Do steroid injections to the peripheral nerve increase perineural fibrosis? An animal experimental study

Abstract

Background/Aim: Perineural fibrosis may be seen in some surgeries after unsuccessful transforaminal injections. This animal experiment aims to investigate the effect of steroids and/or local anesthetic substances used in epidural/transforaminal injections on fibrosis. Methods: A total of 14 male Wistar-Albino rats were separated into two groups of 7. After intraperitoneal anesthesia, right and left sciatic nerves were explored in all groups. In group 1, appropriate dose of methylprednisolone acetate and bupivacaine hydrochloride, and in group 2 only methylprednisolone acetate was administered to the explored left sciatic nerves. The right sciatic nerves were identified and explored without the application of any procedure to secure the control side of the groups. All explored areas were marked for later sampling. After 3 weeks, rats were sacrificed and samples were taken around the sciatic nerve for histopathological examination. Results: In group 1, perineural fibrosis around the left sciatic nerve (intervention side) was seen at grade 3 in five rats and at grade 0 in two. In right sciatic nerve as the control side, grade 2 fibrosis was observed in 5 rats, and fibrosis was not observed in two rats. No statistically significant difference was defined with respect to perineural fibrosis (P=0.128). In group 2, perineural fibrosis was seen around the left sciatic nerve (intervention side) at grade 3 in 5 rats, at grade 4 in one rat, and not observed in one rat. In the control side of the second group, perineural fibrosis was seen at grade 3 and 1 in one each, and was not seen in five rats. The difference between intervention side and control side in the rate of perineural fibrosis seen was statistically significant (P=0.026). Conclusions: The application of steroids alone to the nerve was determined to increase the risk of perineural fibrosis development. The addition of local anesthetics to the steroid in the injection may reduce the possibility of perineural fibrosis.

Keywords

• Perineural fibrosis
• Sciatic nerve
• Methylprednisolone
• Bupivacaine
• Transforaminal injections

Kaynakça

1. 1. Kreiner DS, Shaffer WO, Baisden JL, Gilbert TJ, Summers JT, Toton JF, et al. North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J. 2013;13(7):734-43. doi: 10.1016/j.spinee.2012.11.059. PMID: 23830297.
2. 2. Song SH, Ryu GH, Park JW, Lee HJ, Nam KY, Kim H, et al. The Effect and Safety of Steroid Injection in Lumbar Spinal Stenosis: With or Without Local Anesthetics. Ann Rehabil Med. 2016;40(1):14-20. doi: 10.5535/arm.2016.40.1.14.
3. 3. Kobayashi S, Takeno K, Miyazaki T, Kubota M, Shimada S, Yayama T, et al. Effects of arterial ischemia and venous congestion on the lumbar nerve root in dogs. J Orthop Res. 2008 Nov; 26(11): 1533-40. doi: 10.1002/jor.20696.
4. 4. Stafford MA, Peng P, Hill DA. Sciatica: a review of history, epidemiology, pathogenesis, and the role of epidural steroid injection in management. Br J Anaesth. 2007; 99(4):461-73. doi: 10.1093/bja/aem238.
5. 5. Fritz JM, Delitto A, Welch WC, Erhard RE. Lumbar spinal stenosis: a review of current concepts in evaluation, management, and outcome measurements. Arch Phys Med Rehabil. 1998;79(6):700-8. doi: 10.1016/s0003-9993(98)90048-x.
6. 6. Davis N, Hourigan P, Clarke A. Transforaminal epidural steroid injection in lumbar spinal stenosis: an observational study with two-year follow-up. Br J Neurosurg. 2017; 31(2): 205-208. doi: 10.1080/02688697.2016.1206188.
7. 7. Park Y, Lee WY, Ahn JK, Nam HS, Lee KH. Percutaneous Adhesiolysis Versus Transforaminal Epidural Steroid Injection for the Treatment of Chronic Radicular Pain Caused by Lumbar Foraminal Spinal Stenosis: A Retrospective Comparative Study. Ann Rehabil Med. 2015;39(6):941-9. doi: 10.5535/arm.2015.39.6.941.
8. 8. Manchikanti L, Buenaventura RM, Manchikanti KN, Ruan X, Gupta S, Smith HS, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012;15(3): E199-245.

9. 9. Cirak B, Alptekin M, Palaoglu S, Ozcan OE, Ozgen T. Surgical therapy for lumbar spinal stenosis: evaluation of 300 cases. Neurosurg Rev. 2001; 24(2-3): 80-2. doi: 10.1007/pl00014585.
10. 10. McLain RF, Kapural L, Mekhail NA. Epidural steroid therapy for back and leg pain: mechanisms of action and efficacy. Spine J. 2005;5(2) :191-201. doi: 10.1016/j.spinee.2004.10.046.
11. 11. Nam KY, Ryu GH, Choi JM, Choi JH, Kwuan BS, Park JW. Efficacy of translaminar epidural steroid injection versus combined translaminar epidural steroid injection with selective nerve root injection in spinal stenosis J Korean Acad Rehabil Med 2007;31: 7-13
12. 12. Nahm FS, Lee PB, Choe GY, Lim YJ, Kim YC. Therapeutic effect of epidural hyaluronic acid in a rat model of foraminal stenosis. J Pain Res. 2017;10: 241-248. doi: 10.2147/JPR.S122861.
13. 13. Salafia CM, Weigl C, Silberman L. The prevalence and distribution of acute placental inflammation in uncomplicated term pregnancies. Obstet Gynecol. 1989;73: 383-9.
14. 14. Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med. 2008;358(8):818-25. doi: 10.1056/NEJMcp0708097.
15. 15. British Association of Spine Surgeons (BASS). British Association of Spine Surgeons guidelines 2012
16. 16. Jinkins JR, Whittemore AR, Bradley WG. The anatomic basis of vertebrogenic pain and the autonomic syndrome associated with lumbar disk extrusion. AJR Am J Roentgenol. 1989;152(6): 1277-89. doi: 10.2214/ajr.152.6.1277.
17. 17. Howe JF, Loeser JD, Calvin WH. Mechanosensitivity of dorsal root ganglia and chronically injured axons: a physiological basis for the radicular pain of nerve root compression. Pain. 1977;3(1): 25-41. doi: 10.1016/0304-3959(77)90033-1
18. 18. Trescot AM, Chopra P, Abdi S, Datta S, Schultz DM. Systematic review of effectiveness and complications of adhesiolysis in the management of chronic spinal pain: an update. Pain Physician. 2007;10(1):129-46.
19. 19. Lee JH, Lee SH. Clinical effectiveness of percutaneous adhesiolysis versus transforaminal epidural steroid injection in patients with post lumbar surgery syndrome. Reg Anesth Pain Med. 2014;39(3):214-8. doi: 10.1097/AAP.0000000000000073.
20. 20. Chopra P, Smith HS, Deer TR, Bowman RC. Role of adhesiolysis in the management of chronic spinal pain: a systematic review of effectiveness and complications. Pain Physician. 2005;8(1):87-100.
21. 21. Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Freeman TL, Slaten WK. Complications of fluoroscopically guided transforaminal lumbar epidural injections. Arch Phys Med Rehabil. 2000;81(8):1045-50. doi: 10.1053/apmr.2000.7166.
22. 22. Benedetti EM, Siriwetchadarak R, Stanec J, Rosenquist RW. Epidural steroid injections: complications and management. Tech Reg Anesth Pain Manag. 2009;13: 236-50. DOI 10.1053/j.trap.2009.06.011
23. 23. Behnam H, Mohammad HA, Sirous M, Reza JK, Davood O. The comparison between steroid and hypertonic saline 10 % with steroid in transforaminal epidural injection in patients with unilateral foraminal stenosis ICNSJ; 2015;2(2): 50-54) DOI 10.22037/icnj.v2i2.8771;
24. 24. Helm Ii S, Benyamin RM, Chopra P, Deer TR, Justiz R. Percutaneous adhesiolysis in the management of chronic low back pain in post lumbar surgery syndrome and spinal stenosis: a systematic review. Pain Physician. 2012;15(4): E435-62.
25. 25. Iversen T, Solberg TK, Romner B, Wilsgaard T, Twisk J, Anke A, et al. Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial. BMJ. 2011;343: d5278. doi: 10.1136/bmj.d5278.
26. 26. Yousef AA, EL-Deen AS, Al-Deeb AE. The role of adding hyaluronidase to fluoroscopically guided caudal steroid and hypertonic saline injection in patients with failed back surgery syndrome: a prospective, double-blinded, randomized study. Pain Pract. 2010;10(6): 548-53. doi: 10.1111/j.1533-2500.2009.00357.x.
27. 27. Kim SB, Lee KW, Lee JH, Kim MA, Kim BH. The additional effect of hyaluronidase in lumbar interlaminar epidural injection. Ann Rehabil Med. 2011;35(3): 405-11. doi: 10.5535/arm.2011.35.3.405.
28. 28. Ng L, Chaudhary N, Sell P. The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double-blind, controlled trial. Spine (Phila Pa 1976). 2005;30(8):857-62. doi: 10.1097/01.brs.0000158878.93445.a0
29. 29. Sahu S, Pant R, Sharma S. Image guided transforaminal epidural injection: Is it a viable stop gap therapy for low backache. Indian J Pain; 2018;32:155-62. DOI: 10.4103/ijpn.ijpn_33_18
30. 30. Rabinovitch DL, Peliowski A, Furlan AD. Influence of lumbar epidural injection volume on pain relief for radicular leg pain and/or low back pain. Spine J. 2009;9(6): 509-17. doi: 10.1016/j.spinee.2009.03.003.