Epidural Steroid Infiltrations in Pain Management

Epidural Steroid Infiltrations in Pain Management

Inhoudstabel 1. Introductie 2. Farmacologie 3. Infiltratie 4. Indicatie 5. Resultaten 6. Complicaties 7. Besluit - Discussie

1. Introductie Rugpijn hoge prevalentie socio-economische gevolgen Behandelingsplan rol van IPM? ~ concept pijngeneratoren Epidural steroid infiltration Global Health Estimates Summary Tables: World Health Organization 2014

2. Farmacologie - Farmacokinetiek Methylprednisolone (Depo-Medrol) Triamcinolone (Kenalog) Bethamethasone (Celestone) Preservation matter suspension suspension solution solution IV administration no no yes yes ph 3,5-7 5-7,5 8,5 7,5-10,5 Dexamethasone (Aacidexam) Particle size - 1-10µm - 10-20µm - 20-50µm - >50µm Comparison with RBC Densely packed 49% 11% 31% 9% 12x RBC 12x RBC 37% 28% 31% 4% 61% 7% 10% 22% <RBC 15% 15% 67% 3% Comparison with RBC densely packed 12x RBC 12x RBC <RBC Half-life (hours) - pharmacological - biological 3 5 1,5-5 12-36 12-36 36-72 Equivalent dose (mg) 4 4 0,75 0,6 Potency - anti-inflammatory - sodium-retaining 5 0 Tiso RL, Cutler T, Catania J a., Whalen K. Adverse central nervous system sequelae after selective transforaminal block: The role of corticosteroids. Spine J. 2004;4(4):468 74. Benedetti EM, Siriwetchadarak R, Stanec J, Rosenquist RW. Epidural steroid injections: Complications and management. Tech Reg Anesth Pain Manag [Internet]. Elsevier Inc.; 2009;13(4):236 50. Collighan N, Gupta S. Epidural steroids. Contin Educ Anaesthesia, Crit Care Pain. 2009;10(1):1 5. 5 0 33 0 1,5-5 36-72 27 0

2. Farmacologie - Pathofysiologie McLain RF, Kapural L, Mekhail N a. Epidural steroid therapy for back and leg pain: mechanisms of action and efficacy. Spine J. 2005;5(2):191 201.

3. Infiltratie methode Caudaal: CESI Interlaminair: ILESI Transforaminaal: TFESI Chou et al. Subacute and chronic low back pain: Nonsurgical interventional treatment. Up To Date 2013

4. Indicatie Persisterende radiculopathie S/ neuropathische pijn volgens radiculair patroon KO/ neurologische uitval, gestoorde reflexen, SLR+ D/ discushernia, foraminale stenose

5. Resultaten DePalma M, Slipman C. Evidence-informed management of chronic low back pain with epidural steroid injections. The Spine Journal 2008; 8-1, 45-55

5. Resultaten LUMBAR TFESIs Referentie Patiënten Studie opzet Follow-up Resultaten Devulder 40 1. LA+H+NaCl 2. LA+steroid 3. LA+H+steroid Riew 55 1. LA 2. LA+steroid Karppinen 160 1. LA+steroid 2. NaCl Vad 48 1. LA+steroid 2. NaCl 6m 28m 3m 12m 21m Groep 3 superieur 1. 67% chirurgie 2. 28% chirurgie Groep 1 superieur Geen verschil 1. 84% beterschap 2. 48% beterschap

5. Resultaten Staal JB, de Bie R, et al. Injection therapy for subacute and chronic low-back pain (Review). The Cochrane Library 2011; 3, 1-53

5. Resultaten Staal JB, de Bie R, et al. Injection therapy for subacute and chronic low-back pain (Review). The Cochrane Library 2011; 3, 1-53

5. Resultaten Staal JB, de Bie R, et al. Injection therapy for subacute and chronic low-back pain (Review). The Cochrane Library 2011; 3, 1-53

5. Resultaten Nielens H, Van Zundert J, et al. Chronic Low Back Pain. KCE reports vol 48C, 2006

6. Complicaties PROCEDURE Zenuwschade Infectie / Abces Bloeding / Hematoom Vasculaire schade Transiënte blindheid Exacerbatie rugpijn Vasovagale reactie STEROIDEN Hyperglycemie Adrenale suppressie Menorragie Embolie Facial flushing Lipomatosis Myopathie Dysphonie

6. Complicaties PREVENTIE IPM training Risicofactoren Monitoring Geen sedatie Stabiele buikligging Steriliteit Fluoroscopie + contrast Testdosis LA Trage injectie Dexamethasone (?) Aspiratie (?) Naaldtype (?)

7. Besluit - Discussie Hoge prevalentie Behandelingsmogelijkheden Gelimiteerd bewijs Wereldwijd gebruik Beperkte effectiviteit Complicaties Guidelines Biopyschosociaal multimodaal behandelingsmodel met ESI als mogelijkheid in geselecteerde patiëntenpopulatie

Referenties Global Health Estimates Summary Tables: World Health Organization 2014 Collighan N, Gupta S. Epidural steroids. Contin Educ Anaesthesia, Crit Care Pain. 2009;10(1):1 5. McLain RF, Kapural L, Mekhail N a. Epidural steroid therapy for back and leg pain: mechanisms of action and efficacy. Spine J. 2005;5(2):191 201. Chou et al. Subacute and chronic low back pain: Nonsurgical interventional treatment. Up To Date 2013 Nielens H, Van Zundert J, et al. Chronic Low Back Pain. KCE reports vol 48C, 2006 Abdi S, Datta S, Trescot AM, Schultz DM, Adlaka R, Atluri SL, et al. Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician. 2007;10(1):185 212. Baker R, Dreyfuss P, Mercer S, Bogduk N. Cervical transforaminal injection of corticosteroids into a radicular artery: A possible mechanism for spinal cord injury. Pain. 2003;103(1-2):211 5. Bellini M, Barbieri M. Systemic effects of epidural steroid injections. Anaesthesiol Intensive Ther [Internet]. 2013;45(2):93 8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23877903 Benedetti EM, Siriwetchadarak R, Stanec J, Rosenquist RW. Epidural steroid injections: Complications and management. Tech Reg Anesth Pain Manag [Internet]. Elsevier Inc.; 2009;13(4):236 50. Benzon HT, Chew T-L, McCarthy RJ, Benzon H a, Walega DR. Comparison of the particle sizes of different steroids and the effect of dilution: a review of the relative neurotoxicities of the steroids. Anesthesiology. DePalma MJ, Slipman CW. Evidence-informed management of chronic low back pain with epidural steroid injections. Spine J. 2008;8(1):45 55. Derby R, Lee SH, Date ES, Lee JH, Lee CH. Size and aggregation of corticosteroids used for epidural injections. Pain Med. 2008;9(2):227 34. Dreyfuss P, Baker R, Bogduk N. Comparative effectiveness of cervical transforaminal injections with particulate and nonparticulate corticosteroid preparations for cervical radicular pain. Pain Med. 2006;7(3):237 42. Manchikanti L, Abdi S, Atluri S, Benyamin RM, Boswell M V, Buenaventura RM, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician [Internet]. 2013;16(2 Suppl):S49 283. Available from: httmanchikanti L, Buenaventura RM, Manchikanti KN, Ruan X, Gupta S, Smith HS, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician [Internet]. 2012;15(3):E199 245. Rosen CD, Kahanovitz N, Bernstein R, Viola K. A retrospective analysis of the efficacy of epidural steriod injections.pdf. Clin Orthop Relat Res. 1988;228:270 2. Staal J, de Bie R, de Vet H, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low-back pain ( Review ). Cochrane Libr. 2008;(3):1 53. Watts RW, Silagy C a. A meta-analysis on the efficacy of epidural corticosteroids in the treatment of sciatica. Anaesth Intensive Care. 1995;23(5):564 9. Tiso RL, Cutler T, Catania J a., Whalen K. Adverse central nervous system sequelae after selective transforaminal block: The role of corticosteroids. Spine J. 2004;4(4):468 74.