Korean J Pain.  2015 Jan;28(1):11-21. 10.3344/kjp.2015.28.1.11.

Comparison of the Efficacy of Caudal, Interlaminar, and Transforaminal Epidural Injections in Managing Lumbar Disc Herniation: Is One Method Superior to the Other?

• Manchikanti L
• Singh V
• Pampati V
• Falco FJ
• Hirsch JA

• KMID: 2278248
• DOI: http://doi.org/10.3344/kjp.2015.28.1.11

Abstract

BACKGROUND
Epidural injections are performed utilizing 3 approaches in the lumbar spine: caudal, interlaminar, and transforaminal. The literature on the efficacy of epidural injections has been sporadic. There are few high-quality randomized trials performed under fluoroscopy in managing disc herniation that have a long-term follow-up and appropriate outcome parameters. There is also a lack of literature comparing the efficacy of these 3 approaches.
METHODS
This manuscript analyzes data from 3 randomized controlled trials that assessed a total of 360 patients with lumbar disc herniation. There were 120 patients per trial either receiving local anesthetic alone (60 patients) or local anesthetic with steroids (60 patients).
RESULTS
Analysis showed similar efficacy for caudal, interlaminar, and transforaminal approaches in managing chronic pain and disability from disc herniation. The analysis of caudal epidural injections showed the potential superiority of steroids compared with local anesthetic alone a 2-year follow-up, based on the average relief per procedure. In the interlaminar group, results were somewhat superior for pain relief in the steroid group at 6 months and functional status at 12 months. Interlaminar epidurals provided improvement in a significantly higher proportion of patients. The proportion of patients nonresponsive to initial injections was also lower in the group for local anesthetic with steroid in the interlaminar trial.
CONCLUSIONS
The results of this assessment show significant improvement in patients suffering from chronic lumbar disc herniation with 3 lumbar epidural approaches with local anesthetic alone, or using steroids with long-term follow-up of up to 2 years, in a contemporary interventional pain management setting.

Keyword

Caudal epidural steroids; Disc herniation; Local anesthetic; Lumbar interlaminar steroids; Radiculitis; Transforaminal epidural steroids

MeSH Terms

Chronic Pain
Fluoroscopy
Follow-Up Studies
Humans
Injections, Epidural*
Pain Management
Radiculopathy
Spine
Steroids
Steroids

Figure

• 

  Fig. 1 Illustration of average Numeric Rating Scale scores for pain at different follow-up points by type of epidural. *P value at different time intervals as compared with baseline (within group, pair-wise comparisons with Bonferroni correction) #1 P = 0.058, #2 P = 0.227, #3 P = 0.269, #4 P = 0.355, #5 P = 0.202, #6 P = 0.515 respectively, for between-group comparisons at specified time intervals with Bonferroni correction.

• 

  Fig. 2 Illustration of average Oswestry Disability Index scores for function at different follow-up points by type of epidural. *P value at different time intervals as compared with baseline (within group, pair-wise comparisons with Bonferroni correction) #1 P = 0.052, #2 P = 0.652, #3 P = 0.951, #4 P = 0.896, #5 P = 0.963, #6 P = 0.925 respectively, for between-group comparisons at specified time intervals with Bonferroni correction.

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  Fig. 3 Illustration of reduction (at least 50%) of Numeric Rating Scale scores for pain and Oswestry Disability Index scores for function from baseline (all patients).

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  Fig. 4 Illustration of reduction (at least 50%) of Numeric Rating Scale scores for Pain and Oswestry Disability Index scores for function from baseline (only responsive patients).

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  Fig. 5 Illustration of reduction (at least 50%) of Numeric Rating Scale scores for pain and Oswestry Disability Index scores for function from baseline (all patients).

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  Fig. 6 Illustration of reduction (at least 50%) of Numeric Rating Scale scores for pain and Oswestry Disability Index scores for function from baseline (only responsive patients).

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