Study: More evidence needed for CT-guided transforaminal steroid injections

The lack of concrete data and evidence do not support performing CT-guided lumbar steroid injections, according to a researcher.

Two independent researchers who reviewed the effectiveness and safety of CT-guided lumbar transforaminal injection of steroids for radicular pain found scant evidence of its effectiveness, according to a presentation given at the International Spine Intervention Society Annual Meeting, here.

Nikolai Bogduk, MD, of the University of Newcastle, Australia, presented the findings of the study he and colleague John Bui, MD, conducted. They reviewed 19 publications that addressed the effectiveness and safety of CT-guided lumbar transforaminal injection of steroids. Bogduk said most of the evidence examined failed to support the theory that the injection of steroids can reduce radicular pain in the lumbar spine.

“We saw success, but not defining [success]. There are no numbers, just words; no data at all…The patients were better, but we had no data. Some did not even say how many patients they treated,” Bogduk said of the studies that were analyzed. “Those types of studies do not help you make decisions,” he said.

A lack of evidence

Furthermore, much of the literature the researchers analyzed, Bogduk said, was general and did not contain hard data. In some studies that did provide data, he said half of them gave group data with mean scores without standard deviations. Pain scores went from 7 points to 4 points, or 9 points to 3 points, and the study says that might be an important factor, but many of them did not explain how well the procedures worked in the individuals.

Nikolai Bogduk

“Nothing was concrete,” Bogduk said, and he noted the literature was lacking in solid evidence for the treatment.

For example, two studies reported decreases in mean or median pain scores but no other data. Two other studies reported success rates of 34% to 62% for achieving 50% pain relief at between 1 month and 6 months after treatment.

CT-guided injections also do not avoid catastrophic spinal cord injuries, according to Bogduk.

There is very much a debate, Bogduk told Spine Surgery Today, as to whether fluoroscopy-guided injections are the preferred standard of care over CT-guided injections.

“In Australia and New Zealand, CT scanners are more widely available than fluoroscopes. Very few outfits have a dedicated fluoroscope for injection procedures. Such fluoroscopes that do exist are held in operating theatres, which means that TFIs [transforaminal injections] have to be billed as theatre procedures instead of an outpatient procedure. This all gets dirty financially,” Bogduk told Spine Surgery Today.

Ineffective comparisons

“There was an attempt to compare CT-guided injections vs. fluoroscopic injections, but there were no numbers provided and the text was lost a bit in the translation,” Bogduk said at the meeting. “It was ambiguous. CT had slightly better outcomes than fluoro-guided injections, but it was neither clinically or statistically significant.”

However, the complication rates for both treatment methods and the radiation exposure for patients was monitored, according to Bogduk.

“Conventional CT involves far greater radiation exposure than fluoroscopy guided injections,” he said. “There is no evidence that it is safer.”

There is no separate evidence that showed CT-guided lumbar transforaminal steroid injections are safer that fluoroscopy-guided injections and many practitioners tend to rely on the fluoroscopy-guided injections although that practice is not evidence-based, Bogduk said.

Although the cost of the procedures was not mentioned in the literature or the data that Bogduk and Bui reviewed, Bogduk remarked at the meeting it was his opinion CT-guided lumbar transforaminal steroid injections were more expensive than the fluoroscopy-guided injection methods. – by Robert Linnehan

References:

Bogduk N. A systematic review of the effectiveness of CT-guided, lumbar transforaminal injection of steroids. Presented at: International Spine Intervention Society Annual Meeting; July 30-Aug. 3, 2014; Orlando, Fla.
Bui J. Pain Med. 2013;doi:10.1111/pme.12243.

Disclosure: Bogduk is an International Spine Intervention Society consultant and author. He receives royalties from books he has had published and also receives grant and research support from organizations.