Efficacy of intraoperative epidural triamcinolone application in lumbar microdiscectomy: a matched-control study

Restricted access

OBJECTIVE

The purpose of this study was to investigate whether the intraoperative application of an epidural steroid (ES) on the decompressed nerve root improves short- and midterm subjective and objective clinical outcomes after lumbar microdiscectomy.

METHODS

This study was a retrospective analysis of a 2-center database including consecutive cases in which patients underwent lumbar microdiscectomy. All patients who received ES application (40 mg triamcinolone, ES group) were matched by age and sex to patients who had not received ES application (control group). Objective functional impairment (OFI) was determined using age- and sex-adjusted T-scores of the Timed Up and Go (TUG) test. Back and leg pain (visual analog scale), functional impairment (Oswestry Disability Index [ODI], Roland-Morris Disability Index [RMDI], and health-related quality of life (hrQoL; 12-Item Short Form Health Survey [SF-12] physical component summary [PSC] score and EuroQol [EQ-5D index]) were measured at baseline, on postoperative day 3, and at postoperative week 6.

RESULTS

Fifty-three patients who received ES application were matched with 101 controls. There were no baseline demographic or disease-specific differences between the study groups, and preoperative pain, functional impairment, and hrQoL were similar. On postoperative day 3, the ES group had less disability on the RMDI (mean 7.4 vs 10.3, p = 0.003) and higher hrQoL as determined by the SF-12 PCS (36.5 vs 32.7, p = 0.004). At week 6, the ES group had less disability on the RMDI (3.6 vs 5.7, p = 0.050) and on the ODI by trend (17.0 vs 24.4, p = 0.056); better hrQoL, determined by the SF-12 PCS (44.3 vs 39.9, p = 0.018); and lower OFI (TUG test T-score 100.5 vs 110.2, p = 0.005). The week 6 responder status based on the minimum clinically important difference (MCID) was similar in the ES and control groups for each metric. The rates and severity of complications were similar, with a 3.8% and 4.0% reoperation rate in the ES group and control group, respectively (p = 0.272). There was a tendency for shorter hospitalization in the ES group (5.0 vs 5.8 days, p = 0.066).

CONCLUSIONS

Intraoperative ES application on the decompressed nerve root is an effective adjunct treatment that may lower subjective and objective functional impairment and increase hrQoL in the short and intermediate term after lumbar microdiscectomy. However, group differences were lower than the commonly accepted MCIDs for each metric, indicating that the effect size of the benefit is limited.

■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: retrospective cohort trial; evidence: Class II.

ABBREVIATIONS ASA = American Society of Anesthesiologists; BMI = body mass index; CCI = Charlson Comorbidity Index; ES = epidural steroid; hrQoL = health-related quality of life; LBP = low-back pain; LDH = lumbar disc herniation; MCID = minimum clinically important difference; ODI = Oswestry Disability Index; OFI = objective functional impairment; PCS = physical component summary; RMDI = Roland-Morris Disability Index; RR = risk ratio; SF-12 = 12-Item Short Form Health Survey; TUG = Timed Up and Go; VAS = visual analog scale.

Article Information

Correspondence Martin N. Stienen, Department of Neurosurgery, University Hospital Zürich, Frauenklinikstrasse 10, Zürich 8091, Switzerland. email: mnstienen@gmail.com.

INCLUDE WHEN CITING Published online December 15, 2017; DOI: 10.3171/2017.6.SPINE161372.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Longitudinal measures of subjective (A) and objective (B) functional impairment and hrQoL (C) in patients who underwent lumbar microdiscectomy with or without ES. The x-axes represent the 3 time points at which measurements were obtained: preoperatively (Preop), postoperative day 3 (D3), and postoperative week 6 (W6). Data are presented as group means with 95% confidence intervals (error bars). The OFI T-scores are adjusted for age and sex. *p ≤ 0.05; **p ≤ 0.005.

References

  • 1

    Abrishamkar SRafiei ARSabouri MMoradi STabesh HRahmani P: The effect of impregnated autogenous epidural adipose tissue with bupivacaine, methylprednisolone acetate or normal saline on postoperative radicular and low back pain in lumbar disc surgery under spinal anesthesia; a randomized clinical trial study. J Res Med Sci 16:6216262011

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Akinduro OOMiller BAHaussen DCPradilla GAhmad FU: Complications of intraoperative epidural steroid use in lumbar discectomy: a systematic review and meta-analysis. Neurosurg Focus 39(4):E122015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Aljabi YEl-Shawarby ACawley DTAherne T: Effect of epidural methylprednisolone on post-operative pain and length of hospital stay in patients undergoing lumbar microdiscectomy. Surgeon 13:2452492015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Asher ALChotai SDevin CJArcher-Swygert KParker SLBydon M: Predictive model for return to work after elective surgery for lumbar degenerative disease: an analysis from National Neurosurgery Quality Outcomes Database Registry. Neurosurgery 63 (Suppl 1):1602016 (Abstract 148)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Cenic AKachur E: Lumbar discectomy: a national survey of neurosurgeons and literature review. Can J Neurol Sci 36:1962002009

  • 6

    Charlson MEPompei PAles KLMacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:3733831987

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Copay AGGlassman SDSubach BRBerven SSchuler TCCarreon LY: Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and pain scales. Spine J 8:9689742008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Davis REmmons SE: Benefits of epidural methylprednisolone in a unilateral lumbar discectomy: a matched controlled study. J Spinal Disord 3:2993071990

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Debi RHalperin NMirovsky Y: Local application of steroids following lumbar discectomy. J Spinal Disord Tech 15:2732762002

  • 10

    Delaney TJRowlingson JCCarron HButler A: Epidural steroid effects on nerves and meninges. Anesth Analg 59:6106141980

  • 11

    Deyo RABattie MBeurskens AJBombardier CCroft PKoes B: Outcome measures for low back pain research. A proposal for standardized use. Spine (Phila Pa 1976) 23:200320131998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    EuroQol Group: EuroQol—a new facility for the measurement of health-related quality of life. Health Policy 16:1992081990

  • 13

    Fairbank JCCouper JDavies JBO’Brien JP: The Oswestry low back pain disability questionnaire. Physiotherapy 66:2712731980

  • 14

    Foulkes GDRobinson JS Jr: Intraoperative dexamethasone irrigation in lumbar microdiskectomy. Clin Orthop Relat Res (261):2242281990

    • Search Google Scholar
    • Export Citation
  • 15

    Gautschi OPCorniola MVJoswig HSmoll NRChau IJucker D: The timed up and go test for lumbar degenerative disc disease. J Clin Neurosci 22:194319482015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Gautschi OPCorniola MVSchaller KSmoll NRStienen MN: The need for an objective outcome measurement in spine surgery—the timed-up-and-go test. Spine J 14:252125222014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Gautschi OPCorniola MVSmoll NRJoswig HSchaller KHildebrandt G: Sex differences in subjective and objective measures of pain, functional impairment, and health-related quality of life in patients with lumbar degenerative disc disease. Pain 157:106510712016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Gautschi OPJoswig HCorniola MVSmoll NRSchaller KHildebrandt G: Pre- and postoperative correlation of patient-reported outcome measures with standardized Timed Up and Go (TUG) test results in lumbar degenerative disc disease. Acta Neurochir (Wien) 158:187518812016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Gautschi OPSmoll NRCorniola MVJoswig HChau IHildebrandt G: Validity and reliability of a measurement of objective functional impairment in lumbar degenerative disc disease: the Timed Up and Go (TUG) Test. Neurosurgery 79:2702782016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Gautschi OPSmoll NRJoswig HCorniola MVSchaller KHildebrandt G: Influence of age on pain intensity, functional impairment and health-related quality of life before and after surgery for lumbar degenerative disc disease. Clin Neurol Neurosurg 150:33392016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Gautschi OPStienen MNCorniola MVJoswig HSchaller KHildebrandt G: Assessment of the minimum clinically important difference in the timed up and go test after surgery for lumbar degenerative disc disease. Neurosurgery 80:3803852017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Green LN: Dexamethasone in the management of symptoms due to herniated lumbar disc. J Neurol Neurosurg Psychiatry 38:121112171975

  • 23

    Häckel MMasopust VBojar MGhaly YHorínek D: The epidural steroids in the prevention of epidural fibrosis: MRI and clinical findings. Neuroendocrinol Lett 30:51552009

    • Search Google Scholar
    • Export Citation
  • 24

    Häkkinen AKautiainen HJärvenpää SArkela-Kautiainen MYlinen J: Changes in the total Oswestry Index and its ten items in females and males pre- and post-surgery for lumbar disc herniation: a 1-year follow-up. Eur Spine J 16:3473522007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Hurlbert RJTheodore NDrabier JBMagwood AMSonntag VK: A prospective randomized double-blind controlled trial to evaluate the efficacy of an analgesic epidural paste following lumbar decompressive surgery. J Neurosurg 90 (2 Suppl):1911971999

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Jamjoom BAJamjoom AB: Efficacy of intraoperative epidural steroids in lumbar discectomy: a systematic review. BMC Musculoskelet Disord 15:1462014

  • 27

    Jirarattanaphochai KJung SThienthong SKrisanaprakornkit WSumananont C: Peridural methylprednisolone and wound infiltration with bupivacaine for postoperative pain control after posterior lumbar spine surgery: a randomized double-blinded placebo-controlled trial. Spine (Phila Pa 1976) 32:6096172007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Jones KGBarnett HC: The use of hydrocortisone in spinal surgery. South Med J 48:6176231955

  • 29

    Keats AS: The ASA classification of physical status—a recapitulation. Anesthesiology 49:2332361978

  • 30

    Landriel Ibañez FAHem SAjler PVecchi ECiraolo CBaccanelli M: A new classification of complications in neurosurgery. World Neurosurg 75:709–7156046112011

    • Search Google Scholar
    • Export Citation
  • 31

    Lavyne MHBilsky MH: Epidural steroids, postoperative morbidity, and recovery in patients undergoing microsurgical lumbar discectomy. J Neurosurg 77:90951992

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Lotfinia IKhallaghi EMeshkini AShakeri MShima MSafaeian A: Interaoperative use of epidural methylprednisolone or bupivacaine for postsurgical lumbar discectomy pain relief: a randomized, placebo-controlled trial. Ann Saudi Med 27:2792832007

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Lowell TDErrico TJEskenazi MS: Use of epidural steroids after discectomy may predispose to infection. Spine (Phila Pa 1976) 25:5165192000

  • 34

    Lundin AMagnuson AAxelsson KKogler HSamuelsson L: The effect of perioperative corticosteroids on the outcome of microscopic lumbar disc surgery. Eur Spine J 12:6256302003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Marshall LLTrethewie ER: Chemical irritation of nerve-root in disc prolapse. Lancet 2:3201973

  • 36

    McNeill TWAndersson GBSchell BSinkora GNelson JLavender SA: Epidural administration of methylprednisolone and morphine for pain after a spinal operation. A randomized, prospective, comparative study. J Bone Joint Surg Am 77:181418181995

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Mirzai HTekin IAlincak H: Perioperative use of corticosteroid and bupivacaine combination in lumbar disc surgery: a randomized controlled trial. Spine (Phila Pa 1976) 27:3433462002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Modic MTSteinberg PMRoss JSMasaryk TJCarter JR: Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology 166:1931991988

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Mundry RNunn CL: Stepwise model fitting and statistical inference: turning noise into signal pollution. Am Nat 173:1191232009

  • 40

    Naylor AFlowers MWBramley JE: The value of dexamethasone in the postoperative treatment of lumbar disc prolapse. Orthop Clin North Am 8:381977

  • 41

    Nelson DALandau WM: Intraspinal steroids: history, efficacy, accidentality, and controversy with review of United States Food and Drug Administration reports. J Neurol Neurosurg Psychiatry 70:4334432001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Pfirrmann CWMetzdorf AZanetti MHodler JBoos N: Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine (Phila Pa 1976) 26:187318782001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Ranguis SCLi DWebster AC: Perioperative epidural steroids for lumbar spine surgery in degenerative spinal disease. A review. J Neurosurg Spine 13:7457572010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Rasmussen SKrum-Møller DSLauridsen LRJensen SEMandøe HGerlif C: Epidural steroid following discectomy for herniated lumbar disc reduces neurological impairment and enhances recovery: a randomized study with two-year follow-up. Spine (Phila Pa 1976) 33:202820332008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Roland MFairbank J: The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire. Spine (Phila Pa 1976) 25:311531242000

  • 46

    Shin SHHwang BWKeum HJLee SJPark SJLee SH: Epidural steroids after a percutaneous endoscopic lumbar discectomy. Spine (Phila Pa 1976) 40:E859E8652015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 47

    Stienen MNJoswig HSmoll NRCorniola MVSchaller KHildebrandt G: Influence of body mass index on subjective and objective measures of pain, functional impairment and health-related quality of life in lumbar degenerative disc disease. World Neurosurg 96:570577577.e1 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48

    Stienen MNJoswig HSmoll NRCorniola MVSchaller KHildebrandt G: Short- and long-term outcome of microscopic lumbar spine surgery in patients with predominant back or predominant leg pain. World Neurosurg 93:458465465.e1 2016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 49

    Stienen MNSmoll NRHildebrandt GSchaller KTessitore EGautschi OP: Constipation after thoraco-lumbar fusion surgery. Clin Neurol Neurosurg 126:1371422014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50

    Stienen MNSmoll NRJoswig HCorniola MVSchaller KHildebrandt G: Validation of the baseline severity stratification of objective functional impairment in lumbar degenerative disc disease. J Neurosurg Spine 26:5986042017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 51

    Stratford PWBinkley JMRiddle DLGuyatt GH: Sensitivity to change of the Roland-Morris Back Pain Questionnaire: part 1. Phys Ther 78:118611961998

  • 52

    Than KDCurran JNResnick DKShaffrey CIGhogawala ZMummaneni PV: How to predict return to work after lumbar discectomy: answers from the NeuroPoint-SD registry. J Neurosurg Spine 25:1811862016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 239 239 16
Full Text Views 113 101 3
PDF Downloads 166 136 2
EPUB Downloads 0 0 0

PubMed

Google Scholar