Marys Medicine

WIMJOURNAL, Volume No. 2, Issue No. 1, 2015 Nawab P. Jamadar

A Comparative study of Triamcinolone acetonide with Methylprednisolone
sodium succinate in the management of chronic low back pain
Nawab P. Jamadar1, Aditya V. Vazalwar2 and Basavraj S. Nagoba3 Professor & Head, Anaesthesia1, Resident of Anaesthesia2 and Assistant Dean (R & D)3 M. I. M. S. R. Medical College & Y. C. Rural Hospital, Latur, India. ABSTRACT
bupivacaine diluted in 8 ml of normal saline Background: Low back pain is the most
into the lumbar epidural space. Group B common complaint of young adults in case was given injection methylprednisolone of intervertebral disc herniation. Its sodium succinate 80 mg with 2 ml of 0.5% incidence is high in India due to difficult bupivacaine diluted in 8 ml of normal saline working as well as living environment. Objectives: The present study was carried
Observations: The success rate in group A
out to compare the efficacy of injecting was found to be 68% and the success rate in group B was found to be 80%. The visual methylprednisolone sodium succinate in analog scale score in group A was the management of chronic low back pain. decreased by 20% after one week and by 50 Patients and Methods: This study was
– 60% at the end of 6 months. However, in carried on patients presenting with low group B, the visual analog scale score back pain who had MRI proven lumbar disc decreased by 30% after one week and by prolapsed at different levels and were not 70-80% at the end of 6 months. Conclusion:
responding to conservational management. Methylprednisolone sodium succinate was The study was carried out on 50 subjects found to be more efficacious in the divided into 2 groups, Group A and Group B management of chronic low back pain than of 25 each. Group A was given injection triamcinolone acetonide. triamcinolone 80 mg with 2 ml of 0.5% Keywords-
Methylprednisolone, Low back Pain WIMJOURNAL, Volume No. 2, Issue No. 1, 2015 Nawab P. Jamadar

cause nerve root pain [3], since painful Low back pain (LBP) continues to be a radiculopathy may be the end result of a leading cause of disability. Its life time local chemical contribution from injured incidence in the United States is 80% [1]. tissue [4]. Treating patients suffering from The data of prevalence in India is not LBP can also be challenging and this is available but the prevalence is high because probably why so many treatment methods of difficult working environment and living ranging from conservative management to conditions. This is a disabling condition of surgical management have been introduced young adults and is the most common cause and are supported by literature [2]. of limitation of physical activity [1]. In most Although the actual mechanism of action is of the cases the pain will resolve on its own not fully known, there is evidence that within a few weeks, but recent evidence corticosteroids achieve pain relief by indicates that the relief from ‘self healing' is inhibition of pro inflammatory mediators followed by a significant incidence of namely neural peptides, phospholipase A, recurrence, usually in less than a year. It is acid hydrolases, histamine and kinin. In an unfortunate fact that symptoms result addition to this they also cause a reversible from degenerative changes in the spine – an ongoing process that has no cure. sensitivity of nerve roots to irritants) [5, 6]. Lumbar disc herniation seems to be one of The treatments used to correct this problem nevertheless it is well known that many management, epidural steroid injections and patients, complaining of LBP as well as surgical intervention [7, 8]. Epidural steroid radiating leg pain suggesting sciatica, did injection (ESI) is a non surgical treatment not show lumbar disc herniation in magnetic for management of low back pain as well as resonance imaging (MRI) and computed radicular pain caused by herniated lumbar tomography (CT) [2]. There is emerging disc. The low back pain of mechanical evidence suggesting that this ‘paradox' must origin, accompanied by signs and symptoms be probably attributed to the fact that nerve of nerve root irritation, respond to ESI with root compression is not sufficient by itself to WIMJOURNAL, Volume No. 2, Issue No. 1, 2015 Nawab P. Jamadar

gratifying results. It relieves pain, improves antidepressants, oral steroids, transcutaneous function and reduces the need for surgical electrical nerve stimulation (TENS), traction intervention; thus, being more cost-effective. as well as ultrasound and MRI proven Therefore longer acting ESI are being used lumbar disc prolapsed at different levels and are being slowly but surely established were included in the study. The cases with as a reliable mode of minimally invasive motor deficit, prior lumbar disc surgery, treatment modality in many orthopaedic diabetes, bleeding disorders and those who centres of the world as they are shown to were not willing to participate in the study provide analgesia for variable periods [9, were excluded from the study. This study was carried out on 50 subjects In the present study, an attempt was made to divided into two groups, Group A and study the efficacy of injecting epidural Group B consisting of 25 cases each. Group triamcinolone acetonide in the managements A received Injection Triamcinolone 80 mg of chronic low back pain and its comparison with 2 ml of 0.5% bupivacaine diluted in 8 with methylprednisolone sodium succinate ml of normal saline into the lumbar epidural – a commonly used treatment option for space and group B received Injection chronic low back pain Methylprednisolone sodium succinate 80 mg PATIENTS AND METHODS
(single dose vial of 1 ml consisting of 40 mg This is a prospective comparison study, of the drug; we used 2 such vials) with 2 ml conducted over a period of one year from of 0.5% bupivacaine diluted in 8 ml of March – April 2014 to March – April 2015. normal saline into the lumbar epidural This study was approved by the institutional ethics committee. Written and informed After taking detail history and thorough consent was obtained from each patient. clinical examination, the findings of straight During this period 50 patients presented to leg raising test (SLR), motor and sensory the hospital with the chief complaint of low deficit and deep tendon reflexes (DTR) were back pain radiating to the legs not noted. Routine laboratory investigations responding to conservative management (i.e. including prothrombin time, bleeding time, non steroidal anti-inflammatory drugs – clotting time, platelets and random blood sugar was done. The patients were randomly WIMJOURNAL, Volume No. 2, Issue No. 1, 2015 Nawab P. Jamadar

selected to receive either Triamcinolone or The patients were first reviewed after one Methylprednisolone sodium succinate. All week, and then further follow up was carried patients were given ESI in sitting position. out at one month and six months after receiving the ESI. anaesthesiologist During the follow up, visual analog scale following painting and draping under aseptic (VAS) was used to evaluate the response to treatment. VAS score was used for peripheral venous access was secured in all assessment of current back and lower the patients with 20 G intravenous cannula extremity pain, ranging from 0 (no pain) to on the dorsum of hand. ECG, heart rate, 10 (worst pain). If a patient subjectively non-invasive blood pressure (NIBP) and reported a decrease in pain within one week peripheral oxygen saturation of the patient after a single injection, no more injections were administered. If the patient didn't have The disc level for ESI was located by improvement within a week, a second surface anatomy. Using strict aseptic injection was given. Patients with low back techniques, 2 ml of 1% lidocaine was pain not responding to a second dose of ESI infiltrated into the skin and subcutaneous were considered for surgery. If the patient tissue for surface anaesthesia. An 18 gauge did not have subjective improvement even tuohy epidural needle was inserted into the after a second dose of ESI, it was considered epidural space of herniated lumbar disc as failure of ESI. The success rate of ESI through trans-lumbar route with the bevel was presented as a percentage. All patients upward and stylet in position. The epidural were advised to take mild analgesics (Tab. space was identified by loss of resistance to Diclofenac 75 mg oral 8 hourly for 1 day) during the post injection period. No special After the procedure, patients were advised to exercise program or other physical therapy lie supine in case of bilateral symptoms and was employed after the injection. to lie in left or right lateral position in case of isolated left or right sided symptoms In group A, out of 25 patients eight patients respectively. During this period they were did not improve with ESI. Among them, six observed for any possible complications. patients had to undergo surgery and two WIMJOURNAL, Volume No. 2, Issue No. 1, 2015 Nawab P. Jamadar

patients did not come for follow up. Considering those who did not come for Group No. of No. follow up as failures, the success rate in dropouts responded to group A was 68%. All the six patients who underwent surgery had multilevel disc prolapse (L4-L5 and L5-S1) (Table 1). In group B, out of 25 patients five patients Table 2: The mean VAS scores in group
did not improve with ESI. Among them A and group B patients
three had to undergo surgery and two VAS in Group A VAS in Group B patients did not come for follow up. Considering those two patients as failures we found that the success rate in group B was 80% (Table 1). %. All the three patients After One month After One month who underwent surgery had multilevel disc After Six months After The most common single level disc prolapse months – 2 to 3 was L4-L5 followed by L5-S1. In Group A, the VAS score decreased by DISCUSSION
approximately 20% after one week and by Epidural steroid injections have been used approximately 50 – 60% at the end of 6 for decades in the management of low back months. In Group B, the VAS score pain. It is minimally invasive and an decreased by approximately 30% after one effective treatment modality in many week and by approximately 70-80% at the orthopaedic centers. The first reported use of end of 6 months. epidural steroid was in 1952 by Robecchi No complications were observed except for and Capra [11] and it's still an integral part local pain over injection site in two patients. of non surgical management of low back Comparative
hydrocortisone in the first sacral route. Methylprednisolone sodium succinate in
Epidural steroid is found to be beneficial in the management of chronic low back pain
WIMJOURNAL, Volume No. 2, Issue No. 1, 2015 Nawab P. Jamadar

prolapse intervertebral disc, spinal canal equivalent in biological activity. The relative stenosis and degenerative disc disease potency of methylprednisolone sodium whereas it is found to have no benefits in non specific back pain, facet syndrome, succinate, as indicated by depression of metastatic and metabolic causes [12, 13]. eosinophil count, following intravenous ESI following epidurography (fluoroscopic administration, is at least four to one. It has guidance) is found to be superior to the blind been demonstrated that sodium succinate technique [14]. It is found that in 30 – 70 % ester of methyprednisolone is rapidly and of the cases, there is inappropriate placement of the drug during ESI even with methylprednisolone moiety after all routes the hands of an experienced performer [14]. of administration. Though the short term effect i.e. less than 6 In Bogduk series, out of 40 studies and weeks is superior in the transforaminal more than 4000 patients on lumbar and method than the intralaminar or interspinous technique of epidural steroid deposition, the recommended in favour of the use of ESI in long term outcome is found to be similar lumbosacral pain [19]. Similarly Koes et al. [15]. There are several types of steroids reviewed 12 randomized controlled trials to being used for epidural steroid injections assess the efficacy of epidural steroid injections for low back pain and found six methylprednisolone. studies confirming that ESI were indeed However, different studies have failed to effective [20] . In several studies patients prove superiority of one steroid above the were followed after ESI for periods ranging other [16, 17, 18]. from weeks to one year, showed to be Methylprednisolone as it has a relatively beneficial [21, 22]. The treatment of low back pain with Methylprednisolone sodium succinate has radicular involvement has remained a matter the same metabolic and anti-inflammatory of controversy because of multifactorial actions as methylprednisolone. When given etiology and varying therapeutic modalities. by parenteral route and in equimolar antidepressants, quantities, the two compounds are steroids, transcutaneous electrical nerve WIMJOURNAL, Volume No. 2, Issue No. 1, 2015 Nawab P. Jamadar

stimulation (TENS), traction and ultrasound reported the success rate ranging from 63 to have been used alone or in combination but 80% [28, 29]. Also a significant decrease in without any proven efficacy [23]. Surgery is VAS in Group B was observed. The particularly indicated but its failure rate can decrease in VAS was 30% after one week be as high as 30%. The incidence of and by 70-80% at the end of six months. persistent back pain after surgery was found There are several factors for varied results to be inversely proportional to the degree of like patient selection, technique of injection, herniation [24]. Hence, ESI was found to be dosage of steroid and follow up. In this an alternative treatment modality with good study the patients who had to undergo results in symptomatic herniated disc. The discectomy had large herniated discs, findings of present study are also quite multilevel disc prolapsed and obesity. In this similar to these earlier findings. study, only two patients reported with local In our study, the use of methylprednisolone pain at the injection site, which subsided sodium succinate in group B for the without treatment. management of low back pain showed Conclusion
significant decrease The results of present study indicate that the herniated discs as well as improvement in ESI following lumbar radicular pain using the functional status of the patients. methylprednisolone sodium succinate has a Methylprednisolone is a corticosteroid and better outcome than Triamcinolone acetonid. is well known for its anti-inflammatory However, the frequency of dose of ESI may properties [25] and also stabilizes neural vary depending upon the outcome of the discharges [26], and may have direct Conflicts of Interest: None to declare
anaesthetic effect on small unmyelinated Source of Funding: None to declare
nociceptive type C fibres [27]. In our study, in group A, we found that 17 (68%) cases showed improvement and in improvement. Our findings are quite similar to Swerdlow et al. and Winnie et al. who WIMJOURNAL, Volume No. 2, Issue No. 1, 2015 Nawab P. Jamadar

Physician. 1. Keith DW, Ashley LP. Low back pain & disorders of intervertebral 8. Cuckler JM, Bernini PA, Wiesel SW, discs. S. Terry Canale, editor- Booth RE, Rothman RH, Pickens Campbell's operative orthopaedics GT. The use of epidural steroids in Vol III. 9th ed. Mosby, 2003: 3014- the treatment of lumbar radicular pain. A prospective, randomized, 2. Peng B, Wu W, Li Z, et al. Chemical double-blind study. J Bone Joint radiculitis. Pain 2007;127:11-6 Surg Amer 1985; 67:63-6 3. Mulleman D, Mammou S, Griffoul I, et al. Pathophysiology of disc related injection for low back pain and sciatica. I- evidence supporting a chemical component. Joint Bone Spine 2006;73:151-8 10. Glenn R. Buttermann. Treatment of 4. Kawakami M, Tamaki T, Hayashi N, lumbar disc herniation: Epidural et al. possible mechanism of painful steroid injection compared with herniation. Clin Orthop Relat Res randomized study. J Bone Joint Surg 1998; 351:241-51 5. Abdi S, Datta S, Trescot AM et al. Epidural steroids in the management of chronic spinal pain: A systematic Physician. Rheumatology. Minerva Med 1952; 6. Manchikanti L. role of neuraxial 12. Boswell M, Hansen H, Trescot A, Hirsch J. Epidural steroids in the management. Pain Physician. 2002; management of chronic spinal pain and radiculopathy. Pain Physician 7. Abdi S, Datta S, Trescot AM et al. 2003; 6: 319-334 Epidural steroids in the management 13. Koes BW, Scholten RJ, Mens JM, of chronic spinal pain: A systematic Bouter LM. Efficacy of Epidural WIMJOURNAL, Volume No. 2, Issue No. 1, 2015 Nawab P. Jamadar

steroid injections for low back pain 18. Blankenbaker DG, De Smet AA, and sciatica: a systemic review of Stanczak JD, Fine JP. Lumbar randomized clinic pain 1995; 63: radiculopathy : Treatment with selective nerve route blocks : 14. Botwin KP et al. Fluoroscopically of effectiveness triamcinolone and betamethasone injectable suspensions. Radiology degenerative lumbar stenosis : An 2005; 237: 738-741 outcome study. Am J Phys Med 19. Bogduk N. Epidural steroids for low Rehab 2002; 81(12) : 898-905. back pain and sciatica. Pain Digest 15. Thomas E, Cyteval C, Abiad L et al. 20. Koes BW, Scholten RJPM, Mens interspinous corticosteroid injection JMA, Bouter LM. Efficacy of in discal radiculalgia : A prospective, Epidural steroid injections for low randomized, double blind study. Clin back pain and sciatica: a systemic Rheumatol 2003; 22: 299-304 review of randomized clinical trial. 16. Botwin KB, Gruber RD, Bouchlas Pain 1995; 63: 279-88 CG et al. Fluoroscopically guided 21. Dilke TF, Burry HC, Grahame R. Extradural corticosteroid injection in steroid injections in degenerative management of lumbar nerve root lumbar stenosis : An outcome study. compression. Brit Med J 1973; 2: Am J Phys Med Rehab 2002; 81 : 22. Yates DW. A comparison of the 17. Anwar A, Zaida I, Rozita R. types of epidural injection commonly Prospective randomized single blind used in the treatment of low back study of epidural steroid injection pain and sciatica. Rheumatol Rehabil comparing Triamcinolone acetonide with Methylprednisolone acetate. APLAR J Rheumatology 2005; 8: 1- treatment for chronic low back pain. Ashish D. Diwan, Safdar N. Khan. Ortho Clin North Amer 2004: 57-64 WIMJOURNAL, Volume No. 2, Issue No. 1, 2015 Nawab P. Jamadar

24. Spangfort EV, The lumbar disc 27. Johansson A, Hao J, Sjolund B. analysis of 2504 operations. Acta Othop Scand 1972; 142: 1-95 Anaesthesiol Scand 1990; 34: 335-8 Antiinflammatory steroid induced 28. Swerdlow M, Sayle-Creer W. A biosynthesis of a phospholipase A2 study of extradural medication in the relief of lumbosciatic syndrome. Anesth 1970; 25: 341 1979; 278: 456-9 29. Winnie AP, Hartman JT, Meyers 26. Devor M, Govrin-Lippmann R, HL, Ramamurthy S, Barangan V. Raber P. Corticosteroids suppress ectopic neural discharge originating extradural corticosteroids in sciatica. in experimental neuromas. Pain Anesth Analg 1972; 51: 990. 1985; 22: 127-37
Address for correspondence: Dr. B. S. NAGOBA

Assistant Dean (R&D), Maharashtra Institute of Medical Sciences & Research, Medical College, Latur – 413 531 (M.S.) India E- mail -
Mobile – +91- 09423075786
Walawalkar International Medical Journal



Complete Summary GUIDELINE TITLE The management of persistent pain in older persons. BIBLIOGRAPHIC SOURCE(S) AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc 2002 Jun;50(6 Suppl):S205-24. [126 references] GUIDELINE STATUS This is the current release of the guideline.