Evidence based Practice Changes Spinal Injections

Transcription

1 Evidence based Practice Changes Spinal Injections Kathryn Mueller, MD, MPH, FACOEM Professor, School of Public Health & Department of Physiatry - University of Colorado President - American College of Occupational and Environmental Medicine 1

2 Awareness of Lack of Effectiveness of Spinal Injections Cochrane, British Medical Journal, ACOEM, Academy of Neurology, JAMA editorial recommends against New York Times Sunday magazine recommends against use

3 Epidural Steroid Injections (ESIs) Strong evidence ESI has no short or long term benefit for nonspecific low back pain (Pinto 2012). Good evidence ESIs against low back pain (Cochrane, Staal, 2008). Colorado CP

4 Epidural Steroid Injections (ESIs) - Colorado Strong evidence epidural steroid injections have a small average short term benefit for leg pain and disability for those with sciatica (Pinto, 2012). Good evidence the addition of steroids to a transforaminal bupivacaine injection has a small effect on patient reported pain and disability (Ng, 2005; Tafazal, 2009).

5 Epidural Steroid Injections (ESIs) Some evidence additional steroids may reduce the frequency of surgery in the first year after treatment in patients with neurologic compression and corresponding imaging findings. Patients were strong candidates for surgery and have completed 6 weeks of therapy without adequate benefit (Riew, 2000). Some evidence the benefits for the non-surgical group persisted for at least 5 years in most patients, regardless of the type of block given (Riew, 2006) Colorado CP

6 A Random Trial of Epidural Glucocorticoid Injections for Spinal Stenosis Methods: Double-blind, multisite trial Patients with central spinal stenosis, moderate to severe leg pain and disability. Received epidural injections of glucocorticoids plus lidocaine or lidocaine alone. One or two injections before the primary outcome evaluation, performed 6 weeks after randomized first injection. Outcomes: Primary outcome was the score on the Roland-Morris Disability (RMDQ) questionnaire.

7 Reference: Friedly, JL et al, N. Engl J Med Jul 3 Results: At 6 weeks no significant between group differences in the RMDQ score. 95% confidence interval [CI], -2.1 to 0.1; P=0.07); or The intensity of leg pain (adjusted difference in the average treatment effect, 95% CI, 0.8 to 0.4; P=0.48). Interlaminar vs. transforaminal showed no significant differences at 6 weeks. Conclusions: For lumbar spinal stenosis, epidural injection of glucocorticoids plus lidocaine offered minimal or no short-tem benefit as compared with lidocaine alone.

8 Single Dose of Intravenous Dexamethasone in Emergency Department Patients Methods - double-blind randomized controlled trial 58 Adult ED patients with Low back pain with radiculopathy given 8 mg of intravenous Dexamethasone Results 1.86 point (95% CI 0.32 to 3.42, p=0.19) reduction in VAS pain scores at 24 h

9 Single Dose of Intravenous Dexamethasone in Emergency Results Department Patients Dexamethasone had a significantly shorter ED stays 3.5h vs 18.8h and no difference in functional scores. 6 weeks, both groups had similar significant and sustained decrease in VAS scores compared with baseline Balakrishnamoorthy R, Emergency Medicine 8/22/2014

10 Awareness of Lack of Effectiveness of Spinal Injections Multiple evidence based studies find no evidence for long term benefits of spinal injections exception surgical radiculopathy candidates after 6 weeks of treatment 10

11 Epidural Steroid Injections (ESIs) No proven benefit from adding steroids to local anesthetic spinal injections for most injections based on multiple blinded studies. Steroids are currently used routinely in spinal injections due to a presumed physiologic effect. Therapeutic spinal injections have not been proven to change the long term course of most patients with spinal pain.

12 Injections Epidural Steroid Injections (ESIs) Eval For rare, acute ruptured (herniated) disc with clear objective radiculopathy if, after one to two weeks of initial oral analgesic and conservative treatment, the patient: Has continued pain interfering with most ADL function; and Unable to tolerate the required movements to participate in therapy, and Pain greater in the leg than in the back, and Pain following a correlated radicular pattern &

13 Injections Epidural Steroid Injections (ESIs) Eval Herniated disc on the MRI at the level of subjective and objective findings, and had either Dural tension, signs resulting in radicular symptoms and/or One of the following documented, reproducible findings: Decreased reflexes, or Radicular sensation deficits, or Motor weakness on testing

14 Spinal Stenosis or Herniated Disc Injection Patients with radicular findings Complete 6-8 weeks of active therapy, Has persistent radicular findings and difficulty with some activities, The patient may have one diagnostic injection. Stenosis is not likely to change anatomically, unlike herniated discs