Lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain: a systematic review.

BACKGROUND Low back pain with or without lower extremity pain is the most common problem among chronic pain disorders with significant economic, societal, and health impact. Epidural injections are one of the most commonly performed interventions in the United States in managing chronic low back pain. However the evidence is highly variable among different techniques utilized - namely interlaminar, caudal, transforaminal - and for various conditions, namely - intervertebral disc herniation, spinal stenosis, and discogenic pain without disc herniation or radiculitis. STUDY DESIGN A systematic review of lumbar interlaminar epidural injections with or without steroids. OBJECTIVE To evaluate the effect of lumbar interlaminar epidural injections with or without steroids in managing various types of chronic low back and lower extremity pain emanating as a result of disc herniation or radiculitis, spinal stenosis, and chronic discogenic pain. METHODS Review of the literature and methodologic quality assessment were performed according to the Cochrane Musculoskeletal Review Group Criteria as utilized for interventional techniques for randomized trials and the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF) for therapeutic interventions. Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to November 2008, and manual searches of bibliographies of known primary and review articles. Results of analysis were performed for multiple conditions separately. OUTCOME MEASURES The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. RESULTS The available literature included only blind epidural injections without fluoroscopy. The indicated evidence is positive (Level II-2) for short-term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis. The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections. LIMITATIONS The limitations of this study include paucity of literature, lack of quality evidence, lack of fluoroscopic procedures, and lack of applicable evidence in contemporary interventional pain management practices. CONCLUSION The evidence based on this systematic review is limited for blind interlaminar epidurals in managing all types of pain except for short-term relief of pain secondary to disc herniation and radiculitis. This evidence does not represent contemporary interventional pain management practices and also the evidence may not be extrapolated to fluoroscopically directed lumbar interlaminar epidural injections.

[1]  L. Manchikanti,et al.  Physician payment 2008 for interventionalists: current state of health care policy. , 2007, Pain physician.

[2]  Crock Hv.  A REAPPRAISAL OF INTERVERTEBRAL DISC LESIONS , 1970 .

[3]  C. Harley.  Extradural corticosteroid infiltration. A follow-up study of 50 cases. , 1967, Annals of physical medicine.

[4]  J. Hawley,et al.  Subarachnoid Pneumocephalus From Epidural Steroid Injection , 2005, Headache.

[5]  R. McAllister,et al.  Recurrent persistent hiccups after epidural steroid injection and analgesia with bupivacaine. , 2005, Anesthesia and analgesia.

[6]  D. Griffin,et al.  Epidural steroid injection for nerve root compression. A randomised, controlled trial. , 2005, The Journal of bone and joint surgery. British volume.

[7]  A. Koning,et al.  The period of pain relief following a successful epidural steroid injection for low-back pain , 2002 .

[8]  C. Maynard,et al.  The relationship between repeated epidural steroid injections and subsequent opioid use and lumbar surgery. , 2008, Archives of physical medicine and rehabilitation.

[9]  D. Duncalf,et al.  Treatment of backache with spinal injections of local anesthetics, spinal and systemic steroids. A review , 1985, Pain.

[10]  S. Datta,et al.  Systematic review of caudal epidural injections in the management of chronic low back pain. , 2009, Pain physician.

[11]  G. Buttermann.  The effect of spinal steroid injections for degenerative disc disease. , 2004, The spine journal : official journal of the North American Spine Society.

[12]  N. Birkmeyer,et al.  Descriptive Epidemiology and Prior Healthcare Utilization of Patients in the Spine Patient Outcomes Research Trial’s (SPORT) Three Observational Cohorts: Disc Herniation, Spinal Stenosis, and Degenerative Spondylolisthesis , 2006, Spine.

[13]  L. Manchikanti,et al.  Failed back surgery: etiology and diagnostic evaluation. , 2004, The spine journal : official journal of the North American Spine Society.

[14]  J. Wilkinson,et al.  Chronic lumbosciatic syndrome treated by epidural injection and manipulation. , 1972, The Practitioner.

[15]  S. Abram,et al.  Factors Associated With Failure of Lumbar Epidural Steroids , 1992, Regional Anesthesia & Pain Medicine.

[16]  L. Manchikanti.  The growth of interventional pain management in the new millennium: a critical analysis of utilization in the medicare population. , 2004, Pain physician.

[17]  J. Bensing,et al.  Prevalence of chronic benign pain disorder among adults: a review of the literature , 1998, Pain.

[18]  R. Jamison,et al.  Low back pain patients unresponsive to an epidural steroid injection: identifying predictive factors. , 1991, The Clinical journal of pain.

[19]  N. Kahanovitz,et al.  A retrospective analysis of the efficacy of epidural steroid injections. , 1988, Clinical orthopaedics and related research.

[20]  A. Matsuki,et al.  Comparative Therapeutic Evaluation of Intrathecal Versus Epidural Methylprednisolone for Long-term Analgesia in Patients With Intractable Postherpetic Neuralgia , 1999, Regional Anesthesia & Pain Medicine.

[21]  Walter F. Stewart,et al.  Back Pain Exacerbations and Lost Productive Time Costs in United States Workers , 2006, Spine.

[22]  J. Katz,et al.  Subdural intracranial air: an unusual cause of headache after epidural steroid injection. , 1991, Anesthesiology.

[23]  C. Nordborg,et al.  Autologous nucleus pulposus induces neurophysiologic and histologic changes in porcine cauda equina nerve roots. , 1993, Spine.

[24]  Misha-Miroslav Backonja,et al.  ASSESSMENT: USE OF EPIDURAL STEROID INJECTIONS TO TREAT RADICULAR LUMBOSACRAL PAIN: REPORT OF THE THERAPEUTICS AND TECHNOLOGY ASSESSMENT SUBCOMMITTEE OF THE AMERICAN ACADEMY OF NEUROLOGY , 2007, Neurology.

[25]  S. Ohtori,et al.  Existence of Nerve Growth Factor Receptors, Tyrosine Kinase A and p75 Neurotrophin Receptors in Intervertebral Discs and on Dorsal Root Ganglion Neurons Innervating Intervertebral Discs in Rats , 2008, Spine.

[26]  L. Manchikanti,et al.  Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 3--Post surgery syndrome. , 2008, Pain physician.

[27]  R. Rothman,et al.  The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study. , 1985, The Journal of bone and joint surgery. American volume.

[28]  S. Datta,et al.  Systematic review of diagnostic utility and therapeutic effectiveness of cervical facet joint interventions. , 2009, Pain physician.

[29]  P. Hannaford,et al.  The course of chronic pain in the community: results of a 4-year follow-up study , 2002, PAIN.

[30]  S. Datta,et al.  Systematic review of diagnostic utility and therapeutic effectiveness of thoracic facet joint interventions. , 2008, Pain physician.

[31]  W. Rothfus,et al.  Incorrect needle position during lumbar epidural steroid administration: inaccuracy of loss of air pressure resistance and requirement of fluoroscopy and epidurography during needle insertion. , 2005, AJNR. American journal of neuroradiology.

[32]  V. Singh,et al.  Systematic Review of the Effectiveness of Cervical Epidurals in the Management of Chronic Neck Pain , 2010 .

[33]  R. Jedeikin,et al.  Epidural steroids for treating "failed back surgery syndrome": is fluoroscopy really necessary? , 1999, Anesthesia and analgesia.

[34]  J. Weinstein,et al.  Behavioral and Histologic Changes in a Model of Radicular Pain After Spinal Nerve Root Irritation with Chromic Gut Ligatures in the Rat , 1994, Spine.

[35]  A. Berg,et al.  Introducing the third U.S. preventive services task force , 2001 .

[36]  D. Schiller,et al.  Epidural steroids for sciatica , 1992 .

[37]  L. Manchikanti.  Role of neuraxial steroids in interventional pain management. , 2002, Pain physician.

[38]  L. Yannuzzi,et al.  Central serous chorioretinopathy after epidural corticosteroid injection. , 2001, American journal of ophthalmology.

[39]  D. Bachman,et al.  Documented arterial gas embolism after spinal epidural injection. , 2001, Annals of emergency medicine.

[40]  P. Guyer,et al.  THE SPREAD OF SOLUTIONS INJECTED INTO THE EPIDURAL SPACE A Study using Epidurograms in Patients with the Lumbosciatic Syndrome , 1973 .

[41]  W. Hooten,et al.  Discitis after lumbar epidural corticosteroid injection: a case report and analysis of the case report literature. , 2006, Pain medicine.

[42]  K. Botwin,et al.  Fluoroscopic guided lumbar interlaminar epidural injections: a prospective evaluation of epidurography contrast patterns and anatomical review of the epidural space. , 2004, Pain physician.

[43]  C. Hirsch.  An Attempt to Diagnose the Level of a Disc Lesion Clinically by Disc Puncture , 1949 .

[44]  L. Manchikanti,et al.  Cervical Medial Branch Blocks for Chronic Cervical Facet Joint Pain: A Randomized, Double-Blind, Controlled Trial With One-Year Follow-up , 2008, Spine.

[45]  L. Klenerman,et al.  Lumbar epidural injections in the treatment of sciatica. , 1984, British journal of rheumatology.

[46]  U. Oner,et al.  Epidural corticosteroid injection and amitriptyline for the treatment of chronic low back pain associated with radiculopathy , 2003 .

[47]  A. Mcgregor,et al.  Does the method of injection alter the outcome of epidural injections? , 2001, Journal of spinal disorders.

[48]  L. Manchikanti,et al.  Effectiveness of caudal epidural injections in discogram positive and negative chronic low back pain. , 2002, Pain physician.

[49]  R. Carlier,et al.  [Subdural abscess. Rare complication of epidural infiltration. Apropos of a case and review of the literature]. , 1993, Journal de radiologie.

[50]  S. Sharma,et al.  EPIDURAL STEROIDS: A RETROSPECTIVE ANALYSIS OF THE EFFICACY OF HIGH AND LOW DOSE THERAPY , 1998 .

[51]  N. Salmón,et al.  Extradural block. Confirmation of the injection site by X‐ray monitoring , 1985, Anaesthesia.

[52]  N McKoy,et al.  Systems to rate the strength of scientific evidence. , 2002, Evidence report/technology assessment.

[53]  F. Colò,et al.  Epidural Local Anesthetic Plus Corticosteroid for the Treatment of Cervical Brachial Radicular Pain: Single Injection Versus Continuous Infusion , 2007, The Clinical journal of pain.

[54]  M. Sekiguchi,et al.  Do Corticosteroids Produce Additional Benefit in Nerve Root Infiltration for Lumbar Disc Herniation? , 2008, Spine.

[55]  L. Manchikanti,et al.  Radiation exposure to the physician in interventional pain management. , 2002, Pain physician.

[56]  Howard S. Smith,et al.  Evidence-based medicine, systematic reviews, and guidelines in interventional pain management: Part 2: Randomized controlled trials. , 2008, Pain physician.

[57]  P. Bromage,et al.  Paraplegia Following Intracord Injection During Attempted Epidural Anesthesia Under General Anesthesia , 1997, Regional Anesthesia & Pain Medicine.

[58]  L. Manchikanti,et al.  Interventional techniques in ambulatory surgical centers: a look at the new payment system. , 2007, Pain physician.

[59]  R. Grahame,et al.  Extradural Corticosteroid Injection in Management of Lumbar Nerve Root Compression , 1973 .

[60]  G. Buttermann.  Treatment of Lumbar Disc Herniation : Epidural Steroid Injection Compared with Discectomy , 2004 .

[61]  L. Manchikanti,et al.  A randomized, prospective, double-blind, placebo-controlled evaluation of the effect of sedation on diagnostic validity of cervical facet joint pain. , 2004, Pain physician.

[62]  L. Manchikanti,et al.  A critical appraisal of 2007 American College of Occupational and Environmental Medicine (ACOEM) Practice Guidelines for Interventional Pain Management: an independent review utilizing AGREE, AMA, IOM, and other criteria. , 2008, Pain physician.

[63]  A. Pasqualucci.  Experimental and clinical studies about the preemptive analgesia with local anesthetics. Possible reasons of the failure. , 1998, Minerva anestesiologica.

[64]  H. V. Crock.  A REAPPRAISAL OF INTERVERTEBRAL DISC LESIONS , 1970, The Medical journal of Australia.

[65]  G. Kingsley,et al.  Outpatient lumbar epidural corticosteroid injection in the management of sciatica. , 1988, British journal of rheumatology.

[66]  Andrea Furlan,et al.  Updated Method Guidelines for Systematic Reviews in the Cochrane Collaboration Back Review Group , 2003, Spine.

[67]  Janna Friedly,et al.  Increases in Lumbosacral Injections in the Medicare Population: 1994 to 2001 , 2007, Spine.

[68]  P. Landrigan,et al.  Occupational injury and illness in the United States. Estimates of costs, morbidity, and mortality. , 1997, Archives of internal medicine.

[69]  J. Ekholm,et al.  Degree of Disc Disruption and Lower Extremity Pain , 1997, Spine.

[70]  M. Landau,et al.  Epidural steroid injection in the treatment of lumbar and cervical pain syndrome : a preliminary retrospective comparison , 1991 .

[71]  C. Bombardier,et al.  Outcome assessments in the evaluation of treatment of spinal disorders: summary and general recommendations. , 2000, Spine.

[72]  R. North,et al.  Cost-effectiveness analysis of spinal cord stimulation in treatment of failed back surgery syndrome. , 1997, Journal of pain and symptom management.

[73]  T. Kitahara,et al.  THE SPREAD OF LIDOCAINE AND I‐131 SOLUTION IN THE EPIDURAL SPACE , 1959, Anesthesiology.

[74]  W. Mixter,et al.  Herniation or Rupture of the Intervertebral Disc into the Spinal Canal , 1935 .

[75]  R A Deyo,et al.  Outcome Measures for Low Back Pain Research: A Proposal for Standardized Use , 1998, Spine.

[76]  L. Manchikanti,et al.  Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 2--Disc herniation and radiculitis. , 2008, Pain physician.

[77]  Orin,et al.  Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. , 1997, The New England journal of medicine.

[78]  G. Buttermann.  Lumbar Disc Herniation Regression After Successful Epidural Steroid Injection , 2002, Journal of spinal disorders & techniques.

[79]  Clifford J. Woolf,et al.  Neuronal Plasticity and Signal Transduction in Nociceptive Neurons: Implications for the Initiation and Maintenance of Pathological Pain , 2001, Neurobiology of Disease.

[80]  L. Manchikanti,et al.  Evaluation of the relative contributions of various structures in chronic low back pain. , 2001, Pain physician.

[81]  W. Pang,et al.  Application of spinal pain mapping in the diagnosis of low back pain--analysis of 104 cases. , 1998, Acta anaesthesiologica Sinica.

[82]  D. Brocai,et al.  Epidural Corticosteroid Injection in the Conservative Management of Sciatica , 2000, Clinical orthopaedics and related research.

[83]  B. Rydevik.  The effects of compression on the physiology of nerve roots. , 1992, Journal of manipulative and physiological therapeutics.

[84]  Salahadin Abdi,et al.  Epidural steroids in the management of chronic spinal pain: a systematic review. , 2007, Pain physician.

[85]  E. Tessitore,et al.  Elevated Levels of Tumor Necrosis Factor-Alpha in Periradicular Fat Tissue in Patients With Radiculopathy From Herniated Disc , 2008, Spine.

[86]  P. Staats,et al.  Review of occupational medicine practice guidelines for interventional pain management and potential implications. , 2008, Pain physician.

[87]  C. Warfield,et al.  Epidural steroid injection as a predictor of surgical outcome. , 1987, Surgery, gynecology & obstetrics.

[88]  F. W. Brown.  Management of diskogenic pain using epidural and intrathecal steroids. , 1977, Clinical orthopaedics and related research.

[89]  Intraspinal Steroids: History, Efficacy, Accidentality, and Controversy With Review of United States Food and Drug Administration Reports , 2001 .

[90]  S. Morley,et al.  Intrathecal midazolam for the treatment of chronic mechanical low back pain: a controlled comparison with epidural steroid in a pilot study , 1992, Pain.

[91]  J. Schofferman,et al.  Etiology of long-term failures of lumbar spine surgery. , 2002, Pain medicine.

[92]  R Melzack,et al.  Central Neuroplasticity and Pathological Pain , 2001, Annals of the New York Academy of Sciences.

[93]  L. Manchikanti,et al.  Reassessment of evidence synthesis of occupational medicine practice guidelines for interventional pain management. , 2008, Pain physician.

[94]  L. Lenke,et al.  Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year follow-up. , 2006, The Journal of bone and joint surgery. American volume.

[95]  M. Schaufele,et al.  Interlaminar versus transforaminal epidural injections for the treatment of symptomatic lumbar intervertebral disc herniations. , 2006, Pain physician.

[96]  G. Waddell,et al.  Failed lumbar disc surgery and repeat surgery following industrial injuries. , 1979, The Journal of bone and joint surgery. American volume.

[97]  P. Lavoie,et al.  Mechanisms of the inhibition of fast axonal transport by local anesthetics , 1989, Neuropharmacology.

[98]  J C Fairbank,et al.  The Oswestry low back pain disability questionnaire. , 1980, Physiotherapy.

[99]  A. Bilir,et al.  Cauda equina syndrome after epidural steroid injection: a case report. , 2006, Journal of manipulative and physiological therapeutics.

[100]  J. Pizzimenti,et al.  Central Serous Chorioretinopathy After Epidural Steroid Injection , 2005, Pharmacotherapy.

[101]  K. Olmarker,et al.  Importance of Compression Onset Rate for the Degree of Impairment of Impulse Propagation in Experimental Compression Injury of the Porcine Cauda Equina , 1990, Spine.

[102]  W. Young.  Transient Blindness After Lumbar Epidural Steroid Injection: A Case Report and Literature Review , 2002, Spine.

[103]  L. Manchikanti,et al.  Effectiveness of thoracic medial branch blocks in managing chronic pain: a preliminary report of a randomized, double-blind controlled trial. , 2008, Pain physician.

[104]  P. Maurette,et al.  Long-term results of cervical epidural steroid injection with and without morphine in chronic cervical radicular pain , 1994, Pain.

[105]  M. Kaadan,et al.  Cervical epidural steroid injection for cervicobrachialgia , 1993, Acta anaesthesiologica Scandinavica.

[106]  C. Everett,et al.  Flushing as a side effect following lumbar transforaminal epidural steroid injection. , 2004, Pain physician.

[107]  L. Manchikanti,et al.  Risk of whole body radiation exposure and protective measures in fluoroscopically guided interventional techniques: a prospective evaluation , 2003, BMC anesthesiology.

[108]  R. Derby,et al.  Systematic review of lumbar provocation discography in asymptomatic subjects with a meta-analysis of false-positive rates. , 2008, Pain physician.

[109]  W. Hooten,et al.  Epidural abscess and meningitis after epidural corticosteroid injection. , 2004, Mayo Clinic proceedings.

[110]  P. Rochon,et al.  The prevalence of low back pain in the elderly. A systematic review of the literature. , 1999, Spine.

[111]  L. Manchikanti,et al.  Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 4--Spinal stenosis. , 2008, Pain physician.

[112]  H. Weber,et al.  Double blind evaluation of extradural methyl prednisolone for herniated lumbar discs. , 1977, Acta orthopaedica Scandinavica.

[113]  J. S. Barr,et al.  Rupture of the Intervertebral Disc with Involvement of the Spinal Canal , 1934 .

[114]  U. Lindblom,et al.  Prolonged relief of neuralgia after regional anesthetic blocks. A call for further experimental and systematic clinical studies , 1990, Pain.

[115]  S. Ohtori,et al.  Direct Application of the TNF-Alpha Inhibitor, Etanercept, Does Not Affect CGRP Expression and Phenotypic Change of DRG Neurons Following Application of Nucleus Pulposus Onto Injured Sciatic Nerves in Rats , 2008, Spine.

[116]  L. Manchikanti,et al.  Systematic review of the effectiveness of thermal annular procedures in treating discogenic low back pain. , 2009, Pain physician.

[117]  K. Olmarker,et al.  Edema Formation in Spinal Nerve Roots Induced by Experimental, Graded Compression: An Experimental Study on the Pig Cauda Equina with Special Reference to Differences in Effects between Rapid and Slow Onset of Compression , 1989, Spine.

[118]  S D Kuslich,et al.  The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. , 1991, The Orthopedic clinics of North America.

[119]  H. Benzon.  Epidural steroid injections for low back pain and lumbosacral radiculopathy , 1986, Pain.

[120]  R. Lipton,et al.  Conditions in the US Workforce Lost Productive Time and Cost Due to Common Pain , 2003 .

[121]  L. Manchikanti,et al.  Evaluation of therapeutic thoracic medial branch block effectiveness in chronic thoracic pain: a prospective outcome study with minimum 1-year follow up. , 2006, Pain physician.

[122]  S. Brill,et al.  Epidural steroid injections do not induce weight gain. , 2007, Current Drug Safety.

[123]  R. Grahame,et al.  Extradural corticosteroid injection in management of lumbar nerve root compression. , 1974, British medical journal.

[124]  A. Stout.  Epidural steroid injections for low back pain. , 2010, Physical medicine and rehabilitation clinics of North America.

[125]  E. Vresilovic,et al.  Etiologies of failed back surgery syndrome. , 2002, Pain medicine.

[126]  C. Reale,et al.  Epidural steroids as a pharmacological approach. , 2000, Clinical and experimental rheumatology.

[127]  D. Brodke,et al.  Epidural Injections for the Treatment of Symptomatic Lumbar Herniated Discs , 2002, Journal of spinal disorders & techniques.

[128]  R. Deyo,et al.  An International Comparison of Back Surgery Rates , 1994, Spine.

[129]  R A Deyo,et al.  Lumbar spinal fusion. A cohort study of complications, reoperations, and resource use in the Medicare population. , 1993, Spine.

[130]  S. Ohtori,et al.  Tumor Necrosis Factor-Alpha in the Nucleus Pulposus Mediates Radicular Pain, but Not Increase of Inflammatory Peptide, Associated With Nerve Damage in Mice , 2008, Spine.

[131]  W. A. Katz,et al.  Section 3: The Nature of Pain: Pathophysiology , 2005, Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases.

[132]  M. Bisby.  Inhibition of axonal transport in nerves chronically treated with local anesthetics , 1975, Experimental Neurology.

[133]  H. Ursin,et al.  Chapter 4 European guidelines for the management of chronic nonspecific low back pain , 2006, European Spine Journal.

[134]  R. Grahame,et al.  Outcome Assessment After Epidural Corticosteroid Injection for Low Back Pain and Sciatica , 1993, Spine.

[135]  C. Cooper,et al.  A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study. , 2005, Rheumatology.

[136]  Salahadin Abdi,et al.  Fluoroscopy radiation safety for spine interventional pain procedures in university teaching hospitals. , 2005, Pain physician.

[137]  R. Ito.  The treatment of low back pain and sciatica with epidural corticosteroids injection and its pathophysiological basis. , 1971, Nihon Seikeigeka Gakkai zasshi.

[138]  L. Manchikanti,et al.  Effectiveness of protective measures in reducing risk of radiation exposure in interventional pain management: a prospective evaluation. , 2003, Pain physician.

[139]  R. Derby,et al.  Epidural Injections for the Diagnosis and Treatment of Low-Back Pain , 1980, Spine.

[140]  Laxmaiah Manchikanti,et al.  Evidence-based medicine, systematic reviews, and guidelines in interventional pain management, part I: introduction and general considerations. , 2008, Pain physician.

[141]  K. Olmarker,et al.  Effects of experimental graded compression on blood flow in spinal nerve roots. A vital microscopic study on the porcine cauda equina , 1989, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[142]  O. Gureje,et al.  Persistent Pain and Well Being: a World Health Organization Study in Primary Care , 1999 .

[143]  J. de Andrés,et al.  Epidural and subarachnoidal pneumocephalus after epidural technique. , 1999, European journal of anaesthesiology.

[144]  Howard S. Smith,et al.  Evidence-based medicine, systematic reviews, and guidelines in interventional pain management: part 4: observational studies. , 2009, Pain physician.

[145]  P. H. Kendall,et al.  Corticosteroid infiltration of the extradural space. , 1962, Annals of physical medicine.

[146]  C. Mosdal,et al.  Epidural application of cortico-steroids in low-back pain and sciatica , 2005, Acta Neurochirurgica.

[147]  R. Myers,et al.  Exogenous Tumor Necrosis Factor-Alpha Mimics Nucleus Pulposus-Induced Neuropathology: Molecular, Histologic, and Behavioral Comparisons in Rats , 2000, Spine.

[148]  N. Bogduk,et al.  The Prevalence and Clinical Features of Internal Disc Disruption in Patients With Chronic Low Back Pain , 1995, Spine.

[149]  Howard S. Smith,et al.  Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. , 2007, Pain physician.

[150]  L. Manchikanti,et al.  Caudal epidural injections with sarapin or steroids in chronic low back pain. , 2001, Pain physician.

[151]  P. Guyer,et al.  The spread of solutions injected into the epidural space. A study using epidurograms in patients with the lumbosciatic syndrome. , 1974, British Journal of Anaesthesia.

[152]  Ricardo Pietrobon,et al.  Estimates and Patterns of Direct Health Care Expenditures Among Individuals With Back Pain in the United States , 2004, Spine.

[153]  J. Cassuto,et al.  Anti‐inflammatory properties of local anesthetics and their present and potential clinical implications , 2006, Acta anaesthesiologica Scandinavica.

[154]  K. Olmarker,et al.  Selective Inhibition of Tumor Necrosis Factor-&agr; Prevents Nucleus Pulposus-Induced Thrombus Formation, Intraneural Edema, and Reduction of Nerve Conduction Velocity: Possible Implications for Future Pharmacologic Treatment Strategies of Sciatica , 2001, Spine.

[155]  A. Schnitzler,et al.  Enlargement of a chronic aseptic lumbar epidural abscess by intraspinal injections--a rare cause of progressive paraparesis. , 2000, Zentralblatt fur Neurochirurgie.

[156]  N. Arden,et al.  Cost-effectiveness and safety of epidural steroids in the management of sciatica. , 2005, Health technology assessment.

[157]  P. Côté,et al.  The Saskatchewan Health and Back Pain Survey: The Prevalence of Low Back Pain and Related Disability in Saskatchewan Adults , 1998, Spine.

[158]  J. Ludwig,et al.  Lumbar epidural perineural injection: a new technique , 2005, European Spine Journal.

[159]  L. Bouter,et al.  Efficacy of epidural steroid injections for low-back pain and sciatica: a systematic review of randomized clinical trials , 1995, Pain.

[160]  P. Pynsent,et al.  The Oswestry Disability Index. , 2000, Spine.

[161]  C. Nordborg,et al.  Ultrastructural Changes in Spinal Nerve Roots Induced by Autologous Nucleus Pulposus , 1996, Spine.

[162]  L. Manchikanti,et al.  Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain: preliminary report of a randomized, double-blind controlled trial: clinical trial NCT00355914. , 2007, Pain physician.

[163]  P. Hudkins,et al.  The Inflammatory Effect of Nucleus Pulposus: A Possible Element in the Pathogenesis of Low-back Pain , 1987, Spine.

[164]  A. T. Berman,et al.  The Effects of Epidural Injection of Local Anesthetics and Corticosteroids on Patients with Lumbosciatic Pain , 1984, Clinical orthopaedics and related research.

[165]  S Rupp,et al.  The Failed Back Surgery Syndrome: Reasons, Intraoperative Findings, and Long‐term Results: A Report of 182 Operative Treatments , 1996, Spine.

[166]  Hickey Rf.  Outpatient epidural steroid injections for low back pain and lumbosacral radiculopathy. , 1987 .

[167]  B. Giraudeau,et al.  Epidural corticosteroid injections for sciatica: a randomised, double blind, controlled clinical trial , 2003, Annals of the rheumatic diseases.

[168]  S. Brull,et al.  A comparison of chronic pain behavior following local application of tumor necrosis factor α to the normal and mechanically compressed lumbar ganglia in the rat , 2002, Pain.

[169]  L. Manchikanti,et al.  Lumbar facet joint nerve blocks in managing chronic facet joint pain: one-year follow-up of a randomized, double-blind controlled trial: Clinical Trial NCT00355914. , 2008, Pain physician.

[170]  K. Olmarker,et al.  Experimental Nerve Root Compression: A Model of Acute, Graded Compression of the Porcine Cauda Equina and an Analysis of Neural and Vascular Anatomy , 1991, Spine.

[171]  Spinal manipulation, epidural injections, and self-care for sciatica: a pilot study for a randomized clinical trial. , 2004, Journal of manipulative and physiological therapeutics.

[172]  The use of epidural steroids in the treatment of lumbar radicular pain. , 1986, The Journal of bone and joint surgery. American volume.

[173]  S. Glassman,et al.  Correlation of Spinal Canal Dimensions to Efficacy of Epidural Steroid Injection in Spinal Stenosis , 2007, Journal of spinal disorders & techniques.

[174]  J. Katz,et al.  Effects of epidural steroid injection on pain due to lumbar spinal stenosis or herniated disks: a prospective study. , 1998, Arthritis care and research : the official journal of the Arthritis Health Professions Association.

[175]  C. Helmick,et al.  Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. , 1998, Arthritis and rheumatism.

[176]  H. D. de Vet,et al.  Injection therapy for subacute and chronic low-back pain. , 2008, The Cochrane database of systematic reviews.

[177]  Walter Grassi,et al.  Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale , 2004, European journal of pain.

[178]  G. Guyatt,et al.  Grading strength of recommendations and quality of evidence in clinical guidelines: report from an american college of chest physicians task force. , 2006, Chest.

[179]  N Bogduk,et al.  The pathophysiology of disc degeneration: a critical review. , 2008, The Journal of bone and joint surgery. British volume.

[180]  G. Heyse-Moore.  A rational approach to the use of epidural medication in the treatment of sciatic pain. , 1978, Acta orthopaedica Scandinavica.

[181]  R. Deyo,et al.  United States Trends in Lumbar Fusion Surgery for Degenerative Conditions , 2005, Spine.

[182]  D. Browning.  Acute retinal necrosis following epidural steroid injections. , 2003, American journal of ophthalmology.

[183]  A. Wheeler,et al.  Chronic lumbar spine and radicular pain: Pathophysiology and treatment , 2002, Current pain and headache reports.

[184]  L. Manchikanti,et al.  The effect of neuraxial steroids on weight and bone mass density: a prospective evaluation. , 2000, Pain physician.

[185]  J. Rosenberg,et al.  Fluoroscopic analysis of lumbar epidural contrast spread after lumbar interlaminar injection. , 2008, Archives of physical medicine and rehabilitation.

[186]  Howard S. Smith,et al.  Systematic review of therapeutic lumbar transforaminal epidural steroid injections. , 2009, Pain physician.

[187]  M. Kurosaka,et al.  The Role of Cyclooxygenase-2 in Lumbar Disc Herniation , 2002, Spine.

[188]  M. Fukusaki,et al.  Symptoms of spinal stenosis do not improve after epidural steroid injection. , 1998, The Clinical journal of pain.

[189]  Howard S. Smith,et al.  Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 1--Discogenic pain without disc herniation or radiculitis. , 2008, Pain physician.

[190]  S. Esses,et al.  Spinal epidural lipomatosis: case reports, literature review and meta-analysis. , 2005, The spine journal : official journal of the North American Spine Society.

[191]  C. Argoff,et al.  Assessment: Use of epidural steroid injections to treat radicular lumbosacral pain , 2007, Neurology.