Anti Inflammatory Injection for Back Pain - Tubidal

Pain Management Injection Therapies for Low Back Pain

Technology Assessment Report

Roger Chou, MD, FACP, Robin Hashimoto, PhD, Janna Friedly, MD, Rochelle Fu, PhD, Tracy Dana, MLS, Sean Sullivan, PhD, Christina Bougatsos, MPH, and Jeffrey Jarvik, MD, MPH.

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Structured Abstract

Objectives:

Low back pain is common and injections with corticosteroids are a frequently used treatment option. This report reviews the current evidence on effectiveness and harms of epidural, facet joint, and sacroiliac corticosteroid injections for low back pain conditions.

Data Sources:

A prior systematic review (searches through July 2008), electronic databases (Ovid MEDLINE, Scopus, and the Cochrane Libraries from January 2008 through October 2014), reference lists, and clinical trials registries.

Review Methods:

Using predefined criteria, we selected randomized trials of patients with lumbosacral radiculopathy, spinal stenosis, nonradicular back pain, or chronic postsurgical back pain that compared effectiveness or harms of epidural, facet joint, or sacroiliac corticosteroid injections versus placebo or other interventions. We also included randomized trials that compared different injection techniques and large (sample sizes >1000) observational studies of back injections that reported harms. The quality of included studies was assessed, data were extracted, and results were summarized qualitatively and using meta-analysis on outcomes stratified by immediate- (1 week to ≤2 weeks), short- (2 weeks to ≤3 months), intermediate- (3 months to <1 year), and long-term (>1 year) followup.

Results:

Seventy-eight randomized trials of epidural injections, 13 trials of facet joint injections, and one trial of sacroiliac injections were included. For epidural corticosteroid injections versus placebo interventions for radiculopathy, the only statistically significant effects were on mean improvement in pain at immediate-term followup (weighted mean difference [WMD] −7.55 on a 0 to 100 scale, 95% CI −11.4 to −3.74) (strength of evidence [SOE]: moderate), mean improvement in function at immediate-term followup when an outlier trial was excluded (standardized mean difference [SMD] −0.33, 95% CI −0.56 to −0.09) (SOE: low), and risk of surgery at short-term followup (relative risk [RR] 0.62, 95% CI 0.41 to 0.92) (SOE: low). The magnitude of effects on pain and function was small, did not meet predefined thresholds for minimum clinically important differences, and there were no differences on outcomes at longer-term followup. Evidence on effects of different injection techniques, patient characteristics, or comparator interventions estimates was limited and did not show clear effects. Trials of epidural corticosteroid injections for radiculopathy versus nonplacebo interventions did not clearly demonstrate effectiveness (SOE: insufficient to low).

Evidence was limited for epidural corticosteroid injections versus placebo interventions for spinal stenosis (SOE: low to moderate) or nonradicular back pain (SOE: low), but showed no differences in pain, function, or likelihood of surgery.

Studies found no clear differences between various facet joint corticosteroid injections (intra-articular, extra-articular [peri-capsular], or medial branch) and placebo interventions (SOE: low to moderate). There was insufficient evidence from one very small trial to determine effects of peri-articular sacroiliac joint corticosteroid injections injection (SOE: insufficient).

Serious harms from injections were rare in randomized trials and observational studies, but harms reporting was suboptimal (SOE: low).

Conclusions:

Epidural corticosteroid injections for radiculopathy were associated with immediate improvements in pain and might be associated with immediate improvements in function, but benefits were small and not sustained, and there was no effect on long-term risk of surgery. Evidence did not suggest that effectiveness varies based on injection technique, corticosteroid, dose, or comparator. Limited evidence suggested that epidural corticosteroid injections are not effective for spinal stenosis or nonradicular back pain and that facet joint corticosteroid injections are not effective for presumed facet joint pain. There was insufficient evidence to evaluate effectiveness of sacroiliac joint corticosteroid injections.

Contents

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• Addendum (Submitted July 10, 2015)
• Erratum
• Acknowledgments
• Key Informants
• Technical Expert Panel
• Peer Reviewers
• Executive Summary
• Introduction
  • Background
  • Scope of Review and Key Questions
• Methods
  • Input From Stakeholders
  • Literature Search Strategy
  • Study Selection
  • Data Extraction
  • Assessing Quality
  • Assessing Research Applicability
  • Evidence Synthesis and Rating the Body of Evidence
  • Peer Review and Public Commentary
• Results
  • Epidural Injections
  • Key Question 1 In patients with low back pain, what is the effectiveness of epidural corticosteroid injections, facet joint corticosteroid injections, medial branch blocks, and sacroiliac joint corticosteroid injections versus epidural nonsteroid injection, nonepidural injection, no injection, surgery or nonsurgical therapies on outcomes related to pain, function and quality of life?
  • Key Question 1a How does effectiveness vary according to the medication used (corticosteroid, local anesthetic, or both), the dose or frequency of injections, the number of levels treated, or degree of provider experience?
  • Key Question 1b How does effectiveness vary according to use of imaging guidance or route of administration (interlaminar, transforaminal, caudal for epidural injections or intra-articular, extra-articular [peri-capsular], or medial branch for facet injections)?
  • Key Question 2 In patients with low back pain, what characteristics predict responsiveness to injection therapies on outcomes related to pain, function, and quality of life?
  • Key Question 3 In randomized trials of low back pain injection therapies, how does effectiveness vary according to the comparator used (e.g., epidural nonsteroid injection, nonepidural injection, no injection, surgery, or nonsurgical therapies)?
  • Key Question 3a How do response rates vary according to the specific comparator evaluated (e.g., saline epidural, epidural with local anesthetic, nonepidural injection, no injection, surgery, nonsurgical therapies)?
  • Key Question 4 What are the harms of epidural corticosteroid, facet joint corticosteroid injections, medial branch blocks, and sacroiliac joint corticosteroid injection compared to epidural nonsteroid injection, nonepidural injection, no injection, surgery, or nonsurgical therapies?
• Discussion
  • Key Findings and Strength of Evidence Summary
  • Findings in Relationship to What is Already Known
  • Applicability
  • Implications for Clinical and Policy Decisionmaking
  • Limitations of the Comparative Effectiveness Review Process
  • Limitations of the Evidence Base
  • Research Gaps
• Conclusions
• Abbreviations
• References
• Appendix A Search Strategies
• Appendix B PICOTS
• Appendix C Included Studies
• Appendix D Excluded Studies
• Appendix E1 Epidural Steroid Injections for Radiculopathy and Herniated Disc
• Appendix E2 Epidural Steroid Injections for Spinal Stenosis
• Appendix E3 Epidural Steroid Injections for Nonradicular Pain
• Appendix E4 Epidural Steroid Injections for Post-Surgery Syndrome
• Appendix E5 Epidural Steroid Injections for Facet Joint Pain
• Appendix E6 Epidural Steroid Injections for Sacroiliac Pain
• Appendix F1 Quality Assessment of Epidural Steroid Injections for Radicular Pain and Herniated Disc
• Appendix F2 Quality Assessment of Epidural Steroid injections for Spinal Stenosis
• Appendix F3 Quality Assessment of Epidural Steroid Injections for Nonradicular Pain
• Appendix F4 Epidural Steroid Injections for Postsurgery Pain
• Appendix F5 Quality Rating of Facet Joint Steroid Injections
• Appendix F6 Quality Rating of Epidural Steroid Injections for Sacroiliac Pain
• Appendix G Strength of Evidence

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Original Publication: March 20, 2015

Revised Publication: July 10, 2015

Suggested citation:

Chou R, Hashimoto R, Friedly J, Fu Rochelle, Dana T, Sullivan S, Bougatsos C, Jarvik J. Pain Management Injection Therapies for Low Back Pain. Technology Assessment Report ESIB0813. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. HHSA 290-2012-00014-I.) Rockville, MD: Agency for Healthcare Research and Quality; July 2015.

This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA 290-2012-00014-I). The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or of the U.S. Department of Health and Human Services.

The information in this report is intended to help health care decision-makers; patients and clinicians, health system leaders, and policymakers, make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies may not be stated or implied.

This document is in the public domain and may be used and reprinted without special permission. Citation of the source is appreciated.

Persons using assistive technology may not be able to fully access information in this report. For assistance contact vog.shh.qrha@PAT

None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.

Anti Inflammatory Injection for Back Pain - Tubidal

Source: https://www.ncbi.nlm.nih.gov/books/NBK285206/

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