title: Transforaminal epidural steroid injections followed by mechanical diagnosis and therapy to prevent surgery for lumbar disc herniation.
abstract: METHODS
  Prospective cohort study.
  
  
  OBJECTIVE
  To report the clinical course of patients with MRI-confirmed lumbar disc herniation-related radicular noncentralizing pain who received transforaminal epidural steroid injections (TESIs) and mechanical diagnosis and therapy (MDT).
  
  
  BACKGROUND
  Noncentralizing symptoms in patients with lumbar disc herniation are associated with poor outcome. Commonly used treatments for these patients include TESIs and MDT. No study has evaluated the outcome of combining both strategies.
  
  
  METHODS
  Consecutive candidates for herniated lumbar disc surgery with noncentralizing chronic pain were eligible. Patients received TESIs followed by MDT. The primary outcomes were pain severity in the leg, disability (Roland-Morris Disability Questionnaire for Sciatica), and global perceived effect (GPE). Outcomes were measured at baseline, discharge, and 12 months. Linear mixed-models and McNemar's tests were used to analyze outcome data.
  
  
  RESULTS
  Sixty-nine patients receive TESIs. After TESIs, symptoms were resolved completely in 11 patients (16%). In these patients, symptom resolution was maintained at 12 months. A second subgroup of 32 patients (46%) reported significantly less pain after TESIs and showed centralization with MDT reassessment (significant reductions in leg pain and disability [P < 0.001]) and a satisfaction rate of 90% at 12 months. A third subgroup of 11 patients (16%) reported significantly less pain after TESIs but still showed noncentralization with MDT reassessment (significant reductions in leg pain and disability [P < 0.05] and a satisfaction rate of 50% at 12 months). A fourth subgroup of 15 patients (22%) did not respond on TESIs and received an operative intervention.
  
  
  CONCLUSIONS
  The results indicate that a course of TESIs followed by MDT may be able to avoid surgery in a substantial proportion of candidates for herniated lumbar disc surgery.
authors.affiliation: Medical Back Neck Centre, The Hague and Rugpoli Brabant Tilburg, The Netherlands.
authors.forename: Hans
authors.initials: H
authors.lastname: van Helvoirt
authors.forename: Adri T
authors.initials: AT
authors.lastname: Apeldoorn
authors.forename: Raymond W
authors.initials: RW
authors.lastname: Ostelo
authors.forename: Dirk L
authors.initials: DL
authors.lastname: Knol
authors.forename: Mark P
authors.initials: MP
authors.lastname: Arts
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Kamper
authors.forename: Maurits W
authors.initials: MW
authors.lastname: van Tulder
mesh_terms: D000328:Adult; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage; D015331:Cohort Studies; D003131:Combined Modality Therapy; D003907:Dexamethasone / Q000008:administration & dosage*; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage*; D006801:Humans; D007268:Injections, Epidural; D007405:Intervertebral Disc Displacement / Q000188:drug therapy* / Q000534:rehabilitation*; D008159:Lumbar Vertebrae; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000188:drug therapy / Q000209:etiology / Q000534:rehabilitation; D010147:Pain Measurement; D026741:Physical Therapy Modalities; D016896:Treatment Outcome
chemical_list: D000893:Anti-Inflammatory Agents; D005938:Glucocorticoids; D003907:Dexamethasone
keywords: Herniated Disc; MDT; Surgery; Transforaminal Epidural Injection