Selective nerve root block vs epidural steroid injection

Ashkenazi et al (2010) stated that interventional procedures such as PNBs and trigger point injections (TPIs) have long been used in the treatment of various headache disorders.  There are, however, little data on their effectiveness for the treatment of specific headache syndromes.  Moreover, there is no widely accepted agreement among headache specialists as to the optimal technique of injection, type, and doses of the local anesthetics used, and injection regimens.  The role of corticosteroids in this setting is also being debated.  These investigators performed a PubMed search of the literature to find studies on PNBs and TPIs for the treatment of headaches.  They classified the abstracted studies based on the procedure performed and the treated condition.  These researchers found few controlled studies on the effectiveness of PNBs for headaches, and virtually none on the use of TPIs for this indication.  The most widely examined procedure in this setting was greater occipital nerve block, with the majority of studies being small and non-controlled.  The techniques, as well as the type and doses of local anesthetics used for PNBs, varied greatly among studies.  The specific conditions treated also varied, and included both primary (., migraine, cluster headache) and secondary (., cervicogenic, post-traumatic) headache disorders.  Trigeminal (., supraorbital) nerve blocks were used in few studies.  Results were generally positive, but should be taken with reservation given the methodological limitations of the available studies.  The procedures were generally well-tolerated.  The authors concluded that there is a need to perform more rigorous clinical trials to clarify the role of PNBs and TPIs in the management of various headache disorders, and to aim at standardizing the techniques used for the various procedures in this setting.

In a retrospective study, Narozny and associates (2001) investigated the clinical effectiveness of nerve root blocks (., peri-radicular injection of bupivacaine and triamcinolone) for lumbar mono-radiculopathy in patients with a mild neurological deficit.  These researchers analyzed 30 patients (aged 29 to 82 years) with a minor sensory/motor deficit and an unequivocal MRI finding (20 disc herniations, 10 foraminal stenoses) treated with a SNRB.  Based on the clinical and imaging findings, surgery (decompression of the nerve root) was justifiable in all cases.  Twenty-six patients (87 %) had rapid (1 to 4 days) and substantial regression of pain, 5 required a repeat injection.  Furthermore, 60 % of the patients with disc herniation or foraminal stenosis had permanent resolution of pain, so that an operation was avoided over an average of 16 months (6 to 23 months) follow-up.  The authors concluded that SNRBs are very effective in the non-operative treatment of minor mono-radiculopathy and should be recommended as the initial treatment of choice for this condition.

Rexed lamina II – Composed of tightly packed interneurons. This layer corresponds to the substantia gelatinosa and responds to noxious stimuli while others respond to non-noxious stimuli. The majority of neurons in Rexed lamina II axons receive information from sensory dorsal root ganglion cells as well as descending dorsolateral fasciculus (DLF) fibers. They send axons to Rexed laminae III and IV (fasciculus proprius). High concentrations of substance P and opiate receptors have been identified in Rexed lamina II. The lamina is believed to be important for the modulation of sensory input, with the effect of determining which pattern of incoming information will produce sensations that will be interpreted by the brain as being painful.

No high-quality evidence has proved the effectiveness of manipulative therapy in the treatment of cervical radiculopathy. However, limited evidence suggests that manipulation may provide short-term benefit in the treatment of neck pain, cervicogenic headaches, 3 , 17 and radicular symptoms. 18 Rare complications, such as worsening radiculopathy, myelopathy, and spinal cord injury, may occur. 3 , 19 Because of these risks and the lack of high-quality evidence to support its effectiveness, manipulative therapy cannot be recommended for the treatment of cervical radiculopathy.

Additionally, our study found a statistically significant difference in the discectomy rate for patients receiving an ESI by year. In 2004, % of patients received a discectomy after an ESI injection, while only % of patients received a discectomy after an ESI in 2006. There was also a trend toward a decrease in the crossover rate for SNRB that did not reach statistical significance. This finding may perhaps indicate improved effectiveness for the injection procedures. It may also indicate a trend toward more injections in a population that otherwise would not have been in danger of proceeding to surgery and would have recovered with continued conservative measures that did not include injections.

Selective nerve root block vs epidural steroid injection

selective nerve root block vs epidural steroid injection

No high-quality evidence has proved the effectiveness of manipulative therapy in the treatment of cervical radiculopathy. However, limited evidence suggests that manipulation may provide short-term benefit in the treatment of neck pain, cervicogenic headaches, 3 , 17 and radicular symptoms. 18 Rare complications, such as worsening radiculopathy, myelopathy, and spinal cord injury, may occur. 3 , 19 Because of these risks and the lack of high-quality evidence to support its effectiveness, manipulative therapy cannot be recommended for the treatment of cervical radiculopathy.

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