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.
Keywords
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Article info
Publication history
Accepted:
March 15,
2004
Received:
June 26,
2003
Footnotes
☆FDA device/drug status: not applicable.
☆Nothing of value received from a commercial entity related to this research.
Identification
Copyright
© 2004 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
