The Synergistic Effect of Combined Transforaminal and Caudal Epidural Steroid Injection in Recurrent Lumbar Disc Herniations

Abstract

Background: Recurrent lumbar disc herniation (RLDH) is one of the most common causes of chronic low back and leg pain. Although surgical treatment has high success rates in primary lumbar disc herniations, recurrence is not an uncommon clinic condition after the surgery. Considering the recurrent surgeries have lower success rates and higher risks, such as dural tear and nerve injury, alternative treatment modalities are needed for RLDH patients. Epidural steroid injections (ESI), particularly transforaminal steroid injection (TFESI) and caudal steroid injection (CESI), which are the alternative treatments to surgery, have not shown reasonable results in RLDH separately. In this study, we aimed to investigate the effects of combined TFESI and CESI (TFESI + CESI) treatment, which has been found successful in primary lumbar disc herniation (PLDH) and on pain control and quality of life in RLDH patients for the first time.

Materials and methods: A total of 71 patients, who had ESI treatment as only TFESI or TFESI + CESI because of RLDH in our clinic between March 2017 and February 2020, were investigated retrospectively. The visual analog scale (VAS) leg, VAS back, and Oswestry disability index (ODI) were used to assess leg pain, low back pain, and limitation of daily routine activities. Each assessment was done before the intervention and repeated at the third week, the third month, and the sixth month of injection, and the results were noted.

Results: Out of 71 patients, 38 were female and 33 male. Patients were divided into two subgroups according to the applied ESI methods as only TFESI (n = 32) and TFESI + CESI (n = 39). In the only TFESI group, the mean VAS leg score was 7.84, 4.63, 5.40, and 6.19 before, at the third week, the third month, and the sixth month of the injection, respectively. Also, in this group, the mean VAS back score was 8.06, 4.16, 4.88, and 5.97; the mean ODI score was 55.81, 34.31, 37.5, and 49.04 in the same respect. In the TFESI + CESI group, the mean VAS leg score was 8.20, 2.87, 3.64, 4.23; mean VAS back score 8.03, 3.05, 3.90, 4.08; mean ODI score 56.56, 28.05, 30.21, 33.64 before, at the third week, third month, and sixth month of the injection, respectively. The mean of the initial VAS leg, VAS back, and ODI scores was not found to be statistically significantly different between the two groups. The mean of all VAS leg, VAS back, and ODI scores was found to be lower in the TFESI + CESI group than the only TFESI group at each third-week, third-month, and sixth-month controls, and these differences were statistically significant. (p<0.0001 at each controls for VAS leg; p = 0.001 at third week, p = 0.002 at third month and p <0.0001 at sixth month for VAS back; p= 0.0003 at third week, p<0.0001 at third month, p<0.0001 at sixth month for ODI)

Conclusion: Our study demonstrates that TFESI + CESI treatment is an effective non-surgical treatment for RLDH. Considering the higher risks and lower success rates of recurrent surgeries, TFESI + CESI can be a potential treatment option for RLDH patients.