Presented at the 2012 AAPM Annual Meeting « Back

Discordant Provocation During Transforaminal Lumbosacral Epidural Steroid Injections Resulted in Greater Pain Reduction than Concordant Provocation

Eric Kim, MD, eric.kim@nyumc.org¹, Christopher Gharibo, MD², (1) NYU School of Medicine, New York, New York, (2) NYU-HJD, New York, New York

Objective: Determine the incidence of injection-related provocation during transforaminal epidural steroid injection and relationship between injection-related concordant versus discordant provocation and pain reduction at follow-up. Our hypothesis is that provocative concordance is a predictor of pain reduction. Method: IRB-approved study was based on patients referred to large tertiary hospital for Transforaminal Epidural Steroid Injections (TFESI). Forty-seven patients with radicular lumbosacral pain due to discal and degenerative etiology were treated with fluoroscopically guided lumbar TFESI. Subjects were administered 80mg DepoMedrol and 1cc of 0.25% bupivicaine at two separate levels and follow-up assessment. Concordant or discordant provocation were assessed during injections. The primary outcome measure was self-rated percentage of pain reduction from baseline at follow-up. Secondary outcome measures are differences in activity level and daily analgesic consumption. Results: Forty-seven subjects received fluoroscopically guided lumbar TFESI. There was 100% incidence of injection-related provocation, which was further subclassified as concordant versus discordant. At 2 weeks post-injection follow-up, discordant group achieved a statistically greater decrease in self-reported pain (76%) compared to the concordant group (58%; t = 2.1; df (45); p <0.04). There were no statistically significant differences between concordant and discordant groups with respect to improvements in functional outcome and decreased use of daily oral pain medications. Conclusion: Incidence of provocation was 100%. Concordant provocation did not predict better outcomes. Discordant group had significantly higher self-reported pain reduction in comparison to concordant group without concomitant functional improvements and reduction in medications. Concordant provocation is not a predictor of response to TFESI. References: 1)Caragee E.J., Hannibal M. Diagnostic evaluation of low back pain, orthopedic Clinics of North America 2004;35: 7-16 2)Mark V. Boswell, MD, PhD, Andrea M. Trescot, MD, Sukdeb Datta, MD, David M. Schultz, MD, 3)Kepes ER, Duncalf D. Treatment of backache with spinal injections of local anesthetics, spinal and systemic steroids. A review. Pain 1985;22:33– 47. 4)Cannon DT, Aprill CN. Lumbosacral epidural steroid injections. Arch Phys Med Rehabil 2000;81:S87–S98; quiz S99–S100 5)Evans W, Intrasacral epidural injection therapy in the treatment of sciatica, The Lancet 2(1930), 1225-1229. 6)Riew KD, Park JB, Cho YS, et al. Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year follow-up. J Bone Joint Surg Am 2006; 88(8):1722–5. 7)Nelemans PJ, deBie RA, deVe HC, et al. Injection therapy for subacute and chronic benign low back pain [review]. Spine 2001;26:501–15. 8)Roberts ST, Willick SE, Rho ME, et al. Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review. PM R 2009;1:657–68. 9)Boswell MV, Hansen HC, Trescot AM, et al. Epidural steroids in the management of chronic spinal pain and radiculopathy. Pain Physician 2003;6:319–34. 10)DePalma MJ, Bhargava A, Slipman CW. A critical appraisal of the evidence for selective nerve root injection in the treatment of lumbosacral radiculopathy. Arch Phys Med Rehabil 2005;86:1477–83.

Funding: None