Lumbar Radiculopathy
Conditions
Keywords
lumbar radiculopathy, rTMS, TESI, treatment
Brief summary
The present study aims to investigate the efficacy of repetitive transcranial magnetic stimulation of the motor cortex combined with transforaminal epidural steroid injection in patients with chronic lumbar radiculopathy.
Detailed description
Treatment methods of lumbar radiculopathy include short-term bed rest, medical treatments, physical therapy and rehabilitation techniques, psychotherapy, acupuncture, cryotherapy, epidural steroid injections, and surgical treatment. Epidural steroid injection is an effective treatment procedure in patients whose conservative treatment methods are not successful. Fluoroscopy guided transforaminal epidural steroid injection (TESI) is the most ideal procedure and it is considered as an effective treatment approach in radicular pain and concomitant neuropathic pain because of reaching the target area, which is the origin of pathology. Although radicular pain is usually caused by a peripheral lesion, central sensitization and maladaptive plasticity have been shown to play an important role in the development and chronicity of this pain. These data suggest that central pain processing should be altered or stopped, especially in the presence of refractory pain. Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are non-invasive brain stimulation techniques that are increasingly being used to treat refractory neuropathic pain. Although short-term efficacy of rTMS treatment in radicular pain management was shown in one study, long-term efficacy was not evaluated and the necessity of trials evaluating long-term efficacy was reported. In accordance with these findings, we aimed to investigate the long-term effect of rTMS treatment in patients with chronic lumbar radiculopathy who received TESI. Patients diagnosed with chronic lumbar radiculopathy and planned to administer fluoroscopy-guided TESI will be included in the study. Patients will be randomized into two groups following TESI. Home-based exercise program will be given to both groups after injection. One week after the injection, only the first group will receive 10 sessions of rTMS treatment for 2 weeks in addition to the exercise program. rTMS treatment will be performed with the device used in our clinic for neurological rehabilitation and pain management. Patients will be assessed by a blind researcher using the Visual Analogue Scale (VAS) for low back and leg pain, the Douleur Neuropathique 4 Questions (DN-4) for neuropathic pain, the Oswestry Disability Index for disability, the Beck Depression Scale for depression, and the Central Sensitization Inventory for central sensitization. All assessments will be performed by the same physician before injection, first hour (only VAS), third week, third month, and sixth month after the injection. All adverse events will be noted. After data collection, analysis will be performed with the appropriate statistical method.
Interventions
DEVICERepetitive transcranial magnetic stimulation (rTMS)
Stimulation will be performed from the contralateral M1 cortex of the painful side. Each stimulation session will consist of 1500 pulses (30 trains of 5 seconds each, with an inter-train interval of 25 seconds) delivered at a frequency of 10 Hz. The stimulation intensity will be set at 80% of the resting motor threshold.
An epidural steroid injection under guidance of fluoroscopy is used to reduce inflammation at a lumbar spinal nerve root(s). The following drugs will be used for this procedure: 80mg/2ml triamcinolone acetonide (sinakort-A) and 1 mL 0.5% bupivacaine (marcaine)
Sponsors
Marmara University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to 75 Years
Healthy volunteers
No
Inclusion criteria
1. Aged between 20-60 years 2. Symptoms lasting longer than 3 months 3. To be planned TESI due to root compression which is caused by lumbar disk herniation 4. To agree to participate in the study
Exclusion criteria
1. Lumbar spinal stenosis 2. Presence of clinical findings incompatible with MRI 3. Spinal disease (trauma / tumor) 4. Spondylodiscitis or inflammatory spondylitis 5. Presence of epilepsy 6. Presence of implanted medical devices such as pacemakers, insulin pumps 7. Intracranial metallic implant 8. Previous cranial surgery history 9. Brain tumor 10. Severe hearing and vision loss 11. To be applied TESI for the last six months 12. Presence of surgical history through lumbar region 13. Scoliosis 14. Spodilolistezis 15. Pregnancy 16. Osteoporotic lumbar fracture 17. The presence of inflammatory diseases that affect spinal morphology, such as ankylosing spondylitis 18. Patients with electrophysiologically determined polyneuropathy, amyotrophic lateral sclerosis, etc. neurological disease
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Low back and leg pain | before treatment (T0) | Low back and leg pain will be evaluated with a 10-cm horizontal visual analogue scale (VAS) ranging from 0 cm (no pain) to 10 cm (intolerable pain). |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Quality of life and activities of daily living | before treatment (T0) | The potential changes in quality of life and activities of daily living will be measured by validated Oswestry Disability Index scores. It consists of 10 questions and the patient gets a minimum of 0 and a maximum of 5 points for each question. According to this, it is calculated how many percent of the patient's life activities are affected. Higher scores mean a worse outcome. |
| Neuropathic pain | before treatment (T0) | Douleur Neuropathique 4 questions will be used to determine the presence of neuropathic pain. It consists of ten questions, 7 questions are related with symptoms and the answer to the other 3 questions is determined by clinical examination. Scoring is between 0 and10 and a score of 4 and above is considered as neuropathic pain. |
| Central sensitization | before treatment (T0) | Central sensatization inventory will be used to identify the presence and severity of central sensitization. Central Sensatization Inventory consists of 25 questions. Each question is scored between 0 and 4 (0 = never, 4 = always). A score of 40 or above indicates the presence of central sensitization with 81% sensitivity and 75% specificity. Central sensitization severity was defined as 0-29 subclinical, 30-39 mild, 40-49 moderate, 50-59 severe, \>59 very severe. Higher scores mean a worse outcome. |
| The Beck depression inventory | before treatment (T0) | The Beck depression inventory is a 21-item, self-rated scale that evaluates key symptoms of depression including mood, pessimism, sense of failure, self-dissatisfaction, guilt, punishment, self-dislike, self-accusation, suicidal ideas, crying, irritability, social withdrawal, indecisiveness, body image change, work difficulty, insomnia, fatigability, loss of appetite, weight loss, somatic preoccupation, and loss of libido. The minimum score is 0 and the maximum score is 63. Higher scores mean a worse outcome. Higher scores indicate the severity of depression. |
| Adverse events | before treatment (T0) | All adverse events and complications will be noted. |
Countries
Turkey (Türkiye)
Contacts
Primary ContactSavaş Şencan, Asst. Prof
Backup ContactCanan Şanal Toprak, Asst. Prof
Outcome results
None listed