Abstract
Background:
Lumbar disc herniation (LDH) can cause pain in the lower back and leg, as well as numbness or weakness in the affected area. Various steroids, including methylprednisolone, are currently used for treatment.Objectives:
This study aimed to compare the effectiveness of pulse intravenous infusion of 500 mg methylprednisolone with common non-steroidal anti-inflammatory drugs (NSAIDs) in relieving pain and improving the clinical condition of patients with lumbar disc herniation.Methods:
This clinical trial, registered under code IRCT20211116053077N1, included an experimental group (37 patients) and a control group (35 patients). Pain assessments were conducted before treatment, and at one, two, and three weeks, as well as one and six months after treatment. The control group received common painkillers (diclofenac sodium tablets 100 mg), while the experimental group received a single dose of 500 mg methylprednisolone sodium succinate (intravenous injection in 500 cc normal saline). Pain scores were analyzed using SPSS 16 and statistical tests such as ANOVA, independent t-tests, and repeated measures ANOVA.Results:
Prior to intervention, the mean (SD) pain score was 8.7 (3.57) in the experimental group and 8.17 (0.66) in the control group (P > 0.76). Six months after methylprednisolone injection, the mean (SD) pain score in the experimental group was 1.56 (0.83), compared to 6.48 (0.91) in the control group (P = 0.000). Analysis of variance indicated that methylprednisolone significantly reduced pain in patients with LDH (P = 0.000, F = 660.668).Conclusions:
Given the effectiveness of intravenous pulse infusion of 500 mg methylprednisolone compared to common NSAIDs in relieving pain and improving clinical outcomes for patients with lumbar disc herniation, the use of this drug is recommended for pain reduction in these patients.Keywords
Pain Methylprednisolone Lumbar Disc Herniation Randomized Controlled Trial
1. Background
Back pain is a leading cause of absenteeism and disability in the workplace and is a major reason for hospitalization. The global cost of back pain for an individual is estimated at around $100 million (1, 2). Patients often visit neurosurgery clinics for back pain, which may be managed through outpatient care, physical therapy, narcotic drugs, non-steroidal anti-inflammatory drugs (NSAIDs), or surgery (3, 4). Lumbar disc herniation (LDH) is one of the most prevalent degenerative spine diseases, with a reported prevalence of 2 - 3% (5). Recently, the incidence of LDH has increased, especially among younger people, likely due to decreased physical activity and weight gain. The highest prevalence is reported among individuals aged 30 to 50 (6-8).
The lumbar spine comprises vertebrae and intervertebral discs located in the lower back. Lumbar disc herniation can stimulate or compress adjacent nerves, leading to pain and other symptoms (9-11). Damage to the intervertebral discs in the lower lumbar region, particularly in the L4-L5 or L5-S1 discs, often results from the high mobility of the lower lumbar area (12, 13).
Lumbar disc herniation related pain may manifest in the lower back, leg, and can also include numbness or weakness in the affected area (9-11). Symptoms of lumbar disc herniation include back pain, leg pain, radiating pain along the sciatic nerve, and abnormal gait (14). In the initial stage of the disease, patients primarily experience back pain, while later stages are marked by leg pain and radiating pain (7, 15). Untreated LDH pain can significantly impair quality of life and place a caregiving burden on patients’ caregivers. Recently, there has been an increase in the percentage of patients undergoing surgery for lumbar disc herniation (16, 17).
Lumbar disc herniation is defined through various imaging and intraoperative pathology classifications, which are evaluated using different methods (17). For cases that develop, treatment recommendations during the first 4 to 6 weeks after symptom onset typically include rest and therapeutic measures as advised by a physician. If symptoms persist beyond this period and are confirmed by clinical findings and MRI, surgical treatment may be suggested (2, 6).
Pain is a major concern for LDH patients, with effects extending beyond physical discomfort to include psychological issues, decreased quality of life, and socio-economic impacts (18-22). Corticosteroids, which have anti-inflammatory properties and varying mechanisms of action, are used to reduce pain. These steroids are categorized based on their duration of effect into short, medium, and long-acting types. Anti-inflammatory doses of steroids are commonly employed in the initial treatment phase for various rheumatic diseases (23-25). Currently, steroids are available in various forms, including topical, local injections, and intravenous administration. Methylprednisolone is one such steroid (23-25).
2. Objectives
This study aims to compare the effectiveness of pulse intravenous infusion of 500 mg methylprednisolone with common non-steroidal pain relievers in relieving pain and improving the clinical condition of patients with lumbar disc herniation.
3. Methods
This clinical trial, with ethics code IR.MEDILAM.REC.1400.152 and clinical trial code IRCT20211116053077N1, included experimental (45 patients) and control (45 patients) groups. The study involved individuals over 18 years of age with evident lumbar herniation on MRI results. Participants experienced severe back pain for at least 6 months, with pain extending to the lower limbs.
Exclusion criteria included individuals under 18 years of age, those with a history of spine surgery, patients with neurological defects such as plegia, and those who were unavailable for follow-up (e.g., failure to follow up, death, relocation, or inability to return). Additionally, patients or their families needed to have a mobile phone for communication. Non-cooperation throughout the study (from the beginning to 6 months later, when completing the final questionnaire) also led to exclusion.
Patients were randomly assigned to either the experimental or control group using random blocks. They were given cards and randomly selected one to determine their group assignment.
The pain level was assessed using a scale from 0 to 10 (26). Measurements were taken before treatment and at one, two, and three weeks after treatment, as well as at one and six months after treatment. The control group received common painkillers (diclofenac sodium tablets 100 mg), while the experimental group received methylprednisolone sodium succinate 500 mg (one dose administered intravenously in 500 cc of normal saline). All patients rested for 24 hours post-injection, and MRI scans were conducted before and six months after the intervention to compare and interpret the results.
Ethical considerations included obtaining written consent from participants, randomly assigning study groups, providing free interventions (visits, drugs, MRIs) for both groups, and ensuring patient confidentiality. Pain scores were analyzed using SPSS 16, with analytical tests such as ANOVA, independent t-tests, and repeated measures ANOVA.
4. Results
Of the 90 patients initially included in the study, 72 patients (35 in the control group and 37 in the experimental group) were included in the analysis stage. Exclusions occurred due to reasons such as death, surgery, lack of follow-up, and withdrawal of consent to participate in the study.
According to Table 1, there were no significant differences between the demographic characteristics, including age, gender, and marital status (P > 0.05). Before the intervention, the mean (SD) pain score was 8.7 (3.57) in the experimental group and 8.17 (0.66) in the control group (P > 0.76). Six months after the methylprednisolone injection, the mean (SD) pain score in the experimental group was 1.56 (0.83), compared to 6.48 (0.91) in the control group (P = 0.000) (Table 2).
Comparison of Demographic Characteristics of Patients Under Study a
| Measurement time | Experimental group | Control Group |
|---|---|---|
| Age | 50.29 ± 8.09 | 49.68 ± 9.38 |
| Gender | ||
| Man | 25 ± 67.6 | 24 ± 68.6 |
| Female | 12 ± 32.4 | 11 ± 31.4 |
| Marital status | ||
| Married | 27 ± 73 | 23 ± 65.7 |
| Single | 10 ± 27 | 12 ± 34.3 |
Comparison of Pain Intensity of Patients Before and After the Intervention a
| Measurement Time | Experimental Group | Control Group | P-Value |
|---|---|---|---|
| Before intervention | 8.70 ± 3.57 | 8.17 ± 0.66 | 0.76 |
| One week after the intervention | 2.64 ± 1.43 | 7.85 ± 0.84 | 0.48 |
| Two weeks after the intervention | 2.18 ± 1.54 | 7.37 ± 1.05 | 0.05 |
| Three weeks after the intervention | 2.43 ± 1.3 | 7.25 ± 0.85 | 0.000 |
| One month after the intervention | 1.35 ± 0.82 | 7.17 ± 1.04 | 0.000 |
| 6 months after the intervention | 1.56 ± 0.83 | 6.48 ± 0.91 | 0.000 |
The results of the analysis of variance indicated that methylprednisolone significantly reduces pain in patients with LDH (P = 0.000, F = 660.668). According to Table 3, Mauchly's Test of Sphericity for pain showed Mauchly's W value of 0.25 with a significance level of 0.000 (Tables 3 and 4).
Mauchly's Test of Sphericity for Pain
| Within Subjects Effect | Mauchly's W | Approx. Chi-Square | Sig. | Epsilon | ||
|---|---|---|---|---|---|---|
| Greenhouse-Geisser | Huynh-Feldt | Lower-Bound | ||||
| Factor 1 | 0.025 | 125.383 | 0.000 | 0.413 | 0.439 | 0.200 |
Correlated One-Way ANOVA Measured Four Times After Follow Up Tests
| Source | Type III Sum of Squares | df | Mean Square | F | Sig. |
|---|---|---|---|---|---|
| Intercept | 2200.905 | 1 | 2200.905 | 660.668 | 0.000 |
| Residual Error | 119.928 | 36 | 3.331 |
5. Discussion
Throughout life, individuals may encounter various physical problems, including pain, which can significantly impact all dimensions of health (27-32). To alleviate this pain, both pharmacological and non-pharmacological methods are available (33-35). One common approach involves using corticosteroids, which are effective in reducing pain due to their ability to suppress cytokines (36).
The findings indicate that methylprednisolone, a corticosteroid, effectively reduces patient pain. Numerous pharmacological and non-pharmacological interventions have been explored to manage pain in patients with lumbar disc herniation (LDH). Among non-pharmacological interventions, acupuncture has been noted for its effectiveness. For example, Zhang et al. conducted a meta-analysis of 10 studies involving 838 patients, finding that acupuncture significantly reduces pain in LDH patients (22). Similarly, Kwon et al. studied the impact of lumbar motion-style acupuncture on back pain resulting from road accidents. Their study showed that pain intensity in the experimental group decreased from 6.7 to 3.7, while in the control group, it decreased from 6.3 to 5.55, suggesting that the intervention was effective in reducing pain (37). Acupuncture is a therapeutic or preventive intervention involving the insertion of needles into specific acupoints to enhance patient health (38, 39).
Various studies have investigated the impact of corticosteroids on patients' health. For instance, Stone et al. demonstrated that corticosteroids effectively reduced patient pain (40). Iranmanesh et al. found that corticosteroids alleviated pain in patients with root canal conditions (41). Hayward et al. reviewed eight studies involving 743 patients, revealing that corticosteroids significantly reduced sore throat when administered for more than 6 hours (42). Additionally, Kullenberg et al. showed that corticosteroids improved pain and function in elderly patients with knee osteoarthritis (43). Corticosteroids are utilized both as primary and adjunctive pain relievers, playing a crucial role in reducing skeletal and muscular pain (25).
In relation to low back pain, Friedman et al. examined 82 patients with radicular low back pain and found that corticosteroids effectively reduced their pain (44). Similarly, Quraishi's meta-analysis of three IRCT studies confirmed that corticosteroids alleviated pain in lumbar radiculopathy patients (45), aligning with the findings of this study.
5.1. Conclusions
Given the effectiveness of intravenous pulse infusion of methylprednisolone 500 mg compared to common non-steroidal pain relievers in alleviating pain and improving the clinical condition of patients with lumbar disc herniation, it is recommended to use this drug to reduce patient pain.
References
-
1.
Karamouzian S, Ebrahimi-Nejad A, Shahsavarani S, Keikhosravi E, Shahba M, Ebrahimi F. Comparison of two methods of epidural steroid injection in the treatment of recurrent lumbar disc herniation. Asian Spine J. 2014;8(5):646-52. [PubMed ID: 25346818]. [PubMed Central ID: PMC4206815]. https://doi.org/10.4184/asj.2014.8.5.646.
-
2.
Yan Y, Zhu M, Cao X, Zhang Y, Zhang X, Xu M, et al. Different approaches to percutaneous endoscopic lumbar discectomy for L5/S1 lumbar disc herniation: A retrospective study. Br J Neurosurg. 2024;38(1):16-22. [PubMed ID: 33331186]. https://doi.org/10.1080/02688697.2020.1861218.
-
3.
Shimia M, Babaei-Ghazani A, Sadat BE, Habibi B, Habibzadeh A. Risk factors of recurrent lumbar disk herniation. Asian J Neurosurg. 2013;8(2):93-6. [PubMed ID: 24049552]. [PubMed Central ID: PMC3775189]. https://doi.org/10.4103/1793-5482.116384.
-
4.
Surianta INB, Tinduh D, Sulastri N, Melaniani S. Effects of additional walking aerobic exercise on pain intensity and disability status in office workers with mechanical chronic low back pain at Dr. Soetomo Surabaya Hospital. J Med Chem Sci. 2023;6(12):2985-93. https://doi.org/10.26655/JMCHEMSCI.2023.12.13.
-
5.
Amin RM, Andrade NS, Neuman BJ. Lumbar Disc Herniation. Curr Rev Musculoskelet Med. 2017;10(4):507-16. [PubMed ID: 28980275]. [PubMed Central ID: PMC5685963]. https://doi.org/10.1007/s12178-017-9441-4.
-
6.
Wang Z, Liu X, Gao K, Tuo H, Zhang X, Liu W. Clinical effects and biological mechanisms of exercise on lumbar disc herniation. Front Physiol. 2024;15:1309663. [PubMed ID: 38292068]. [PubMed Central ID: PMC10824856]. https://doi.org/10.3389/fphys.2024.1309663.
-
7.
Zheng K, Wen Z, Li D. The clinical diagnostic value of lumbar intervertebral disc herniation based on MRI Images. J Healthc Eng. 2021;2021:5594920. [PubMed ID: 33880169]. [PubMed Central ID: PMC8046570]. https://doi.org/10.1155/2021/5594920.
-
8.
Hashemi SE, Hariri SY, Ghanjal A, Gharedaghi FA, Hesarikia H. [Evaluation and comparison of the effectiveness of epidural injection and acupuncture in patients with failed back surgery syndrome referred to Baqiyatallah Clinic in 2021]. Eurasian Chemical Communications. 2022;4(4):347-59. Persian.
-
9.
Panneerselvam K, Kanna RM, Shetty AP, Rajasekaran S. Impact of acute lumbar disk herniation on sexual function in male patients. Asian Spine J. 2022;16(4):510-8. [PubMed ID: 34784704]. [PubMed Central ID: PMC9441438]. https://doi.org/10.31616/asj.2021.0083.
-
10.
Sahin CU, Aydin M, Kalkisim S, Sahin H, Arslan FC. Comparison of preoperative and postoperative sexual dysfunction in male patients with lumbar disc herniation. Turk Neurosurg. 2022;32(3):442-8. [PubMed ID: 34859837]. https://doi.org/10.5137/1019-5149.Jtn.35810-21.2.
-
11.
Moradi Z, Shahali S, Ahmadi F, Montazeri A. Correlates of sexual function in women with acute lumbar disc herniation in Iran: A cross-sectional study. Sci Rep. 2024;14(1):6430. [PubMed ID: 38499726]. [PubMed Central ID: PMC10948880]. https://doi.org/10.1038/s41598-024-57274-w.
-
12.
Sun D, Liu P, Cheng J, Ma Z, Liu J, Qin T. Correlation between intervertebral disc degeneration, paraspinal muscle atrophy, and lumbar facet joints degeneration in patients with lumbar disc herniation. BMC Musculoskelet Disord. 2017;18(1):167. [PubMed ID: 28427393]. [PubMed Central ID: PMC5399427]. https://doi.org/10.1186/s12891-017-1522-4.
-
13.
Kim KT, Lee DH, Cho DC, Sung JK, Kim YB. Preoperative risk factors for recurrent lumbar disk herniation in L5-S1. J Spinal Disord Tech. 2015;28(10):E571-7. [PubMed ID: 25089673]. https://doi.org/10.1097/BSD.0000000000000041.
-
14.
Huang YP, Bruijn SM, Lin JH, Meijer OG, Wu WH, Abbasi-Bafghi H, et al. Gait adaptations in low back pain patients with lumbar disc herniation: Trunk coordination and arm swing. Eur Spine J. 2011;20(3):491-9. [PubMed ID: 21181483]. [PubMed Central ID: PMC3048239]. https://doi.org/10.1007/s00586-010-1639-8.
-
15.
Booz C, Noske J, Martin SS, Albrecht MH, Yel I, Lenga L, et al. Virtual noncalcium dual-energy CT: Detection of lumbar disk herniation in comparison with standard Gray-scale CT. Radiology. 2019;290(2):446-55. [PubMed ID: 30615548]. https://doi.org/10.1148/radiol.2018181286.
-
16.
Lee JH, Choi KH, Kang S, Kim DH, Kim DH, Kim BR, et al. Nonsurgical treatments for patients with radicular pain from lumbosacral disc herniation. Spine J. 2019;19(9):1478-89. [PubMed ID: 31201860]. https://doi.org/10.1016/j.spinee.2019.06.004.
-
17.
Todorov PT, Nestorova R, Batalov A. Diagnostic value of musculoskeletal ultrasound in patients with low back pain - a review of the literature. Med Ultrason. 2018;1(1):80-7. [PubMed ID: 29400373]. https://doi.org/10.11152/mu-1245.
-
18.
Vasigh A, Tarjoman A, Borji M. The effect of spiritual-religious interventions on patients' pain status: Systematic review. Anaesthesia, Pain Intensive Care. 2018;22(4).
-
19.
Vasigh A, Tarjoman A, Borji M. Relationship between spiritual health and pain self-efficacy in patients with chronic pain: A cross-sectional study in west of Iran. J Relig Health. 2020;59(2):1115-25. [PubMed ID: 31087227]. https://doi.org/10.1007/s10943-019-00833-7.
-
20.
Hatefi M, Parvizi R, Borji M, Tarjoman A. Effect of self-management program on pain and disability index in elderly men with osteoarthritis. Anesth Pain Med. 2019;9(4). e92672. [PubMed ID: 31750095]. [PubMed Central ID: PMC6820295]. https://doi.org/10.5812/aapm.92672.
-
21.
Samuelly-Leichtag G, Eisenberg E, Zohar Y, Andraous M, Eran A, Sviri GE, et al. Mechanism underlying painful radiculopathy in patients with lumbar disc herniation. Eur J Pain. 2022;26(6):1269-81. [PubMed ID: 35357731]. [PubMed Central ID: PMC10083974]. https://doi.org/10.1002/ejp.1947.
-
22.
Zhang W, Liu H, Le X, Song K, Yang F, Cui Z, et al. Acupuncture for postoperative pain of lumbar disc herniation: A systematic review and meta-analysis. Medicine (Baltimore). 2022;101(49). e32016. [PubMed ID: 36626470]. [PubMed Central ID: PMC9750534]. https://doi.org/10.1097/MD.0000000000032016.
-
23.
Tahghighi F, Ziaee V. [The role of corticosteroids in treatment of autoimmune and rheumatologic disorders]. Clinical Excellence. 2019;8(4):39-52. Persian.
-
24.
Cheema HA, Musheer A, Ejaz A, Paracha AA, Shahid A, Rehman MEU, et al. Efficacy and safety of corticosteroids for the treatment of community-acquired pneumonia: A systematic review and meta-analysis of randomized controlled trials. J Crit Care. 2024;80:154507. [PubMed ID: 38128217]. https://doi.org/10.1016/j.jcrc.2023.154507.
-
25.
Leppert W, Buss T. The role of corticosteroids in the treatment of pain in cancer patients. Curr Pain Headache Rep. 2012;16(4):307-13. [PubMed ID: 22644902]. [PubMed Central ID: PMC3395343]. https://doi.org/10.1007/s11916-012-0273-z.
-
26.
Pool JJ, Ostelo RW, Hoving JL, Bouter LM, de Vet HC. Minimal clinically important change of the neck disability index and the numerical rating Scale for patients with neck pain. Spine (Phila Pa 1976). 2007;32(26):3047-51. [PubMed ID: 18091500]. https://doi.org/10.1097/BRS.0b013e31815cf75b.
-
27.
Karbasfrushana A, Karimiyarandib H. Role of vitamin D on knee osteoarthritis pain: A systematic review. rheumatism. 2022;12:13. https://doi.org/10.22034/ecc.2022.351411.1505.
-
28.
Komlakh K, Karbasfrushan A. The effect of Pregabalin on the pain status of patients with disc and spinal surgeries: A systematic review of drug therapy. Eurasian Chem Commun. 2022;4(11):1147-55.
-
29.
Hatefi M, KomLakh K. [Investigation of the effect of Duloxetine on pain status of patients with spinal cord injuries: A systematic review of drug therapy]. Eurasian Chem Commun. 2022;4(3):256-62. https://doi.org/10.22034/ecc.2022.324516.1298.
-
30.
Mohammadia HR, Erfania A, Jamshidbeigib Y, Rahmatianc A, Otaghid M. Effect of using rituximab on disability in patients with multiple sclerosis. J Med Pharm Chem Res. 2024;5:7. https://doi.org/10.48309/JMPCR.2024.450019.1158.
-
31.
Karimian M, Asadoola Y, Amin NG, Rahmatian A, Mohammadi HR, Shokri F, et al. Comparison of effectiveness of gabapentin and sodium valproate in patients with migraine. Gomal J Med Sci. 2024;22(1). https://doi.org/10.46903/gjms/22.01.1329.
-
32.
Hatefi M, Komlakh K. The effect of Atorvastatin on chronic subdural hematoma status: A systematic review of drug therapy. Eurasian Chem Commun. 2022;4(11):1130-7. https://doi.org/10.22034/ecc.2022.345173.1483.
-
33.
Tahmasbi F, Madani Neishaboori A, Mardani M, Toloui A, Komlakh K, Azizi Y, et al. Efficacy of polyarginine peptides in the treatment of stroke: A systematic review and meta-analysis. Brain Behav. 2023;13(1). e2858. [PubMed ID: 36542540]. [PubMed Central ID: PMC9847609]. https://doi.org/10.1002/brb3.2858.
-
34.
Rahmatian A, Bastani E, Shokri F, Karbasfrushan A. Prevalence of hemiplegic shoulder pain in iran: A systematic review and meta-analysis. Anesth Pain Med. 2023;13(3). e136423. [PubMed ID: 38021328]. [PubMed Central ID: PMC10664159]. https://doi.org/10.5812/aapm-136423.
-
35.
Bastani E, Rizehbandi M, Shokri F. Prevalence of pain and factors affecting it in patients with lung Cancer in Ilam. Int J Cancer Manag. 2024;17(1). https://doi.org/10.5812/ijcm-136637.
-
36.
Knezevic NN, Jovanovic F, Voronov D, Candido KD. Do corticosteroids still have a place in the treatment of chronic pain? Front Pharmacol. 2018;9:1229. [PubMed ID: 30443214]. [PubMed Central ID: PMC6221932]. https://doi.org/10.3389/fphar.2018.01229.
-
37.
Kwon OB, Hwang DW, Kang DH, Yoo SJ, Lee DH, Kwon M, et al. Effectiveness of lumbar motion style acupuncture treatment on inpatients with acute low back pain: A pragmatic, randomized controlled trial. Complement Ther Med. 2024;82:103035. [PubMed ID: 38513746]. https://doi.org/10.1016/j.ctim.2024.103035.
-
38.
Zhou X, Zhang J, Jiang L, Zhang S, Gu Y, Tang J, et al. Therapeutic efficacy of acupuncture point stimulation for stomach cancer pain: A systematic review and meta-analysis. Front Neurol. 2024;15:1334657. [PubMed ID: 38638316]. [PubMed Central ID: PMC11024429]. https://doi.org/10.3389/fneur.2024.1334657.
-
39.
Xia X, Liang Y, Cao S, Yao X. Treatment ideas of acupuncture and moxibustion for adenomyosis based on" etiology, location, nature and development of disease". Zhongguo Zhen jiu= Chinese Acupuncture & Moxibustion. 2024;44(4):455-9. [PubMed ID: 38621734]. https://doi.org/10.13703/j.0255-2930.20230726-k0001.
-
40.
Stone S, Malanga GA, Capella T. Corticosteroids: Review of the history, the effectiveness, and adverse effects in the treatment of joint pain. Pain Physician. 2021;24(S1). S233. https://doi.org/10.36076/ppj.2021.24.S233-S246.
-
41.
Iranmanesh F, Parirokh M, Haghdoost AA, Abbott PV. Effect of corticosteroids on pain relief following root canal treatment: A systematic review. Iran Endod J. 2017;12(2):123-30. eng. [PubMed ID: 28496516]. [PubMed Central ID: PMC5421265]. https://doi.org/10.22037/iej.2017.26.
-
42.
Hayward G, Thompson M, Heneghan C, Perera R, Del Mar C, Glasziou P. Corticosteroids for pain relief in sore throat: Systematic review and meta-analysis. Bmj. 2009;339:b2976. eng. [PubMed ID: 19661138]. [PubMed Central ID: PMC2722696]. https://doi.org/10.1136/bmj.b2976.
-
43.
Kullenberg B, Runesson R, Tuvhag R, Olsson C, Resch S. Intraarticular corticosteroid injection: Pain relief in osteoarthritis of the hip? J Rheumatol. 2004;31(11):2265-8. eng. [PubMed ID: 15517641].
-
44.
Friedman BW, Esses D, Solorzano C, Choi HK, Cole M, Davitt M, et al. A randomized placebo-controlled trial of single-dose IM corticosteroid for radicular low back pain. Spine (Phila Pa 1976). 2008;33(18):E624-9. [PubMed ID: 18665021]. [PubMed Central ID: PMC2597789]. https://doi.org/10.1097/BRS.0b013e3181822711.
-
45.
Quraishi NA. Transforaminal injection of corticosteroids for lumbar radiculopathy: Systematic review and meta-analysis. Eur Spine J. 2012;21(2):214-9. [PubMed ID: 21892774]. [PubMed Central ID: PMC3265602]. https://doi.org/10.1007/s00586-011-2008-y.