Ann Rehabil Med.  2011 Jun;35(3):405-411. 10.5535/arm.2011.35.3.405.

The Additional Effect of Hyaluronidase in Lumbar Interlaminar Epidural Injection

• Kim SB
• Lee KW
• Lee JH
• Kim MA
• Kim BH

• KMID: 2266861
• DOI: http://doi.org/10.5535/arm.2011.35.3.405

Abstract

OBJECTIVE
To evaluate the effect of hyaluronidase in lumbar interlaminar epidural injection (LIEI) for low back pain and sciatica. METHOD: Sixty-one patients suffering from severe low back pain and sciatica were randomly allocated into three groups. Group T (n=18, mean duration of illness: 2.12+/-1.16 months) received lumbar interlaminar epidural injection (LIEI) with 2 ml triamcinolone (40 mg/ml) and 5 ml bupivacaine (0.25%). Group H (n=16, mean duration of illness: 2.05+/-1.12 months) received LIEI with 1,500 IU hyaluronidase and 5 ml bupivacaine (0.25%). Group TH (n=27, mean duration of illness: 2.16+/-1.65 months) received LIEI with 1,500 IU hyaluronidase, 2 ml triamcinolone (40 mg/ml), and 5 ml bupivacaine (0.25%). The effects were evaluated using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) at preinjection and 2 weeks, 4 weeks, and 8 weeks after LIEI.
RESULTS
Pain improved in all groups after 2 weeks (p<0.05). After 8 weeks, there was no significant difference in VAS improvement among the 3 groups. However, pain improved in 70.4% of Group TH compared with preinjection, in contrast to 44.4% of Group T and 31.3% of Group H. The ODI improved significantly only in Group TH after 8 weeks (p<0.05).
CONCLUSION
LIEI with triamcinolone and hyaluronidase is more effective for reducing pain after 8 weeks than injection with triamcinolone or hyaluronidase alone.

Keyword

Hyaluronidase; Low back pain; Sciatica; Epidural injection

MeSH Terms

Bupivacaine
Humans
Hyaluronoglucosaminidase
Injections, Epidural
Low Back Pain
Sciatica
Stress, Psychological
Triamcinolone
Bupivacaine
Hyaluronoglucosaminidase
Triamcinolone

Figure

• 

  Fig. 1 Comparison of mean change of Visual Analogue Scale. T: Triamcinolone and Bupivacaine, H: Hyaluronidase and Bupivacaine, TH: Triamcinolone, Hyaluronidase, and Bupivacaine

• 

  Fig. 2 Comparison of mean change of Oswestry Disability Index. T: Triamcinolone and Bupivacaine, H: Hyaluronidase and Bupivacaine, TH: Triamcinolone, Hyaluronidase, and Bupivacaine.*p<0.05

• 

  Fig. 3 Pain relief > 50% as measured by Visual Analogue Scale. T: Triamcinolone and Bupivacaine, H: Hyaluronidase and Bupivacaine, TH: Triamcinolone, Hyaluronidase, and Bupivacaine

Reference

1. Andersson GB. Epidemiological features of chronic low-back pain. Lancet. 1999; 354:581–585. PMID: 10470716.

2. Jung SG. Epidural steroid injection in lumbosacral radiculopathy (due to herniated intervertebral disc) efficacy-randomized placebo controlled studies. J Korean Assoc Pain Med. 2007; 6:14–23.

3. Hayashi N, Weinstein JN, Meller ST, Lee HM, Spratt KF, Gebhart GF. The effect of epidural injection of betamethasone or bupivacaine in a rat model of lumbar radiculopathy. Spine. 1998; 23:877–885. PMID: 9580954.

4. Murata Y, Onda A, Rydevik B, Takahashi K, Olmarker K. Distribution and appearance of tumor necrosis factor-alpha in the dorsal root ganglion exposed to experimental disc herniation in rats. Spine. 2004; 29:2235–2241. PMID: 15480134.

5. Brisby H, Byröd G, Olmarker K, Miller VM, Aoki Y, Rydevik B. Nitric oxide as a mediator of nucleus pulposus-induced effects on spinal nerve roots. J Orthop Res. 2000; 18:815–820. PMID: 11117305.

6. McLain RF, Kapural L, Mekhail NA. Epidural steroid therapy for back and leg pain; mechanism of action and efficacy. Spine J. 2005; 5:191–201. PMID: 15749619.

7. Lee KJ, Han SG, Yoon SH, Kim JS, Lee YS. Nerve root block with corticosteroids, hyaluronidase, and local anesthetic in the failed back surgery syndrome. J Korean Pain Soc. 1999; 12:191–194.

8. Jo DH, Hong JH, Kim MH. The effect of transforaminal epidural block with hyaluronidase and triamcinolone. Korean J Pain. 2005; 18:176–180.

9. Carette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A, Truchon R, Parent F, Levesque J, Bergeron V, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med. 1997; 336:1634–1640. PMID: 9171065.

10. Wilson-MacDonald J, Burt G, Griffin D, Glynn C. Epidural steroid injection for nerve root compression. A randomised, controlled trial. J Bone Joint Surg Br. 2005; 87:352–355. PMID: 15773645.

11. Buchner M, Zeifang F, Brocai DR, Schiltenwolf M. Epidural corticosteroid injection in the conservative management of sciatica. Clin Orthop Relat Res. 2000; 375:149–156. PMID: 10853164.

12. Menzel EJ, Farr C. Hyaluronidase and its substrate hyaluronan: biochemistry, biological activities and therapeutic uses. Cancer Lett. 1998; 131:3–11. PMID: 9839614.

13. Devulder J, Deene P, De Laat M, Van Bastelaere M, Brusselmans G, Rolly G. Nerve root sleeve injections in patients with failed back surgery syndrome: a comparison of three solutions. Clin J Pain. 1999; 15:132–135. PMID: 10382927.