Evaluating the effectiveness of cervical epidural methylprednisolone acetate injection in treating cervical disc displacement

Nội dung text: Evaluating the effectiveness of cervical epidural methylprednisolone acetate injection in treating cervical disc displacement

1. Journal of military parmaco-medicine n 07-2017 EVALUATING THE EFFECTIVENESS OF CERVICAL EPIDURAL METHYLPREDNISOLONE ACETATE INJECTION IN TREATING CERVICAL DISC DISPLACEMENT Dinh Huy Cuong*; Nguyen Van Chuong**; Nhu Dinh Son** SUMMARY Objectives: To evaluate the effectiveness and safety of cervical epidural methylprednisolone acetate injection in treating cervical disc displacement. Subjects and methods: A descriptive study on 82 patients who underwent cervical disc displacement were positive diagnosed by clinical and magnetic resonance imaging and treated in Neurology Department, Ninhbinh Hospital from May, 2015 to December, 2016. These patients were randomly divided into two groups: the study group (42 patients) and the control group (40 patients). The study group was treated with drugs and fluoroscopic cervical interlaminar epidural Depo-medrol 40 mg + 2 mL lidocaine 2% injection 2 times. The control group was treated with drug and paraspinal muscle Depo-medrol 40 mg + 2 mL lidocaine 2% injection 2 times. The interval between injections was 1 week. Results: All patients in both groups improved after treatment. However, patients treated with cervical epidural methylprednisolone acetat had better results than those treated with paraspinal muscle methylprednisolone acetate: in the patient group (block epidural area - BEA), the rate of patients achieving very good level was 61.9% (reduction ≥ 75% of symptoms,) good level (decrease ≥ 50% of symptoms) accounted for 35.7%. In general, this group fell ≥ 50% of symptoms (97.6%). The control group (PBCCS) achieved very good level: 5% (decrease ≥ 75% of symptoms), good level (decrease ≥ 50% of symptoms) (62.5%). Overall, that one ≥ 50% of symptoms explained 67.5%. Conclusion: Cervical epidural methylprednisolone acetate injection is a safe and effective method in managing cervical disc displacement. * Keywords: Cervical disc displacement; Cervical epidural injection. INTRODUCTION disease is accelarating. Treatment is Hereditary spinal disc herniation therefore essential. There are many treatment (HSDH) is a quite common disease methods available such as that of medical among the groups of working-age people, conservation, minimum intervention, operation. which has a bad influence on the quality In many cases, if treatment is purely of life and working capacity of the patients medical, sometimes its outcomes are not as well as the society. high or unsuccessful. Human activities in modern society are The problem is how to improve the increasingly complex, all of which affect effectiveness of preservative treatment. In the cervical spine, thus the incidence of this preservation treatment, block epidural area * Ninhbinh Hospital ** 103 Military Hospital Corresponding author: Dinh Huy Cuong (dinhuycuongbvnb@gmail.com) Date received: 10/07/2017 Date accepted: 07/08/2017 112
2. Journal of military phrmaco-medicine n O7-2017 method is an important content, which * Inclusion criteria: can be considered as a key therapeutic - Clinical: Patients ≤ 70 years of age method determining the effectiveness of with cervical spine syndrome, cervical nerve preservation treatment, also as a positive root syndrome and may be associated solution with its advantage that anti- with the following symptoms: spinal cord inflammatory drugs are introduced into compression, circulatory circulation and the epidural area access directly into autonomic nervous system disorder. - Sub-clinical: 100% of patients underwent nerve roots which are stimulated and spinal MRI recieved HSDH images. inflammed due to discs pinched. Hence, it brings about rapid remission and side - Patients should have clinical and diagnostic imaging correlation. effects of drugs to the body. In treatment of HSDH, the procedure * Exclusion criteria: with methylprednisolone is a routine Patients with hypersensitivity to Depo- indication, with very positive treatment medrol and lidocain, with neck infection, or systemic infection, abnormal anatomy results and the rate of recovery is very of the scoliosis of the spine, prehistory of high. Only a few authors have done the operating the neck spine, HSDH with cervical spine lymphoma therapy (BEA) other neck diseases such as tuberculosis, with methylprednisolone, which brings good old spinal cord injury and associated effect to treatment. It is due to the complexity pathologies may be aggravated when using of the functional structure of the spinal corticosteroids such as hyperparathyroidism, column, which threatens severe stroke, if dyspigmented diabetes, coagulation disorder the treatment is not strictly adhering to the and using anticoagulant medications. procedure and lack of sufficient experience. Patients disagree to apply the method. Because of the above reasons, we have 2. Method research. conducted this research with a view to: * Study method: Descriptive study on Evaluating the effect of the treatment, 82 patients who were divided into two drug infusion, adverse effects and safety groups: of block epidural area (BEA) cervical spine - Study group: 42 patients received method. basic medical treatment with analgesics, SUBJECTS AND METHODS anti-inflammatory, muscle relaxation, neurotransmitter enhancement and myelin 1. Subjects. reconstruction, combined with the cervical 82 patients who were diagnosed with spine through the lining of the spine, HSDH and treated in Department of under the bright-heighten screen, each Neurology in Ninhbinh General Hospital block of 1 mL lidocain 2% + 40 mg Depo- from early May, 2015 to the end of medrol to BEA cervical spine using Tuohy December, 2016. dedicated needle in the time of 2 weeks. 113
3. Journal of military parmaco-medicine n 07-2017 - Control group: 40 patients received Patients were followed 6 months after basic medical treatment in combination the end of treatment, the improvement of with block cervical spine 2 times, each the symptoms more than 50% is considered time a week apart, usually blocked from to achieve treatment goals. 2 to 3 sites depending on the nerve root * Compare the treatment effect: lesions, the total amount of blocking drug - Remission score and coefficient: each time is 40 mg Depo-medrol + 1 - 2 mL + Remission score (RS) = (a-b), of which: lidocain 2%. a = clinical point before treatment; b = clinical * Research targets: point after treatment. - Pain level: VAS (Visual analogue + Remission coefficient RC = RS/a. scale) score consists of 10 points divided - Evalutaing the treatment effects: very into 5 levels: painless (0 points), mild pain good: RC (0.8 - 1.0); good: RC (0.65 - 0.8); (1 - 2 points), moderate pain (3 - 5 points); fair: RC (0.5 - 0.65); poor: RC < 0.5; echo (6 - 8 points); intense pain (9 - treatment goals failed to achieve when 10 points). RC < 0.5. - Muscle strength: According to the British Medical Council's 5-point scale, Evaluating the side effects of the methods: the 5-strongest to the 1-point scale is Clinical complications caused by each completely paralyzed. method were recorded evaluating the effect of both methods on liver and kidney - Improved cervical spine’s function function. The data were processed based level: assessment is based on NDI (Neck Disablity Index): intensity of pain; on computerized statistical algorithms using personal self-care; heavy lifting; read the SPSS software program 160. book; headache; concentration; work; drive; sleep; reaction. RESULTS AND DISCUSSION This is a set of 10 questions, each Table 1: Comparing VAS at times of evaluation. question has 6 answers to the score from 0 to 5, the total score is 50 to self- The average VAS (mean ± SD) assessment of the impact of neck pain to Time p-values Patients Control personal daily activities. The higher the group group NDI score, the lower the spinal function, Before treatment (1) 5.62 ± 1.04 5.62 ± 1.37 > 0.05 the more the patient's daily activities are After treatment (2) 1.10 ± 1.22 2.72 ± 1.04 < 0.05 affected. The above criteria were evaluated 6 months after 0.76 ± 0.96 2.48 ± 1.04 < 0.05 at 3 times: before treatment, immediately treatment (3) after treatment and 6 months after treatment. p(time) < 0.001 < 0.001 * Evaluating treatment results: The pre-treatment VAS scores between There are 5 levels of symptom the two groups were almost identical improvement in general: very good; good; (p > 0.05). However, the difference in fair; poor; very bad; corresponding to the VAS after treatment and 6 months after improvement in the symptoms with ≥ 75%; treatment was statistically significant ≥ 50 - 74%; ≥ 25 - 49%; < 25%; unsuccessful, (p < 0.05). At times (2) and (3) p (time- the symptoms get more severe. point 2, 3) < 0.001), our study is similar [1, 4]. 114
4. Journal of military phrmaco-medicine n O7-2017 Table 2: Comparion on the level of pain between 2 groups at time of treatment. Before treatment After treatment 6 months after treatment Level of pain Patient Control Patient Control Patient Control group; group; group; group; group; group ; n (%) (1) n (%) (2) n (%) (3) n (%) (4) n (%) (5) n (%) (6) No pain 0 0 42.9% (18) 5% (2) 59.5% (25) 5% (2) Mild pain 0 0 54.8% (23) 37.5% (15) 40.5% (17) 55% (22) Moderate pain 33.3% (14) 42.5% (17) 2.4% (1) 57.5% (23) 0 40% (16) Intense pain 66.7% (28) 57.5% (23) 0 0 0 0 Very intense pain 0 0 0 0 0 0 p (patients-control) > 0.05 < 0.001 < 0.05 Prior to treatment, the majority of patients At the end of 6 months’ treatment, the in both groups were moderately severe pain remission level continued to be and painful; the difference in pain degree improved, 59.5% of patients had pain relief and 40.5% of patients had mild pain, between the two groups was not statistically 5% of patients suffered from pain, mild significant (p > 0.05). At the end of 1,2 pain accounted for 55%, moderate pain treatment, most patients had only mild was 40%, meaningful difference (p 5,6 < 0.05). pain, 18 patients with pain relief (42.9%) According to Nguyen Van Chuong, BEA is and 23 patients with mild pain (54.8%). a fast and effective pain relief because While in the control group, as many as this technique under the guidance of bright 2 patients had no pain (5%) and 15 patients fluorescence, the needle is introduced with mild pain (37.5%) and 23 patients into the BEA, near the nerve root site before it enters. The combination of lidocain were at moderate level (57.5%), meaningful and Depo-medrol is precisely introduced into difference (p < 0.001). 3,4 the BEA, allowing the drug to concentrate Nguyen Van Chuong [1] applied BEA at a specific location, influencing almost for 40 patients, after the end of treatment, directly the nerve root and multiple nerve he showed that pain relief was found in roots at the same time, through diffusion of the drug mixture when entering the BEA. 3 patients (7.5%), 23 patients with mild pain (57.5%) and 14 patients with Clinical experience shows that if the 2 mL contrast medium is injected at the moderate pain (35%). This result was C6-C7 position, the images impregnated similar to that of Castagnera’s [3] and with contrast medium, observed on the Stav’s [5]. However, our results are higher bright screen, will extend from two to because the patients in our sample are three cervical vertebrae (C 3-C4) and the primarily at grade I and type II herpes. image recorded is "bamboo leaf". 115
5. Journal of military parmaco-medicine n 07-2017 The process of impregnating the contrast medium (author's data). - If injected with 5 mL of contrast medium, the drug will spread, covering the entire BEA from C 7 up to C 1. On the brightening screen, it could be observed that the image of the infusion of the entire cervical spine, which are "blocks", running along the neck, multi-forms, depending on the size, circulation of the BEA, due to pressure squeezing into the BEA. We applied the block epidural area solution as follows: 1 mL Depo-medrol 40 mg + 1 mL lidocain 2% + 3 mL serum = 5 mL solution, so that all the nerve roots were absorbed, helping high-neck, multi-rooted root canal exacerbations without catheter insertion, which also explain why C 6-C7 interstitial injection make the symptoms of occipital nerve pain relieve rapidly. Meanwhile, in the PBCSC group, the drug mixture is near the nerve roots and only affects the blocked roots. Besides, when blocking a small amount of drug into the living muscle, reducing the concentration, drug’s effects promote time, thus reducing the effect of the drug, on the other side, increased the side effects of steroids due to the infiltration into the body. Table 3 : Levels of muscle strength improved. Muscle Patient Control Patient Control Patient Control group; strength group; group; group; group; group; n (%) (6) n (%) (1) n (%) (2) n (%) (3) n (%) (4) n (%) (5) Level 5 2.4% (1) 17.5% (7) 52.4% (22) 35% (14) 85.7% (36) 37.5% (15) Level 4 73.8% (31) 62.5% (25) 47.6% (20) 55% (22) 14.3% (6) 57.5% (23) Level 3 23.8% (10) 17.5% (7) 0 10% (4) 0 5% (2) Level 2 0 2.5% (1) 0 0 0 0 Level 1 0 0 0 0 0 0 p-values p1,2 > 0.05 p3,4 < 0.05 p5,6 < 0.05 Before treatment, 97.6% of patients had weak muscules; after treatment this firgure dropped to 47.6%. In the control group, before treatment, 82.5% of patients suffered from weak muscles; after treatment, this firgure decreased to 65% with significant difference (p 3,4 < 0.05). 116
6. Journal of military phrmaco-medicine n O7-2017 After 6 months of treatment, there was an improvement in both groups (14.3%), while that of the control group was worse (62%), significant difference (p 5,6 < 0.05). Research by Bush and Hiller [2], prior to the treatment, 75% of patients had weak muscles; after the treatment, the median follow-up of 39 months meaned that 73% of patients no longer had weak muscles. Table 4: Evaluating the degree of improvement of the cervical function based on NDI point at time of treatment. Patient group Control group p Group time 123(patients-control) mean ± SD mean ± SD Before treatment (1) 16.19 ± 5.27 16.38 ± 4.67 > 0.05 After treatment (2) 3.10 ± 2.91 5.98 ± 2.60 < 0.001 6 months after treatment (3) 2.26 ± 2.52 5.85 ± 2.52 < 0.001 p(time) p1,2 < 0.001 p1,2 < 0.001 p2,3 0.05 Prior to NDI treatment of 2 homologous groups (p > 0.05), after the treatment and 6-month follow-up, the CSC continued to improve significantly (p > 0.05) (p < 0.001). Comparison at the time of the study, in the study group, CSC’s function was improved significantly after the end of treatment and after 6 months (p < 0.001), while in the control group at the time (2) immediately after the end of treatment, the CSC function was significantly improved (p < 0.001), but after 6 months, CSC function improved but not statistically significant. This proves that the cervical spine block drug concentration method only affects the nerve roots immediately after the blockade and then disperses into the body. Table 5: The level of symptom improvement in general. Patient group (n = 42) Control group (n = 42) Symptom improvement degree p ( χ 2 ) n % n % ≥ 75% (very good) 26 61.9% 2 5% 50 - 74% (good) 15 35.7% 25 62.5% 25 - 49% (fair) 1 2.4% 13 32.5% < 0.05 < 25% (poor) 0 0 0 0 (33.328) Unsuccessful 0 0 0 0 After the intervention, the symptoms of both groups were significantly reduced, no cases of clinical symptoms aggravated. However, in the patient group, the proportion of patients who improve ≥ 50% the symptoms (97.6%) was higher than that of the control group (67.5%), which was statistically significant with p < 0.05. In the Manchikati’s 117
7. Journal of military parmaco-medicine n 07-2017 study [4], the proportion of patients who improved ≥ 50% of the symptoms was 82% and that in Nguyen Van Chuong’s study [1] was 72.5%. Table 6: Comparing VAS before and after treatment. Evaluating measure Patient group (n = 42) Control group (n = 40) p-values VAS before treatment (a) 5.62 ± 1.04 5.62 ± 1.37 > 0.05 VAS after treatment (b) 1.10 ± 1.12 2.72 ± 1.04 < 0.05 Remission score (a-b) 4.64 ± 1.01 2.9 ± 0.90 < 0.05 Remission coeficient = RS/a 0.84 ± 0.16 0.52 ± 0.14 < 0.05 Remission coeficient = RS/a 0.84 ± 0.16 0.52 ± 0.14 < 0.05 Before the treatment, VAS scores of the two groups was similar (p > 0.05). After the treatment, remission score was 4.64 ± 1.01, the difference was statistically significant (p < 0.05). The remission coefficient of group of patients (0.84 ± 0.16) was higher than that of the control group (0.52 ± 0.14), significantly different (p < 0.05). Table 7: Comparing NDI score before and after treatment. Method Patient group (n = 42) Control group (n = 40) p-values The score before treatment (a) 16.19 ± 5.27 16.38 ± 4.67 > 0.05 The score after treatment (b) 3.10 ± 2.91 5.98 ± 2.60 < 0.05 Remission score (a-b) 13.10 ± 3.48 10.40 ± 3.10 < 0.05 RC = RS/a 0.86 ± 0.15 0.63 ± 0.13 < 0.05 Before the treatment, NDI of two groups were approximately equal (p > 0.05). The remission coinfficient of the patients (0.86 ± 0.15) was higher than that of the control group (0.63 ± 0.13) with (p < 0.05). Table 8: Comparing the muscle strength before and after treatment. Assessment method Patient group (n = 42) Control group (n = 40) p-values The score before treatment (a) 3.79 ± 0.47 4.00 ± 0.60 > 0.05 The score after treatment (b) 4.52 ± 0.51 4.25 ± 0.63 < 0.05 Remission score (a-b) 0.74 ± 0.54 0.25 ± 0.44 < 0.05 RC = RS/a 0.16 ± 0.12 0.05 ± 0.09 < 0.05 Before treatment, the muscle strength of the two groups was similar (p > 0.05). The remission coefficient of the disease group (0.16 ± 0.12) was higher than the control group (0.05 ± 0.09) (p < 0.05) demonstrating that BEA blocking technique is more effective than block cervical spine. 118
8. Journal of military phrmaco-medicine n O7-2017 Table 9: Comparing stroke and complication. Group of patients (n = 42) Controll group (n = 40) Stroke and complication n % n % Pain in place after injection 3 7.1 4 10 Hard membrane is pierced 0 0 0 0 The spinal cord is touched 0 0 0 0 Touch the nerve root 1 2.4 2 5 Drugs insensitivity rise 0 0 0 0 Infection 0 0 0 0 Bleeding 0 0 0 0 Temporary hypertension 1 2.4 3 7.5 Insomnia 4 9.5 6 15 Stomach pain 2 4.7 5 12 Water retention 4 9.5 6 15 CONLCUSION On avarage, the proportion of patients with ≥ 50% reduction symptoms was 67.5%. Through the study on 82 patients who - The overall symptom remission coifficient were divided into two groups and performed of BEA was statistically higher than that of by the method of BEA cervical spine, we block (p < 0.05) which demonstrated that could draw the following conclusions: BEA method is better than traditional - All patients in the two groups improved treatment. after treatment, but the study group was - Safety: During the procedure, the better than the control group. two methods had not caused any major + In the study group, 61.9% of patients strokes or complications. Only a few side achieved a very good result (reduced effects of the drug was documented which ≥ 75% of the symptoms); 35.7% of the were stable after a few days of the patients had good result (decreased ≥ 50% treatment. of the symptoms). On average, 97.6% of people had ≥ 50% reduction of the REFERENCES symptoms. 1. Nguy ễn V ăn Ch ươ ng và CS . Bước đầ u + In the control group, 5% of patients đánh giá hi ệu qu ả c ủa k ỹ thu ật tiêm ngoài gained excellent outcome (reduction of màng c ứng c ột s ống c ổ b ằng steroid trong ≥ 75% of symptoms) 62.5% had a good điều tr ị thoát v ị đĩ a đệ m c ột s ống c ổ. Tạp chí result (decrease ≥ 50% symptoms). Y h ọc Vi ệt Nam. 2013, 11 (2), tr.105-111. 119
9. Journal of military parmaco-medicine n 07-2017 2. Bush K, Hillier S. Outcome of cervical 4. Manchikati L, cash K.A, Pampati V, radiculopathy treated with periradicular/epidural Wargo B.W, Malla Y . The effectiveness of corticosteroid ịnections: A prospective study fluoroscopic cervical interiaminar epidural with independent clinical review. Eur Spine injections in managing chronic cervical disc Journal. 1996, 5, pp.319-325. herniation and radicculitis preliminary results of a randomized, double-blind, controlled trial 3. Castagnera L, Mauette P, Pointilart V, pain physician. 2010, 13, pp.223-236. Vi-tal J.M, Emy P, Senegas J. Long-tem results 5. Stav A, Ovadia L, Sternberg A, Kaadan M, of cervical eoidural steroid injection without Weksler N. Cervical epidural steroid injection morphine in chronic cervical radisuler pain. Pain. for crevicobrachialgia. Acta Anaesthesiol Scand. 1994, 58, pp.239-243. 1993, 37, pp.562-566. 120