Abdülkadir ATIM, Süleyman DENİZ, Oğuz KILIÇKAYA, Mehmet Emin ORHAN, Tarık PURTULOĞLU, Ercan KURT

Terapotik lomber transforaminal epidural steroid enjeksiyonu uygulamasının etkinliğinin değerlendirilmesi

Amaç: Transforaminal epidural steroid enjeksiyonu (TFESE) bel ağrısında kullanılan minimal invaziv bir tedavi yöntemidir. Bu çalışmada, konservatif tedavi yöntemleri ya da cerrahi tedaviyle iyileşmeyen bel ağrısı şikayeti olan hastalara uyguladığımız TFESE tedavisinin etkinliğini incelemeyi amaçladık. Gereç ve Yöntem: Çalışma, kliniğimizde bel ağrısı nedeniyle TFESE tedavisi uygulanan 37 hastaya (yaşları 24-80 arası) ait kayıtların retrospektif olarak incelenmesi ile gerçekleştirildi. Ağrı şiddeti 3. hafta ve 6. ayda Vizüel Analog Skala (VAS) ile değerlendirildi. Bulgular: Hastaların yaş ve şikayet süreleri ortanca olarak 50 yıl ve 48 ay bulundu. Hastaların tanılarının %51’inin lomber disk hastalığı (LDH), %38’inin başarısız bel cerrahisi sendromu (BBCS) ve %11’inin de spinal stenoz (SS) olduğu tespit edildi. Üç grupta da işlem öncesi VAS skorları birbirine benzerdi. TFESE tedavisi sonrası LDH ve BBCS tanılı olguların 3. hafta ve 6. ay VAS değerleri, geliş VAS değerlerine göre istatistiksel olarak anlamlı derecede düşük bulundu (p0.05). Tedavi uygulaması sonrası ağrı düzeyinin %50 ve daha fazla düşmesi başarılı olarak kabul edildiğinde, uyguladığımız tedavi tüm olgularda VAS-0’a göre VAS-3 haftada %84, VAS-6 ayda %78 başarılı bulundu. Sonuç: TFESE tedavisinin LDH, BBCS ve SS’ye bağlı bel ağrısı olan hastaların çoğunda uzun süren bir ağrısız dönem oluşturması uygulanan işlemin etkinliğini göstermektedir. Minimal invaziv bir yöntem olan TFESE tedavisinin LDH, BBCS ve SS’ye bağlı radikülopatik bel ağrısı olan hastalara uygulanmasıyla başarılı sonuçlara ulaşabileceğimiz kanısındayız.

Assessment of the effectiveness of lumbar transforaminal epidural steroid injection for low back pain

Objectives: Transforaminal epidural steroid injection (TFESI) is a minimally invasive technique used for low back pain. We aimed to assess the efficiency of TFESI in patients with low back pain who did not respond to conservative or surgical methods. Methods: This study was a retrospective analysis of the records of 37 patients (range: 24-80 years) who presented to our clinic with low back pain and were treated by TFESI. Outcomes were assessed by Visual Analog Scale (VAS) measured at the 3rd week and 6th month. Results: Median age of the patients was 50 years, and mean duration of symptoms was 48 months. Diagnosis was lumbar disc herniation (LDH) in 51%, failed back surgery syndrome (FBSS) in 38%, and spinal stenosis (SS) in 11% of the patients. Baseline VAS scores were similar between the three groups. The 3rd week and 6th month VAS scores of LDH and FBSS cases were significantly decreased compared to baseline scores (p<0.001, p=0.001), and no significant change was observed between the VAS scores at the 3rd week and 6th month (p>0.05). If success is defined as 50% or more decrease in VAS scores, the success rate of TFESI was 84% at the 3rd week and 78% at the 6th month. Conclusion: TFESI significantly reduced the intensity of low back pain in most of the patients with LDH, FBSS or SS; thus, it may be considered as an effective method in the treatment of low back pain.

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1. Cassidy JD, Carroll LJ, Côté P. The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults. Spine (Phila Pa 1976) 1998;23(17):1860-7.
2. Rosenberg SK, Grabinsky A, Kooser C, Boswell MV. Effectiveness of transforaminal epidural steroid injections in low back pain: a one year experience. Pain Physician 2002;5(3):266-70.
3. Guo HR, Tanaka S, Halperin WE, Cameron LL. Back pain prevalence in US industry and estimates of lost workdays. Am J Public Health 1999;89(7):1029-35.
4. Saal JA, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy. An outcome study. Spine (Phila Pa 1976) 1989;14(4):431-7.
5. Saal JS, Saal JA, Yurth EF. Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine (Phila Pa 1976) 1996;21(16):1877-83.
6. Manchikanti L. Transforaminal lumbar epidural steroid injections. Pain Physician 2000;3(4):374-98.
7. Evans W. Intrasacral epidural injection in the treatment of sciatica. Lancet 1930;2:1225-9.
8. Lee JW, Kim SH, Lee IS, Choi JA, Choi JY, Hong SH, et al. Therapeutic effect and outcome predictors of sciatica treated using transforaminal epidural steroid injection. AJR Am J Roentgenol 2006;187(6):1427-31.
9. Lee JW, Kim SH, Choi JY, Yeom JS, Kim KJ, Chung SK, et al. Transforaminal epidural steroid injection for lumbosacral radiculopathy: preganglionic versus conventional approach. Korean J Radiol 2006;7(2):139-44.
10. Vad VB, Bhat AL, Lutz GE, Cammisa F. Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Spine (Phila Pa 1976) 2002;27(1):11-6.
11. Gajraj NM. Selective nerve root blocks for low back pain and radiculopathy. Reg Anesth Pain Med 2004;29(3):243-56.
12. Sitzman BT. Epidural injections. In: Fenton DS, Czervionke LF, editors. Image-guided spine intervention. Philadelphia: Saunders; 2003. p. 99-126.
13. Abdi S, Datta S, Trescot AM, Schultz DM, Adlaka R, Atluri SL, Smith HS, Manchikanti L. Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician 2007;10:185-212.
14. Karppinen J, Ohinmaa A, Malmivaara A, Kurunlahti M, Kyllönen E, Pienimäki T, et al. Cost effectiveness of periradicular infiltration for sciatica: subgroup analysis of a randomized controlled trial. Spine (Phila Pa 1976) 2001;26(23):2587-95.
15. Riew KD, Park JB, Cho YS, Gilula L, Patel A, Lenke LG, et al. Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year follow-up. J Bone Joint Surg Am 2006;88(8):1722-5.
16. Jeong HS, Lee JW, Kim SH, Myung JS, Kim JH, Kang HS. Effectiveness of transforaminal epidural steroid injection by using a preganglionic approach: a prospective randomized controlled study. Radiology 2007;245(2):584-90.
17. Vad VB, Bhat AL, Lutz GE, Cammisa F. Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Spine (Phila Pa 1976) 2002;27(1):11-6.
18. Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Sanelli JT, Freeman ED, et al. Fluoroscopically guided lumbar transformational epidural steroid injections in degenerative lumbar stenosis: an outcome study. Am J Phys Med Rehabil 2002;81(12):898-905.
19. Ackerman WE 3rd, Ahmad M. The efficacy of lumbar epidural steroid injections in patients with lumbar disc herniations. Anesth Analg 2007;104(5):1217-22.
20. Franson RC, Saal JS, Saal JA. Human disc phospholipase A2 is inflammatory. Spine (Phila Pa 1976) 1992;17(6 Suppl):S129-32.
21. Kang JD, Georgescu HI, McIntyre-Larkin L, Stefanovic-Racic M, Evans CH. Herniated cervical intervertebral discs spontaneously produce matrix metalloproteinases, nitric oxide, interleukin-6, and prostaglandin E2. Spine (Phila Pa 1976) 1995;20(22):2373-8.
22. Ergin A. Epidural steroid injections and low back pain. Agri 2005;17(1):23-7.
23. Devor M, Govrin-Lippmann R, Raber P. Corticosteroids suppress ectopic neural discharge originating in experimental neuromas. Pain 1985;22(2):127-37.
24. Buenaventura RM, Datta S, Abdi S, Smith HS. Systematic review of therapeutic lumbar transforaminal epidural steroid injections. Pain Physician 2009;12(1):233-51.
25. Manchikanti L, Datta S, Gupta S, Munglani R, Bryce DA, Ward SP, et al. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 2. Therapeutic interventions. Pain Physician 2010;13(4):E215-64.
26. Manchikanti L, Cash KA, Pampati V, Damron KS, McManus CD. Evaluation of lumbar transforaminal epidural injections with needle placement and contrast flow patterns: a prospective, descriptive report. Pain Physician 2004;7(2):217-23.
27. Glaser SE, Shah RV. Root cause analysis of paraplegia following transforaminal epidural steroid injections: the ‘unsafe’ triangle. Pain Physician 2010;13(3):237-44.