Parasagittal Beats Midline for Lumbar Steroid Injections

PALM SPRINGS, CALIF. (EGMN) – A parasagittal approach – but not a midline approach – to interlaminar lumbar epidural steroid injections for unilateral lumbosacral radiculopathic pain significantly improved quality of life and functionality in a prospective, randomized, single-blind study of 44 adults.

The steroid injections significantly improved pain in both groups, with Numeric Rating Scale scores during movement decreasing from a preinjection average of 8 in the parasagittal group and 7 in the midline group, to 3 and 4, respectively, on days 1, 7, and 28 after injection. Pain scores at rest decreased from 5 in both groups before injection to 3 in the parasagittal group and 4 in the midline group on follow-up days 1, 7, and 28, Dr. Kenneth D. Candido and his associates reported in a prize-winning poster and plenary presentation at the annual meeting of the American Academy of Pain Medicine.

"The analgesic benefit is profound over the first 30 days; it’s about 50%," he said. There have been few previous reports, however, assessing quality of life and functionality after interlaminar lumbar epidural steroid injections, said Dr. Candido of Advocate Illinois Masonic Medical Center, Chicago.

All patients completed the Oswestry Low Back Pain Questionnaire 20 minutes before injection and at each of the follow-ups. The questionnaire is designed to assess how back pain affects patients’ ability to manage in everyday life, with sections focused on impairments (such as pain) and abilities, including personal care, lifting, walking, sitting, standing, sleeping, social life, sex life, and traveling.

Oswestry scores averaged 21 in the parasagittal group and 20 in the midline group before injection, a difference that was not significant. Scores improved in both groups after injection, but only the parasagittal group showed statistically significant improvements compared with baseline.

Oswestry scores decreased in the parasagittal group from 21 at baseline to approximately 12 on follow-up day 1, and to approximately 10 on days 7 and 28. Oswestry scores in the midline group decreased from 20 at baseline to approximately 15 on follow-up day 1, to 13 on day 7, and to 12 on day 28.

The results suggest that the parasagittal approach was more effective than the midline approach in patients with unilateral lumbosacral radiculopathic pain, Dr. Candido said.

Both approaches to lumbar epidural steroid injections are accepted treatments in the conservative care of low back pain with radiculopathy secondary to lumbar disk disease, but there are few previous data on functional improvements after lumbar epidural steroid injections. "I regularly practice both of these in my practice," he said.

Patients were randomized to the parasagittal or midline interlaminar approach. All received 120 mg (2 mL) of methylprednisolone acetate with 1 mL of normal saline solution and 1 mL of lidocaine 1%.

The ongoing study has randomized 55 more patients, and the investigators are gathering data from 6 months of follow-up.

Patient characteristics were similar between groups. The average age was 49 years in the parasagittal group and 50 in the midline group. Approximately half in each group were male. Low back pain symptoms had been present for an average of 18 months in the parasagittal group and 24 months in the midline group.

The study excluded patients with discogenic pain without radiculopathic pain; a history of previous spinal surgery; a lumbar epidural steroid injection in the past year; allergy to methylprednisolone, lidocaine, or iodine-based contrast; concurrent use of systemic steroid medications; or habituation to opioids.

Dr. Candido reported having no financial disclosures.

PALM SPRINGS, CALIF. (EGMN) – A parasagittal approach – but not a midline approach – to interlaminar lumbar epidural steroid injections for unilateral lumbosacral radiculopathic pain significantly improved quality of life and functionality in a prospective, randomized, single-blind study of 44 adults.

The steroid injections significantly improved pain in both groups, with Numeric Rating Scale scores during movement decreasing from a preinjection average of 8 in the parasagittal group and 7 in the midline group, to 3 and 4, respectively, on days 1, 7, and 28 after injection. Pain scores at rest decreased from 5 in both groups before injection to 3 in the parasagittal group and 4 in the midline group on follow-up days 1, 7, and 28, Dr. Kenneth D. Candido and his associates reported in a prize-winning poster and plenary presentation at the annual meeting of the American Academy of Pain Medicine.

"The analgesic benefit is profound over the first 30 days; it’s about 50%," he said. There have been few previous reports, however, assessing quality of life and functionality after interlaminar lumbar epidural steroid injections, said Dr. Candido of Advocate Illinois Masonic Medical Center, Chicago.

All patients completed the Oswestry Low Back Pain Questionnaire 20 minutes before injection and at each of the follow-ups. The questionnaire is designed to assess how back pain affects patients’ ability to manage in everyday life, with sections focused on impairments (such as pain) and abilities, including personal care, lifting, walking, sitting, standing, sleeping, social life, sex life, and traveling.

Oswestry scores averaged 21 in the parasagittal group and 20 in the midline group before injection, a difference that was not significant. Scores improved in both groups after injection, but only the parasagittal group showed statistically significant improvements compared with baseline.

Oswestry scores decreased in the parasagittal group from 21 at baseline to approximately 12 on follow-up day 1, and to approximately 10 on days 7 and 28. Oswestry scores in the midline group decreased from 20 at baseline to approximately 15 on follow-up day 1, to 13 on day 7, and to 12 on day 28.

The results suggest that the parasagittal approach was more effective than the midline approach in patients with unilateral lumbosacral radiculopathic pain, Dr. Candido said.

Both approaches to lumbar epidural steroid injections are accepted treatments in the conservative care of low back pain with radiculopathy secondary to lumbar disk disease, but there are few previous data on functional improvements after lumbar epidural steroid injections. "I regularly practice both of these in my practice," he said.

Patients were randomized to the parasagittal or midline interlaminar approach. All received 120 mg (2 mL) of methylprednisolone acetate with 1 mL of normal saline solution and 1 mL of lidocaine 1%.

The ongoing study has randomized 55 more patients, and the investigators are gathering data from 6 months of follow-up.

Patient characteristics were similar between groups. The average age was 49 years in the parasagittal group and 50 in the midline group. Approximately half in each group were male. Low back pain symptoms had been present for an average of 18 months in the parasagittal group and 24 months in the midline group.

The study excluded patients with discogenic pain without radiculopathic pain; a history of previous spinal surgery; a lumbar epidural steroid injection in the past year; allergy to methylprednisolone, lidocaine, or iodine-based contrast; concurrent use of systemic steroid medications; or habituation to opioids.

Dr. Candido reported having no financial disclosures.

PALM SPRINGS, CALIF. (EGMN) – A parasagittal approach – but not a midline approach – to interlaminar lumbar epidural steroid injections for unilateral lumbosacral radiculopathic pain significantly improved quality of life and functionality in a prospective, randomized, single-blind study of 44 adults.

The steroid injections significantly improved pain in both groups, with Numeric Rating Scale scores during movement decreasing from a preinjection average of 8 in the parasagittal group and 7 in the midline group, to 3 and 4, respectively, on days 1, 7, and 28 after injection. Pain scores at rest decreased from 5 in both groups before injection to 3 in the parasagittal group and 4 in the midline group on follow-up days 1, 7, and 28, Dr. Kenneth D. Candido and his associates reported in a prize-winning poster and plenary presentation at the annual meeting of the American Academy of Pain Medicine.

"The analgesic benefit is profound over the first 30 days; it’s about 50%," he said. There have been few previous reports, however, assessing quality of life and functionality after interlaminar lumbar epidural steroid injections, said Dr. Candido of Advocate Illinois Masonic Medical Center, Chicago.

All patients completed the Oswestry Low Back Pain Questionnaire 20 minutes before injection and at each of the follow-ups. The questionnaire is designed to assess how back pain affects patients’ ability to manage in everyday life, with sections focused on impairments (such as pain) and abilities, including personal care, lifting, walking, sitting, standing, sleeping, social life, sex life, and traveling.

Oswestry scores averaged 21 in the parasagittal group and 20 in the midline group before injection, a difference that was not significant. Scores improved in both groups after injection, but only the parasagittal group showed statistically significant improvements compared with baseline.

Oswestry scores decreased in the parasagittal group from 21 at baseline to approximately 12 on follow-up day 1, and to approximately 10 on days 7 and 28. Oswestry scores in the midline group decreased from 20 at baseline to approximately 15 on follow-up day 1, to 13 on day 7, and to 12 on day 28.

The results suggest that the parasagittal approach was more effective than the midline approach in patients with unilateral lumbosacral radiculopathic pain, Dr. Candido said.

Both approaches to lumbar epidural steroid injections are accepted treatments in the conservative care of low back pain with radiculopathy secondary to lumbar disk disease, but there are few previous data on functional improvements after lumbar epidural steroid injections. "I regularly practice both of these in my practice," he said.

Patients were randomized to the parasagittal or midline interlaminar approach. All received 120 mg (2 mL) of methylprednisolone acetate with 1 mL of normal saline solution and 1 mL of lidocaine 1%.

The ongoing study has randomized 55 more patients, and the investigators are gathering data from 6 months of follow-up.

Patient characteristics were similar between groups. The average age was 49 years in the parasagittal group and 50 in the midline group. Approximately half in each group were male. Low back pain symptoms had been present for an average of 18 months in the parasagittal group and 24 months in the midline group.

The study excluded patients with discogenic pain without radiculopathic pain; a history of previous spinal surgery; a lumbar epidural steroid injection in the past year; allergy to methylprednisolone, lidocaine, or iodine-based contrast; concurrent use of systemic steroid medications; or habituation to opioids.

Dr. Candido reported having no financial disclosures.