Editorial. Topical epidural steroids after lumbar spine surgery: do the benefits observed after microdiscectomy extend to lumbar fusion?

Armaan K. MalhotraDivision of Neurosurgery, St. Michael’s Hospital, University of Toronto, Ontario; and

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Jefferson R. WilsonDivision of Neurosurgery, St. Michael’s Hospital, University of Toronto, Ontario; and
Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada

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 MD, PhD, FRCSC
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Degenerative lumbar spinal disease is a common condition associated with reduced quality of life for individuals and economic strain on healthcare systems. Due to a growing population of elderly patients with degenerative lumbar conditions, both the volume and complexity of spine surgery have increased in recent decades, with a particular rise in lumbar spinal instrumentation procedures.1,2 Given these circumstances, identification of modifiable factors influencing postoperative patient outcomes has become imperative.

Poor postoperative pain control has been associated with prolonged hospitalization, elevated risk of chronic pain, increased complication rates, and overall healthcare costs.3,4 Therefore, interventions targeted toward reducing postoperative pain are not only beneficial to individual patients, by improving postsurgical suffering and reducing complications, but also to the healthcare system as a whole by maximizing surgical efficiency and optimizing patient flow. This has motivated many advances in the field, such as minimally invasive approaches, application of enhanced recovery after surgery principles, and multimodal nonopioid analgesia strategies.

One intervention that has shown effectiveness in improving postoperative pain after lumbar spine surgery is the intraoperative application of topical epidural steroids. Although most of the existing literature focuses on microdiscectomy, in the current issue of the Journal of Neurosurgery: Spine, Tavanaei et al. investigate the role of this treatment in the context of lumbar instrumented fusion.5 Specifically, they report on a randomized placebo-controlled double-blind trial recruiting 100 patients with degenerative lumbar pathology who, at the conclusion of surgery, received epidural Gelfoam soaked in either triamcinolone acetonide or normal saline. Surgical intervention involved single or multilevel posterolateral fusion (no interbody fusion) coupled with posterior decompression.

The primary outcome was defined as visual analog scale leg pain scores at multiple time points within the first postoperative day, with primary analysis demonstrating no significant difference in pain scores between treatment and control groups during this early postoperative period. There was also no change in secondary outcome measures including disability index scores, opiate requirements, length of stay, or complications (although there was a nonsignificantly increased skin and soft-tissue infection rate in the steroid cohort). Strengths of this study include the randomized and placebo-controlled methodology as well as the high rates of clinical follow-up. Potential weaknesses include the lack of fusion outcomes and the single-center, single-surgeon design. The group highlights the fact that larger multicenter and multisurgeon collaborations would be necessary in the future to continue to explore this clinical question.

Although the current study was negative, the literature is replete with studies demonstrating improvement in postoperative outcomes, including decreased morphine consumption, length of stay, and visual analog scale pain scores with topical steroid administration following microdiscectomy.6–9 Interestingly, similar benefits have been demonstrated in single-level lumbar discectomy cases with intravenous steroid administration.10 Arirachakaran et al. corroborated these findings in lumbar microdiscectomy cases by performing a systematic review and meta-analysis comparing randomized trials assessing epidural steroid versus placebo in lumbar microdiscectomy.11 Their review showed reduced postoperative back pain, morphine consumption, and length of stay in the topical steroid group compared to placebo, particularly in open compared to minimally invasive cases. Specifically, they showed a pooled mean 8.47-mg reduction in morphine consumption in the first 24 hours postoperatively and a 0.89-day shorter hospitalization in patients treated with intraoperative epidural steroids. Furthermore, they demonstrated there was no difference in surgical infections between groups.

There is a strong biological rationale for topical steroid use in surgery for degenerative lumbar pathologies. After lumbar microdiscectomy, the mechanism for persistent postoperative pain may be driven by direct nerve root manipulation, as well as by further inflammation associated with resultant peridural fibrosis and scarring.8,12 Immediate intraoperative steroid administration is believed to interrupt these secondary inflammatory pathways, thus reducing the magnitude of dural reaction following surgery.

Given evidence to support the role of intraoperative topical corticosteroid administration following microdiscectomy, it is somewhat surprising that the study by Tavanaei et al. failed to find an effect within the context of lumbar fusion. The rationale for Gelfoam as a vehicle for steroid in the epidural space was to minimize the loss of local steroid flowing to the dependent disc space as well as to reduce dilution by blood products and fluids during wound closure.13,14 However, given the known propensity of Gelfoam to swell in the postoperative period, one wonders if such swelling could impact outcomes by contributing to persistent neural element compression following decompression. From a dosing perspective, the selection of 40-mg triamcinolone acetate was made based on demonstrations of efficacy in the microdiscectomy literature.6,9 The optimal dose and delivery vehicle to the epidural space following lumbar fusion remains unknown and there is a paucity of current literature comparing specific steroid types (dexamethasone compared to triamcinolone acetate or methylprednisolone) and doses.

Beyond the drug delivery, there are surgical differences between lumbar microdiscectomy and posterolateral lumbar fusion that may diminish the utility of topical epidural steroids. A major operative difference is the extent of muscle dissection and soft-tissue injury. The effect of topical epidural steroids for the increased pain following lumbar fusion may be inconsequential given that these patients often require patient-controlled analgesia and increased opiate utilization perioperatively. It is possible that one or several of the factors listed above could have contributed to the absence of effect seen in the current study.

In summary, despite a strong biological rationale and supporting evidence for their application in microdiscectomy, the current study does not support the use of topical steroids in lumbar fusion. In spite of this, Tavanaei et al. should be commended for their important contribution to the literature and, in particular, for the rigorous study methods they used to help answer this question. In light of the aforementioned possibilities explaining the lack of observed effect, additional studies would be useful in this domain, perhaps exploring different modes of topical delivery (not involving the use of Gelfoam) or consideration of different steroid formulations or dosages. Certainly, given the large burden of disease and the volume of lumbar fusions completed annually, even incremental improvements in postoperative outcomes discovered with this therapy in the future could have a significant impact at both the patient and healthcare system levels.

Disclosures

Dr. Wilson is a consultant for Stryker. Dr. Wilson would also like to acknowledge support from the Labatt Family Endowed Chair in Neurosurgery at St. Michael’s Hospital, University of Toronto.

References

  • 1

    Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010;303(13):12591265.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Jensen RK, Jensen TS, Koes B, Hartvigsen J. Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis. Eur Spine J. 2020;29(9):21432163.

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

    van Boekel RLM, Warlé MC, Nielen RGC, et al. Relationship between postoperative pain and overall 30-day complications in a broad surgical population: an observational study. Ann Surg. 2019;269(5):856865.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Fletcher D, Stamer UM, Pogatzki-Zahn E, et al. Chronic postsurgical pain in Europe: an observational study. Eur J Anaesthesiol. 2015;32(10):725734.

  • 5

    Tavanaei R, Ahmadi P, Malekipour B, et al. Effects of local intraoperative epidural use of triamcinolone acetonide–soaked Gelfoam on postoperative outcomes in patients undergoing posterolateral lumbar spinal fusion surgery: a randomized, placebo-controlled, double-blind trial. J Neurosurg Spine. Published online April 15, 2022. doi:10.3171/2022.1.SPINE211418

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Pobereskin LH, Sneyd JR. Does wound irrigation with triamcinolone reduce pain after surgery to the lumbar spine. Br J Anaesth. 2000;84(6):731734.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Aljabi Y, El-Shawarby A, Cawley DT, Aherne T. Effect of epidural methylprednisolone on post-operative pain and length of hospital stay in patients undergoing lumbar microdiscectomy. Surgeon. 2015;13(5):245249.

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

    Diaz RJ, Myles ST, Hurlbert RJ. Evaluation of epidural analgesic paste components in lumbar decompressive surgery: a randomized double-blind controlled trial. Neurosurgery. 2012;70(2):414424.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Bahari S, El-Dahab M, Cleary M, Sparkes J. Efficacy of triamcinolone acetonide and bupivacaine for pain after lumbar discectomy. Eur Spine J. 2010;19(7):10991103.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Aminmansour B, Khalili HA, Ahmadi J, Nourian M. Effect of high-dose intravenous dexamethasone on post lumbar discectomy pain. Spine (Phila Pa 1976). 2006;31(21):24152417.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Arirachakaran A, Siripaiboonkij M, Pairuchvej S, et al. Comparative outcomes of epidural steroids versus placebo after lumbar discectomy in lumbar disc herniation: a systematic review and meta-analysis of randomized controlled trials. Eur J Orthop Surg Traumatol. 2018;28(8):15891599.

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

    Ranguis SC, Li D, Webster AC. Perioperative epidural steroids for lumbar spine surgery in degenerative spinal disease. A review. J Neurosurg Spine. 2010;13(6):745757.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Mishra LD, Nath SS, Gairola RL, Verma RK, Mohanty S. Buprenorphine-soaked absorbable gelatin sponge: 353 an alternative method for postlaminectomy pain relief. J Neurosurg Anesthesiol. 2004;16(2):115121.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Kumari K, Kamal M, Singariya G, et al. Effect of epidural levobupivacaine with or 355 without dexamethasone soaked in gelfoam for postoperative analgesia after lumbar laminectomy: a double 356 blind, randomised, controlled trial. Indian J Anaesth. 2018;62(7):509515.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
Roozbeh TavanaeiFunctional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and

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Pooria AhmadiFunctional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and

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Bahador MalekipourFunctional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and

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Bijan Herfedoust BiazarFunctional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and

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Mohsen KeikhaeeFunctional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and

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Kaveh Oraii YazdaniDepartment of Cardiovascular Diseases, Zahedan University of Medical Science, Zahedan, Iran

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Alireza ZaliFunctional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and

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Saeed Oraee-YazdaniFunctional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and

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Response

We appreciate the interest of Drs. Malhotra and Wilson in our article. They made several valid and remarkable points in their letter, including the potential impact of various factors such as steroid type, dosing, delivery method, and type of procedure on the observed results and differences found with prior studies on lumbar microdiscectomy.

Drs. Malhotra and Wilson exquisitely described potential underlying factors that might have affected our results in addition to limitations associated with our article. We agree with the authors that prior evidence regarding the efficacy of local steroid application in lumbar microdiscectomy has been substantially different from our finding in the lumbar fusion procedure.1,2 In line with our findings, Haws et al. found no significant effect for local use of methylprednisolone delivered via a Gelfoam carrier on postoperative pain, opioid consumption, and patient-reported outcome measures in patients undergoing minimally invasive transforaminal lumbar interbody fusion.3 Similarly, Jirarattanaphochai et al., despite a significant effect on postoperative morphine consumption for local administration of methylprednisolone through the infiltration method in their discectomy group, found no such significant change in their fusion group.4 However, the sample size of the fusion procedure group was relatively small (n = 16), and no information regarding the type of fusion procedure was provided in their study.

We also agree that there might be a potential for the Gelfoam carrier to affect the study outcomes given its tendency to swell postoperatively. However, taking into account the use of Gelfoam as the placebo in our control group and the negative findings in prior studies concerning the fusion procedure, particularly the one conducted by Haws et al., although possible, it is unlikely that Gelfoam swelling contributed to our negative results.3,4 As stated by Drs. Malhotra and Wilson, we believe that surgical differences, including the muscle dissection and resultant soft-tissue injury, are the major contributing factor to the differences in the observed results compared with the lumbar discectomy. Nevertheless, further investigations are greatly needed to address this potential problem. Drs. Malhotra and Wilson raised significant concerns about the impact of various factors regarding steroid application, such as dosing, delivery method, and the steroid type. As mentioned earlier, besides our study, the only existing article in regard to effects of local application of steroids in spinal fusion is the report of the study conducted by Haws et al. on patients undergoing minimally invasive transforaminal lumbar interbody fusion that used Gelfoam soaked in 1 ml of methylprednisolone (80 mg), which was placed in the transforaminal space.3 Therefore, we agree that future investigations are highly warranted to consider evaluating the various aforementioned factors in lumbar fusion surgery.

We appreciate Drs. Malhotra and Wilson for their thorough and insightful remarks on our article, and believe that based on existing evidence, although scarce, it seems that the routine use of local steroids in lumbar fusion procedures for both minimally invasive and conventional methods did not exert similar effects to those observed in lumbar discectomy. Nonetheless, future high-quality clinical trials are especially required to validate our findings.

References

  • 1

    Ranguis SC, Li D, Webster AC. Perioperative epidural steroids for lumbar spine surgery in degenerative spinal disease. A review. J Neurosurg Spine. 2010;13(6):745757.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Arirachakaran A, Siripaiboonkij M, Pairuchvej S, et al. Comparative outcomes of epidural steroids versus placebo after lumbar discectomy in lumbar disc herniation: a systematic review and meta-analysis of randomized controlled trials. Eur J Orthop Surg Traumatol. 2018;28(8):15891599.

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

    Haws BE, Khechen B, Patel D V, et al. Impact of local steroid application in a minimally invasive transforaminal lumbar interbody fusion: results of a prospective, randomized, single-blind trial. J Neurosurg Spine. 2018;30(2):222227.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Jirarattanaphochai K, Jung S, Thienthong S, Krisanaprakornkit W, Sumananont 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). 2007;32(6):609617.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand

Images from de Andrada Pereira et al. (pp 525–534).

  • 1

    Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010;303(13):12591265.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Jensen RK, Jensen TS, Koes B, Hartvigsen J. Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis. Eur Spine J. 2020;29(9):21432163.

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

    van Boekel RLM, Warlé MC, Nielen RGC, et al. Relationship between postoperative pain and overall 30-day complications in a broad surgical population: an observational study. Ann Surg. 2019;269(5):856865.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Fletcher D, Stamer UM, Pogatzki-Zahn E, et al. Chronic postsurgical pain in Europe: an observational study. Eur J Anaesthesiol. 2015;32(10):725734.

  • 5

    Tavanaei R, Ahmadi P, Malekipour B, et al. Effects of local intraoperative epidural use of triamcinolone acetonide–soaked Gelfoam on postoperative outcomes in patients undergoing posterolateral lumbar spinal fusion surgery: a randomized, placebo-controlled, double-blind trial. J Neurosurg Spine. Published online April 15, 2022. doi:10.3171/2022.1.SPINE211418

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Pobereskin LH, Sneyd JR. Does wound irrigation with triamcinolone reduce pain after surgery to the lumbar spine. Br J Anaesth. 2000;84(6):731734.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Aljabi Y, El-Shawarby A, Cawley DT, Aherne T. Effect of epidural methylprednisolone on post-operative pain and length of hospital stay in patients undergoing lumbar microdiscectomy. Surgeon. 2015;13(5):245249.

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

    Diaz RJ, Myles ST, Hurlbert RJ. Evaluation of epidural analgesic paste components in lumbar decompressive surgery: a randomized double-blind controlled trial. Neurosurgery. 2012;70(2):414424.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Bahari S, El-Dahab M, Cleary M, Sparkes J. Efficacy of triamcinolone acetonide and bupivacaine for pain after lumbar discectomy. Eur Spine J. 2010;19(7):10991103.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Aminmansour B, Khalili HA, Ahmadi J, Nourian M. Effect of high-dose intravenous dexamethasone on post lumbar discectomy pain. Spine (Phila Pa 1976). 2006;31(21):24152417.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Arirachakaran A, Siripaiboonkij M, Pairuchvej S, et al. Comparative outcomes of epidural steroids versus placebo after lumbar discectomy in lumbar disc herniation: a systematic review and meta-analysis of randomized controlled trials. Eur J Orthop Surg Traumatol. 2018;28(8):15891599.

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

    Ranguis SC, Li D, Webster AC. Perioperative epidural steroids for lumbar spine surgery in degenerative spinal disease. A review. J Neurosurg Spine. 2010;13(6):745757.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Mishra LD, Nath SS, Gairola RL, Verma RK, Mohanty S. Buprenorphine-soaked absorbable gelatin sponge: 353 an alternative method for postlaminectomy pain relief. J Neurosurg Anesthesiol. 2004;16(2):115121.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Kumari K, Kamal M, Singariya G, et al. Effect of epidural levobupivacaine with or 355 without dexamethasone soaked in gelfoam for postoperative analgesia after lumbar laminectomy: a double 356 blind, randomised, controlled trial. Indian J Anaesth. 2018;62(7):509515.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 1

    Ranguis SC, Li D, Webster AC. Perioperative epidural steroids for lumbar spine surgery in degenerative spinal disease. A review. J Neurosurg Spine. 2010;13(6):745757.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Arirachakaran A, Siripaiboonkij M, Pairuchvej S, et al. Comparative outcomes of epidural steroids versus placebo after lumbar discectomy in lumbar disc herniation: a systematic review and meta-analysis of randomized controlled trials. Eur J Orthop Surg Traumatol. 2018;28(8):15891599.

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

    Haws BE, Khechen B, Patel D V, et al. Impact of local steroid application in a minimally invasive transforaminal lumbar interbody fusion: results of a prospective, randomized, single-blind trial. J Neurosurg Spine. 2018;30(2):222227.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Jirarattanaphochai K, Jung S, Thienthong S, Krisanaprakornkit W, Sumananont 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). 2007;32(6):609617.

    • Crossref
    • Search Google Scholar
    • Export Citation

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