Scientific and Technological Research
Efficacy of epidural methylprednisolone in radicular pain
Eficacia de la metilprednisolona epidural en el dolor radicular
Adelaida Álvarez Correaa,
, Roberto Carlo Rivera Díazb, Mario Andrés Arcila Loteroc
Corresponding author
a Anaesthesia Resident, Universidad Pontificia Bolivariana, Medellín, Colombia
b Anesthesiologist, Subspecialist in Pain, Professor of Anaesthesia and Pain, Universidad CES, Instituto Colombiano del Dolor, Medellín, Colombia
c Anesthesiologist, Magister in Epidemiology, Professor of Anaesthesia, Universidad CES, Instituto Colombiano del Dolor, Medellín, Colombia
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"figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1002 "Ancho" => 1622 "Tamanyo" => 77673 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Procedures performed in patients with radicular pain.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic pain is one of the main reasons for visits to the emergency services as well as for general and specialized medical consultations. It has a significant impact on quality of life, leading to multiple instances of absence from work, and has a high impact on healthcare costs.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–5</span></a></p><p id="par0325" class="elsevierStylePara elsevierViewall">Spinal pain is one of the most common forms of chronic pain.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Between 70% and 80% of the population will suffer from lumbar pain during their lifetime. It is estimated that prevalence ranges between 12% and 15%, although it may be as high as 28–40%, depending on the different studies.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–11</span></a> National statistics for the United States show that chronic lumbar pain is the most frequent cause of functional limitation in people over 45 years of age, the second cause of visits to medical doctors, fifth cause of admission and third reason for surgery.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,12,13</span></a> Cervical and dorsal pain has also increased as a result of longer life expectancy.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aetiology of cervical, dorsal and lumbar pain is quite broad, including muscle disorders, disc disease,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> bone diseases, primary or metastatic vertebral tumours,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a> spinal cord, cone or cauda equina tumours, intra-abdominal or retroperitoneal tumours, vertebral fractures or dislocations, ankylosing spondylitis, lumbar arthrosis, vertebral-epidural infections or abscesses, diabetic neuropathy, congenital abnormalities, among others.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18–21</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Vertebral and disc disease may produce mechanical nerve-root compression, while the local inflammatory effects of cytokines lead to reduced blood flow, intravascular coagulation and reduced nerve conduction velocity, affecting spinal nerve transmission and creating pain with a dermatome pattern called radicular pain.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,22,23</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Discussed in the literature since 1950,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> following the initial experiences by Jean Enthuse Sicard and Fernand Cathelin, epidural steroid injections are the cornerstone in the treatment of axial as well as radicular chronic pain.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Steroids are a therapeutic option when conservative treatment has failed, pain relief being the result of reduced oedema and improved microcirculation.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24,25</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Because of their inhibitory effect on different cytokines, steroids have a potent anti-inflammatory effect and also variable results in terms of membrane stabilization, hyperpolarization of spinal neurons and c-fibre transmission inhibition. Epidural steroids are preferred over oral and intravenous steroids because they act on more specific targets.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The epidural space may be accessed through the caudal, interlaminar and transforaminal approaches. It is recommended, within the basic care standards, that all procedures be guided by fluoroscopy in order to increase safety and the probability of success.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">For this reason, a study addressing the question “Is epidural methylprednisolone effective and safe in radicular pain?” is described below.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Objectives</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">General objective</span><p id="par0050" class="elsevierStylePara elsevierViewall">To assess the efficacy and safety of epidural methylprednisolone in patients with radicular pain.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Specific objectives</span><p id="par0055" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">To describe the social and demographic characteristics of the patients included in the study.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">To describe the main diagnoses that led to the performance of analgesic procedures.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">To describe the main analgesic procedures performed.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">To evaluate the proportion of patients who responded to the analgesic procedure.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall">The evaluate percentage pain improvement after the analgesic procedure.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">To evaluate the proportion of patients who responded to the analgesic procedure by type of epidural analgesia utilized.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall">To evaluate the duration of the analgesic effect after the procedure.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">To evaluate the adverse effects associated with the analgesic procedure.</p></li></ul></p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Materials and methods</span><p id="par0100" class="elsevierStylePara elsevierViewall">Longitudinal retrospective descriptive study undertaken after obtaining the approval from the ethics committee of the Instituto Colombiano del Dolor (Medellín-Colombia) once it was also endorsed and approved by the ethics committee of Universidad Pontificia Bolivariana, considering that the study was classified as a no-risk research pursuant to Ministry of Health Resolution 8430 of 1993. The study was conducted in patients with chronic radicular pain who underwent interventional treatment under fluoroscopic guidance at Instituto Colombiano del Dolor (Medellín-Colombia) between July 2010 and December 2011. The analysis included the clinical records of 441 patients undergoing interventional analgesic procedures with some form of epidural approach and a follow-up period of no less than 8 weeks.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The following were the inclusion criteria: (1) radicular pain, (2) age 18 years and over, (3) use of fluoroscopy to guide the blockade.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The following were the exclusion criteria: (1) multiple procedures, (2) labour lawsuit, (3) prior spinal surgery, (4) diagnosis of fibromyalgia, (5) diagnosis of complex regional pain syndrome, (6) non-radicular pain, (7) age under 18, (8) follow-up during at least 8 weeks.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Steroid infiltration into the epidural space was done using one of the following approaches: interlaminar, caudal or transforaminal.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The technique used for performing epidural analgesia under fluoroscopic guidance in the patients included in this report was conducted in accordance with the protocols of the Instituto Colombiano del Dolor (Medellín-Colombia). The interlaminar technique with a Touhy 17 gauge needle was used for the epidural approaches, using loss of resistance to air or saline solution as confirmation, and verification of adequate placement with the help of contrast medium. Volumes of 10<span class="elsevierStyleHsp" style=""></span>mL were used. The local anaesthetic used was 0.5% bupivacaine without epinephrine (10<span class="elsevierStyleHsp" style=""></span>mg) and the particulate steroid was methylprednisolone acetate (80<span class="elsevierStyleHsp" style=""></span>mg). The same doses were used for the caudal approach.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Transforaminal blocks were performed through a subpedicular approach using a 22-gauge spinal needle and contrast medium for confirmation. The doses used at the institution are 40<span class="elsevierStyleHsp" style=""></span>mg of the same steroid plus 10<span class="elsevierStyleHsp" style=""></span>mg of bupivacaine (3<span class="elsevierStyleHsp" style=""></span>mL total volume). All patients were placed in prone recumbent position.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The magnitude of pain was assessed using the visual analogue scale (VAS) (with scores ranging from 0 to 10: 0, absence of pain; 1–4, mild pain; 5–7, moderate pain; and 8–10, severe pain) at 3, 4, 6 and 8 weeks.<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">Age: Years at the time of performing the procedure.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Gender: patient gender.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">Diagnosis: Diagnoses of patients with radicular pain were grouped according to the affected limb, as follows: right upper limb, left upper limb or both upper limbs; and right lower limb, left lower limb or both lower limbs.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall">Procedure performed: Type of epidural analgesia, including interlaminar cervical, thoracic or lumbar; transforaminal cervical, thoracic or lumbar; and caudal.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Improvement of pain after the procedure: Reduction of the pain score on the VAS after the procedure, classified as less than 20% improvement, 20–50% improvement, and more than 50% improvement.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">Response to the analgesic procedure: Significant relief was defined as a 50% reduction on the VAS when compared to the level of pain before the procedure.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Duration of the analgesic effect after the procedure: Time in weeks during which the patient continues to experience pain relief after the procedure.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">Complications: The complications described include post-puncture headache – requiring or not a blood patch – bleeding, nervous, infectious and metabolic complications.</p></li></ul></p><p id="par0175" class="elsevierStylePara elsevierViewall">Data were obtained from secondary sources on the basis of the notes written in the clinical records. Records of patients with a follow-up of at least 8 weeks were considered.</p><p id="par0180" class="elsevierStylePara elsevierViewall">The information was stored in a Microsoft Excel<span class="elsevierStyleSup">®</span> database, and the statistical analysis was performed using the SPSS 18 package. A descriptive analysis of all the variables of the study was done on the basis of calculated proportions, central trend and scatter measurements. An association was also established between some qualitative variables using Pearson's Chi-square test. Statistical significance was set at less than 5%, with 95% confidence intervals.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0185" class="elsevierStylePara elsevierViewall">Overall, 441 fluoroscopy-guided interventional analgesic procedures were performed at the Instituto Colombiano del Dolor (Medellín-Colombia) between July 2010 and December 2011. Of the patients, 68 were excluded because they had been undergone multiple procedures (facet block having been the most frequent), 14 due to lawsuits, 37 because of prior spinal surgery, 30 because of non-radicular pain and one individual under 18 years of age. Overall, 254 patients were analyzed.</p><p id="par0190" class="elsevierStylePara elsevierViewall">The mean age was 52.8 years (SD<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15), and 52.8% of the patients were males. The main diagnosis was lower limb radicular pain (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">The main procedures were transforaminal lumbar injection (54.3%) and interlaminar lumbar injection (17.7%) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">The proportion of patients with more than 50% pain improvement was 85.8%. Improvement in 6.3% of patients ranged between 20% and 49%, and only 7.9% reported less than 20% improvement in pain intensity after the analgesic procedure (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 2</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0205" class="elsevierStylePara elsevierViewall">The best analgesic response was obtained in the group that received the interlaminar lumbar injection (91%). However, there were no statistically significant differences among the four types of blocks (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.7) (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 3</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0210" class="elsevierStylePara elsevierViewall">The majority of patients experienced pain relief for more than eight weeks (<a class="elsevierStyleCrossRef" href="#fig4">Fig. 4</a>).</p><elsevierMultimedia ident="fig4"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">There were two complications (0.78% incidence): one patient who received cervical interlaminar injection had post-puncture headache, which improved with conventional analgesic management and did not require a blood patch; and one patient who received a lumbar transforaminal injection developed a localized puncture-site infection which was resolved satisfactorily with a 7-day antibiotic regimen.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0220" class="elsevierStylePara elsevierViewall">Current studies on the efficacy of epidural steroids are questionable given the absence of control and the lack of quality of the majority of them. The reason for the varying results of these studies is the absence of guidelines supporting dose, type of steroid, frequency of administration, or injection volume. Moreover, most of these studies were done without fluoroscopic guidance or contrast medium.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Most of the studies report the use of epidural steroids for isolated lumbosacral radiculopathy, although others have addressed less specific pain such as that caused by lumbar stenosis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">The use of epidural steroids has been assessed in observational studies. However, in our population, there are no follow-up reports of cohorts as the one proposed in this study. Additionally, the published literature is limited to different spinal segments, while this study addresses all spinal levels.</p><p id="par0235" class="elsevierStylePara elsevierViewall">Success rates in the literature range from 18% to 90% depending on the methodology, the outcome assessed, patient selection and the technique used. This case series reported a high proportion of patients with improved pain scores, probably associated with patient selection and the use of fluoroscopy.</p><p id="par0240" class="elsevierStylePara elsevierViewall">Interlaminar injections have shown strong evidence in favour of short-term improvement (less than 6 weeks)<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26–28</span></a> but weak evidence for long-term improvement (more than 6 weeks).<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7,29,30</span></a> Epidural injections are recommended in patients with both subacute (6 to 8 weeks) as well as chronic (more than 12 weeks) pain secondary to radiculopathy in the cervical and lumbar regions.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7,31,32</span></a> Findings were indeterminate in cervical and axial lumbar pain, and in lumbar stenosis,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> hence the lack of sufficient evidence to support or refute the use of steroids in patients with no radicular pain.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Transforaminal cervical procedures are not recommended and the total annual dose of steroids must be limited in order to avoid complications.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The results of this study show short-term as well as long-term improvement, with no significant differences depending on the type of procedure.</p><p id="par0245" class="elsevierStylePara elsevierViewall">Although outcomes also vary, Riew et al. reported lower rates of surgery following these types of procedures.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">The incidence of complications following these procedures varies among the various studies from 0.07% to 0.5%,<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> similar to the findings of this study.</p><p id="par0255" class="elsevierStylePara elsevierViewall">Although infrequent, adverse events may be catastrophic; knowledge of the local anatomy and the use of fluoroscopic guidance are key in preventing complications.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,36</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Complications may occur as a result of the procedure itself or due to the injected drugs.</p><p id="par0265" class="elsevierStylePara elsevierViewall">Complications associated with the procedure include post-lumbar puncture headache, with an incidence as low as 7.5% but which may also be as high as 75% depending on variables such as the technique, needle size and experience.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> The incidence ranges between 1.4 and 6% for lumbar interlaminar injection, 3.1% for transforaminal lumbar injection, 2.6% for thoracic interlaminar injection and up to 21% after caudal injection. Headache resolves spontaneously within seven days in 72% of patients and after six weeks in 85%.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38–40</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">The incidence of infection is 1%. Most infections are minor such as local skin infections, but may also be as severe as epidural and intradural abscesses, osteomyelitis and meningitis. The main risk factor for their occurrence is a history of diabetes mellitus.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35,38</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">Haemorrhagic complications associated with the procedure include acute subdural as well as epidural and subarachnoidal haematomas.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41,42</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">From the neurological standpoint there may be transient motor weakness, cauda equina syndrome (very few cases reported) with symptoms usually resolving within hours or days; there may also be direct neurological damage.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43–45</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">Metabolic adverse events, associated with steroid use, include hyperglicemia with blood sugar levels derangement lasting at least 2 weeks in diabetic patients.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">46,47</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">Suppression of the hypothalamic-pituitary axis may also occur over a period of 4–7 days. Exceptionally, Cushing syndrome may be present when steroid doses are very high over very short periods of time.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">Other steroid-associated complications include psychotic reactions, transient blindness,<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> vasovagal episodes,<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> chorioretinopathy,<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> myopathy, anaphylaxis and facial flushing<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> after dexamethasone administration, among others.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35,53,54</span></a></p><p id="par0300" class="elsevierStylePara elsevierViewall">In this case series, the incidence of complications of less than 1% may be related to the use of fluoroscopy, which contributes to an important reduction thereof.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusions</span><p id="par0305" class="elsevierStylePara elsevierViewall">The treatment of radicular pain is mainly conservative, based on pharmacological and physical therapy, but in cases of refractory pain, epidural methylprednisolone is an effective, safe and readily available therapeutic option.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Funding</span><p id="par0315" class="elsevierStylePara elsevierViewall">This work was funded with own resources and with the advice of the Universidad Pontificia Bolivariana University and CES.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0310" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:2 [ "identificador" => "xres412689" "titulo" => array:6 [ 0 => "Abstract" 1 => "Introduction" 2 => "Objectives" 3 => "Methodology" 4 => "Results" 5 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec388415" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres412690" "titulo" => array:6 [ 0 => "Resumen" 1 => "Introducción" 2 => "Objetivos" 3 => "Metodología" 4 => "Resultados" 5 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec388414" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Objectives" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "General objective" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Specific objectives" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Materials and methods" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 12 => array:2 [ "identificador" => "xack121983" "titulo" => "Acknowledgements" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-08-04" "fechaAceptado" => "2014-09-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec388415" "palabras" => array:5 [ 0 => "Pain" 1 => "Steroids" 2 => "Anesthesia, Epidural" 3 => "Analgesia" 4 => "Fluoroscopy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec388414" "palabras" => array:5 [ 0 => "Dolor" 1 => "Esteroides" 2 => "Anestesia Epidural" 3 => "Analgesia" 4 => "Fluoroscopía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Degenerative disc disease is a prevalent and disabling disease. When the conservative treatment fails to obtain pain relief, epidural steroids are an alternative frequently used worldwide.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To evaluate the efficacy and safety of epidural methylprednisolone in patients with radicular pain.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Methodology</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Descriptive longitudinal retrospective study in patients with chronic radicular pain who received fluoroscopy-guided interventional treatment, between July 2010 and December 2011 at Instituto Colombiano del Dolor (Medellín-Colombia), to determine the efficacy and safety of epidural methylprednisolone in clinical practice. Pain relief was followed using the visual analogue scale, during at least 8 weeks.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">254 patients were analyzed. The mean age of the patients was 52.8 years (SD<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15); 52.8% were men. The main diagnosis was lower-limb radicular pain (87.7%). The most frequent procedures were transforaminal lumbar injection (54.3%) and interlaminar lumbar injection (17.7%). The proportion of patients with more than 50% pain relief 50% was 85.8%. There were no differences in efficacy between the procedures. Pain improvement lasted more than 8 weeks in 55% of patients. The incidence of complications was lower than 1%.</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">When radicular pain is refractory to conservative treatment based on pharmacological and physical therapy, epidural methylprednisolone is an effective and safe method in our setting.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Introducción</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La enfermedad discal degenerativa es una enfermedad muy prevalente e incapacitante. Cuando el manejo conservador falla los esteroides epidurales son una alternativa de uso frecuente en todo el mundo.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Evaluar la eficacia y seguridad de la metilprednisolona epidural en pacientes con dolor radicular.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Metodología</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo longitudinal retrospectivo, en pacientes con dolor radicular crónico que recibieron tratamiento intervencionista guiado por fluoroscopia en el Instituto Colombiano del Dolor (Medellín-Colombia) en el período comprendido entre julio de 2010 y diciembre de 2011, para determinar la eficacia clínica y seguridad de la metilprednisolona epidural. Se realizó seguimiento del control del dolor medido por escala visual análoga por al menos 8 semanas.</p> <span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 254 pacientes. La edad promedio de los pacientes intervenidos fue de 52,8 años (DE<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15), el 52,8% fueron hombres. El principal diagnóstico fue el dolor radicular en los miembros inferiores (87,7%). Los procedimientos más frecuentes fueron; inyección transforaminal lumbar (54,3%) e inyección interlaminar lumbar (17,7%). El 85.8% de los pacientes presentó disminución del dolor mayor al 50%. No hubo diferencias en la eficacia entre los diferentes bloqueos. En el 55% de los pacientes el tiempo de mejoría fue superior a 8 semanas. La incidencia de complicaciones fue menor al 1%.</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Cuando el dolor radicular es refractario al tratamiento conservador basado en terapia farmacológica y física, la metilprednisolona epidural es un método eficaz y seguro disponible en nuestro medio.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Correa AÁ, Díaz RCR, Lotero MAA. Eficacia de la metilprednisolona epidural en el dolor radicular. Rev Colomb Anestesiol. 2015;43:61–67.</p>" ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1002 "Ancho" => 1622 "Tamanyo" => 77673 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Procedures performed in patients with radicular pain.</p>" ] ] 1 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1303 "Ancho" => 1620 "Tamanyo" => 54151 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Pain relief distribution in patients with radicular pain following steroid blockade.</p>" ] ] 2 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1959 "Ancho" => 1658 "Tamanyo" => 122627 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Proportion of patients with or without pain relief according to the type of block.</p>" ] ] 3 => array:8 [ "identificador" => "fig4" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1325 "Ancho" => 1664 "Tamanyo" => 66012 ] ] "descripcion" => array:1 [ "en" => "<p id="spar1055" class="elsevierStyleSimplePara elsevierViewall">Pain relief duration in patients treated with epidural steroids.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors." "tabla" => array:2 [ "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">SD, standard deviation.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>254 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age in years (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.8 (±15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Female gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47.2% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.8% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Right upper limb pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Left upper limb pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Bilateral upper limb pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.9% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Right lower limb pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Left lower limb pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Bilateral lower limb pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.1% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab642087.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">General characteristics of the patients assessed.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:54 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Low back pain: an approach to diagnosis and management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L. 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Vaglienti" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pain Physician" "fecha" => "2010" "volumen" => "13" "paginaInicial" => "481" "paginaFinal" => "484" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20859317" "web" => "Medline" ] ] ] ] ] ] ] ] 53 => array:3 [ "identificador" => "bib0270" "etiqueta" => "54" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Myelopathy after intrathecal administration of hypertonic saline" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R.C. Kim" 1 => "R.W. Porter" 2 => "B.H. Choi" 3 => "S.W. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Neurosurgery" "fecha" => "1988" "volumen" => "22" "paginaInicial" => "942" "paginaFinal" => "945" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3380287" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack121983" "titulo" => "Acknowledgements" "texto" => "<p id="par0320" class="elsevierStylePara elsevierViewall">The authors thank the doctor and anesthesiologist Epidemiologist Nelson Fonseca for his contribution.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/22562087/0000004300000001/v1_201501210932/S2256208714001084/v1_201501210932/en/main.assets" "Apartado" => array:4 [ "identificador" => "951" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific and Technological Research" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22562087/0000004300000001/v1_201501210932/S2256208714001084/v1_201501210932/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2256208714001084?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 1 | 10 |
| 2024 October | 46 | 7 | 53 |
| 2024 September | 47 | 9 | 56 |
| 2024 August | 49 | 16 | 65 |
| 2024 July | 51 | 1 | 52 |
| 2024 June | 28 | 2 | 30 |
| 2024 May | 33 | 2 | 35 |
| 2024 April | 39 | 9 | 48 |
| 2024 March | 69 | 5 | 74 |
| 2024 February | 145 | 12 | 157 |
| 2024 January | 75 | 5 | 80 |
| 2023 December | 64 | 6 | 70 |
| 2023 November | 78 | 15 | 93 |
| 2023 October | 83 | 4 | 87 |
| 2023 September | 30 | 6 | 36 |
| 2023 August | 24 | 6 | 30 |
| 2023 July | 12 | 8 | 20 |
| 2023 June | 21 | 4 | 25 |
| 2023 May | 14 | 5 | 19 |
| 2023 April | 16 | 1 | 17 |
| 2023 March | 8 | 6 | 14 |
| 2023 February | 16 | 4 | 20 |
| 2023 January | 16 | 2 | 18 |
| 2022 December | 19 | 5 | 24 |
| 2022 November | 15 | 6 | 21 |
| 2022 October | 12 | 7 | 19 |
| 2022 September | 9 | 10 | 19 |
| 2022 August | 10 | 12 | 22 |
| 2022 July | 13 | 7 | 20 |
| 2022 June | 6 | 13 | 19 |
| 2022 May | 6 | 6 | 12 |
| 2022 April | 8 | 7 | 15 |
| 2022 March | 11 | 10 | 21 |
| 2022 February | 11 | 3 | 14 |
| 2022 January | 8 | 9 | 17 |
| 2021 December | 16 | 7 | 23 |
| 2021 November | 8 | 7 | 15 |
| 2021 October | 25 | 6 | 31 |
| 2021 September | 13 | 7 | 20 |
| 2021 August | 10 | 5 | 15 |
| 2021 July | 12 | 4 | 16 |
| 2021 June | 5 | 7 | 12 |
| 2021 May | 13 | 8 | 21 |
| 2021 April | 30 | 34 | 64 |
| 2021 March | 19 | 10 | 29 |
| 2021 February | 4 | 17 | 21 |
| 2021 January | 8 | 7 | 15 |
| 2020 December | 5 | 7 | 12 |
| 2020 November | 6 | 11 | 17 |
| 2020 October | 9 | 17 | 26 |
| 2020 September | 10 | 10 | 20 |
| 2020 August | 12 | 13 | 25 |
| 2020 July | 9 | 10 | 19 |
| 2020 June | 5 | 6 | 11 |
| 2020 May | 11 | 3 | 14 |
| 2020 April | 3 | 3 | 6 |
| 2020 March | 4 | 0 | 4 |
| 2020 February | 5 | 1 | 6 |
| 2020 January | 5 | 3 | 8 |
| 2019 December | 7 | 6 | 13 |
| 2019 November | 3 | 2 | 5 |
| 2019 October | 0 | 0 | 0 |
| 2019 September | 1 | 1 | 2 |
| 2019 August | 1 | 0 | 1 |
| 2019 July | 1 | 5 | 6 |
| 2019 June | 1 | 2 | 3 |
| 2019 May | 1 | 8 | 9 |
| 2018 September | 1 | 0 | 1 |
| 2018 June | 2 | 3 | 5 |
| 2018 May | 74 | 12 | 86 |
| 2018 April | 39 | 5 | 44 |
| 2018 March | 28 | 6 | 34 |
| 2018 February | 19 | 6 | 25 |
| 2018 January | 41 | 2 | 43 |
| 2017 December | 30 | 6 | 36 |
| 2017 November | 32 | 2 | 34 |
| 2017 October | 26 | 7 | 33 |
| 2017 September | 48 | 10 | 58 |
| 2017 August | 69 | 4 | 73 |
| 2017 July | 70 | 4 | 74 |
| 2017 June | 70 | 6 | 76 |
| 2017 May | 54 | 6 | 60 |
| 2017 April | 55 | 12 | 67 |
| 2017 March | 32 | 11 | 43 |
| 2017 February | 27 | 1 | 28 |
| 2017 January | 24 | 10 | 34 |
| 2016 December | 43 | 17 | 60 |
| 2016 November | 31 | 11 | 42 |
| 2016 October | 48 | 13 | 61 |
| 2016 September | 66 | 10 | 76 |
| 2016 August | 55 | 8 | 63 |
| 2016 July | 24 | 7 | 31 |
| 2016 June | 0 | 7 | 7 |
| 2016 May | 3 | 12 | 15 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 1 | 19 | 20 |
| 2016 January | 0 | 11 | 11 |
| 2015 December | 23 | 19 | 42 |
| 2015 November | 54 | 13 | 67 |
| 2015 October | 65 | 17 | 82 |
| 2015 September | 60 | 12 | 72 |
| 2015 August | 44 | 7 | 51 |
| 2015 July | 48 | 12 | 60 |
| 2015 June | 34 | 7 | 41 |
| 2015 May | 49 | 7 | 56 |
| 2015 April | 50 | 14 | 64 |
| 2015 March | 70 | 18 | 88 |
| 2015 February | 66 | 14 | 80 |
| 2015 January | 43 | 8 | 51 |
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