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.
Vikram A. Mhaskar, 5/407 Mowbray Road,
Chatswood, New South Wales, Australia, Tel:
Submitted: 22 March 2015
Accepted: 07 April 2015
Published: 09 April 2015
© 2015 Mhaskar et al.
• Epidural steroid injection
• Fenestration discectomy
• Blood pressure
Epidural Steroid Injection:
A Convenient Short Term
Alternative to Fenestration
Discectomy in Lumbar Disc
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
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.
ESI: Epidural Steroid Injection; SF36: Short Form 36; VAS:
Visual Analogue Scale
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 . 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 . Treatment for
lumbar disc herniation can be conservative or surgical, and which
one is effective is always controversial . 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 . 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 . 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 . 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.
Mhaskar al. (2015)
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.
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.
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
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
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