The first of these analyses, which was presented in a “best papers” session at NASS, focused on patients with lumbar stenosis. Radcliff explained
that epidural steroidal injections were a common treatment for lumbar stenosis, with studies showing that the potential advantages were that they provided “temporary pain relief, a possibility of surgical avoidance, and improvement in short-term outcome.” However, he added, studies have also shown epidural steroidal injections in this setting to be also associated with a possible increased rate of surgery and increased rate of opioid use.
He said: “The hypothesis of this study is that patients with lumbar stenosis who received epidural steroidal injections would have an improved
outcome or improved surgical avoidance, or there would be an increased crossover from patients who had chosen or who had been assigned to receive surgery at baseline to ultimately have non-surgical treatment.” Radcliff said there were no baseline differences between groups. Comparing the change in outcome between groups, after four years, in surgically treated patients who had received epidural steroidal injections
versus surgically treated patients who had not received epidural steroidal injections, showed that there was significantly less improvement in patients who had received the injections in the SF36 physical function score (14.8 vs. 22.5; p=0.025, respectively). In non-surgically treated patients, there was significantly less improvement in the SF36 bodily pain score (7.3 vs.16.7; p≤.01, respectively) and in the SF36 physical function score (5.5 vs. 15.2; p<0.01, respectively) in the group of patients who had received epidural steroidal injections compared with those who had not. Additionally, although epidural steroidal injections were associated with an increased crossover from surgery to non-surgical
treatment, there was also an increased crossover from non-surgical treatment to surgery in this group.
The design of the lumbar disc herniation study was similar to the spinal stenosis study. In this subgroup analysis, the outcomes of patients who
received epidural steroidal injections were not significantly different from those of patients who had not received injections. But, these findings againcontradicted the study’s hypothesis—which was that patients who received epidural steroidal injections would have improved outcomes compared with those who did not receive injections. Also, again there was no definitive surgical avoidance. Radcliff told Spinal News International: “The significant contribution of our studies is that we compared change in outcome as well as ‘surgical avoidance.’ We believe that
future studies, in addition to proving surgical avoidance, should also demonstrate prove equivalent or better outcomes in the non-surgically
treated patients. Otherwise patients are crossing over to a treatment arm associated with a less successful outcome. The other significant contribution of our study was that we assessed baseline preference for treatment. Not surprisingly, we new study recommends surgical treatment
for type II odontoid fractures. A study presented at the annual meeting of NASS has found that surgical treatment may improve functional and quality of life outcomes, compared with conservative treatment, in older patients with type II odontoid fractures. Although there is relative consensus for the management of type I and type III odontoid fractures, according to a study presenter Christopher Kepler, Thomas Jefferson
University, Philadelphia, USA, there is still a divergence of opinion in the spinal community about the management of type II odontoid fractures. Kepler explained that at present, the benefits and risks of surgical treatment vs. conservative treatment have not been fully determined. He said,
therefore: “The purpose of this study was to compare treatment outcomes in surgically and conservatively treated elderly patients who present
with a type II odontoid fracture.”
In his prospective, multicentre, cohort study, 159 patients aged 65 years or older with a type II odontoid fracture were managed with surgical or conservative treatment. Kepler explained: “This was not a randomised study: patients received non-operative (57) or surgical treatment (102) at the discretion of the surgical team, based on a discussion with the patient and their family.” He added that the patients were followed for 12 months or until they died, whichever came first. To measure the outcomes of the different treatment approaches, the investigators used the neck disability index score, the SF36v2 health survey, and reviewed treatment-associated rates of mortality and complications. Kepler said: “On enrollment, patients were similar in the surgical and non-surgical cohorts with respect to age, gender, ethnic background, marital status, associated injuries, comorbidities, and living arrangements.” Patients were also similar in terms of their
baseline neck disability scores and SF36v2 scores, but the bodily pain and physical component scores of the SF36v2 were slightly better in the patients treated conservatively. Posterior C1-C2 fusion, using screw fixation, was the most common approach used in the surgical group and the most of the conservative group patients were immobilised with a hard cervical orthosis.
After 12 months, there was no significant difference between the two groups in treatment-related complications (48 vs. 37; p=0.4805). However,
patients in the conservative group had a significant four-fold increase in the rate of nonunion compared with those in the surgical group (5 vs. 12; p=0.003). “It is probably worth mentioning that of the 12 patients in the conservative group who developed non-union, eight of them ultimately
required surgery for associated symptoms.” Kepler said. The neck disability index score worsened in both groups after 12 months, but significantly more so in the conservative group (5.7±18.5 vs. 14.7±18.1; p=0.0184). Kepler said: “The difference between the surgical and the non-operative group exceeded previously established estimates of the minimal clinically important difference.” He explained that a commonly quoted estimate of the mini-found that patients who chose to undergo epidural steroid injections were more reluctant to have surgery at baseline
and therefore more likely to ultimately ‘avoid surgery.’ This selection bias in which patients receive epidural steroid injections may confound
surgical avoidance which other studies report. Only a prospective, randomised, blinded ‘injection vs. no injection’ study will really answer this question.”
Source: Spinal News International
