Evaluating the effectiveness of cervical epidural methylprednisolone acetate injection in treating cervical disc displacement

Objectives: To evaluate the effectiveness and safety of cervical epidural methylprednisolone acetate injection in treating cervical disc displacement. Subjects and methods: A descriptive study on 82 patients who underwent cervical disc displacement were positive diagnosed by clinical and magnetic resonance imaging and treated in Neurology Department, Ninhbinh Hospital from May, 2015 to December, 2016.

Journal of military parmaco-medicine n07-2017 EVALUATING THE EFFECTIVENESS OF CERVICAL EPIDURAL METHYLPREDNISOLONE ACETATE INJECTION IN TREATING CERVICAL DISC DISPLACEMENT Dinh Huy Cuong*; Nguyen Van Chuong**; Nhu Dinh Son** SUMMARY Objectives: To evaluate the effectiveness and safety of cervical epidural methylprednisolone acetate injection in treating cervical disc displacement Subjects and methods: A descriptive study on 82 patients who underwent cervical disc displacement were positive diagnosed by clinical and magnetic resonance imaging and treated in Neurology Department, Ninhbinh Hospital from May, 2015 to December, 2016 These patients were randomly divided into two groups: the study group (42 patients) and the control group (40 patients) The study group was treated with drugs and fluoroscopic cervical interlaminar epidural Depo-medrol 40 mg + mL lidocaine 2% injection times The control group was treated with drug and paraspinal muscle Depo-medrol 40 mg + mL lidocaine 2% injection times The interval between injections was week Results: All patients in both groups improved after treatment However, patients treated with cervical epidural methylprednisolone acetat had better results than those treated with paraspinal muscle methylprednisolone acetate: in the patient group (block epidural area - BEA), the rate of patients achieving very good level was 61.9% (reduction ≥ 75% of symptoms,) good level (decrease ≥ 50% of symptoms) accounted for 35.7% In general, this group fell ≥ 50% of symptoms (97.6%) The control group (PBCCS) achieved very good level: 5% (decrease ≥ 75% of symptoms), good level (decrease ≥ 50% of symptoms) (62.5%) Overall, that one ≥ 50% of symptoms explained 67.5% Conclusion: Cervical epidural methylprednisolone acetate injection is a safe and effective method in managing cervical disc displacement * Keywords: Cervical disc displacement; Cervical epidural injection Hereditary spinal disc herniation (HSDH) is a quite common disease among the groups of working-age people, which has a bad influence on the quality of life and working capacity of the patients as well as the society disease is accelarating Treatment is therefore essential There are many treatment methods available such as that of medical conservation, minimum intervention, operation In many cases, if treatment is purely medical, sometimes its outcomes are not high or unsuccessful Human activities in modern society are increasingly complex, all of which affect the cervical spine, thus the incidence of this The problem is how to improve the effectiveness of preservative treatment In preservation treatment, block epidural area INTRODUCTION * Ninhbinh Hospital ** 103 Military Hospital Corresponding author: Dinh Huy Cuong (dinhuycuongbvnb@gmail.com) Date received: 10/07/2017 Date accepted: 07/08/2017 112 Journal of military phrmaco-medicine nO7-2017 method is an important content, which can be considered as a key therapeutic method determining the effectiveness of preservation treatment, also as a positive solution with its advantage that antiinflammatory drugs are introduced into the epidural area access directly into nerve roots which are stimulated and inflammed due to discs pinched Hence, it brings about rapid remission and side effects of drugs to the body In treatment of HSDH, the procedure with methylprednisolone is a routine indication, with very positive treatment results and the rate of recovery is very high Only a few authors have done the cervical spine lymphoma therapy (BEA) with methylprednisolone, which brings good effect to treatment It is due to the complexity of the functional structure of the spinal column, which threatens severe stroke, if the treatment is not strictly adhering to the procedure and lack of sufficient experience Because of the above reasons, we have conducted this research with a view to: Evaluating the effect of the treatment, drug infusion, adverse effects and safety of block epidural area (BEA) cervical spine method SUBJECTS AND METHODS Subjects 82 patients who were diagnosed with HSDH and treated in Department of Neurology in Ninhbinh General Hospital from early May, 2015 to the end of December, 2016 * Inclusion criteria: - Clinical: Patients ≤ 70 years of age with cervical spine syndrome, cervical nerve root syndrome and may be associated with the following symptoms: spinal cord compression, circulatory circulation and autonomic nervous system disorder - Sub-clinical: 100% of patients underwent spinal MRI recieved HSDH images - Patients should have clinical and diagnostic imaging correlation * Exclusion criteria: Patients with hypersensitivity to Depomedrol and lidocain, with neck infection, or systemic infection, abnormal anatomy of the scoliosis of the spine, prehistory of operating the neck spine, HSDH with other neck diseases such as tuberculosis, old spinal cord injury and associated pathologies may be aggravated when using corticosteroids such as hyperparathyroidism, dyspigmented diabetes, coagulation disorder and using anticoagulant medications Patients disagree to apply the method Method research * Study method: Descriptive study on 82 patients who were divided into two groups: - Study group: 42 patients received basic medical treatment with analgesics, anti-inflammatory, muscle relaxation, neurotransmitter enhancement and myelin reconstruction, combined with the cervical spine through the lining of the spine, under the bright-heighten screen, each block of mL lidocain 2% + 40 mg Depomedrol to BEA cervical spine using Tuohy dedicated needle in the time of weeks 113 Journal of military parmaco-medicine n07-2017 - Control group: 40 patients received basic medical treatment in combination with block cervical spine times, each time a week apart, usually blocked from to sites depending on the nerve root lesions, the total amount of blocking drug each time is 40 mg Depo-medrol + - mL lidocain 2% * Research targets: - Pain level: VAS (Visual analogue scale) score consists of 10 points divided into levels: painless (0 points), mild pain (1 - points), moderate pain (3 - points); echo (6 - points); intense pain (9 10 points) - Muscle strength: According to the British Medical Council's 5-point scale, the 5-strongest to the 1-point scale is completely paralyzed - Improved cervical spine’s function level: assessment is based on NDI (Neck Disablity Index): intensity of pain; personal self-care; heavy lifting; read book; headache; concentration; work; drive; sleep; reaction This is a set of 10 questions, each question has answers to the score from to 5, the total score is 50 to selfassessment of the impact of neck pain to personal daily activities The higher the NDI score, the lower the spinal function, the more the patient's daily activities are affected The above criteria were evaluated at times: before treatment, immediately after treatment and months after treatment Patients were followed months after the end of treatment, the improvement of the symptoms more than 50% is considered to achieve treatment goals * Compare the treatment effect: - Remission score and coefficient: + Remission score (RS) = (a-b), of which: a = clinical point before treatment; b = clinical point after treatment + Remission coefficient RC = RS/a - Evalutaing the treatment effects: very good: RC (0.8 - 1.0); good: RC (0.65 - 0.8); fair: RC (0.5 - 0.65); poor: RC < 0.5; treatment goals failed to achieve when RC < 0.5 Evaluating the side effects of the methods: Clinical complications caused by each method were recorded evaluating the effect of both methods on liver and kidney function The data were processed based on computerized statistical algorithms using the SPSS software program 160 RESULTS AND DISCUSSION Table 1: Comparing VAS at times of evaluation Time The average VAS (mean ± SD) Patients group p-values Control group Before treatment (1) 5.62 ± 1.04 5.62 ± 1.37 > 0.05 After treatment (2) 1.10 ± 1.22 2.72 ± 1.04 < 0.05 months after treatment (3) 0.76 ± 0.96 2.48 ± 1.04 < 0.05 < 0.001 < 0.001 p(time) * Evaluating treatment results: There are levels of symptom improvement in general: very good; good; fair; poor; very bad; corresponding to the improvement in the symptoms with ≥ 75%; ≥ 50 - 74%; ≥ 25 - 49%; < 25%; unsuccessful, the symptoms get more severe 114 The pre-treatment VAS scores between the two groups were almost identical (p > 0.05) However, the difference in VAS after treatment and months after treatment was statistically significant (p < 0.05) At times (2) and (3) p (timepoint 2, 3) < 0.001), our study is similar [1, 4] Journal of military phrmaco-medicine nO7-2017 Table 2: Comparion on the level of pain between groups at time of treatment Before treatment After treatment months after treatment Patient group; n (%) (1) Control group; n (%) (2) Patient group; n (%) (3) Control group; n (%) (4) Patient group; n (%) (5) Control group; n (%) (6) No pain 0 42.9% (18) 5% (2) 59.5% (25) 5% (2) Mild pain 0 54.8% (23) 37.5% (15) 40.5% (17) 55% (22) Moderate pain 33.3% (14) 42.5% (17) 2.4% (1) 57.5% (23) 40% (16) Intense pain 66.7% (28) 57.5% (23) 0 0 0 0 0 Level of pain Very intense pain p > 0.05 (patients-control) < 0.001 Prior to treatment, the majority of patients in both groups were moderately severe and painful; the difference in pain degree between the two groups was not statistically significant (p1,2 > 0.05) At the end of treatment, most patients had only mild pain, 18 patients with pain relief (42.9%) and 23 patients with mild pain (54.8%) While in the control group, as many as patients had no pain (5%) and 15 patients with mild pain (37.5%) and 23 patients were at moderate level (57.5%), meaningful difference (p3,4 < 0.001) Nguyen Van Chuong [1] applied BEA for 40 patients, after the end of treatment, he showed that pain relief was found in patients (7.5%), 23 patients with mild pain (57.5%) and 14 patients with moderate pain (35%) This result was similar to that of Castagnera’s [3] and Stav’s [5] However, our results are higher because the patients in our sample are primarily at grade I and type II herpes < 0.05 At the end of months’ treatment, the pain remission level continued to be improved, 59.5% of patients had pain relief and 40.5% of patients had mild pain, 5% of patients suffered from pain, mild pain accounted for 55%, moderate pain was 40%, meaningful difference (p5,6 < 0.05) According to Nguyen Van Chuong, BEA is a fast and effective pain relief because this technique under the guidance of bright fluorescence, the needle is introduced into the BEA, near the nerve root site before it enters The combination of lidocain and Depo-medrol is precisely introduced into the BEA, allowing the drug to concentrate at a specific location, influencing almost directly the nerve root and multiple nerve roots at the same time, through diffusion of the drug mixture when entering the BEA Clinical experience shows that if the mL contrast medium is injected at the C6-C7 position, the images impregnated with contrast medium, observed on the bright screen, will extend from two to three cervical vertebrae (C3-C4) and the image recorded is "bamboo leaf" 115 Journal of military parmaco-medicine n07-2017 The process of impregnating the contrast medium (author's data) - If injected with mL of contrast medium, the drug will spread, covering the entire BEA from C7 up to C1 On the brightening screen, it could be observed that the image of the infusion of the entire cervical spine, which are "blocks", running along the neck, multi-forms, depending on the size, circulation of the BEA, due to pressure squeezing into the BEA We applied the block epidural area solution as follows: mL Depo-medrol 40 mg + mL lidocain 2% + mL serum = mL solution, so that all the nerve roots were absorbed, helping high-neck, multi-rooted root canal exacerbations without catheter insertion, which also explain why C6-C7 interstitial injection make the symptoms of occipital nerve pain relieve rapidly Meanwhile, in the PBCSC group, the drug mixture is near the nerve roots and only affects the blocked roots Besides, when blocking a small amount of drug into the living muscle, reducing the concentration, drug’s effects promote time, thus reducing the effect of the drug, on the other side, increased the side effects of steroids due to the infiltration into the body Table 3: Levels of muscle strength improved Muscle strength Patient group; n (%) (1) Control group; n (%) (2) Patient group; n (%) (3) Control group; n (%) (4) Patient group; n (%) (5) Control group; n (%) (6) Level 2.4% (1) 17.5% (7) 52.4% (22) 35% (14) 85.7% (36) 37.5% (15) Level 73.8% (31) 62.5% (25) 47.6% (20) 55% (22) 14.3% (6) 57.5% (23) Level 23.8% (10) 17.5% (7) 10% (4) 5% (2) Level 2.5% (1) 0 0 Level 0 0 0 p-values p1,2 > 0.05 p3,4 < 0.05 p5,6 < 0.05 Before treatment, 97.6% of patients had weak muscules; after treatment this firgure dropped to 47.6% In the control group, before treatment, 82.5% of patients suffered from weak muscles; after treatment, this firgure decreased to 65% with significant difference (p3,4 < 0.05) 116 Journal of military phrmaco-medicine nO7-2017 After months of treatment, there was an improvement in both groups (14.3%), while that of the control group was worse (62%), significant difference (p5,6 < 0.05) Research by Bush and Hiller [2], prior to the treatment, 75% of patients had weak muscles; after the treatment, the median follow-up of 39 months meaned that 73% of patients no longer had weak muscles Table 4: Evaluating the degree of improvement of the cervical function based on NDI point at time of treatment Patient group mean ± SD Control group mean ± SD p123(patients-control) Before treatment (1) 16.19 ± 5.27 16.38 ± 4.67 > 0.05 After treatment (2) 3.10 ± 2.91 5.98 ± 2.60 < 0.001 months after treatment (3) 2.26 ± 2.52 5.85 ± 2.52 < 0.001 p1,2 < 0.001 p1,2 < 0.001 p2,3 < 0.001 p2,3 > 0.05 Group time p(time) Prior to NDI treatment of homologous groups (p > 0.05), after the treatment and 6-month follow-up, the CSC continued to improve significantly (p > 0.05) (p < 0.001) Comparison at the time of the study, in the study group, CSC’s function was improved significantly after the end of treatment and after months (p < 0.001), while in the control group at the time (2) immediately after the end of treatment, the CSC function was significantly improved (p < 0.001), but after months, CSC function improved but not statistically significant This proves that the cervical spine block drug concentration method only affects the nerve roots immediately after the blockade and then disperses into the body Table 5: The level of symptom improvement in general Patient group (n = 42) Control group (n = 42) Symptom improvement degree p (χ 2) n % n % ≥ 75% (very good) 26 61.9% 5% 50 - 74% (good) 15 35.7% 25 62.5% 25 - 49% (fair) 2.4% 13 32.5% < 0.05 (33.328) < 25% (poor) 0 0 Unsuccessful 0 0 After the intervention, the symptoms of both groups were significantly reduced, no cases of clinical symptoms aggravated However, in the patient group, the proportion of patients who improve ≥ 50% the symptoms (97.6%) was higher than that of the control group (67.5%), which was statistically significant with p < 0.05 In the Manchikati’s 117 Journal of military parmaco-medicine n07-2017 study [4], the proportion of patients who improved ≥ 50% of the symptoms was 82% and that in Nguyen Van Chuong’s study [1] was 72.5% Table 6: Comparing VAS before and after treatment Evaluating measure Patient group (n = 42) Control group (n = 40) p-values VAS before treatment (a) 5.62 ± 1.04 5.62 ± 1.37 > 0.05 VAS after treatment (b) 1.10 ± 1.12 2.72 ± 1.04 < 0.05 Remission score (a-b) 4.64 ± 1.01 2.9 ± 0.90 < 0.05 Remission coeficient = RS/a 0.84 ± 0.16 0.52 ± 0.14 < 0.05 Remission coeficient = RS/a 0.84 ± 0.16 0.52 ± 0.14 < 0.05 Before the treatment, VAS scores of the two groups was similar (p > 0.05) After the treatment, remission score was 4.64 ± 1.01, the difference was statistically significant (p < 0.05) The remission coefficient of group of patients (0.84 ± 0.16) was higher than that of the control group (0.52 ± 0.14), significantly different (p < 0.05) Table 7: Comparing NDI score before and after treatment Method Patient group (n = 42) Control group (n = 40) p-values The score before treatment (a) 16.19 ± 5.27 16.38 ± 4.67 > 0.05 The score after treatment (b) 3.10 ± 2.91 5.98 ± 2.60 < 0.05 Remission score (a-b) 13.10 ± 3.48 10.40 ± 3.10 < 0.05 RC = RS/a 0.86 ± 0.15 0.63 ± 0.13 < 0.05 Before the treatment, NDI of two groups were approximately equal (p > 0.05) The remission coinfficient of the patients (0.86 ± 0.15) was higher than that of the control group (0.63 ± 0.13) with (p < 0.05) Table 8: Comparing the muscle strength before and after treatment Assessment method Patient group (n = 42) Control group (n = 40) p-values The score before treatment (a) 3.79 ± 0.47 4.00 ± 0.60 > 0.05 The score after treatment (b) 4.52 ± 0.51 4.25 ± 0.63 < 0.05 Remission score (a-b) 0.74 ± 0.54 0.25 ± 0.44 < 0.05 RC = RS/a 0.16 ± 0.12 0.05 ± 0.09 < 0.05 Before treatment, the muscle strength of the two groups was similar (p > 0.05) The remission coefficient of the disease group (0.16 ± 0.12) was higher than the control group (0.05 ± 0.09) (p < 0.05) demonstrating that BEA blocking technique is more effective than block cervical spine 118 Journal of military phrmaco-medicine nO7-2017 Table 9: Comparing stroke and complication Stroke and complication Group of patients (n = 42) Controll group (n = 40) n % n % Pain in place after injection 7.1 10 Hard membrane is pierced 0 0 The spinal cord is touched 0 0 Touch the nerve root 2.4 Drugs insensitivity rise 0 0 Infection 0 0 Bleeding 0 0 Temporary hypertension 2.4 7.5 Insomnia 9.5 15 Stomach pain 4.7 12 Water retention 9.5 15 CONLCUSION On avarage, the proportion of patients with ≥ 50% reduction symptoms was 67.5% Through the study on 82 patients who were divided into two groups and performed by the method of BEA cervical spine, we could draw the following conclusions: - The overall symptom remission coifficient of BEA was statistically higher than that of block (p < 0.05) which demonstrated that BEA method is better than traditional treatment - Safety: During the procedure, the two methods had not caused any major strokes or complications Only a few side effects of the drug was documented which were stable after a few days of the treatment - All patients in the two groups improved after treatment, but the study group was better than the control group + In the study group, 61.9% of patients achieved a very good result (reduced ≥ 75% of the symptoms); 35.7% of the patients had good result (decreased ≥ 50% of the symptoms) On average, 97.6% of people had ≥ 50% reduction of the symptoms + In the control group, 5% of patients gained excellent outcome (reduction of ≥ 75% of symptoms) 62.5% had a good result (decrease ≥ 50% symptoms) REFERENCES Nguyễn Văn Chương CS Bước đầu đánh giá hiệu kỹ thuật tiêm màng cứng cột sống cổ steroid điều trị thoát vị đĩa đệm cột sống cổ Tạp chí Y học Việt Nam 2013, 11 (2), tr.105-111 119 Journal of military parmaco-medicine n07-2017 Bush K, Hillier S Outcome of cervical radiculopathy treated with periradicular/epidural corticosteroid ịnections: A prospective study with independent clinical review Eur Spine Journal 1996, 5, pp.319-325 Castagnera L, Mauette P, Pointilart V, Vi-tal J.M, Emy P, Senegas J Long-tem results of cervical eoidural steroid injection without morphine in chronic cervical radisuler pain Pain 1994, 58, pp.239-243 120 Manchikati L, cash K.A, Pampati V, Wargo B.W, Malla Y The effectiveness of fluoroscopic cervical interiaminar epidural injections in managing chronic cervical disc herniation and radicculitis preliminary results of a randomized, double-blind, controlled trial pain physician 2010, 13, pp.223-236 Stav A, Ovadia L, Sternberg A, Kaadan M, Weksler N Cervical epidural steroid injection for crevicobrachialgia Acta Anaesthesiol Scand 1993, 37, pp.562-566  ... reconstruction, combined with the cervical spine through the lining of the spine, under the bright-heighten screen, each block of mL lidocain 2% + 40 mg Depomedrol to BEA cervical spine using Tuohy dedicated... consists of 10 points divided into levels: painless (0 points), mild pain (1 - points), moderate pain (3 - points); echo (6 - points); intense pain (9 10 points) - Muscle strength: According to the. .. when blocking a small amount of drug into the living muscle, reducing the concentration, drug’s effects promote time, thus reducing the effect of the drug, on the other side, increased the side