Fluoroscopic lumbar interlaminar epidural injections in managing chronic lumbar axial or discogenic pain

Journal of Pain Research Dovepress open access to scientific and medical research O ri g i n al R esearc h Journal of Pain Research downloaded from https://www.dovepress.com/ by 219.254.85.100 on 31-May-2020 For personal use only. Open Access Full Text Article Fluoroscopic lumbar interlaminar epidural injections in managing chronic lumbar axial or discogenic pain This article was published in the following Dove Press journal: Journal of Pain Research 23 August 2012 Number of times this article has been viewed Laxmaiah Manchikanti 1,2 Kimberly A Cash 1 Carla D McManus 1 Vidyasagar Pampati 1 Ramsin Benyamin 3,4 Pain Management Center of Paducah, Paducah, KY; 2University of Louisville, Louisville, KY; 3Millennium Pain Center, Bloomington, IL; 4University of Illinois, Urbana-Champaign, IL, USA 1 Abstract: Among the multiple causes of chronic low back pain, axial and discogenic pain are common. Various modalities of treatments are utilized in managing discogenic and axial low back pain including epidural injections. However, there is a paucity of evidence regarding the effectiveness, indications, and medical necessity of any treatment modality utilized for managing axial or discogenic pain, including epidural injections. In an interventional pain management practice in the US, a randomized, double-blind, active control trial was conducted. The objective was to assess the effectiveness of lumbar interlaminar epidural injections of local anesthetic with or without steroids for managing chronic low back pain of discogenic origin. However, disc herniation, radiculitis, facet joint pain, or sacroiliac joint pain were excluded. Two groups of patients were studied, with 60 patients in each group receiving either local anesthetic only or local anesthetic mixed with non-particulate betamethasone. Primary outcome measures included the pain relief-assessed by numeric rating scale of pain and functional status assessed by the, Oswestry Disability Index, Secondary outcome measurements included employment status, and opioid intake. Significant improvement or success was defined as at least a 50% decrease in pain and disability. Significant improvement was seen in 77% of the patients in Group I and 67% of the patients in Group II. In the successful groups (those with at least 3 weeks of relief with the first two procedures), the improvement was 84% in Group I and 71% in Group II. For those with chronic function-limiting low back pain refractory to conservative management, it is concluded that lumbar interlaminar epidural injections of local anesthetic with or without steroids may be an effective modality for managing chronic axial or discogenic pain. This treatment appears to be effective for those who have had facet joints as well as sacroiliac joints eliminated as the pain source. Keywords: lumbar disc herniation, axial or discogenic pain, lumbar interlaminar epidural injections, local anesthetic, steroids, controlled comparative local anesthetic blocks, NCT00681447 Introduction Correspondence: Laxmaiah Manchikanti 2831 Lone Oak Road, Paducah, KY 42003, USA Tel +1 270 554 8373 ext 101 Fax +1 270 554 8987 Email submit your manuscript | www.dovepress.com Dovepress http://dx.doi.org/10.2147/JPR.S32699 Powered by TCPDF (www.tcpdf.org) Epidural injections are one of the most commonly utilized treatment modalities for managing chronic low back pain with or without lower extremity pain.1–12 Despite increasing utilization of lumbar epidural injections, significant debate continues regarding their effectiveness, specifically any conditions other than disc herniation and compressive radiculitis. The pathophysiology of low back pain and radicular pain is the subject of ongoing research and controversy, with discogenic pain assuming a major role as a cause of non-specific low back pain, beyond disc herniation.13–16 In fact, soon after the description of intervertebral disc herniation by Mixter and Barr17 in American medical literature in 1934 with their landmark description of the herniated nucleus pulposus, Journal of Pain Research 2012:5 301–311 301 © 2012 Manchikanti et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. Dovepress Journal of Pain Research downloaded from https://www.dovepress.com/ by 219.254.85.100 on 31-May-2020 For personal use only. Manchikanti et al Mixter and Ayers18 showed that radicular pain can occur without disc herniation. Further, non-specific low back pain constitutes 80% or 90% of low back pain without identifiable causes with a large proportion having chronic axial low back pain secondary to progressive degenerative disc disease.2,19–22 It has been shown that discs have innervation with deep ingrowth into degenerated intervertebral discs.23–26 Animal models have identified upregulation of various molecules such as calcitonin gene-related peptide and substance P in dorsal root ganglion neurons innervating degenerated intervertebral discs.27,28 Research also has detected high levels of inflammatory mediators in degenerated discs. While the majority of patients with axial low back pain improve with conservative management, various types of interventions have been described for chronic patients, but most interventions are highly variable and are associated with poor outcomes.29–40 In the past, all axial pain was attributed to disc degeneration. However, the development of controlled diagnostic blocks, and interventional techniques including discography, facet joint blocks, and sacroiliac joint blocks, have provided evidence that axial pain can also be caused by facet joints and sacroiliac joints. Utilizing provocation discography, the prevalence of pain due to internal disc disruption was reported to be 39% in patients suffering with chronic low back pain,41 whereas primary discogenic pain was reported in 26%42 when no other cause was suspected. In addition, facet joint pain has been shown to be present in 21%–41% of patients,43 whereas sacroiliac joint pain has been established in 10%–38% of a selected population.44 The underlying mechanism of action for epidurally administered local anesthetic and steroids has been described, though not well understood. However, historically it has been believed that epidural steroids function by reducing inflammation, thus limiting the indications to compressive radiculopathy or, at best, radiculitis secondary to chemical irritation. Much of the literature on lumbar interlaminar epidurals has been negative except in recent years when fluoroscopic guidance was utilized.39,45–53 A variation of lumbar interlaminar injections, caudal epidural injections, have also been proven to be effective in multiple causes of low back pain with or without lower extremity pain.38,48,54–57 Recent evidence also has demonstrated effectiveness for fluoroscopically administered epidural injections in the cervical spi (...truncated)