Prospective Placebo-controlled Randomized Trial to compare the Efficacy of Ketamine as an Adjuvant to Epidural Steroids in preventing Repeat Blocks in Chronic Low Back Pain
Citation Information :
Singh S, Gupta R, Bawa C, Mahajan L, Kaur B, Kaur T. Prospective Placebo-controlled Randomized Trial to compare the Efficacy of Ketamine as an Adjuvant to Epidural Steroids in preventing Repeat Blocks in Chronic Low Back Pain. Curr Trends Diagn Treat 2017; 1 (1):15-21.
Low back pain behaves as a “silent epidemic,” ranking first among complications related to work. Often there is a large gap between a patient's desired pain reduction and the minimum percentage of improvement that would make a treatment worthwhile. Consequently, debate continues as to the value of epidural steroid injections, supremacy of one adjuvant over others, various doses, and concentrations in optimizing pain management.
Objective
To compare the efficacy of ketamine vs normal saline as an adjuvant to epidural steroids in chronic low back pain.
Study design
Randomized prospective placebo-controlled study.
Materials and methods
The study was conducted on 60 patients of age group 18 to 70 years having chronic lower backache with or without radiculitis of minimum 3 months duration and having no relief with conventional treatment. The patients selected were randomly allocated into two groups of 30 patients each: Group I (n = 30) given triamcinolone 40 mg, preservative-free ketamine 30 mg (0.6 mL) made up to 6 mL solution with 0.25% bupivacaine and group II (n = 30) given 0.6 mL normal saline instead of ketamine.
Outcome measures
The primary outcome measured was number of patients requiring repeat blocks and number of repeat blocks administered in 3 months. Other outcome measures were functional improvement quantified by visual analog scale (VAS) and Oswestry disability index (ODI) as well as improvement in psychological status by depression scoring, all taken at 2 weeks interval for 3 months. The periprocedural complications were also noted at the end of the study.
Results
In managing lumbar radicular pain with lumbar epidural steroid injection (LESI), ketamine's role as an adjuvant proved to be advantageous for long-term relief by its inhibition of dorsal horn “wind up” phenomenon through N-methyl-D-aspartate (NMDA) receptor antagonism, thus reducing frequency of repeat blocks in group II (ketamine).
Conclusion
Thus to conclude, ketamine's advantage as a drug that prolongs pain relief from LESI is an avenue for further research and promises a bright future in the field of interventional pain medicine.
How to cite this article
Gupta R, Bawa C, Singh S, Mahajan L, Kaur B, Kaur T. Prospective Placebo-controlled Randomized Trial to compare the Efficacy of Ketamine as an Adjuvant to Epidural Steroids in preventing Repeat Blocks in Chronic Low Back Pain. Curr Trends Diagn Treat 2017;1(1):15-21.
Our experience with epidural steroid injections in the management of low back pain and sciatica. Intern J Orthop Surg 2012;19(2):1-6. [cited 2014 Nov 14]. Available from: http://ispub.com/IJOS/19/2/13781
Chronic pain. In: DeLisa JA, Gans BM, Walsh NE, editors. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2005. p. 518.
Hypothalamic-pituitary-adrenal suppression and iatrogenic Cushing's syndrome as a complication of epidural steroid injections. Case Rep Endocrinol 2013;Article ID 617042:4. Available from: http://dx.doi.org/10.1155/2013/617042.
Learning and memory in pain pathways. Pain 2000 Nov;88(2):113-118.
Spine epidural steroids for patients with lumbar spinal stenosis. Spine 1997 Oct;22(19):2313-2317.
Clinical outcome and fluoroscopic comparison of two different approaches of epidural steroid in low backache patients. J Evol Med Dent Sci 2014 May;3(19):5161-5171.
Correlation between epidurographic contrast flow patterns and clinical effectiveness in chronic lumbar discogenic radicular pain treated with epidural steroid injections via different approaches. Korean J Pain 2014 Oct;27(4):353-359.
Evaluation of the safety and efficacy of epidural ketamine combined with morphine for postoperative analgesia after major upper abdominal surgery. J Clin Anesth 2001 Aug;13(5):339-344.
Analgesic effects of caudal and intramuscular S(+)-ketamine in children. Anesthesiology 2000 Oct;93(4):976-980.
Epidural vs subcutaneous application of s-ketamine for postoperative pain management after total knee replacement. Eur J Anaesthesiol 2010 Jun;27(47):205.
Effect of pre-emptive ketamine on sensory changes and postoperative pain after thoracotomy: comparison of epidural and intramuscular routes. Br J Anaesth 2004 Sep;93(3):356-361.
S(+)-ketamine for caudal block in paediatric anaesthesia. Br J Anaesth 2000 Mar;84(3):341-345.
From the racemate to the eutomer: (S)-ketamine. Renaissance of a substance? Anaesthesist 1997 Dec;46(12):1026-1042.
Epidural morphine plus ketamine for upper abdominal surgery: improved analgesia from preincisional versus postincisional administration. Anesth Analg 1997 Mar;84(3):560-563.
Pre-emptive analgesia with ketamine, morphine and epidural lidocaine prior to total knee replacement. Can J Anaesth 1997 Jan;44(1):31-37.
Intrathecal ketamine reduces morphine requirements in patients with terminal cancer pain. Can J Anaesth 1996 Apr;43(4):379-383.
Epidural ketamine for post operative analgesia. Can Anaesth Soc J 1986 Jan;33(1):16-21.
Epidural coadministration of ketamine, morphine and bupivacaine attenuates post-herpetic neuralgia – A case report. Acta Anaesthesiol Sin 1996 Sep;34(3):151-155.
Effect of high-volume injectate in lumbar transforaminal epidural steroid injections: a randomized, active control trial. Pain Physician 2015 Nov;18(6):519-525.
N-methyl-D-aspartate receptor regulation of uncompetitive antagonist binding in rat brain membranes: kinetic analysis. Mol Pharmacol 1988 Sep;34(3):250-255.
Pharmacokinetics and distribution of ketamine after extradural administration to dogs. Br J Anaesth 1991 Sep;67(3):310-316.
Effect of addition of epidural ketamine to steroid in lumbar radiculitis: one-year follow up. Pain Physician 2011 Sep-Oct;14(5):475-481.
Epidural ketamine in post spinal cord injury-related chronic pain. Anesth Essays Res 2011 Jan-Jun;5(1):83-86.
Adjuvant hyaluronidase to epidural steroid improves the quality of analgesia in failed back surgery syndrome: a prospective randomized clinical trial. Pain Physician 2014 Jan-Feb;17(1):75-82.
Epidural ketamine versus epidural clonidine as therapeutic for refractory neuropathic chronic pain. Rev Bras Anestesiol Campinas 2002 Jan-Feb;52(1):34-40.
Pharmacokinetic and clinical evaluation of ketamine administered by i.v. and epidural routes. Int J Clin Pharmacol Ther Toxicol 1987 Feb;25(2):77-80.
Role of physical exercise in low back pain rehabilitation – a randomized controlled trial of a three month exercise program in patients who have completed multidisciplinary rehabilitation. Spine 2010 May;35(12):1192-1199.
