Anesthesia: Essays and Researches

REVIEW ARTICLE
Year
: 2022  |  Volume : 16  |  Issue : 2  |  Page : 187--190

The lead of direct adjuvant intraoperative foraminal steroids' infiltration


Allouzi Rakan1, Renad Aldurgham2, Anas Al Abdallat3, Sa'ed Haddad2, Jraisat Ibrahim4, Rami Yousef Alqroom1, Hussam Abu Nowar1, Amro Odeh5,  
1 Department of Neurosurgery, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
2 Department of Radiology, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
3 Department of Orthopedics, Farah Medical Center, Royal Medical Services, Amman, Jordan
4 Department of Anesthesia, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
5 Department of Pediatric Neurology, Queen Rania Medical Center, Royal Medical Services, Amman, Jordan

Correspondence Address:
Dr. Rami Yousef Alqroom
Department of Neurosurgery, King Hussein Medical Center, Royal Medical Services, Amman
Jordan

Abstract

Low back pain generally involves lumbosacral radicular syndrome, nerve root pain, and nerve root entrapment/irritation. Management options for patients are variable and diverging. To the highlight the efficacy of combined early decompressive surgery plus intraoperative steroid injections in terms of postoperative back pain in patients managed by our combined team. A prospective study conducted by reviewing all consecutive patients managed, over a 1-year period (2018-2019). This study showed that adjunct use of intraoperative foraminal and epidural steroids injections to treat back pain in patients with degenerative spine disease could significantly improve the pain score which leads to significant decrease in working days off and the need for pain killer medications or even obviating the usage rate.



How to cite this article:
Rakan A, Aldurgham R, Al Abdallat A, Haddad S, Ibrahim J, Alqroom RY, Nowar HA, Odeh A. The lead of direct adjuvant intraoperative foraminal steroids' infiltration.Anesth Essays Res 2022;16:187-190


How to cite this URL:
Rakan A, Aldurgham R, Al Abdallat A, Haddad S, Ibrahim J, Alqroom RY, Nowar HA, Odeh A. The lead of direct adjuvant intraoperative foraminal steroids' infiltration. Anesth Essays Res [serial online] 2022 [cited 2022 Dec 4 ];16:187-190
Available from: https://www.aeronline.org/text.asp?2022/16/2/187/356175


Full Text

 Introduction



Low back pain (LBP), in general terms, represents the lumbosacral radicular syndrome, lumbar radiculopathy, nerve root pain, and nerve root entrapment/irritation.[1],[2],[3] It is a heterogenic entity in terms of causes involved: might be due to lumbar canal or foraminal stenosis, inflammatory processes around the nerve root, epidural venous engorgement, and/or lumbar disc herniation.[4] Among all the causes, degenerative disc disease is the most common cause of sciatica, leading to surgical interventions.[5] Management options of patients vary and diverge.

Primary care includes conservative care, physiotherapy, and steroid injections, but a small proportion is referred to secondary care and may eventually undergo surgery if complaints persist for more than 6 weeks.[6],[7] For some patients, lumbar spinal surgery indeed is beneficial, but its postoperative results are highly varying and challenging to predict for the individual patient.[8],[9] Surrounded by various modalities applied in the conservative management of painful conditions of the spine, steroid injections are one of the at-most applied nonsurgical interventions.[10],[11],[12],[13]

This study aims to emphasize the early efficacy of combined decompressive surgery plus intraoperative epidural steroid injections in alleviation of the postoperative back pain in patients managed by our combined team in our institution.

 Materials and Methods



Ethics

Patient reports were retrieved from the electronic hospital database for a 1-year period (2018–2019) and reviewed for a retrospective analysis. This study was approved by the institutional ethics committee (IRB: 25/3/2022) on May 8, 2022. As this study was a retrospective analysis, the requirement for patient consent was waived. Procedure follows the guidelines laid down in the Declaration of Helsinki (2013).

Patients

We collected data from 147 consecutive patients according to our rigid protocol of admission and data registration, who had one level lumbar degenerative disease (canal stenosis, foraminal stenosis, disc herniation) with moderate or very severe low back with and without radicular pain (4<visual analog scale [VAS] <10) for LBP and leg pain, with persistent pain lasting more than 6 weeks, despite the utility of other conservative treatment options (physical therapy, medication, etc.). We excluded patients with acute deficits, spinal instrumentations, discectomy, and spinal tumors surgery and those who lost follow-up.

Study design

This review conducted in a retrospective manner. The final group included 78 patients; we collected patient's data on sex, age, duration of symptoms, and medical and social history. All 78 patients were randomly allocated into two groups giving their sequences of operating room administration, methylprednisolone acetate (Group 1) or irrigation with normal saline (Group 2). Patients received intraoperative surgery for canal/foraminal stenosis combined with epidural and transforaminal steroid injections (the surgeon introduced 40 mg of methylprednisolone acetate around the nerve root and the thecal sac) targeting the affected level on symptomatic side. To minimize bias, independent reviewers collected the data, including side effects, when patients visited the hospital for follow-up. Patients underwent decompressive surgery of the affected nerve root without fusion of the spinal segment, and all the patients were operated by one neurosurgeon (Al. R) with the same technique, he/she was completely aware of the group allocated, but the associate neurosurgeon who was responsible for follow-up and analysis of the data was completely blind to the group. At the end of surgery, the patients were transferred to the ward and were evaluated for outcome measurements; VAS evaluations of LBP were also collected preoperatively, as well as at 24 h, 1 week, and 2 weeks after initial surgery by associate neurosurgeon who had no information about which drug has been used for each patient.

Statistical analysis

In order to compare clinical outcome, we conducted unpaired sample t-test (Excel 2010) for 3 scenarios: pre-operative period vs after 24-hours post- operative, pre-operative period vs after 1-week follow-up, pre-operative period vs after 2- weeks follow-up. The unpaired Student's t-test was used to compare between the two groups.

Three patients were excluded from the study final analysis due to encountered thecal sac injury during surgery, because this may jeopardize the postoperative general condition in terms of cerebrospinal fluid leakages, mandatory bed rest, and associated risk of pain [Figure 1].{Figure 1}

 Results



The study population included 46 men and 32 women who met the inclusion/exclusion criteria, with a male-to-female ratio of 1.7:1. Age of the patients ranged between 30 and 71 years, with a mean of 56.4 ± 6.7 years. No statistically significant difference in mean age and sex distribution of the patients was existed among two groups (P = 0.4 and 0.6, respectively). The most common age group in this study was 40–50 years [Table 1]. Clinically, the mean symptom duration was 12.4 ± 3.2 months. The levels involved were L2–L3, L3–L4, L4–L5, and L5–S1 [Figure 2]. Patients demonstrated a substantial decrease in VAS scores of LBP [Table 2]. There were neither technical difficulties in the procedure nor procedure-related major complications. One patient had uncontrolled bleeding during the surgery. During the follow-up at 6 months, two patients had a disc herniation and thus underwent a discectomy. No patient had a postoperative complication. No patient developed a postoperative infection or other complication related to steroid application.{Figure 2}{Table 1}{Table 2}

 Discussion



Epidural and foraminal steroid injections are common treatment modalities for patients with degenerative disc disease with LBP and radiating leg pain. They have been in use since 1922 and are still an essential part of the nonsurgical management of a variety of spine-related problems.[12],[13],[14],[15] Modern reports showed that pain following spine surgery provoked by a variety of dynamics, such as soft tissue disturbance and direct nerve root handling, which trigger the inflammatory cascade.[15],[16],[17] The cardinal goal of the injection is pain reduction, to decrease the inflammatory process involving the nerve root to increase the quality of life and increase the individuals' productivity.[17]

Lumbar spine surgeries are common surgical procedures performed worldwide in patients suffering from back pain associated with radiculopathy due to degenerative spine disease, though different surgical approaches have evolved since the first discectomy done by Oppenheim and Fedre Krause in 1906.[11],[18],[19],[20],[21],[22] Still, open interlaminar approach is considered highly effective.[21],[22] For some patients, lumbar spinal surgery indeed is beneficial, but its results are highly variable and hard to predict for the individual patient, mandating adjunct measures to augment the postoperative results.[8],[9] Hence, efforts are focusing toward the insufficiently treated postoperative pain following usual surgical procedures. It is crucial to achieve effective pain treatment with a minimum side effect to encourage postoperative recovery. Multimodal analgesia schemes are recruited in reducing postoperative pain. As an essential prerequisite for the strategy of combing different medications with different mechanisms of action, is to minimize or to alleviate side effects when compared to a single drug.[10],[23],[24],[25],[26],[27],[28] The introduction of intraoperative epidural steroids has been applied as an additive pain treatment in lumbar spine surgery. It is main mechanism of action in reducing postoperative pain, is by suppressing pain mediators and inflammation such as prostaglandins, bradykinin and histamine.[23]

In this study, we decided to apply steroid to decrease postoperative pain after spinal surgery. According to our experience at 24 h and 1 week postoperatively, the average VAS score for LBP was 1.96 (±1.12) and 1.63 (±1.21) for methylprednisolone group, but after 2 weeks of operation, both groups were equal. This study encountered some limitations: the relatively small sample size and the short follow-up periods, which might limit the comparability and long-term outcomes. On the other hand, analgesics taken by patients were not evaluated as there was no record of pain-relieving medication usage when the patients are at home. Socioeconomic variables that might affect the study results were also not incorporated in this study.

Nevertheless, there is still a noticeable lack of documentation for the consequences and the adverse side effects of these analgesic regimens. Spine surgery has been associated with significant intensities of pain compared to other surgical procedures. Therefore, we considered spine surgery to pose a group adjunct pain reliever directing to improve the multifactorial methodology in pain management.

 Conclusion



This study, although included small sample and has not assessed either the mid-term or long-term complications, showed that adjunct use of intraoperative foraminal and epidural steroid injections to treat back pain in patients with degenerative spine disease could significantly improve the pain score, which leads to significant decrease in working days off and in need of pain killer medications or even obviating the usage rate. In addition, steroids are clinically availing and safe. Conversely, this “relief” may simply coincide with the natural course of the treatment.

Future work

We need a large randomized, controlled, double-blind study and a larger population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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