Long-Term Effects of Repeated Injections of Local Anesthetic with or Without Corticosteroid for Lumbar Spinal Stenosis

Eku Oben, Mercer University College of Pharmacy

Lumbar spinal stenosis is the narrowing of the space around the spinal cord, most commonly caused by arthritis. [1] Guidelines recommend nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, corticosteroid injections, anesthetic injections, physical therapy, or a lumbar brace for treatment of lumbar spinal stenosis. [2] Comparing lumbar spinal stenosis patient pain scores shows no difference between groups that received steroid injections after anesthesia and placebo groups at the first month (p= 0.793). [3]

Design Multicenter, double-blind, randomized controlled trial; N= 400
Objective To determine the effectiveness of treatment with epidural corticosteroid injection for lumbar spinal stenosis, and the effect of repeat injections
Study Group Epidural injections with corticosteroid plus lidocaine (n= 200); lidocaine alone (n= 200)
Methods Participants completed a Roland-Morris Disability Questionnaire (higher scores indicating disability ranged from 0 – 24) and leg pain intensity ranged from 0 (no pain) to 10 (worst pain).

 

Participants received two epidural injections during the initial six weeks of the study, before another two injections were added (between months six and 12).

 

Daily logs were used to measure the use of anesthetics, and results were recorded using electronic medical records and patient self-reported pain diaries.

Duration 12 months
Primary Outcome Measure A high questionnaire score indicating disability and intense leg pain
Baseline Characteristics
Characteristics Lidocaine (n= 200) Corticosteroid + lidocaine (n= 200)
Age 68.1±10.2 68±9.8
Female 104 (52) 117 (58.5)
Race
White 139 (69.5) 137 (68.5)
Black 52 (26) 53 (26.5)
Other 9 (4.5) 10 (5)
Hispanic ethnicity 6 (3) 11 (5.5)
Education
High school, GED or less 67 (33.5) 60 (30)
Some college, vocational or technical 56 (28) 72 (36)
College graduate 32 (16) 33 (16.5)
Professional or graduate degree 45 (22.5) 35 (17.5)
Married or living with other 111 (55.5) 126 (63)
Employment
Full or part time 71 (35.5) 57 (28.5)
Retired, not disabled 88 (44) 93 (46.5)
Retired, disabled 23 (11.5) 31 (15.5)
Other 18 (9) 19 (9.5)
Current smoker 32 (16.1) 25 (12.5)
Diabetes, taking insulin 15 (7.5) 16 (8)
Body mass index 29.7±6 31.1±6.5

 

 

Results Injections by randomized treatment group

0 – 6 weeks
Treatment Lidocaine Corticosteroid + lidocaine p
No of epidural injections 0.68
0 N/A N/A
1 124 (62) 120 (60)
2 76 (38) 80 (40)
≥3 0 (0) 0 (0)
Mean ±SD 1.94±0.76 1.84±0.86 0.25
6 – 12 weeks
No of epidural injections <0.001
0 76 (39.4) 98 (50.8
1 91 (47.2) 67 (34.7)
2 26 (13.5) 28 (14.5)
≥3 0 (0) 0 (0)
Mean ±SD 0.74±0.68 0.64±0.72 0.15
12 weeks – 12 months
No of epidural injections 0.02
0 141 (77) 125 (66.1)
1 12 (6.6) 31 (16.4)
2 23 (12.6) 26 (13.8)
≥3 7 (3.8) 7 (3.7)
Mean ±SD 0.48±1.04 0.58±0.96 0.33
Adverse Effects Common: none reported
Serious: none reported
Percentage that discontinued due to adverse events: none reported
Study Author Conclusions No additional benefit is seen when treating patients with lumbar central canal spinal stenosis with epidural injections of corticosteroids plus lidocaine, compared to the when lidocaine is used alone from six to 12 months.

This study shows no significant difference between the lidocaine plus corticosteroid group compared to the lidocaine group alone, or leg pain. 46.5% of participants in the “lidocaine alone” group had >50% improvement in leg pain by the end of the study, compared to 36.7% in the lidocaine plus corticosteroid group. However, this data was not statistically significant. [4] The study was based on participants responses, which could be a limitation because of recall bias. In addition, the study did not include patients who had herniated disk pain or foraminal stenosis, which could be a limitation for an accurate study population.

 

References

[1] Lumbar spinal stenosis. American Academy of Orthopedic Surgeons. http://orthoinfo.aaos.org/topic.cfm?topic=a00329. Updated December 2013. Accessed September 2, 2017.

[2] Spinal stenosis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. https://www.niams.nih.gov/health_info/spinal_stenosis/. Accessed September 1, 2017.

[3] Song SH, Ryu GH, Park JW, et al. The effect and safety of steroid injection in lumbar spinal stenosis: with or without local anesthetics. Ann Rehabil Med. 2016;40(1):14-20.

[4] Friedly JL, Comstock BA, Turner JA, et al. Long-term effects of repeated injections of local anesthetic with or without corticosteroid for lumbar spinal stenosis. Arch Phys Med Rehabil. 2017;98(8):1499-1507.

 

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