Clinical StudiesThe effect of spinal steroid injections for degenerative disc disease☆
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
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