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Letters to the Editor to:
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- Scientific Articles:
Glenn R. Buttermann
- Treatment of Lumbar Disc Herniation: Epidural Steroid Injection Compared with Discectomy. A Prospective, Randomized Study
J Bone Joint Surg Am 2004; 86: 670-679
[Abstract]
[Full text]
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Electronic letters published:
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Dr. Butterman responds to Dr Scher
- Glenn R Buttermann
(14 September 2004)
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TREATMENT OF LUMBAR DISC HERNIATION: EPIDURAL STEROID INJECTION COMPARED WITH DISCECTOMY
- Michael A. Scher
(26 August 2004)
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Dr. Buttermann responds:
- Glenn R. Buttermann
(7 June 2004)
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"Is Discectomy Still Warranted After Failed Epidural Steroid Injection?"
- Robert F. McLain, M.D.
(7 June 2004)
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Dr. Butterman responds to Dr Scher |
14 September 2004 |
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Glenn R Buttermann,
physician
Midwest Spine Institute
Send letter to journal:
Re: Dr. Butterman responds to Dr Scher
butte011{at}umn.edu Glenn R Buttermann
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To the Editor:
I am pleased to respond to the questions posed by Dr.Scher. In our study, a number
of patients were excluded so that the study groups would be more
homogeneous. Clinically, these patients were not excluded from being
treated with spinal steroid injections; they just were not reported
in the paper. Many of the patients who did not fit our entry criteria
still had favorable responses from injection. Dr. Scher's
calculations are correct as to the volume of steroid preparation given
and, yes, a local anesthetic was also administered.
As to Dr. Scher's comments regarding complications, I would agree
that the probability of an inadvertent dural puncture is less with the
caudal approach, as it also is with the transforaminal approach, when
compared to the translaminar approach used in this study. The risk of
infection is remote regardless of the approach, in my opinion, and I (and
my partners) have never seen one.
I currently recommend the transforaminal approach for epidural steroid
injections when flouroscopy is available. This is especially true for
patients with a far lateral disc herniation. My anecdotal experience with
the caudal approach has been less favorable, especially when the disc
herniations, or stenosis, are above L5-S1. However, my opinion is that
favorable results are probably more related to the experience of the
physician performing the injection than it is to the approach.
Dr. Scher also notes his experience with patients who only had short
term benefit from injections. Unlike Dr. Scher's experience with
patients who have had a sequestered disc herniation, those in my study
generally did well. These patients often had the most severe pain and
usually required short term narcotic pain medication in addition to the
steroid injection. Although not part my study, I concur with Dr. Scher
that patients with recurrent disc herniation or stenosis have a less
predictable long term response to epidural steroid injections.
Sincerely, Glenn Buttermann, MD |
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TREATMENT OF LUMBAR DISC HERNIATION: EPIDURAL STEROID INJECTION COMPARED WITH DISCECTOMY |
26 August 2004 |
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Michael A. Scher,
Orthopaedic Surgeon
Consultant- private practise
Send letter to journal:
Re: TREATMENT OF LUMBAR DISC HERNIATION: EPIDURAL STEROID INJECTION COMPARED WITH DISCECTOMY
drscher{at}iafrica.com Michael A. Scher
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The Editor:
I read with great interest the article “Treatment of Lumbar Disc
Herniation: Epidural Steroid Injection Compared with Discectomy ” by Buttermann, and I have several questions and comments.
In the Material and Methods, why were the following
patients excluded - those older than 70 years, those with a pars defect
at the level of disc herniation, or a far lateral disc herniation, or
multilevel disc herniations and recurrent disc herniations? The dose of
steroid (betamethasone) used was 10-15 mg. The usual dose would be 6 mg per
ml, was this on average a 2 ml injection? Was the volume further
increased with saline and was local anaesthetic added?
In discussing complications in the Results, Buttermann
reported a 4% incidence (2 of out of 50 patients) who had a dural
puncture. I have personally performed caudal epidural steroid
infiltrations (1) for some 20 years for clinically diagnosed
neurogenic leg pain of spinal origin. The advantages of a caudal injection site
as opposed to a lumbar epidural is that the complication rate is lower, it
may be readily performed as an outpatient procedure and the outcome
is comparable. Based on more than 2500 randomised cases I was interested
to see that my experience with this technique tallied with the results
achieved by Dr Buttermann in his well-constructed study.
I am a
consultant orthopaedic surgeon in private practice. Patients usually
present 1-2 months after onset of symptoms. My indications for
recommending caudal epidural infiltration are leg pain usually accompanied
by objective findings. These physical signs may be a positive sciatic
nerve or femoral nerve stretch test, focal signs including motor fall-out
(but motor strength not less than grade 3/5) and diminished tendon
reflexes. In older patients where degenerative spinal stenosis was the
provisional diagnosis, there is usually a paucity of objective signs. The
epidural is usually performed as an out-patient procedure.
All patients have preliminary plain
lumbar spine x-rays. the patient. Fewer than 10% of the patients have had
preliminary MR Imaging, this group would mostly have come for a second
opinion. A 30 ml solution made up of 5 ml steroid (betamethasone 30 mg),
local anaesthetic up to 5 ml 1% lignocaine (in the older more frail
patients 2 ml is used) and normal saline to make up the volume. This is
administered with a 3.5 inch spinal needle (20 gauge ) introduced via the
sacral hiatus. The procedure takes a few minutes. Afterwards the patient
is encouraged to have a cup of tea and may invariably go home within ten
minutes. Complications have been infrequent and included 2 dural taps,
probably due to an abberrant sac. In these instances the spinal needle
was withdrawn and a shorter one used. One patient had transient paralysis
of the lower intercostal nerves and lower limb paresis with loss of
bladder sensation. He was brought to a semi reclining position and
recovered spontaneously over 1-2 hours as the local anaesthetic wore off.
Infrequently patients (less than ten cases overall) have experienced
transient perineal numbness with weakness of one or both legs such that
they had to wait a couple of hours before being able to go home. Minor
side affects (less than 15% ) have been facial flushing and less
frequently headaches over the initial 24-48 hours. Diabetic patients are
warned that their serum glucose may rise but will revert to normal within
24-36 hours.
Although Buttermann did not report deep infection, the
potential risk of sepsis would probably be less at caudal level. Patients
telephone my office two days later to report back, are seen 1-2 weeks
later and followed-up as necessary. The vast majority (in excess of 90%)
report considerable symptomatic relief 1-2 days later. Looking ahead the
pattern tends to follow “the rule of thirds” i.e. one third report short
term relief lasting days some 1-2 weeks, one third have considerable
relief (more than 75% subjective pain reduction) for a few months and the
remainder have relief of up to one year or longer.
Based on my experience of patients who have had MR Scans prior to
epidural, I found, unlike Dr Buttermann, the younger patient with a
sequestrated disc has short term relief and would more likely fall into
the group that opts for early surgery. The younger patient with a
herniated disc has a better chance of avoiding surgery. When the far
lateral disc is in the foramen or root canal I have found that the results
are similar to when the impingement is more central. In the case of a
recurrent disc herniation my experience has been that these cases have
short term symptomatic respite i.e. relief which may last a couple of
weeks. The older patient with multi level degenerative pathology namely
central and/or root canal impingement has a relatively poor prognosis
following epidural. However this is invariably the patient who would be
best served with a non-operative approach and occasionally a gratifying
response lasting months is achieved and the epidural may be repeated.
Since the morbidity of caudal epidural steroid infiltration is so low, I
encourage patients who have had relief of more than 3 months to have the
procedure repeated before looking to a more active approach.
1. Scher MA. Caudal Epidural Analgesia for Neurogenic Leg Pain. S
AFR MED J 1986:69:668 |
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Dr. Buttermann responds: |
7 June 2004 |
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Glenn R. Buttermann,
Physician
Midwest Spine Institute
Send letter to journal:
Re: Dr. Buttermann responds:
butte011{at}umn.edu Glenn R. Buttermann
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To the Editor:
In his recent letter, Dr. McLain posed a question about whether our results would have been different if there were there no crossover group. That is, once the patient was randomized to the
epidural steroid injection group, he/she would have been prevented from crossing over to the discectomy group.
The simple answer is that patients would have gone
elsewhere for treatment had they had a failure of epidural steroid injection
and had already previously failed trials of physical therapy, chiropractic,
medications, etc.
One should note that enrolling patients into this type
of study is very time consuming and I think that to try and enroll
patients into a study where there would be no crossover group permitted,
would be extremely difficult with so many patients opting not to
participate that any results would be invalid as the few
enrolled patients would not be representative of HNP patients as a whole.
But more to the point,
I think that in the long-term (one
year or more), there would have been improvement in the majority of
patients regardless of treatment. I believe our treatments improve the quality of life in the relative short to moderate term
follow-up period. This study did not specifically analyze the scenario
that Dr. McLain questions and thus, my answers are speculative.
Dr. McLain also asked for clarification of the crossover group in the
figures of the outcome scores. This is probably most easily seen in
Figure #3 which demonstrates that as a group, the patients who considered
themselves failures of epidural steroid injection still
had some mild improvement in their outcome scores. For the hypothetical
case that Dr. McLain refers to, I think that this group of patients, had
they not have been allowed to cross over to discectomy, would have
had higher (worse) scores over the first six to twelve months, but then
at one to two years, would have probably had scores similar to the
discectomy group. However, this was not addressed in the study and thus,
my comments remain speculative.
Finally, my clinical impression is in
agreement with the comments made by Dr. McLain -- surgical treatment
provides rapid relief of symptoms but that in the long term, that is one
to two years later, symptoms would probably be fairly similar in all groups.
Thus, I feel discectomy or successful epidural steroid injections in the
patients in our study who were treated after a minimum of six weeks of
nonoperative treatment, provided significant improvement in their quality of
life within the first year from symptom onset.
I think that the take home message of this study is that we can
improve patients' symptoms substantially in the first few months
and allow them to become functional again in a reasonable amount of time
(weeks rather than years). The indications for treatment for many
orthopaedic procedures is to get people functional in a timely fashion so
they can become productive again and avoid the financial and
emotional hardships of prolonged pain and disability.
Thank you.
Glenn R. Buttermann, M.D. |
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"Is Discectomy Still Warranted After Failed Epidural Steroid Injection?" |
7 June 2004 |
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Robert F. McLain, M.D.,
Director, Spine Fellowship Program; Director of Orthopaedic Spinal Research
The Cleveland Clinic Foundation; The Cleveland Clinic Spine Institute, Cleveland, OH 44195
Send letter to journal:
Re: "Is Discectomy Still Warranted After Failed Epidural Steroid Injection?"
mclainr{at}ccf.org Robert F. McLain, M.D.
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To the Editor:
I would like to compliment Dr. Buttermann on a well conceived and
executed study, presented in "Treatment of Lumbar Disc Herniation:
Epidural Steroid Injection Compared with Discectomy" (2004; 86:670-679).
This study supports the commonly held notion that discectomy provides
rapid pain relief and accelerates recovery, but does not promise a
quantifiably better result in the long run.
However, the open crossover design muddies the results a bit. Would a
design that prevented crossover, at least for a defined period of many
months to a year (a common clinical scenario in managed care and worker's
compensation systems) have provided the same results?
It is unclear from my reading whether the timetable for the crossover
group was in step with the steroid group or the surgical group. If the
values recorded for monthly intervals were measured from the time of the
ESI, then these patients are included in some but not all of the data-
points in Figures 1 and 2. These patients were at least somewhat improved
when they opted to crossover, though to what degree is unknown. The "n"
for the "Epidural" group would have also changed during early follow-up.
On the other hand, if the timetable for the crossover group was reset
to the time of surgery, then post-injection follow-up data may not be
included in these figures, where it would raise early ESI scores relative
to other groups. Also, if those patients had been retained in the ESI
group over the course of an entire year, their true response to ESI would
have been seen. Either: 1) the failed ESI patients would have persisted as
failures, elevating the subsequent pain and motor deficit scores
throughout the remaining timepoints and amplifying the clinical efficacy
of surgery, or; 2) these patients would have also experienced clinical
improvement over the subsequent months, consistent with previous
observations of ESI, (1).
Since the improvement seen with surgical treatment, relative to ESI,
was only significant in the early follow-up period, and since the
improvement seen with ESI, relative to placebo or untreated controls, is
also only significant during the earliest post-treatment intervals,(2 -
5), it might be argued that the treatment of HNP with discectomy is
effective only in providing more rapid recovery, with no expectation of
incremental longterm benefit. It is difficult to argue, from the data
available here, that the crossover group's good final outcome was the
result of subsequent surgical treatment as opposed to the eventual arrival
of healing promised by natural history. Perhaps the author's insight could
clarify this important aspect of the study.
References:
1.Watts RW. Silagy CS: A meta-analysis on the efficacy of epidural
corticosteroids in the treatment of sciatica. Anaesth Intens Care 1995;
23:564-9.
2.Abram SE. Treatment of Lumbosacral Radiculopathy with Epidural Steroids.
Anesthesiology 1999; 91(6): 1937 - 1941.
3.Bush K, Hillier S: A controlled study of caudal epidural injections of
triamcinolone plus procaine for the management of intractable sciatica.
Spine 1991; 16:572-575.
4.Carette, S, Leclaire, R, Marcoux, S, Morin, F, Blaise, GA, St-Pierre, A,
Truchon, R Parent, F, Levesque, J, Bergeron, V, Montminy, P, Blanchette,
C: Epidural corticosteroid injections for sciatica due to herniated
nucleus pulposus. N Engl J Med 1997; 336:1634 - 40.
5. Ridley MG, Kingsley GH, Gibson T, Grahame R: Outpatient lumbar epidural
corticosteroid injection in the management of sciatica. Br J Rheumatol
1988; 27:295-299.
Respectfully,
Robert F. McLain, M.D.
Member, Surgical Staff
Fellowship Director, Spine Fellowship Program
Cleveland Clinic Spine Institute
The Cleveland Clinic Foundation |
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