Spinal Stenosis, Low Back Pain
Conditions
Keywords
Epidural Steroid Injection, Low Back Pain, Spinal Stenosis, Elderly
Brief summary
The broad, long-term objective of this research protocol is to improve the quality of life for patients suffering from lumbar spinal stenosis. This objective will be met by examining the safety and clinical efficacy of epidural steroid injections for treatment of pain associated with lumbar spinal stenosis. This prospective, randomized, double-blind controlled trial (RCT) will test the hypothesis that the effectiveness of epidural steroid injections (ESI) plus local anesthetic (LA) is greater than epidural injections of LA alone in older adults with lumbar spinal stenosis.
Detailed description
Lumbar spinal stenosis is one of the most common causes of low back pain in the elderly and can lead to significant disability. The symptoms of spinal stenosis range from low back pain to neurogenic claudication with lower extremity pain, weakness and/or sensory changes related to activities. As spinal stenosis can affect the central canal as well as the lateral recesses and intervertebral foramen variably, symptoms can involve single or multiple myotomes and dermatomes. Since the causes of spinal stenosis are most frequently degenerative changes, the symptoms of spinal stenosis often, but not always, worsen over time. Despite the prevalence of spinal stenosis, treatment of spinal stenosis remains somewhat controversial. Common treatments include conservative measures such as non-steroidal anti-inflammatories (NSAIDS), activity modification and physical therapy as well as more invasive treatments such as epidural steroid injections and surgery. Although surgery has been demonstrated to provide some benefit to many individuals with spinal stenosis, ESI are being used with increasing frequency as a less invasive, potentially more cost effective and safer treatment for spinal stenosis. However, there is a lack of data to demonstrate the effectiveness and safety of epidural steroid injections for spinal stenosis, particularly in the older adults. Because of the compelling need for effective therapy for patients suffering from spinal stenosis and because epidural steroid injections are rapidly becoming standard of care for treating these patients - even in the absence of compelling clinical evidence - we are conducting a randomized, controlled trial in order to test the hypothesis that lumbar epidural steroid injections improve functional status and pain associated with spinal stenosis. The main objective of the study is to conduct a blinded, randomized controlled trial (RCT) in elderly patients with spinal stenosis to test if the effectiveness of epidural steroid injections (ESI) plus local anesthetic (LA) is greater than LA alone.
Interventions
PROCEDUREEpidural steroid with local anesthetic injection
Epidural steroid injectate will be 2cc of 1% lidocaine followed by 1-3 cc of 40 mg/cc Kenalog (i.e. 40-120 mg Kenalog) or an equivalent steroid medication (depo-medrol 60-120 mg, betamethasone 6-12 mg or dexamethasone 8-10 mg) in an opaque syringe.
PROCEDUREEpidural local anesthetic injection
Epidural injectate will be 2cc of .25-1% lidocaine followed by 1-3cc of 1% lidocaine in an opaque syringe.
Epidural steroid injectate will be 2cc of .25 - 1% lidocaine followed by 1-3 cc of 40 mg/cc Kenalog (i.e. 40-120 mg Kenalog) or an equivalent steroid medication (depo-medrol 60-120 mg, betamethasone 6-12 mg or dexamethasone 8-10 mg) in an opaque syringe.
Sponsors
Kaiser Permanente
University of California, San Francisco
Henry Ford Hospital
Harvard Pilgrim Health Care
Harvard Vanguard Medical Associates
University of Colorado, Denver
Mayo Clinic
Stanford University
Massachusetts General Hospital
Virginia Spine Research Institute
Oregon Health and Science University
Dallas VA Medical Center
University of Washington
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
TRIPLE (Subject, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
50 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Pain in the low back, buttock, and/or lower extremity (pain NRS\>=5) with standing, walking and/or spinal extension (buttock/leg\>back pain). 2. Modified Roland-Morris score of at least 7. 3. Mild-severe lumbar central canal spinal stenosis (Boden et al. criteria18) identified by MRI or CT scan. 4. Lower extremity symptoms consistent with neurogenic claudication. 5. Must be able to read English and complete the assessment instruments. 6. Age 50 or older.
Exclusion criteria
1. Cognitive impairment that renders the patient unable to give informed consent or provide accurate data. 2. Clinical co-morbidities that could interfere with the collection of data concerning pain and function. Known dx of fibromyalgia, chronic widespread pain, amputees, parkinsons, head injury, dementia, stroke, other neurologic conditions Collect date about cervical spinal stenosis, painful peripheral neuropathy, EMGs 3. Severe vascular, pulmonary or coronary artery disease that limits ambulation including recent myocardial infarction (within 6 months). 4. Spinal instability requiring surgical fusion. 5. Severe osteoporosis as defined by multiple compression fractures or a fracture at the same level as the stenosis. 6. Metastatic cancer. 7. Excessive alcohol consumption or evidence of non-prescribed or illegal drug use. 8. Possible pregnancy or other reason that precludes the use of fluoroscopy. 9. Concordant pain with internal rotation of the hip (or known hip joint pathology). 10. Active local or systemic infection. 11. Abnormal coagulation. 12. Allergy to local anesthetic, steroid or contrast. 13. Previous lumbar spine surgery. 14. Epidural steroid injection within previous 6 months.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Roland Morris | 6 weeks | The primary outcome measure will be back specific functional status, measured by the Roland Scale at 6 weeks. The RDQ is a back pain specific functional status questionnaire adapted from the Sickness Impact Profile (SIP). The RDQ consists of 24 yes/no items, which represent common dysfunctions in daily activities experienced by subjects with low back pain. A single unweighted score is derived by summing the 24 items, with higher scores indicating worse function with 0 (no disability) to 24 (maximum disability). Our primary analysis will be a simple 2-group comparison of the mean Roland score as an evaluation of the short-term efficacy of epidural steroid injection. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Pain Numeric Rating Scale | 6 weeks | Leg Pain NRS is a second primary outcome at 6 weeks We measured leg pain using a 0-10 pain NRS (0=no pain and 10=worst pain imaginable) assessing average pain over the past week. |
| Roland Morris Disability Questionnaire (RDQ) | 12 months | The RDQ is a back pain specific functional status questionnaire adapted from the Sickness Impact Profile (SIP). The RDQ consists of 24 yes/no items, which represent common dysfunctions in daily activities experienced by subjects with low back pain. A single unweighted score is derived by summing the 24 items, with higher scores indicating worse function with 0 (no disability) to 24 (maximum disability). Our primary analysis will be a simple 2-group comparison of the mean Roland score as an evaluation of the short-term efficacy of epidural steroid injection. |
| Leg Pain NRS | 12 months | Leg Pain NRS 0-10 scale |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Epidural Steroid Injection Intervention: Epidural steroid with local anesthetic injection
2cc of .25 - 1% lidocaine and glucocorticoid (Kenalog 40-120 mg, depo-medrol 60-120 mg, betamethasone 6-12 mg or dexamethasone 8-10 mg)in an opaque syringe.
Epidural steroid with local anesthetic injection: Epidural steroid injectate will be 2cc of 1% lidocaine followed by 1-3 cc of 40 mg/cc Kenalog (i.e. 40-120 mg Kenalog) or an equivalent steroid medication (depo-medrol 60-120 mg, betamethasone 6-12 mg or dexamethasone 8-10 mg) in an opaque syringe.
Epidural steroid injection: Epidural steroid injectate will be 2cc of .25 - 1% lidocaine followed by 1-3 cc of 40 mg/cc Kenalog (i.e. 40-120 mg Kenalog) or an equivalent steroid medication (depo-medrol 60-120 mg, betamethasone 6-12 mg or dexamethasone 8-10 mg) in an opaque syringe. | 200 |
| Epidural Local Anesthetic Injection Intervention: Epidural injectate will be 2cc of .25-1% lidocaine followed by 1-3cc of 1% lidocaine in an opaque syringe.
Epidural local anesthetic injection: Epidural injectate will be 2cc of .25-1% lidocaine followed by 1-3cc of 1% lidocaine in an opaque syringe. | 200 |
| Total | 400 |
Baseline characteristics
| Characteristic | Epidural Steroid Injection | Epidural Local Anesthetic Injection | Total |
|---|---|---|---|
| Age, Continuous | 68.0 years STANDARD_DEVIATION 9.8 | 68.1 years STANDARD_DEVIATION 10.2 | 68 years STANDARD_DEVIATION 10 |
| Sex: Female, Male Female | 117 Participants | 104 Participants | 221 Participants |
| Sex: Female, Male Male | 83 Participants | 96 Participants | 179 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 43 / 200 | 31 / 200 |
| serious Total, serious adverse events | 5 / 200 | 4 / 200 |
Outcome results
Primary
Roland Morris
The primary outcome measure will be back specific functional status, measured by the Roland Scale at 6 weeks. The RDQ is a back pain specific functional status questionnaire adapted from the Sickness Impact Profile (SIP). The RDQ consists of 24 yes/no items, which represent common dysfunctions in daily activities experienced by subjects with low back pain. A single unweighted score is derived by summing the 24 items, with higher scores indicating worse function with 0 (no disability) to 24 (maximum disability). Our primary analysis will be a simple 2-group comparison of the mean Roland score as an evaluation of the short-term efficacy of epidural steroid injection.
Time frame: 6 weeks
Population: 6 week follow up rate was 97% (n=193/200, n=193/200).
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Epidural Steroid Injection | Roland Morris | 11.8 units on a scale | Standard Deviation 6.3 |
| Epidural Local Anesthetic Injection | Roland Morris | 12.5 units on a scale | Standard Deviation 6.4 |
Secondary
Leg Pain NRS
Leg Pain NRS 0-10 scale
Time frame: 12 months
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Epidural Steroid Injection | Leg Pain NRS | 4.7 units on a scale | Standard Deviation 3.1 |
| Epidural Local Anesthetic Injection | Leg Pain NRS | 4.3 units on a scale | Standard Deviation 3.1 |
Secondary
Pain Numeric Rating Scale
Leg Pain NRS is a second primary outcome at 6 weeks We measured leg pain using a 0-10 pain NRS (0=no pain and 10=worst pain imaginable) assessing average pain over the past week.
Time frame: 6 weeks
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Epidural Steroid Injection | Pain Numeric Rating Scale | 4.4 units on a scale | Standard Deviation 2.9 |
| Epidural Local Anesthetic Injection | Pain Numeric Rating Scale | 4.6 units on a scale | Standard Deviation 2.9 |
Secondary
Roland Morris Disability Questionnaire (RDQ)
The RDQ is a back pain specific functional status questionnaire adapted from the Sickness Impact Profile (SIP). The RDQ consists of 24 yes/no items, which represent common dysfunctions in daily activities experienced by subjects with low back pain. A single unweighted score is derived by summing the 24 items, with higher scores indicating worse function with 0 (no disability) to 24 (maximum disability). Our primary analysis will be a simple 2-group comparison of the mean Roland score as an evaluation of the short-term efficacy of epidural steroid injection.
Time frame: 12 months
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Epidural Steroid Injection | Roland Morris Disability Questionnaire (RDQ) | 12.0 units on a scale | Standard Deviation 6.5 |
| Epidural Local Anesthetic Injection | Roland Morris Disability Questionnaire (RDQ) | 11.5 units on a scale | Standard Deviation 7.1 |