Effect of epidural methylprednisolone on post-operative pain and length of hospital stay in patients undergoing lumbar microdiscectomy
Introduction
Treatment for Nucleus Pulposus herniation is discectomy if conservative treatment fails. Discectomy significantly alleviates back pain as well as radicular symptoms post-operatively.1 Yet, in a large proportion of patients who undergo discectomy, residual back discomfort and radicular leg pain are not uncommon.2 This pain may vary in intensity, from mild to severe, and can cause significant postoperative disability, prolonged hospital stay, and occupational as well as social implications.
Reduction of inflammation and oedema of the affected nerve root should, theoretically, reduce the postoperative pain intensity. Many surgeons routinely use local corticosteroids during lumbar discectomy to reduce traumatic nerve root inflammation and oedema; however, such practice seems to be controversial. A number of studies have assessed the advantages, and others, the disadvantages, of this practice in terms of reduction of post-operative pain and improving functional outcome; however, most of these studies have been inclusive or based on small study samples.3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16
The following report presents a prospective, randomized case-control study of local application of DepoMedrol™ (methylprednisolone) on the affected nerve root perioperatively. We compared the outcome of the use of intra-operative corticosteroids with a control group that received a local application of saline intra-operatively. We assume that local application of low-dose steroid alone is sufficient to reduce the postoperative morbidity without increasing side effects or complications.
In the present study, the primary end point was level of pain in the post-operative period following local application of epidural steroid in lumbar microdisectomies in the perioperative period. Secondary end points were hospital stay and duration to return to daily living activities. This study was conducted in Tawam Hospital – Al Ain, United Arab Emirates, in affiliation with Johns Hopkins Medical – USA.
Section snippets
Methods
From June 2010, to September 2012, 162 patients with unilateral herniated lumbar disc were evaluated for our study. 150 patients were included in the study, 7 were excluded due to preoperative infection and 5 were excluded as they had spinal stenosis rather than true lumbar disc herniation. In the control group (39 males and 36 females, median age 42 years, 18–60) 44 L3/L4 and 31 L4/L5 were performed; and in the intervention were group; 35 males and 40 females, median age 45 years, 21–53) 51
Results
Average age of patients was 45.1 years (S.D. ± 13.7) with a male to female ratio of 1:1. Average hospital stay was 2.3 days (S.D. ± 2.1). The mean postoperative analgesic medications consumed was 15.6 ± 1.9 mg of morphine equivalents in the corticosteroid group versus 10.3 ± 1.8 mg of morphine equivalents in the control group.
Differences in the OLBI scores were statistically significant at all post-operative intervals. At baseline (preoperatively), group 1 (DepoMedrol™ group) had an average
Discussion
Upon a detailed review of the literature, we found 13 studies assessing steroid use after lumbar discectomy.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 Of those reporting on neurological deficits 2 did not find any benefit for the use of epidural steroids (Manniche et al. & Naylor et al.), 2 found reduced duration of hospitalization (Watters et al. & Lundin et al.), 2 reduced pain (Karst el al and Watters et al.) and 1 enhanced return to work (Lundin et al.). Unfortunately most of these trials
Conclusion
We conclude that local application of corticosteroids during discectomy procedures is beneficial in terms of reducing post-operative pain, duration of hospital stay and return to daily life activities and improving functional outcome.
Conflict of interest
The authors declare no conflict of interest in relation to this manuscript.
References (22)
- et al.
The value of dexamethasone in the postoperative treatment of lumbar disc prolapse
Orthop Clin North Am
(1977) - et al.
Perioperative single-dose glucocorticoid administration: pathophysiological effects and clinical implications
J Am Coll Surg
(2002) - et al.
Microdiscectomy versus chemonucleolysis
Neurosurgery
(1985) - et al.
Long-term back pain after a single-level discectomy for radiculopathy: incidence and health care cost analysis
J Neurosurg Spine
(2010) - et al.
The perioperative use of corticosteroids and bupivacaine in the management of lumbar disc disease
J Neurosurg
(1993) - et al.
The use of dexamethasone in primary lumbar disc surgery. A prospective, randomized, double-blind study
Spine
(1989) - et al.
Intraoperative dexamethasone irrigation in lumbar microdiskectomy
Clin Orthop Relat Res
(1990) - et al.
Benefits of methylprednisolone in a unilateral lumbar discectomy: a matched controlled study
J Spinal Disord
(1990) - et al.
Epidural steroids, postoperative morbidity, and recovery in patients undergoing microsurgical discectomy
J Neurosurg
(1992) - et al.
Peroperative prednisolone fails to improve the clinical outcome following surgery for prolapsed lumbar intervertebral disc. A randomized controlled trial
Scand J Rheumatol
(1994)
Epidural administration of methylprednisolone and morphine for pain after spinal operation
J Bone Jt Surg Am
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