Comparison of clinical efficacy of transforaminal and caudal epidural steroid injection in lumbar and lumbosacral disc herniation: A systematic review and meta-analysis

BACKGROUND CONTEXT: Epidural steroid injection has been used to treat back or radicular pain from lumbar and lumbosacral disc herniation (LDH). However, the superiority of transforaminal injection (TFESI) to caudal injection (CESI) remains controversial. PURPOSE: This systematic review and meta-analysis aimed to investigate whether TFESI was more useful than CESI for achieving clinical outcomes in patients with LDH. STUDY DESIGN/SETTING: A systematic review and/or is not appropriate. A systematic review and meta-analysis. Spine hospital and tertiary care hospital. PATIENT SAMPLE: Articles were chosen that compared the clinical efficacy of TFESI and CESI for treatment of low back and radicular leg pain caused by LDH. OUTCOMES MEASURES: Visual analogue scale, numeric rating scale, and Oswestry disability index. METHODS: A literature search was performed using MEDLINE, EMBASE, Cochrane review, and KoreaMed databases for studies published until July 2017. After reviewing titles, abstracts, and full-texts of 6,711 studies after initial database search, six studies were included in a qualitative synthesis. Data including pain score, functional score, and follow-up period were extracted from four studies and were analyzed using a random effects model to obtain effect size and its statistical significance. Quality assessment and evidence level were established in accordance with the grading of recommendations assessment, development and evaluation methodology. RESULTS: Among six studies, four articles supported the superiority of TFESI to CESI, one article showed no significant difference, and one article supported the superiority of CESI to TFESI. To obtain compatible or superior clinical results to TFESI, CESI might need to inject a larger amount of medication than was usually used. A meta-analysis showed short-term and long-term trends toward better clinical efficacy with TFESI than with CESI without statistical significance. The evidence level was low because of inconsistency and imprecision. CONCLUSIONS: Comprehensive reviews of selected articles revealed better clinical benefits with TFESI than with CESI, possibly because TFESI had the ability to deliver medication directly into the target area. Because of a low level of evidence and no significant results on meta-analysis, TFESI could be weakly recommended over CESI. (C) 2018 Published by Elsevier Inc.