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Clinical and imaging characteristics of patients with extreme low back pain or sciatica referred for spinal injection

Neuroradiology volume 61, pages 881–889 (2019)Cite this article

Abstract

Purpose

To analyze the causes of pain, imaging characteristics, and therapeutic effect of spinal injection in patients with extreme low back pain or sciatica.

Methods

We analyzed 381 consecutive patients with extreme low back pain or sciatica visiting our spinal intervention center between January and December 2017. Clinical and imaging characteristics were analyzed. The treatment response, defined as a numerical pain rating scale decrease of ≥ 30%, was measured. Fisher’s exact test was performed to identify the association between the injection response and subsequent lumbar surgery rate.

Results

The most frequent cause of pain was spinal stenosis, followed by herniated intervertebral disc, facet osteoarthritis, and osteoporotic compression fracture. A herniated intervertebral disc was the most common disorder in patients < 50 years of age, while spinal stenosis was the most common in patients ≥ 50 years of age. Women comprised 66.4% of the study population. The majority of lumbar pathologies occurred below L3/4. Spinal injection was found to be effective in 44.2% of cases. Those who responded to the injection showed a significantly lower rate of lumbar surgery within 6 months (P = 0.004).

Conclusions

Those with extreme low back pain or sciatica had clinical and imaging characteristics similar to those with typical low back pain referred for spinal injection. Spinal injection could be an effective method of pain control for patients with extreme low back pain or sciatica.

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References

  1. Gureje O, Von Korff M, Simon GE, Gater R (1998) Persistent pain and well-being: a World Health Organization study in primary care. JAMA 280(2):147–151

    Article  CAS  Google Scholar 

  2. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ, Underwood M, Buchbinder R, Hartvigsen J, Cherkin D, Foster NE, Maher CG, Underwood M, van Tulder M, Anema JR, Chou R, Cohen SP, Menezes Costa L, Croft P, Ferreira M, Ferreira PH, Fritz JM, Genevay S, Gross DP, Hancock MJ, Hoy D, Karppinen J, Koes BW, Kongsted A, Louw Q, Öberg B, Peul WC, Pransky G, Schoene M, Sieper J, Smeets RJ, Turner JA, Woolf A (2018) What low back pain is and why we need to pay attention. Lancet 391(10137):2356–2367

    Article  Google Scholar 

  3. Manchikanti L, Singh V, Datta S, Cohen SP, Hirsch JA (2009) Comprehensive review of epidemiology, scope, and impact of spinal pain. Pain Physician 12(4):E35–E70

    PubMed  Google Scholar 

  4. Verhagen AP, Downie A, Popal N, Maher C, Koes BW (2016) Red flags presented in current low back pain guidelines: a review. Eur Spine J 25(9):2788–2802

    Article  Google Scholar 

  5. Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA, Maher CG, Buchbinder R, Hartvigsen J, Cherkin D, Foster NE, Maher CG, Underwood M, van Tulder M, Anema JR, Chou R, Cohen SP, Menezes Costa L, Croft P, Ferreira M, Ferreira PH, Fritz JM, Genevay S, Gross DP, Hancock MJ, Hoy D, Karppinen J, Koes BW, Kongsted A, Louw Q, Öberg B, Peul WC, Pransky G, Schoene M, Sieper J, Smeets RJ, Turner JA, Woolf A (2018) Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 391(10137):2368–2383

    Article  Google Scholar 

  6. Qaseem A, Wilt TJ, McLean RM, Forciea MA (2017) Clinical Guidelines Committee of the American College of Physicians (2017) Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med 166(7):514–530

    Article  Google Scholar 

  7. National Institute for Health and Care Excellence (2016) Low back pain and sciatica in over 16s: assessment and management. National Institute for Health and Care Excellence: Clinical Guidelines, London

    Google Scholar 

  8. Oliveira CB, Maher CG, Pinto RZ, Traeger AC, Lin CWC, Chenot JF, van Tulder M, Koes BW (2018) Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J 27(11):2791–2803

    Article  Google Scholar 

  9. Manchikanti L, Abdi S, Atluri S et al (2013) An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician 16(2):S49–S283

    PubMed  Google Scholar 

  10. Kreiner DS, Shaffer WO, Baisden JL, Gilbert TJ, Summers JT, Toton JF, Hwang SW, Mendel RC, Reitman CA, North American Spine Society (2013) An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J 13(7):734–743

    Article  Google Scholar 

  11. Kreiner DS, Hwang SW, Easa JE, Resnick DK, Baisden JL, Bess S, Cho CH, DePalma M, Dougherty P 2nd, Fernand R, Ghiselli G, Hanna AS, Lamer T, Lisi AJ, Mazanec DJ, Meagher RJ, Nucci RC, Patel RD, Sembrano JN, Sharma AK, Summers JT, Taleghani CK, Tontz WL Jr, Toton JF, North American Spine Society (2014) An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J 14(1):180–191

    Article  Google Scholar 

  12. MacVicar J, King W, Landers MH, Bogduk N (2013) The effectiveness of lumbar transforaminal injection of steroids: a comprehensive review with systematic analysis of the published data. Pain Med 14(1):14–28

    Article  Google Scholar 

  13. Sharma AK, Vorobeychik Y, Wasserman R, Jameson J, Moradian M, Duszynski B, Kennedy DJ, Standards Division of the Spine Intervention Society (2017) The effectiveness and risks of fluoroscopically guided lumbar interlaminar epidural steroid injections: a systematic review with comprehensive analysis of the published data. Pain Med 18(2):239–251

    PubMed  Google Scholar 

  14. Wilson DJ, Owen S, Corkill RA (2011) Facet joint injections as a means of reducing the need for vertebroplasty in insufficiency fractures of the spine. Eur Radiol 21(8):1772–1778

    Article  Google Scholar 

  15. Bogduk N, MacVicar J, Borowczyk J (2010) The pain of vertebral compression fractures can arise in the posterior elements. Pain Med 11(11):1666–1673

    Article  Google Scholar 

  16. Hawker GA, Mian S, Kendzerska T, French M (2011) Measures of adult pain: Visual Analog Scale for pain (VAS Pain), Numeric Rating Scale for pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken) 63(Suppl 11):S240–S252

    Article  Google Scholar 

  17. Shim E, Lee JW, Lee E, Ahn JM, Kang Y, Kang HS (2017) Fluoroscopically guided epidural injections of the cervical and lumbar spine. Radiographics 37(2):537–561

    Article  Google Scholar 

  18. Patel IJ, Davidson JC, Nikolic B, Salazar GM, Schwartzberg MS, Walker TG, Saad WE, Standards of Practice Committee, with Cardiovascular and Interventional Radiological Society of Europe (CIRSE) Endorsement, Standards of Practice Committee of the Society of Interventional Radiology (2013) Addendum of newer anticoagulants to the SIR consensus guideline. J Vasc Interv Radiol 24(5):641–645

    Article  Google Scholar 

  19. Lee JW, Myung JS, Park KW, Yeom JS, Kim KJ, Kim HJ, Kang HS (2010) Fluoroscopically guided caudal epidural steroid injection for management of degenerative lumbar spinal stenosis: short-term and long-term results. Skelet Radiol 39(7):691–699

    Article  Google Scholar 

  20. Hwang SY, Lee JW, Lee GY, Kang HS (2013) Lumbar facet joint injection: feasibility as an alternative method in high-risk patients. Eur Radiol 23(11):3153–3160

    Article  Google Scholar 

  21. Manchikanti L, Singh V, Cash KA, Pampati V, Datta S (2012) Fluoroscopic caudal epidural injections in managing post lumbar surgery syndrome: two-year results of a randomized, double-blind, active-control trial. Int J Med Sci 9(7):582–591

    Article  CAS  Google Scholar 

  22. Fardon DF, Williams AL, Dohring EJ, Murtagh FR, Gabriel Rothman SL, Sze GK (2014) Lumbar disc nomenclature: version 2.0: recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. Spine J 14(11):2525–2545

    Article  Google Scholar 

  23. Lee GY, Lee JW, Choi HS, Oh KJ, Kang HS (2011) A new grading system of lumbar central canal stenosis on MRI: an easy and reliable method. Skelet Radiol 40(8):1033–1039

    Article  Google Scholar 

  24. Lee S, Lee JW, Yeom JS, Kim KJ, Kim HJ, Chung SK, Kang HS (2010) A practical MRI grading system for lumbar foraminal stenosis. AJR Am J Roentgenol 194(4):1095–1098

    Article  Google Scholar 

  25. Lakadamyali H, Tarhan NC, Ergun T, Cakir B, Agildere AM (2008) STIR sequence for depiction of degenerative changes in posterior stabilizing elements in patients with lower back pain. AJR Am J Roentgenol 191(4):973–979

    Article  Google Scholar 

  26. Park P, Garton HJ, Gala VC, Hoff JT, McGillicuddy JE (2004) Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Spine (Phila Pa 1976) 29(17):1938–1944

    Article  Google Scholar 

  27. Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole RM (2001) Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 94(2):149–158

    Article  CAS  Google Scholar 

  28. Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, Woolf A, Vos T, Buchbinder R (2012) A systematic review of the global prevalence of low back pain. Arthritis Rheum 64(6):2028–2037

    Article  Google Scholar 

  29. Deyo RA, Rainville J, Kent DL (1992) What can the history and physical examination tell us about low back pain. JAMA 268(6):760–765

    Article  CAS  Google Scholar 

  30. Heliövaara M (1988) Epidemiology of sciatica and herniated lumbar intervertebral disc. Publications of the Social Insurance Institution, Helsinki

  31. Spangfort EV (1972) The lumbar disc herniation. A computer-aided analysis of 2,504 operations. Acta Orthop Scand Suppl 142:1–95

    Article  CAS  Google Scholar 

  32. Kalichman L, Li L, Kim DH, Guermazi A, Berkin V, OʼDonnell CJ, Hoffmann U, Cole R, Hunter DJ (2008) Facet joint osteoarthritis and low back pain in the community-based population. Spine (Phila Pa 1976) 33(23):2560–2565

    Article  Google Scholar 

  33. Postacchini F, Cinotti G (1999) Etiopathogenesis. In: Postacchini F (ed) Lumbar disc herniation. Spring-Verlag, New York, pp 151–164

    Chapter  Google Scholar 

  34. van Tulder M, Becker A, Bekkering T et al (2006) Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 15(Suppl 2):S169–S191

    Article  Google Scholar 

  35. Iguchi T, Wakami T, Kurihara A, Kasahara K, Yoshiya S, Nishida K (2002) Lumbar multilevel degenerative spondylolisthesis: radiological evaluation and factors related to anterolisthesis and retrolisthesis. J Spinal Disord Tech 15(2):93–99

    Article  Google Scholar 

  36. Standaert CJ, Herring SA (2000) Spondylolysis: a critical review. Br J Sports Med 34(6):415–422

    Article  CAS  Google Scholar 

  37. Soler T, Calderon C (2000) The prevalence of spondylolysis in the Spanish elite athlete. Am J Sports Med 28(1):57–62

    Article  CAS  Google Scholar 

  38. Friberg S, Hirsch C (1949) Anatomical and clinical studies on lumbar disc degeneration. Acta Orthop Scand 19(2):222–242 illust

    Article  CAS  Google Scholar 

  39. Schultz A, Andersson G, Ortengren R, Haderspeck K, Nachemson A (1982) Loads on the lumbar spine. Validation of a biomechanical analysis by measurements of intradiscal pressures and myoelectric signals. J Bone Joint Surg Am 64(5):713–720

    Article  CAS  Google Scholar 

  40. Lee JW, Choi SW, Park SH, Lee GY, Kang HS (2013) MR-based outcome predictors of lumbar transforaminal epidural steroid injection for lumbar radiculopathy caused by herniated intervertebral disc. Eur Radiol 23(1):205–211

    Article  Google Scholar 

  41. El-Yahchouchi C, Wald J, Brault J et al (2014) Lumbar transforaminal epidural steroid injections: does immediate post-procedure pain response predict longer term effectiveness? Pain Med 15(6):921–928

    Article  Google Scholar 

  42. Lee JW, Lee E, Lee GY, Kang Y, Ahn JM, Kang HS (2018) Epidural steroid injection-related events requiring hospitalisation or emergency room visits among 52,935 procedures performed at a single centre. Eur Radiol 28(1):418–427

    Article  CAS  Google Scholar 

  43. Doan L, Patel H, Aronova Y, Gharibo C (2018) Variations in interlaminar epidural steroid injection practice patterns by interventional pain management physicians in the United States. Pain Physician 21(5):E493–E499

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Radiology, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea

    Youngjune Kim, Eugene Lee, Joon Woo Lee, Yusuhn Kang, Joong Mo Ahn & Heung Sik Kang

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  1. Youngjune Kim
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Correspondence to Eugene Lee.

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Kim, Y., Lee, E., Lee, J.W. et al. Clinical and imaging characteristics of patients with extreme low back pain or sciatica referred for spinal injection. Neuroradiology 61, 881–889 (2019). https://doi.org/10.1007/s00234-019-02222-z

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  • DOI: https://doi.org/10.1007/s00234-019-02222-z

Keywords

  • Spinal injection
  • Extreme low back pain
  • Clinical characteristics
  • Treatment outcome