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Research Article Epidural Steroid Injection · PDF file Research Article Epidural Steroid Injection: A Convenient Short Term Alternative to Fenestration Discectomy in Lumbar Disc Herniation

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  • Central JSM Neurosurgery and Spine

    Cite this article: Mhaskar VA, Pai SN (2015) Epidural Steroid Injection: A Convenient Short Term Alternative to Fenestration Discectomy in Lumbar Disc Herniation. JSM Neurosurg Spine 3(2): 1057.

    *Corresponding author Vikram A. Mhaskar, 5/407 Mowbray Road, Chatswood, New South Wales, Australia, Tel: 0416866047; Email

    Submitted: 22 March 2015

    Accepted: 07 April 2015

    Published: 09 April 2015

    Copyright © 2015 Mhaskar et al.


    Keywords • SF36 • VAS • Epidural steroid injection • Fenestration discectomy • Stroke • Blood pressure • Hypertension

    MRI • Recovery

    Research Article

    Epidural Steroid Injection: A Convenient Short Term Alternative to Fenestration Discectomy in Lumbar Disc Herniation Vikram A. Mhaskar1* and Sudhir N. Pai2 1Department of Orthopaedics, Royal Prince Alfred Hospital, Australia 2Department of Orthopaedics, Saint John’s Medical College Hospital, India


    Background: To test the null hypothesis that epidural steroid injection and fenestration discectomy equally improve the quality of life over six months in patients with lumbar disc herniation and to compare the pain component of the SF 36 questionnaire and VAS scale with physical impairment.

    Methods: Prospective study of 51 patients, 27 of which underwent epidural steroid injection and 24 fenestration discectomy with evidence of lumbar disc herniation on MRI using the SPORT (Spinal Outcomes Research Trial) eligibility criteria from April 2009 and February 2012.

    Results: Of the 51 patients, 27 were treated with Epidural steroid injection and 24 with Fenestration Discectomy, at 6 months primary outcomes of Physical Functioning, Energy /Fatigue, Emotional, Pain and General health improved in both groups with no statistically significant difference between the two, Social Functioning did not improve significantly. There was a statistically significant variation of end line as well as percentage change in physical index score with SF36 and VAS scores.

    Conclusions: There was significant improvement in quality of life of life of patients treated with both epidural steroid injection and fenestration discectomy with no statistically significant difference between the two groups at all intervals till six months. There was no significant difference between the VAS and pain component of SF 36 scale in measuring improvement in pain. The improvement in quality of life co related with the improvement in physical signs and symptoms.

    ABBREVIATIONS ESI: Epidural Steroid Injection; SF36: Short Form 36; VAS:

    Visual Analogue Scale

    INTRODUCTION Back pain is now an international health issue of major

    significance. About 80% suffer from this at some time in their life, ranked as the most frequent cause of limitation of activity in people younger than 45 years by the National Centre for Health Statistics. Only routine examinations post-operative check-up and upper respiratory tract symptoms surpass back problems as a cause of office visits to physicians [1]. Disc herniation is an important cause of low back pain with L3-4 and L4-5 showing maximum predisposition for disc degeneration [2,3].

    Disc prolapse accounts for 5% of lower back disorders and is one of the most common causes for surgery [4]. Treatment for

    lumbar disc herniation can be conservative or surgical, and which one is effective is always controversial [5]. Choosing the best form of treatment has always posed a challenge to the treating physician. Popular forms of conservative treatment are physical therapy, epidural steroid injection, chiropathy, anti-inflammatory agents and opioid analgesics which are a lot cheaper and less invasive than surgical techniques [4]. Epidural steroid injection is a very popular and low risk alternative to surgical intervention in lumbar disc herniation. It enjoys reasonable success rates for alleviation of radicular symptoms from lumbar herniated discs [6]. Fenestration discectomy as a surgical procedure is less time consuming with less blood loss, less post-operative complications and does not compromise the stability of the spine when compared to laminectomy and discectomy [7]. However it is a surgical procedure and entails the risks of complications associated with any surgical procedure. One needs to weigh the benefits versus the fallacies associated with any intervention before advocating it as a routine treatment measure.

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    Mhaskar al. (2015) Email:

    JSM Neurosurg Spine 3(2): 1057 (2015) 2/5

    This study intends to compare the changes in quality of life of individuals with low back ache and radiculopathy for at least six weeks, undergoing epidural steroid injection or fenestration discectomy using the SF 36 and VAS scales, over a period of six months. With this study we intend to explore whether the solution to a crippling problem can be non- surgical (epidural steroid injection) and whether it can be an effective long term alternative to fenestration discectomy for single level disc herniation.

    MATERIALS AND METHODS Subjects and Methods

    This study was conducted from April 2009 to February 2012 in patients between the age group 20years - 65years. 51 patients were recruited in all. 27 underwent epidural steroid injection and 24 fenestration discectomy. The patient was evaluated by an independent surgeon pre and post operatively.

    Inclusion criteria

    Back pain and radiculopathy for at least six weeks in an adult male/female with evidence of lumbar disc herniation as a single level protrusion occupying > 25 % of the spinal cross sectional area on an axial section MRI and had been counselled about the requirement of a fenestration discectomy were included.

    Exclusion Criteria

    Patients with back pain for less than six weeks and with evidence of more than single level lumbar disc herniation on MRI, those with the disc occupying < 25% of the spinal cross sectional area measured on an axial section, asymptomatic individuals with/without evidence of lumbar disc herniation on MRI, those with osseous cause for lumbar canal stenosis on MRI, individuals with signs of lumbar disc degeneration without lumbar disc herniation, patients who previously underwent discectomies, epidural steroid injections, patients with associated spinal pathologies and cauda equina syndrome and patients without radiculopathy even if there was evidence of lumbar disc herniation on MRI with low back ache were excluded.

    Patients were assessed clinically, a thorough history and clinical and neurological examination was carried out, the subjective symptoms and objective signs were recorded. This was followed by routine pre-operative investigations as well as a MRI scan of the lumbosacral spine of all the patients to confirm the diagnosis. The study was conducted for a period of six months on a patient. The change in quality of life was evaluated by administering the SF36 quality of life questionnaire and Visual Analogue Scale (VAS).

    a) Before the start of treatment b) two weeks after the completion of treatment

    c) one month after the completion of treatment d) six months after completion of the treatment.

    Those candidates that underwent surgical treatment after the epidural steroid injection were excluded.

    The scoring was done according to the SF36 scoring system and VAS scales.

    Operative Procedure of Discectomy by the Fenestration Method

    Patient was positioned in the prone knee chest position, care being taken to see if the abdomen is free to prevent undue engorgement of the epidural veins and thus decrease the extent of intraoperative blood loss. The affected lumbar space was localized using X ray intra op.

    A vertical midline incision was made after localizing the level of the disc. The para-spinal muscles were retracted and the inter- laminar space exposed. Only the ligamentum flavum was excised, without removing any part of the lamina. The cord was retracted, the disc herniation identified and discectomy carried out using disc removing forceps. The entire disc at that level was removed. The cord and the roots are confirmed to be decompressed and lying freely in their respective canals. The wound was closed in layers and dressing done.

    Epidural steroid Injection Dosage and Procedure

    The patient was positioned in the left lateral position/sitting in the epidural steroid injection room .The level of the disc was pre-determined by MRI. The drugs to be injected were kept ready. The mixture used contained 40 mg Triamcinolone acetate which corresponds to approximately 4 ml, mixed with 4 ml of 0.5% sensorcaine and 12 ml of normal saline to make a 20 ml mixture according to the anesthesia department’s protocol. This mixture was then injected in the epidural space one level higher to the level of disc herniation causing compression via interlaminar technique.

    An IV cannula was placed in situ for at least 4 hrs to be able to tackle any hypotension that ensued.

    The mixture was then injected into the epidural space. No X-ray control or contrast medium was used.

    Types of Outcome Measures

    Patient centered outcomes analyzing a) Proportion of patients who recovered according to self, clinicians assessment or both b) Proportion of patients who had improvement or resolution of pain c) Proportion of patients who had an improvement in function measured on the SF 36 quality of life scale, and d) the rate of subsequent back surgery were used.

    Measures of Objective physical impairment

    SLRT (Straight Leg Raising Test), alterat

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