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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6032_Библиотеки_им_академика_М_И_Перельмана
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interlaminar injection with local anesthetic alone may provide pain relief
equivalent to that of interlaminar ESI.
5,7
Low-quality prospective and
retrospective comparison studies that include patients with lumbar radicular
pain resulting from any cause do not show a difference in effectiveness
between transforaminal ESI and interlaminar ESI; additionally, both
transforaminal ESI and interlaminar ESI typically demonstrate better results
than those of caudal ESIs.
5
Patients most likely to respond to ESI for radicular pain include those
who have a diagnosis of intervertebral disk herniation, higher initial Oswestry
Disability Index scores, and electromyography-confirmed
radiculopathy.
19,26,27
Results are better in patients with contained
intervertebral disk herniations (75% success rate) than in patients who have
extrusions with severe nerve compression.
5,19
Predictors of poorer response
include duration of pain greater than 1 year, prior surgery, high preinjection
anxiety, catastrophizing, fear avoidance, and low treatment expectations.
27
Expected outcomes of spine interventional treatments are included in Table
2.
5,7,11,12,15,17,19,25,28-44
Lumbar Radicular Pain or Neurogenic Claudication Resulting
From Spinal Stenosis
Many patients with lumbar spinal stenosis report stability of symptoms over
years, with some periods of worsening and some periods of improvement.
Theoretically, a nonsurgical treatment such as an ESI that can offer even
temporary improvement during flare-ups may reduce the need for surgery in
some patients.
Even though 25% of ESIs are performed for spinal stenosis, there are no
level I trials assessing the efficacy of ESI for lumbar stenosis against a true
placebo.28 In 2013, the North American Spine Society reported that there is
insufficient evidence to make a recommendation for or against the efficacy of
transforaminal ESI to manage neuroforaminal stenosis or central canal
stenosis.15 A Cochrane review published that same year indicated that
supportive evidence for ESI to manage lumbar spinal stenosis with
neurogenic claudication is limited to low-quality evidence.29 The authors of a
higher quality multicenter study published in 2014 randomly assigned 400
patients to either any type of lumbar ESI or epidural injection of lidocaine.
28
At 6-week follow-up, patients in both treatment groups achieved statistically
significant improvements in pain and function. Specifically, 30% to 40% of
patients achieved at least 30% improvement in Roland-Morris Disability
Questionnaire scores, and 40% of patients achieved at least 50%
improvement in leg pain. All patients had central canal stenosis, but it is
unclear how many had multilevel stenosis or coexisting neuroforaminal
stenosis or how many patients had leg pain resulting from neurogenic
claudication versus monoradicular pain. Although small differences favored
the corticosteroid group in physical function, patient satisfaction, and
depression, there were no statistically significant differences in leg pain
between the corticosteroid and local anesthetic-only group. In addition, there
were no significant differences in outcomes between transforaminal ESI and
interlaminar ESI. Similarly, neither SPORT nor LSOS cohorts experienced a
significant positive effect on long-term outcome after ESI to manage spinal
stenosis.
22,23
A trial of an epidural injection of corticosteroid and/or local
anesthetic is a reasonable (albeit debatable) treatment option for carefully
selected patients with moderate to severe leg pain from spinal stenosis.
Cervical Radicular Pain
Although cervical radiculopathy is less extensively studied than lumbar
radiculopathy, nonsurgical management of this condition also has a similarly
high success rate of approximately 80% to 90%, and cervical radicular pain
can be responsive to cervical ESI.
30,31
No level I studies have been published.
A clinically useful study compared cervical ESI to intramuscular tender-point
injection with corticosteroid to manage cervical radicular pain that was
unresponsive to physical therapy or NSAIDs.32 This study included only 50
patients, and 8 of 25 patients in the intramuscular steroid group were
excluded from the study. At 1-week follow-up, 44% of patients treated with
ESI and 18% of patients treated with intramuscular steroid achieved at least
75% improvement (NNT = 3.8). Greater than 60% of patients treated with
ESI achieved this outcome at 1-year follow-up (NNT = 2). Pooled data from
multiple level II, III, and IV studies on cervical interlaminar ESI and cervical
transforaminal ESI indicate at least 50% improvement in pain for a duration
of 1 to 6 months, with one or two injections required. Response rates ranged
from 40% to 70%.
30,31
Data indicate that a smaller percentage of patients
experience improved pain for 12 months. Based on the available evidence, it
remains unclear if cervical interlaminar ESI is more effective than cervical
transforaminal ESI or if ESI is more effective than epidural injection of local
anesthetic or saline.
Table 2
Reducing the Need for Surgery
The role of injections in preventing the need for surgery, primarily as a
secondary outcome measure, has been evaluated. According to a 2015
review, low-quality evidence suggests that ESI can prevent the need for
surgery (at least in the short term) in one-third to one-half of patients
considering surgery to manage radicular pain resulting from intervertebral
disk herniation or stenosis.
33
Whether ESI is a surgery-sparing treatment remains debatable. The only
prospective study in which surgery was the primary outcome demonstrated
that surgical candidates with radicular pain resulting from intervertebral disk
herniation or lumbar spinal stenosis treated with up to four transforaminal
ESIs had a significantly lower surgical rate than patients injected with local
anesthetic only (29% and 67%, respectively; P < 0.004).45 A 5-year followup study of those same patients reported that 81% of patients who avoided
surgery at 1 year had avoided surgery at 5 years as well, irrespective of their
initial treatment group.45 These findings suggest that ESI may help patients
by managing acute flares of pain, and radicular pain will subside in many
patients over time. A single ESI does not affect surgical rates in patients with
spinal stenosis,23 which suggests that repeat injections are required to reduce
the need for surgery in these patients.
Predicting Surgical Outcomes
Retrospective evidence suggests that fluoroscopically guided ESIs that
produce at least 80% immediate improvement in radicular symptoms (local
anesthetic effect) and at least 50% pain relief for at least 1 week
(corticosteroid effect) are predictive of at least 50% pain relief with surgical
decompression (positive predictive value of 85% to 91% and negative
predictive value of 77%, irrespective of duration of symptoms).
3,7,34
A
completely negative response to ESI reduces the likelihood of positive
response to decompression surgery.
3,7,34
Axial Discogenic Pain
Approximately 40% of all cases of LBP are believed to be discogenic.
1,8
Annular fissures and disk degeneration can be accompanied by nociceptive
nerve ingrowth, and stimulation of these nerve endings via inflammatory
mediators can result in pain.
8,35
Despite the high prevalence of discogenic
LBP, no single interventional treatment has proved to be consistently
effective or to have sustained benefits over time. As with surgery, emotional
and psychological factors influence the perception of discogenic pain and
affect percutaneous treatment outcomes. Diskography remains the preferred
method for diagnosing discogenic pain; strict procedural guidelines must be
followed.
3,5,8
MRI findings, including Modic type I or II end plate changes
and high-intensity zone in the outer anulus fibrosus, can support a clinical
diagnosis of discogenic pain.5 Percutaneous techniques for managing
discogenic pain have largely disappointed, including ESI, intradiscal
injections, intradiscal neurolysis, and percutaneous diskectomy.
No high-quality level I or II trials of ESI for axial discogenic LBP or neck
pain without radicular pain have been performed; therefore, it is not clear
whether ESI is better than placebo for this condition. Findings from level II
and III studies suggest that only 25% of patients with axial discogenic LBP
and up to 50% of patients with neck pain will achieve at least 50% short-term
improvement of pain.
5,7,8,36
Retrospective studies indicate that some patients
report benefits lasting 1 to 2 years.
5,7
Based on limited and conflicting evidence, it remains unclear whether
intradiscal steroids are helpful for some patients; however, the risk of
iatrogenic discitis, calcification, degeneration, and vertebral end plate
necrosis remains a prohibitive concern for many surgeons.35 Although animal
models have suggested that intradiscal injection of tumor necrosis factor-α
inhibitor (such as etanercept) administered around the time of intervertebral
disk herniation can prevent onset of pain behavior and pathologic nerve root
changes, clinical study in humans showed no efficacy compared with placebo
at 1 month in patients with positive diskography findings.
5
Both chymopapain and methylene blue showed promise for managing
discogenic pain, but they have largely been abandoned in the United States.
Chymopapain is a proteolytic enzyme that can have a neurolytic effect on
annular nociceptors and can degrade the nucleus, thereby reducing intradiscal
pressure in the setting of contained disk herniations. Although clinical results
of this enzyme were mostly favorable, use in the United States halted in 1999
because of a series of severe anaphylactic reactions believed to occur in
approximately 1% of patients, as well as even more rare cases of hemorrhage,
transverse myelitis, and discitis.46 Chymopapain remains in use elsewhere in
the world.
Methylene blue can also act as a chemoneurolytic agent. Recent trials
have been unable to replicate the remarkably positive results reported in a
level I study that was published in 2010.
35,37,47
A feasibility trial published in
2016 indicated that 6 of 15 patients experienced 30% pain relief 6 months
after treatment.37 A placebo-controlled randomized controlled trial (RCT)
based on these data is planned, but such a trial will likely require high
numbers of patients to demonstrate substantial improvement compared with
placebo. Of additional concern is the potential neurotoxic effect of methylene
blue should extravasation occur into the epidural space.
Intradiscal injection of ozone was first proposed as a treatment for
intervertebral disk herniation in the 1980s as a means of reducing the size of
Figure 5
herniation through chemically induced nucleus degradation. Although
intradiscal injection of ozone is frequently used in Europe and especially
Italy, no level I trials exist for this indication. Observational and retrospective
studies indicate a 75% success rate maintained for 10 years after injection of
intradiscal ozone.48 Controlled trials are needed to confirm treatment effect
beyond the natural history of the condition.
Illustration of the Dwyer diagram, which maps common
somatic referred pain patterns from the cervical facet joints.
Application of thermal energy to an injured disk has been proposed as a
means to coagulate nociceptive nerve endings within the disk anulus fibrosus
(or to target the ramus communicans). Although it has not been clinically
proven, it may also be possible to use thermal energy to shrink collagen
Figure 6
fibrils within the anulus fibrosus to reduce the size of annular fissures and
intervertebral disk herniation. Thermal neurolysis techniques include
intradiscal electrothermal annuloplasty, percutaneous intradiscal
radiofrequency thermocoagulation, electrothermal ablation of ramus
communicans, and intradiscal biacuplasty. These modalities have shown
some therapeutic benefit compared with placebo in a small proportion of
patients with discogenic pain.
1,5,8
Each study that shows positive effect has
some pitfalls that limit generalizability to all patients with discogenic pain. A
recent systematic review concluded that intradiscal electrothermal
annuloplasty and percutaneous intradiscal radiofrequency thermocoagulation
are likely ineffective for treating the general discogenic pain population and
that ablation of the ramus communicans and intradiscal biacuplasty offer
some promise in carefully selected patients.35 Because of the limited or
conflicting research, most payers consider these treatments investigational.
Fluoroscopic images show intra-articular injection to
manage spinal facet joint pain. A, AP view demonstrates
needle placement into the left C5-6 facet joint. B, AP view
demonstrates the appearance of the contrast injection into the left C56 facet joint capsule.
Spinal Facet Joint Pain
Spinal facet joints, that is, zygapophyseal joints (Z-joints), are a well-known
source of chronic axial spine pain, especially in patients with paracentral neck
pain or LBP who are older than age 55 years and in all patients with chronic
neck pain after a whiplash-type motor vehicle collision injury. The spinal
facet joints are also often implicated in cervicogenic headaches and axial pain
resulting from degenerative spondylolisthesis. In the cervical spine, the facet
joints often cause pain in well-known distributions (Figure 5). Referral
patterns from the lumbar spine are less specific. There are no historical
features, physical examination maneuvers, or radiographic findings by which
it is possible to specifically and definitively identify facet joint pain.
Identification of mobile spondylolisthesis on radiography, increased uptake
on single photon emission computed tomography, and/or increased signal in
the perifacet bone marrow or intra-articular edema on T2-weighted or short
tau inversion recovery MRI sequences can support a diagnosis of facet joint
pain.
3,7
Nonetheless, the preferred method for diagnosis remains controlled
anesthetic blocks to the specific joint or its nerve supply.
Percutaneous therapeutic treatment options for spinal facet joint pain
include intra-articular injection and RFN. To date, no RCTs have used a dual
anesthetic block protocol for patient selection to study the effectiveness of
intra-articular facet joint injections. Although intra-articular facet joint
injection is still used as a diagnostic tool, its therapeutic value is not
supported in the literature. For some patients, intra-articular facet joint
injection (Figure 6) may reduce pain, reduce frequency of cervicogenic
headaches, and improve tolerability of active physical therapy; however,
injection should not be used as a stand-alone treatment.
38,39
Figure 7
Fluoroscopic images show intra-articular injection to
manage sacroiliac joint pain. A, AP view demonstrates
needle placement in the inferior right sacroiliac joint, with intra-articular
contrast flow cephalad. B, Lateral view demonstrates needle
placement in the posteroinferior aspect of the joint as well as contrast
filling the inferior recess of the joint (arrow).
Alternatively, RFN has been shown to be effective in studies that used
rigorous selection criteria and anatomically correct techniques (Table 2).
Positive results have been obtained in studies that selected patients on the
basis of at least 80% improvement on two separate anesthetic injections in
the lumbar spine and 100% improvement in the cervical spine. Only a small
number (<20%) of patients selected for diagnostic medial branch blocks will
meet these strict inclusion criteria.
5,9,38
Recent prospective cohort studies of
patients carefully selected on the basis of 100% relief after dual anesthetic
blocks reported greater than 50% success in the lumbar spine and greater than
60% success in the cervical spine after a single RFN treatment, with success
defined as complete relief of pain for 6 months or more, complete restoration
of activities of daily living, no need for further healthcare interventions, and
return to work.
11,49
These studies used optimal technique with 16-gauge
needles. Less rigorous selection and technical variation negatively affects
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