The Effect of Nerve-Root Injections on the Need for Operative Treatment of Lumbar Radicular Pain

BACKGROUND: The purpose of the present study was to determine the effectiveness of selective nerve-root injections in obviating the need for an operation in patients with lumbar radicular pain who were otherwise considered to be operative candidates. Although selective nerve-root injections are used widely, we are not aware of any prospective, randomized, controlled, double-blind studies demonstrating their efficacy. METHODS: Fifty-five patients who were referred to four spine surgeons because of lumbar radicular pain and who had radiographic confirmation of nerve-root compression were prospectively randomized into the study. All of the patients had to have requested operative intervention and had to be considered operative candidates by the treating surgeon. They then were randomized and referred to a radiologist who performed a selective nerve-root injection with either bupivacaine alone or bupivacaine with betamethasone. The treating physicians and the patients were blinded to the medication. The patients were allowed to choose to receive as many as four injections. The treatment was considered to have failed if the patient proceeded to have the operation, which he or she could opt to do at any point in the study. RESULTS: Twenty-nine of the fifty-five patients, all of whom had initially requested operative treatment, decided not to have the operation during the follow-up period (range, thirteen to twenty-eight months) after the nerve-root injections. Of the twenty-seven patients who had received bupivacaine alone, nine elected not to have the operation. Of the twenty-eight patients who had received bupivacaine and betamethasone, twenty decided not to have the operation. The difference in the operative rates between the two groups was highly significant (p < 0.004). CONCLUSIONS: Our data demonstrate that selective nerve-root injections of corticosteroids are significantly more effective than those of bupivacaine alone in obviating the need for a decompression for up to thirteen to twenty-eight months following the injections in operative candidates. This finding suggests that patients who have lumbar radicular pain at one or two levels should be considered for treatment with selective nerve-root injections of corticosteroids prior to being considered for operative intervention.