 3
    
4.
Kennedy DJ, Plastaras C, Casey E, Visco CJ, Rittenberg JD, Conrad B et al. Comparative effectiveness of lumbar transforaminal epidural steroid injections with particulate versus nonparticulate corticosteroids for lumbar radicular pain due to intervertebral disc herniation: a prospective, randomized, double-blind trial. Pain Med 2014; 15:548–555.  Back to cited text no. 4
    
5.
Schaufele MK, Hatch L, Jones W. Interlaminar versus transforaminal epidural injections for the treatment of symptomatic lumbar intervertebral disc herniations. Pain Physician 2006; 9:361–366  Back to cited text no. 5
    
6.
Taskaynatan MA, Tezel K, Yavuz F, Tan AK. The effectiveness of transforaminal epidural steroid injection in patients with radicular low back pain due to lumbar disc herniation two years after treatment. J Back Musculoskelet Rehabil. 2014; 28:447–451  Back to cited text no. 6
    
7.
Leslie NG, Neeraj C, Philip S. The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double-blind, controlled trial. Spine 2005; 30:857–862.  Back to cited text no. 7
    
8.
Simopoulos TT, Kraemer JJ, Nagda JV, Aner M, Bajwa ZH. Response to pulsed and continuous radiofrequency lesioning of the dorsal root ganglion and segmental nerves in patients with chronic lumbar radicular pain. Pain Physician 2008; 11:137–144  Back to cited text no. 8
    



 
 
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Introduction
Patients and methods
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