Elsevier

The Spine Journal

Volume 4, Issue 5, September–October 2004, Pages 495-505
The Spine Journal

Clinical Studies
The effect of spinal steroid injections for degenerative disc disease

https://doi.org/10.1016/j.spinee.2004.03.024Get rights and content

Abstract

Background

No conclusive evidence exists to determine that spinal steroid injections give lasting improvement in patients with predominantly axial low back pain resulting from lumbar degenerative disc disease (DDD).

Purpose

The objectives of the study were to determine the effect of epidural steroid injections (ESIs) and intradiscal steroid injections (ISIs) in patients who exhibit DDD symptoms for more than 1 year and to determine whether patients with inflammatory end-plate changes are a unique subgroup of DDD patients in terms of treatment response.

Study design

Pain and function in patients with DDD were prospectively assessed by an outcomes questionnaire before and after various spinal injections. Further correlation was made with end-plate inflammatory (Modic Type 1) changes identified on magnetic resonance imaging (MRI).

Patient sample

ESI was performed in 232 patients who were referred for treatment of DDD, and discography with or without intradiscal steroid was performed in 171 patients who were possible spinal arthrodesis candidates.

Outcome measures

Pain and function were determined by a self-administered outcomes questionnaire that consisted of a visual analog pain scale, pain drawing, Oswestry Disability Index, use of pain medication and opinion of treatment success.

Methods

ESI was performed in 93 patients with DDD and inflammatory end-plate changes and in 139 patients without inflammatory end-plate changes. Patients with inflammatory end-plate changes (n=78) or without inflammatory end-plate changes (n=93), all of whom were considered fusion candidates, underwent discography with or without intradiscal steroid in a randomized fashion. Pain and function were prospectively determined by a self-administered outcomes survey (VAS pain, Oswestry Disability index [ODI], pain diagram [PD] and opinion of success) before and after the patients' injection for a 2-year follow-up period. MRI and discography results were correlated with patient outcomes scores.

Results

ESI was effective in improving pain and function, as assessed by outcomes scores at short-term follow-up. However, at 2 years, less than one-third had not had additional invasive treatment. Patients with inflammatory end-plate changes had greater improvement in ODI and PD scores in the first 6 months than did those patients without the end-plate changes. Intradiscal steroid injections into discs with concordant pain at the time of discography led to significant improvement in patients with inflammatory end-plate changes in all outcomes scales, but only minimal temporary improvement in patients without the end-plate changes. Disc pressure manometry at the time of discography found that discs with adjacent inflammatory end-plate changes reproduced symptoms at pressures significantly lower than those in other types of discs.

Conclusions

Spinal steroid injections, both ESI and ISI, are beneficial for a small number of patients with advanced DDD and chronic low back pain. For those patients in whom a beneficial effect is found, spinal steroid injection is a low-risk and rapid treatment option. Spinal steroid injections are more effective in patients with MRI findings of discogenic inflammation, specifically adjacent inflammatory end-plate changes.

Introduction

Low back pain typically responds to conservative treatment or resolves spontaneously within 6 weeks [1]. In some cases, low back pain may become chronic owing to progressive degenerative disc disease (DDD), a condition in which a degenerating disc becomes painful. The pain is thought to be the result of the disc itself rather than of nerve root irritation or impingement [2].

Treatment for “discogenic” pain is typically conservative. Surgical treatment may also be an option for selected patients; however, the indications vary among spine surgeons and range from performing surgery after only 3 months of failed nonoperative treatment to no surgical treatment at all [3], [4]. Part of the treating spine specialists' armamentarium includes the use of spinal steroid injections.

Currently, no strong evidence corroborates that lumbar epidural steroid injections (ESIs) or intradiscal steroid injections (ISIs) are effective for patients with predominantly axial low back pain due to DDD without spinal stenosis. ESIs have been studied more extensively than have ISIs. Although there is evidence that ESI may be beneficial in some patients with radiculitis, meta-analysis studies of spinal steroid injections for chronic axial back pain are inconclusive [5], [6], [7]. Furthermore, the results of ISI are mixed and there is no strong evidence that ISI as a treatment for low back pain is beneficial. A number of studies, including some that were prospective and randomized to other treatments (Marcaine [Abbott Laboratories, Abbott Park, IL] or chemonucleolysis) have found improved pain symptoms in the short term, but with longer follow-up, the initial improvement after ISI deteriorated over time [8], [9], [10], [11], [12], [13], [14]. More recently, a study evaluated a subgroup of patients with DDD with magnetic resonance imaging (MRI) evidence of posterior annular tear, identified as a high-intensity zone, of which most were successfully treated with ISIs [15]. Owing to the variability of results, the foregoing studies raise questions as to the true success rate of ISI or ESI in patients with DDD.

Additionally, the author noted anecdotally that some patients with inflammatory end-plate changes on MRI had concordant pain during provocative discography at low intradiscal pressures [16], [17]. Many of these patients subsequently had improvement in pain with the application of ISI. This prompted a prospective evaluation of patients who had chronic low back pain treated with spinal steroid injections. The purpose of this study is to determine the efficacy of spinal steroid injections in patients with chronic DDD and to determine whether a subtype of patients with DDD, those with inflammatory end-plate changes, may respond more to a particular type of injection than would others.

Section snippets

Materials and methods

All patients who had been referred to and treated by the author for low back pain related to DDD, and who had symptoms of more than 1 year's duration, were followed prospectively during the 4-year period January 1, 1996, to January 1, 2000. Inclusion criteria were symptoms related to DDD as diagnosed by a combination of clinical examination, medical history, MRI scan, and that patients had undergone a spinal steroid injection as a treatment option after failure of other noninvasive conservative

ESI

Of the patients who had inflammatory end-plate changes (n=93), approximately one-half of patients expressed a positive opinion as to whether their ESI was successful in the treatment of their symptoms during the first 3 months. Over subsequent follow-up periods, the success rate declined (Table 3). The use of pain medication (narcotics or nonsteroidal anti-inflammatories) was found generally to have decreased during the follow-up periods. During the first 3-month follow-up, 3 of 93 patients

Discussion

This study demonstrated that many patients with more than 1 year of lower back pain resulting from DDD, and no stenosis, may have short-term benefit by ESI. Initially, more than one-half of patients had decreased pain and improved function. Patients who responded usually did so within weeks of the injection; of these, one-fourth to one-third had lasting improvement. This study also assessed ISI for patients with DDD who failed nonoperative treatment, including ESI. ISI was effective only in a

References (61)

  • H.L. Feffer

    Therapeutic intradiscal hydrocortisone—a long-term study

    Clin Orthop

    (1969)
  • H.L. Feffer

    Treatment of low-back and sciatic pain by the injection of hydrocortisone into degenerated intervertebral discs

    J Bone Joint Surg

    (1956)
  • C.E. Graham

    Chemonucleolysis: a double blind study comparing chemonucleolysis with intra-discal hydrocortisone in the treatment of backache and sciatica

    Clin Orthop

    (1976)
  • S. Ito et al.

    Intradiscal injection of corticosteroids for the treatment of low back pain in the middle-aged and aged patients

    Neuro-Orthopedics

    (1991)
  • L. Leao

    Intradiscal injection of hydrocortisone of prednisone in the treatment of low back pain

    Rheumatism

    (1960)
  • J.W. Simmons et al.

    Intradiscal steroids: a prospective double-blind clinical trial

    Spine

    (1992)
  • H.A. Wilkenson et al.

    Intradiscal corticosteroids in the treatment of lumbar and cervical disc problems

    Spine

    (1980)
  • K.P. Schellhas et al.

    Lumbar disc high-intensity zone: correlation of magnetic resonance imaging and discography

    Spine

    (1996)
  • M.T. Modic et al.

    Degenerative disk disease: assessment of changes in vertebral body marrow with MR Imaging

    Radiology

    (1988)
  • T. Toyone et al.

    Vertebral bone-marrow changes in degenerative lumbar disc disease

    J Bone Joint Surg

    (1994)
  • G.R. Buttermann

    Lumbar disc herniation regression after successful epidural steroid injection

    J Spinal Disord Tech

    (2002)
  • P.J. Moroney et al.

    PH and anti-inflammatory agents modulate nucleus pulposus cytokine secretion

    Spine J

    (2002)
  • K. Fujita et al.

    Neural proteinases in human intervertebral disc: role in degeneration and probable origin

    Spine

    (1993)
  • P. Goupille et al.

    Matrix metalloproteinases: the clue to intervertebral disc degeneration?

    Spine

    (1998)
  • M. Kanemoto et al.

    Immunohistochemical study of matrix metalloproteinase-3 and tissue inhibitor of metalloproteinase-1 in human intervertebral discs

    Spine

    (1996)
  • J.D. Kang et al.

    Herniated lumbar intervertebral discs spontaneously produce matrix metalloproteinases, nitric oxide, interleukin-6, and prostaglandin E2

    Spine

    (1996)
  • J. Liu et al.

    Identification of human intervertebral disc stromelysin and its involvement in matrix degradation

    J Orthop Res

    (1991)
  • O. Nemoto et al.

    The effects of IL-1 and IL-6 on the production of MMP-3 and TIMP-1 in human degenerative spinal disc

    Rinsho Seikei Geka

    (1994)
  • J.S. Saal et al.

    High levels of inflammatory phospholipase A2 activity in lumbar disc herniations

    Spine

    (1990)
  • H. Takahashi et al.

    Inflammatory cytokines in the herniated disc of the lumbar spine

    Spine

    (1996)
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