Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2010 | Month : August | Volume : 4 | Issue : 4 | Page : 2844 - 2850

The efficacy of the epidural depo-methylprednisolone and triamcinolone acetate in relieving the symptoms of lumbar canal stenosis: A comparative study

HUDA N *, BANSAL P**, GUPTA S M ***, RUHELA A****, REHMAN M*****, AFZAL M******

*(M.S.) Assistant professor, Dept. of orthopaedics, **(M.D.) Assistant Professor, Dept. of Anesthesia, ***(D.Orth), Resident,****(D.Orth), Resident,*****(D.Orth),Resident, ******(D.Orth) Resident, Dept. of orthopaedics, Teerthankar Mahaveer Medical College, Moradabad, U.P.(INDIA)

Correspondence Address :
Dr. Najmul Huda
Assistant Professor,Department of
Orthopaedics, Teerthankar Mahaveer
Medical College and University,
Near Pakbara town, Moradabad, U.P.
Email: najam1973@rediffmail.com

Abstract

Objective: To compare the efficacy of depo-methylprednisolone and triamcinolone acetate in pain relief and in the improvement in claudication distance after two doses of epidural injections in patients with clinically diagnosed lumbar canal stenosis.
Material and Methods: This prospective, randomized trial was performed in seventy patients with the clinical features of lumbar canal stenosis, who received epidural medications for pain relief. The patients were grouped into two; the T group receiving an injection of 80mg triamcinolone acetate with bupivacaine (0.125%) diluted in normal saline and the M group receiving 80 mg methylprednisolone acetate with bupivacaine (0.125%) diluted in normal saline solution (total volume of 20 ml in each group). The pain relief was assessed at 1, 3 and 6 months post-procedurally for improvement in the VAS pain scores and for the increase in the claudication distance.
Results: Of the 70 patients who were included in the study, 40% were females (n=28) and 60% were males (n=42). In the M group, 24 patients (68.5%) reported improvement in the VAS pain scores at the end of 6 months, as compared to 14 (40%) patients in the T group. The pre-intervention mean claudication distance was 163 meters in the group M and 170 meters in the group T, which improved to 637 metres and 350 meters in groups M (P < .001) and T (P>0.05) respectively, at the end of a 6 month follow up. In group M, the average VAS scores decreased from 7.34 in the pre-treatment phase, to 3.64 at the end of a 6 month follow up, which was significantly low (P=0.02). Comparatively, in group T the pre-treatment VAS score value decreased from 6.4 to 4.8 after 6 months of treatment (P< 0.05).
Conclusion: Both triamcinolone and methylprednisolone are effective epidural medications for symptomatic relief in lumbar canal stenosis, though depo-methylprednisolone showed better long term pain relief and improved walking distance at long term intervals as compared to triamcinolone.

Keywords

: Lumbar canal stenosis (LCS), Epidural steroid injection (ESI), triamcinolone acetate, depo-methylprednisolone.

Introduction
Lower back pain is the most common of all chronic pain disorders, with a life time prevalence of 54% to80% (1). It is one of the most common health problems worldwide and a leading cause of disability in persons older than 45 years (2). Lumbar canal stenosis (LCS) is a common source of lower back pain and disability in almost all the age groups, with a strong preponderance in the elderly population. The disease encompasses a wide array of triggering factors including most commonly, the prolapsed intervertebral disc, followed by ligamentum flavum hypertrophy and facet joint arthropathy. All these factors lead to chronic inflammation, thus causing compression of the nerve root and ischaemia, oedema and eventually scarring, with perineural fibrosis (3).

Due to ignorance, lack of regular health check-ups and financial constraints, the disease largely remains undiagnosed in the general population until a later stage, where conservative treatment is left with a subtle role. The disease starts as vague backaches or sometimes as thigh or leg pain. Delay in treatment in the early stages leads to progression of the disease to the stage of neurogenic claudication that becomes a hallmark symptom in the fully established stenosis of the spinal canal. The pain classically presents in the buttock and the bilateral lower limbs, which is initiated by walking, prolonged standing or walking downhill (relative lumbar extension) and is relieved by sitting, bending forward or pushing a grocery cart.

The treatment approaches to lumbar stenosis consists of bed rest, non steroidal anti-inflammatory drugs, muscle relaxants, opioids and corticosteroids which are administered through the oral or the epidural route (4). Intravenous infusion of infliximab or the subcutaneous perispinal administration of etanercept has also been associated with a dramatic response (5),(6). The surgical mode of treatment consists of the removal of the prolapsed disc or laminectomy. Surgery may be contraindicated in many stenotic patients due to associated medical illnesses or co-morbidities. Conservative management therefore remains as a necessary and viable treatment option for such patients.

Only few studies have been conducted to evaluate the effectiveness of the various modalities available. In the Maine lumbar spine study, patients with lumbar stenosis reported better results with the surgical mode of treatment in the initial years post operatively; however, with progressing time period, the results of surgery somewhat declined.

The use of epidural injections was first described by Evans in 1930 (7). Epidural injections of local anaesthetics, with or without steroids, have been widely used for the treatment of radicular pain, with encouraging results. There are multiple mechanisms of action of pain relief for corticosteroids. These include the inhibition of nerve root oedema with improved microcirculation (8), reducing ischaemia by increased blood flow to the neural elements (9), an anti-inflammatory effect by inhibiting prostaglandin synthesis (10) and direct inhibition of the nociceptive C-fiber neuronal membrane excitation (11).

Though used frequently, the epidural steroid injection (ESI) procedure for the treatment of LSS is controversial. Most of the studies which have been done so far compared epidural steroids with anaesthetics or normal saline. The steroids reported to have been of beneficial use through the epidural route include methylprednisolone, triamcinolone acetate and betamethasone acetate.

To our knowledge, no published study has compared the efficacy of epidural, depo-methylprednisolone and triamcinolone acetate, for providing pain relief in the patients of LSS. Moreover, their role in improving claudication distance has largely been unexplored. However, in controlled trials, both have been reported to be equally effective and safe (12).

The aim of our study was to compare the efficacy of epidurally administered depo-methylprednisolone and triamcinolone acetate in providing long term pain relief and in improving claudication distance at varying time intervals in patients suffering from lumbar canal stenosis.

Material and Methods

This prospective, double blinded study was conducted in the Department of Orthopaedics of our institute from May 2009 to April 2010 (12 months), after approval from the institutional ethical committee. Seventy patients (n=70) with clinically diagnosed signs and symptoms of lumbar canal stenosis, with refractory pain even after taking a full dose of NSAIDs or physiotherapy for more than two weeks of duration, were included in the study. The exclusion criteria included patients with prior back surgery, back or leg pain due to other aetiologies (e.g. spinal fracture, metastasis, neuropathy, vascular claudication etc.) pregnancy, breast feeding status or medical disorders like bleeding diathesis, diabetes, connective tissue disorders, excessive smoking and severe COPD.

The cases enrolled in the study were planned for treatment with epidural injections through the caudal route. The patients were randomly distributed to the T or M groups by using computer generated numbers. In the M group, patients received 2ml of depo-methyl prednisolone (80mg) mixed with 5ml of bupivacaine and diluted in 13 ml of normal saline. In the T group, the patients were given 2ml of triamcinolone acetate (80 mg) with 5ml of bupivacaine diluted in 13ml of normal saline. Thus, the concentration of bupivacaine was standardized to 0.125% and the volume was made to 20 ml in both the groups.

After completing the history taking and clinical examination, an informed consent was taken and the patient was asked to lie down in the lateral position with the knees and hips fully flexed. The skin was cleaned with betadine and a 22 gauge needle, about one and a half inches long, was inserted into the sacral hiatus, which was located as a v-shaped depression, about an inch or more proximal to the coccygeal vertebrae. The epidural space was sensed using the “loss of resistance” and was confirmed by “woosh test”. A 20ml syringe containing the treatment drug was prepared by an independent investigator who was not involved in the management of the patients. All injections were given under aseptic precautions through the caudal route by a single operator who was blinded to the chemical nature of the drug and thus, the study was double-blinded.

The cases were followed up fortnightly for the first month and then at monthly intervals for 6 months. The second ESI was given 2 weeks after the first injection. The response was measured in terms of improvement in the claudication distance and the visual analogue scale (VAS) pain scores at 1, 3 and 6 month intervals and was compared with the initial values. To measure the claudication distance, the patient was asked to walk along a 100 metre long straight line. Claudication distance was defined as the distance for which the patient could walk before stopping because of pain. Any decrement in the VAS pain scores of more than two scales was considered to be significant. Any increase in the claudication distance for more than 100 meters was defined as significant improvement. All the cases were screened for any complications during the study period. The patients were given NSAIDs as rescue medications on an as and when needed basis.

The data were analyzed by using the statistical software SPSS, version 17.0. The categorical data was analyzed by using the x2 test, while the continuous variables were analyzed by using the Student t-test. The results were presented as median (range) and number (percentage) for continuous variables. A P-value <0.05 was considered as statistically significant and P values <0.001 as highly significant.

Results

Of the 70 cases, 28 were females (40%) and 42 were males (60%). The patient characteristics were comparable in both the groups (P= 0.92) prior to intervention (Table/Fig 1) .

A significant number of cases (n= 33, 30 and 28 cases, respectively) reported improvement in the VAS pain scores at 1, 3 and 6 months intervals (P= 0.012, 0.021, 0.029, respectively) in the M group. In the T group, 30 (85.7%), 26 and 21 cases reported significant improvement in the VAS pain scores at 1, 3 and 6 months respectively (P= 0.02, 0.026, 0.038 respectively) (Table/Fig 2) .

In the M group, the mean claudication distance was 467 meters at 1 month, 587 meters at 3 months and 637 meters at 6 months follow up, which was significantly high (P=0.034; 0.013 and 0.001 respectively); however, it was 280m at 1 month (P<0.05), 312 meters at 3 months and 350 meters at 6 months in the T group (P>0.05) (Table/Fig 3) (Table 2). The average VAS score in group M was 6.34 pre-intervention, 5.65 at 1 month follow up and 3.64 at the end of 6 months of follow up, which showed a significant improvement (P =0.02) (Table/Fig 4) (Fig. 2). In the T group, the average pre-injection VAS score was 6.4. At 1 month follow-up, it was 5.42 and 4.80 at 6 months of follow up, which depicted an insignificant improvement (P>0.05). No serious complications like epidural abscess, infection or haematoma were reported in any patient of either group during the study period of 12 months.

Discussion

Due to spinal canal stenosis, mechanical compression of the nerve roots causes oedema producing pain. Pro-inflammatory agents such as the tumour necrosis factor alpha (TNF-α), phospholipase A2 (13) and the interleukins (IL) (14) have been shown to play a significant role in producing pain due to damaged discs. Accordingly, anti-inflammatory agents have been found to have a role in controlling the signs and symptoms of lumbar radicular pain. Epidural steroid injections are a mode of direct delivery of the anti-inflammatory agents to the site of inflammation. This type of therapy ensures the delivery of a higher concentration of drug to the diseased area and lower rate of systemic effects such as neuro-endocrine axis suppression, hyperglycaemia and osteoporosis.

To date, many studies have been undertaken to compare the efficacy of different types of steroids for treating lumbar radicular pain. Jeffery S et al (15) in their retrospective study on 597 patients of low back pain, compared the efficacy of triamcinolone and betamethasone and reported that though both the steroids were effective in reducing lower back and radicular pain, triamcinolone was found to reduce pain in a significantly larger number of patients than betamethasone at 1 and 2 weeks after injection. Epidural steroid injections do not correct the anatomical abnormalities which cause canal stenosis, but rather provide only symptomatic relief. Our results indicated that depo-ethylprednisolone is superior to triamcinolone in providing short and long term pain relief. A greater percentage of cases in the M group (94.2%) as compared to the T group (85.7%), showed pain relief at the end of 1 month. The improved efficacy of depo-methylprednisolone was clearly apparent at 3 and 6 months of follow up, when pain relief was seen in 85.7% and 80% of patients respectively, as compared to the T group, where only 74.2% patients showed improvement at 3 months and 60% patients at 6 months of follow up. Pirubdak et al (16) conducted a prospective randomised study to compare the effectiveness of the epidural, triamcinolone and betamethasone on 70 patients of discal radiculalgia. They reported significantly lower VAS values at the first, second and sixth weeks in patients who received 80 mg of triamcinolone by epidural injections.

Only a few articles have previously reported the efficacy of steroids in improving the claudication distance. Fukusaki et al (17) conducted a study on 53 patients of spinal stenosis with features of claudication and injected 8ml of mepivacaine plus 40mg of methylprednisolone in 19 patients. They reported good to excellent results in improving claudication distance in 3 patients after 3 months and only 1 patient at 6 months of follow up. Our results showed that, though initially the results were not very encouraging, they tended to improve on long term follow up, probably due to the halting of the disease process in the early stages. Moreover, the role of physiotherapy has not been studied in improving the outcome in the study group, though it was advised to all patients with back pain as a part of the routine treatment. Koc et al (18) conducted a randomized controlled trial to compare the effects of epidural steroid injections and the physical therapy program on pain and function in patients with lumbar spinal stenosis. Both epidural steroids and physical therapy groups have demonstrated significant improvement in pain and the functional parameters and no significant difference was noted between the 2 treatment groups. Pain and the functional assessment scores (RMDI and NHP physical activity subscore) were significantly more improved in the ESI group as compared to the controls at the second week. Our results have shown that epidural steroid administration improved physical ability and claudication distance by more than 200 metres at 6 month intervals in both groups, thus aiding an early return to routine activities.

A few shortcomings of our study were that a large sample sized study over a prolonged duration could have added more precision to our results. Secondly, the diagnosis of lumbar canal stenosis was purely clinical and the objective measurement of spinal canal diameter was not done; so, a few patients with other disorders could have been categorised with the same diagnosis. Moreover, the calculation of the reduction in analgesic requirements could have added new dimensions to our results, while an increase in the follow up time for years could have helped to evaluate the long term efficacy of steroids in providing permanent relief or halting the disease process.

Conclusion

We conclude that two doses of depo-methylprednisolone given epidurally creates more effective intervention as compared to triamcinolone acetate in providing long term pain relief in a high percentage of patients who suffer from lumbar canal stenosis. It improves walking distance in these patients and facilitates an early resumption of daily activities on a long term basis. We recommend the use of depo-methylprednisolone for epidural injections as a safe, minimally invasive and long term method of alleviating the symptoms of lumbar canal stenosis.

References

1.
Hult L; The Munkfors investigation. Acta Orthop Scand Suppl 1954,16:1.
2.
Reston VA. Acute low back pain: ACR appropriateness criteria. American college of radiology; 2003:479-85.
3.
Arden NK, Price C, Reading I, Stubbing J, et al. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study. Rheumatology2005; 44(11): 1399-406.
4.
Malmivaara A, Hakkinen U, Aro T, et al. The treatment of acute low back pain – bed rest,excercisaes, or ordinary activity. N Eng J Med 1995; 332 :1786-7.
5.
Tobinik E, Davoodilfar S. Efficacy of etanercept delivered by perispinal administration for chronic back and /or neck disc related pain, a study of clinical observation in 143 patients. Curr Med Res Opn. 2004 ; 20:1075-85.
6.
Atcheson SG, Dyumnec T. Rapid resolution of chronic sciatica with intravenous infliximab after failed epidural steroid injection. Spine 2004;29: 248-50.
7.
Evans W. Intrasacral epidural injection in the treatment of sciatica. Lancet. 1930;16:1225-8.
8.
Rydevik B, Browm MD,Lundborg G.Pathoanatomy and pathophysiology of nerve root compression. Spine 1984; 9:7-15.
9.
Kantrowitz F,Robinson DR,McGurie MB,Levine L. Corticosteroids inhibit prostaglandin production by rheumatoid synovia. Nature 1975; 258:737-9.
10.
Fukusaki M, Kobayashi I, HaraT, Sumikawa K. Symptoms of spinal stenosis do not improve after epidural steroid injection;2001;223-238
11.
Johansson A, Hao J, Sjolund B. Local corticosteroid application blocks transmission in normal nociceptor C fibres. Acta Anaesthesiol Scand. 1990. 34:335-8
12.
Robert EM, Honorio TB. . Current status of epidural steroids. Current pain and headache reports. 1997;1:61-9.
13.
Snal JS, Frunson RC,Dobrow R,Saal JA,White AH and Goldthwaite N – High levels of inflammatory phospholipaseA2 activity in lumbar disc herniation. Spine 1990 Jul; 15(7):674-8.
14.
Burke JG et al – Intervertebral discs causing LBP secretehigh levels of proinflammatory mediators. JBJS 2002 84B:196-201.
15.
Jeffery S, Donna GB,Arthur A De S, Jason F. Efficacy of epidural injections of Kenalog and Celestone in the treatment of low back pain. American J of radiology.2003 ;181:1255-58.
16.
Pirubdak L,Karakurum G,Oner U, Gulec A,Karadasli H. Epidural corticosteroid injection and amitryptiline for the treatment of chronic low back pain associated with radiculopathy. Pain Clinic 2003;15:247-53.
17.
Fukusaki M, Kobayashi I, Hara T,Sumikawa K. Symptoms of spinal stenosis do not improve after epidural steroid injection. Clin. J Pain.1998;14(2):148-51.
18.
Koc Zarife, Ozcakir S, Sivrioglu K, Gubert A, Kucukoglu S. Effectiveness of physical therapy and epidural steroid injection in lumbar spinal stenosis. Spine;2009 34(10):985-99.

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