Treatment of acute sciatica with transforaminal epidural corticosteroids and local anesthetic: Design of a randomized controlled trial

Bastiaan C. Ter Meulen, Esther T. Maas, Amrita Vyas, Marinus Van Der Vegt, Koo De Priester, Michiel R. De Boer, Maurits W. Van Tulder, Henry C. Weinstein, Raymond W.J.G. Ostelo

Research output: Contribution to JournalArticleAcademicpeer-review

Abstract

Background: Transforaminal epidural injections with steroids (TESI) are used increasingly for patients with sciatica. However there is much debate about their safety and effectiveness. It is important to identify patients that benefit most from TESI and only few trials have yet evaluated the effects in patients with acute sciatica. Methods: We describe a prospective, randomized controlled trial (RCT), with the aim to evaluate the hypothesis that TESI plus Levobupivacaine (TESI-plus) added to oral pain medication is more effective compared to pain medication alone or compared to transforaminal injection with a local anesthetic of short duration among patients with acute sciatica. We will recruit a total of 264 patients with sciatica (<8 weeks) caused by a herniated disc, from two clinical sites. Participants are randomly assigned one of three study groups: 1) oral pain medication (control group), 2) oral pain medication and TESI-plus (intervention group one), 3) oral pain medication and transforaminal epidural injection (TEI) with Levobupivaine and saline solution (intervention group two). Primary outcomes are functional status (Roland-Morris Disability Questionnaire), pain intensity for both leg and back, (100 mm visual analogous scale (VAS)), and global perceived recovery (GPR, reported on a 7-point Likert scale, dichotomized into 'recovered' and 'not recovered'). The secondary outcomes are health-related quality of life (EQ5D-5 L) and patient satisfaction (7-point Likert scale). We will also collect information on healthcare utilization and costs, to perform an economic evaluation. All outcomes are measured at three and six weeks, three and six months after randomization. We defined a minimal clinically relevant difference between groups as a difference between both intervention groups and the control group of 20 points for pain (100-point VAS), four points for functional status (24-point RDQ) and a 20% difference on dichotomized GPR (recovered versus not recovered). Discussion: A clinically relevant outcome in favor of TESI-plus implies that future patients with acute sciatica should be recommended TESI-plus within the first few weeks rather than being treated with pain medication alone in order to relieve pain and improve their functioning. In case of a negative result (no relevant differences in outcome between the three study arms), pain medication will remain the mainstay of treatment in the acute stages of sciatica. Trial registration: Dutch National trial register: NTR4457 (March, 6th, 2014)

Original languageEnglish
Article number215
JournalBMC Musculoskeletal Disorders
Volume18
Issue number1
DOIs
Publication statusPublished - 25 May 2017

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Sciatica
Local Anesthetics
Epidural Injections
Adrenal Cortex Hormones
Randomized Controlled Trials
Pain
Steroids
Therapeutics
Intervertebral Disc Displacement
Control Groups
Random Allocation
Patient Satisfaction
Sodium Chloride
Health Care Costs
Cost-Benefit Analysis
Leg
Arm
Quality of Life
Safety

Keywords

  • Economic evaluation
  • Lumbar disc herniation
  • Randomized controlled trial
  • Sciatica
  • Transforaminal epidural steroids

Cite this

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title = "Treatment of acute sciatica with transforaminal epidural corticosteroids and local anesthetic: Design of a randomized controlled trial",
abstract = "Background: Transforaminal epidural injections with steroids (TESI) are used increasingly for patients with sciatica. However there is much debate about their safety and effectiveness. It is important to identify patients that benefit most from TESI and only few trials have yet evaluated the effects in patients with acute sciatica. Methods: We describe a prospective, randomized controlled trial (RCT), with the aim to evaluate the hypothesis that TESI plus Levobupivacaine (TESI-plus) added to oral pain medication is more effective compared to pain medication alone or compared to transforaminal injection with a local anesthetic of short duration among patients with acute sciatica. We will recruit a total of 264 patients with sciatica (<8 weeks) caused by a herniated disc, from two clinical sites. Participants are randomly assigned one of three study groups: 1) oral pain medication (control group), 2) oral pain medication and TESI-plus (intervention group one), 3) oral pain medication and transforaminal epidural injection (TEI) with Levobupivaine and saline solution (intervention group two). Primary outcomes are functional status (Roland-Morris Disability Questionnaire), pain intensity for both leg and back, (100 mm visual analogous scale (VAS)), and global perceived recovery (GPR, reported on a 7-point Likert scale, dichotomized into 'recovered' and 'not recovered'). The secondary outcomes are health-related quality of life (EQ5D-5 L) and patient satisfaction (7-point Likert scale). We will also collect information on healthcare utilization and costs, to perform an economic evaluation. All outcomes are measured at three and six weeks, three and six months after randomization. We defined a minimal clinically relevant difference between groups as a difference between both intervention groups and the control group of 20 points for pain (100-point VAS), four points for functional status (24-point RDQ) and a 20{\%} difference on dichotomized GPR (recovered versus not recovered). Discussion: A clinically relevant outcome in favor of TESI-plus implies that future patients with acute sciatica should be recommended TESI-plus within the first few weeks rather than being treated with pain medication alone in order to relieve pain and improve their functioning. In case of a negative result (no relevant differences in outcome between the three study arms), pain medication will remain the mainstay of treatment in the acute stages of sciatica. Trial registration: Dutch National trial register: NTR4457 (March, 6th, 2014)",
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Treatment of acute sciatica with transforaminal epidural corticosteroids and local anesthetic : Design of a randomized controlled trial. / Ter Meulen, Bastiaan C.; Maas, Esther T.; Vyas, Amrita; Van Der Vegt, Marinus; De Priester, Koo; De Boer, Michiel R.; Van Tulder, Maurits W.; Weinstein, Henry C.; Ostelo, Raymond W.J.G.

In: BMC Musculoskeletal Disorders, Vol. 18, No. 1, 215, 25.05.2017.

Research output: Contribution to JournalArticleAcademicpeer-review

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T1 - Treatment of acute sciatica with transforaminal epidural corticosteroids and local anesthetic

T2 - Design of a randomized controlled trial

AU - Ter Meulen, Bastiaan C.

AU - Maas, Esther T.

AU - Vyas, Amrita

AU - Van Der Vegt, Marinus

AU - De Priester, Koo

AU - De Boer, Michiel R.

AU - Van Tulder, Maurits W.

AU - Weinstein, Henry C.

AU - Ostelo, Raymond W.J.G.

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KW - Sciatica

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