Accepted Manuscript

Epidural steroids at closure post-microdiscectomy/laminectomy for reduction of post-

operative analgesia: systematic review and meta-analysis

Ash Wilson-Smith, Nicholas Chang, Victor M. Lu, MPhil, Ralph J. Mobbs, MD MS

FRACS, Matthew Fadhil, Declan Lloyd, Sara Kim, Kevin Phan, MD BSc MPhil MSc

PII: S1878-8750(17)31861-2
DOI: 10.1016/j.wneu.2017.10.133
Reference: WNEU 6786

To appear in: World Neurosurgery

Received Date: 26 September 2017

Revised Date: 22 October 2017
Accepted Date: 24 October 2017

Please cite this article as: Wilson-Smith A, Chang N, Lu VM, Mobbs RJ, Fadhil M, Lloyd D, Kim
S, Phan K, Epidural steroids at closure post-microdiscectomy/laminectomy for reduction of post-
operative analgesia: systematic review and meta-analysis, World Neurosurgery (2017), doi: 10.1016/
j.wneu.2017.10.133.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
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 ACCEPTED MANUSCRIPT
Epidural steroids at closure post-microdiscectomy/laminectomy for reduction of post-operative

analgesia: systematic review and meta-analysis

Ash Wilson-Smitha* , Nicholas Changa*, Victor M Lud MPhil, Ralph J Mobbsa,b,c MD MS FRACS, Matthew

Fadhil, Declan Lloyd, Sara Kima , Kevin Phana,b, c, d MD BSc MPhil MSc

*equal first

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AUTHOR AFFILIATION ADDRESSES

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a
Faculty of Medicine, The University of New South Wales, Sydney, Australia
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NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia

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c
Department of Neurosurgery, Prince of Wales Hospital, Randwick, Australia 2031
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Faculty of Medicine, Sydney Medical School, University of Sydney, Australia.

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CORRESPONDING AUTHOR
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Kevin Phan, NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Randwick, Sydney, Australia.

Email: kphan.vc@gmail.com
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DISCLOSURE
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The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified
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in this paper. This research did not receive any specific grant from funding agencies in the public, commercial, or not-

for-profit sectors.
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ABBREVIATIONS LIST

CCRCT: Cochrane Central Register of Controlled Trials, CDSR: Cochrane Database of Systematic Reviews, COX-2:
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cyclo-oxygenase-2, DEX: dexamethasone, EPI: epidural, IM: intramuscular, IV: intravenous, MOOSE: Meta-analyses of
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Observational Studies in Epidemiology, LBP: lower back pain, LDH: lumbar disc herniation, LM: laminectomy, LOS:

length of hospital stay, MD: microdiscectomy, MP: Methylprednisolone, MPSS: methylprednisolone sodium succinate,

MS: morphine sulphate, N: no, NSAID: non-steroidal anti-inflammatory, RLB: radicular leg pain, RT: randomized trial,

TAC: triamcinolone, TNF-α: tumor-necrosis factor alpha, U: undermined/not provided, VAS: Visual Analogue Scale, Y:

yes
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ABSTRACT

Background: This review assessed the efficacy of epidural steroid administration on the reduction of pain,

hospital stay time and use of opioid analgesics postoperatively.

Methods: We searched Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials (CCRCT)

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and Cochrane Database of Systematic Reviews (CDSR) for studies utilizing epidural steroids through any

route following lumbar surgery. The primary study outcomes included pre- and postoperative pain as assessed

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through the use of a Visual Analogue Scale (VAS), length of hospital stay and postoperative use of opioid

analgesics. The data were extracted and stratified according to the administered steroid administered. Data

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was then assessed for heterogeneity, subgroup differences and ultimately tabulated in a Forest plot.

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Results: 17 RCTs were included in this review, with 16 undergoing quantitative analysis. Steroids were
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shown to be superior in terms of VAS outcome at 24 hours, with triamcinolone (TAC) and dexamethasone

(DEX) performing similarly. Methylprednisolone (MP) paradoxically performed worse at the 24-hour mark.
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At 1 month, all steroids illustrated superiority in terms of VAS outcome. Steroids also proved superior in
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reducing hospital length of stay and postoperative use of opioid analgesia.

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Conclusion: Intra/perioperative epidural administration of steroids offers significant benefits in terms of pain
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control, reduction in length of hospital stay time and use of postoperative opioid analgesia. Before steroids are

routinely employed by spinal surgeons, however, significantly more research is required. A particular
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emphasis should be placed on quality study protocols and data recording, to allow for more thorough analyses
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in the future.

KEYWORDS

Analgesics; epidural steroid; laminectomy; lumbar vertebrae; opioids; pain reduction; postoperative
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INTRODUCTION

Surgical procedures on the spine, specifically microdiscectomy and laminectomies, are becoming more

frequent in the setting of an ageing population 1. Whilst these surgeries have been shown to effectively

alleviate lower back pain (LBP) and radicular leg pain (RLP), a significant number of patients report

persistent residual symptoms 2. When considering the implications for short-term management, this residual

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pain translates into prolonged hospitalization time, prolonged time of convalescence (i.e. time to returning to

normal daily activities) and an increased uptake of postoperative opioid analgesics 3. With the taxpayer and

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healthcare system already struggling to adapt to increasingly large numbers of ageing patients - and

demographic trends suggesting that this will worsen markedly in the next half-century - instituting intelligent,

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cost-effective peri- and postoperative management pathways in spine surgery is more pertinent than ever.

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It has been reported previously that the administration of steroids at closure may be effective in the relief of
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residual postoperative pain, in addition to shortening hospital stay time and reducing opioid analgesia use.

Whilst the precise mechanism of action is under debate, steroids are widely thought to reduce the effect of
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surgical trauma on an immunomodulatory basis, that is, by reducing the amplitude of inflammatory cascades

and the subsequent nerve root inflammation 4. The benefits of this approach seem apparent at first glance;
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improvements in patient outcomes, a reduction in treatment costs and the avoidance of unnecessary opioid
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administration. However, the existing literature reflects ongoing controversy surrounding steroid use at

closure, with a number of studies some citing superiority of control treatments over the active treatments.
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Recently, Lotfinia et al. (27) reported no significant difference in postoperative LBP or RLP within their

treatment groups, treated with epidural methylprednisolone, bupivacaine or saline, at 96 hours

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postoperatively. These findings support the earlier work of Lavyne et al. (15), who found that there was no
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difference in the amount of postoperative opioid analgesia use in their cohorts, nor any difference in time to

return to work. It is important to note that Lotfinia et al. did not follow up past 96 hours or report any study

limitations. Given their findings are inconsistent with the wider surgical community, this is a significant point

of concern. Lavyne et al. also conceded that both treatment groups attained identical maximum outcome

scores postoperatively.
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Although there is reasonable evidence to suggest that the application of epidural steroids is both effective and

sensible, it would be imprudent if further investigations were not conducted to confirm substantive efficacy

and address historical points of contention. In this review, we sought to analyze the existing literature to

assess the efficacy of epidural steroid administration on the reduction of postoperative pain, length of stay and

use of opioid analgesics.

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MATERIALS AND METHODS

Literature search and outcome measures

The present study was performed according to recommended PRISMA guidelines 5,6. We analyzed a series of

studies where patients underwent spinal surgery, primarily microdiscectomy and laminectomy, with

administration of epidural steroids at closure. Five electronic databases, namely Medline, Pubmed, Embase,

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Cochrane Central Register of Controlled Trials (CCRCT) and Cochrane Database of Systematic Reviews

(CDSR) were searched from their date of inception until 1 August 2017 for studies investigating the use of

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epidural steroids during spinal surgery. The search terms are listed under the appendix. Relevant studies were

then systematically reviewed, in accordance with the inclusion and exclusion criteria, by an independent

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author. A PRISMA diagram detailing the search process is shown by Supplementary Figure 1. We identified

the differences in patient pain levels [using Visual Analogue Scale data (VAS) pre-operatively, 24 hours

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postoperatively and 1 month postoperatively], mean length of hospital stay (LOS) and postoperative use of
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opioid medications at 24 hours and 48 hours postoperatively in those who either received a placebo or no

treatment at closure. The data were extracted and stratified according to the administered steroid, with the
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continuous data being presented in terms of means and mean differences. These values were then assessed for
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heterogeneity, subgroup differences and ultimately tabulated in a Forest plot, with statistical significance
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accepted at a P value of 0.05.

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Inclusion/exclusion criteria

Randomized controlled trials or cohort studies of patients who underwent lumbar spinal surgery and had
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steroids administered into the epidural space, or onto the exposed nerve root, were included in this review.
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This review includes studies in which the steroids were administered intraoperatively and in those where

steroids were administered perioperatively. We included studies that provided sufficient data relating to all or

part of the following: VAS pain scores pre-operatively, 24 hours and 1 month postoperatively, LOS and

postoperative opioid usage. However, studies that reported patients in whom the steroids were administered

intramuscularly or intravenously were excluded from this review. Similarly, we excluded studies of patients

who received epidural steroids without surgery and studies in which patients were treated with non-steroidal

medications. This review was limited to studies that were published before 1 August 2017
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Data extraction, analysis and quality assessment

An independent reviewer extracted the data from the studies selected and recorded the results in Microsoft

Excel. The characteristics of the studies, in terms of their methods and clinical criterion, are outlined in Table

1. With regards to quality assessment, the Meta-analyses of Observational Studies in Epidemiology (MOOSE)

checklist was utilized in this review. The primary domains assessed under this checklist are: clear definition of

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the study population; clear definition of outcomes and outcome assessment; independent assessment of

outcome parameters; sufficient duration of follow-up; no selective loss during follow-up, and; important

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confounders and prognostic factors identified. The primary outcomes of interest were the pre- and

postoperative VAS scores, the length of hospital stay and the amount of opioid analgesics used

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postoperatively.

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RESULTS

Search strategy and critical appraisal

A total of 1571 studies were identified through a comprehensive search of five electronic databases and from

other sources, such as reference lists. After exclusion of duplicate and irrelevant references, 1489 potentially

relevant articles were retrieved. After detailed evaluation of these articles, 17 studies remained for analysis,

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encompassing a total of 1727 patients who were treated with epidural steroids at closure after lumbar spinal

surgery 4,7-21. According to the MOOSE criteria, by which the quality of studies was assessed, of the fourteen

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included studies, only four attained the maximum score. Seven studies attained a score of five, four studies

attained a score of four and two studies scored only three. These findings are reflected in Table 2. Only five

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included studies reported mean-follow up equal or greater than 6 months 4,11,12,21,22.

Visual Analogue Scale (VAS)

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Five studies assessed pain via VAS at 24 hours (Figure 1). The statistical analysis illustrated that the control

group was superior to the use of MP with a mean difference of -0.29 [95% confidence interval (CI): -0.56, -
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0.01], which was statistically significant at a P value of 0.04 (Figure 1). This finding was unexpected,
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particularly in comparison to the rest of the study findings. As expected, TAC and DEX both illustrated
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superior performance with a mean difference of 1.34 (CI = 0.79, 1.88) and 1.66 (CI = 0.55, 2.77),

respectively. The three studies assessing VAS at 1 month all illustrated superior performance utilizing MP and
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TAC, at a mean difference of 0.49 (0.39, 0.58) and 0.37 (-0.07, 0.81)(Figure 2). However, only the results

from the MP analyses were statistically significant at a P value of 0.00001, compared to TAC at a P value of
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0.10.
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Hospital stay time

With respect to length of stay (LOS), the use of MP, TAC and DEX all illustrated superior results in

comparison to the control groups. The overall mean difference was 0.92 days (95% CI: 0.57, 1.27) and was

statistically significant at a P value of 0.00001 (Figure 3).

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Use of perioperative steroids and postoperative analgesia

As expected, the perioperative administration of steroids all reduced use of opioid analgesia postoperatively,

with an overall mean difference of 6.41 units (2.26, 10.56) and a statistically significant P value of 0.002

(Figure 4).

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Complications

We found no significant difference in the control vs steroid groups in terms of total adverse events (2.2% vs

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5%, OR 0.50; 95% CI 0.19-1.31; P=0.16; I2=0%)(Figure 5). In terms of infection rates, there was also no

significant differences found between control and steroids groups (1.5% vs 3.9%; OR 0.52; 95% CI 0.14-1.94l

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P=0.33; I2=0%). There were no events of pseudomeningocele reported. CSF leaks were very poorly reported

amongst steroid subgroups and thus could not be analyzed statistically.

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DISCUSSION
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From the analyses, perioperative steroid administration was proven to be superior to control or placebo groups
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in most key study outcomes (VAS, LOS, postoperative opioid analgesia use). The only outcome measure
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which suggested that the steroid was less effective than control was the statistically significant association

between a higher VAS score at 24 hours and epidural administration of MP. Overall, these findings are
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encouraging given the strong association with good pain control and better postoperative performance after

surgery 23.
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Pathophysiology of lower back pain and radicular back pain

Macroscopic degenerative and proliferative changes have been linked to back pain from as early as the 1950s
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, however, the exact pathophysiological mechanism of lower back pain (LBP) and radicular leg pain (RLP)

still remains unclear. Whilst research initially indicated mechanical compression as the sole generator of pre-

and postoperative pain, the additional contribution of inflammatory molecules in this process appears logical.

In 1956, Kelly et al. 25 postulated that the chronic compression of nerve roots induced a “chemical factor” that
9,26 17,27
leads to clinical hyperalgesia. In the contemporary setting, Bahari et al. and Lotfinia et al. both cite
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studies that confirm that nucleus pulposus debris acts as a potent inducer of inflammatory cascades, markedly

increasing levels of phospholipase A2, prostaglandins, leukotrienes and other cytokines. Intraoperative

manipulation of lumbar nerve roots and surgically-induced tissue trauma also contributes to the induction of

inflammation, thereby making perioperative administration of steroids a logical decision. Whilst the precise

mechanism of action of corticosteroids remains unknown, a number of research models have suggested that

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they may target the production of these inflammatory molecules through the inhibition of cyclo-oxygenase-2

(COX-2) mRNA expression, as alluded to in Rasmussen et al. 4. This inhibition has the added benefit of

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down-regulating levels of tumor-necrosis factor alpha (TNF-α), Interleukin-1β and Interleukin-6 whilst

contributing to membrane stabilization, reversible local anesthesia and decreased postoperative fibrous

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formations.

Visual Analogue Scale

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Lotfinia et al. 17 report a RCT consisting of 150 patients undergoing surgery due to symptomatic lumbar disc

herniation (LDH). They split their patient cohort into three treatment groups, namely those receiving
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methylprednisolone, bupivacaine or saline. Surprisingly, no significant difference existed between the three
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groups’ VAS at 96 hours after surgery, with a mean difference of -0.34 (-0.42, 0.26, P = 0.04). RCTs by
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Aljabi et al. 8 and Shin et al.21 both report support steroid use at mean differences of 0.40 (-0.12, 0.92) and

0.37 (-0.07, 0.81).

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Length of hospital stay

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Davis et al. 10 report an RCT where 43 consecutive patients underwent surgery for symptomatic unilateral disc
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protrusion. The patients who received MP stayed an average of 2.60 days, versus the control stay time of 4.11

days. Diaz et al. 11 examined the efficacy of MP acetate, MS, a combination of the two, or a placebo, in a 201-

patient RCT. Their study indicated a trend toward a reduced hospital stay time in patients managed with MP

and MS, with an average time to discharge of 41 ± 6 hours versus 72 ± 6 in the control group.

Postoperative use of opioid analgesia

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11
The RCT by Diaz et al. illustrated superior performance of steroids over placebo in their cohorts, with

postoperative analgesic consumption three times higher in the placebo group (27.1 ± 11.8 unit doses)
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compared to the steroid group (8.4 ± 1.1 unit doses, P = 0.001). Jirarattanaphochai et al. report marked

reduction in overall cumulative morphine dose favoring the steroid treatment group (-8.24, CI = -18.47, -1.30)

over a 48-hour study period, in comparison to a placebo (P =0.01). Interestingly, they also undertook an SF-

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36 Health Questionnaire with all values, inclusive of bodily pain perception, favoring steroid treatment.

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Benefits and deficits of steroid use

It is clear that there are a number of benefits in adopting perioperative steroid administration. The

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immunomodulatory effects illustrated by steroids are clearly exploitable and as further improvements are

made to formulations and delivery mechanisms, it is expected that more surgeons will consider this

management pathway. For example, Debi et al. 28

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explain the potential for future use of
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biodegradable release modules, enabling standardized quantities of steroids to be administered. Rasmussen et

al. 4 demonstrated the superiority of steroids over non-steroidal anti-inflammatory (NSAID) medications, but
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illustrated good data regarding the combination of the two in addressing late pain generation and
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inflammation due to surgical trauma and neuroendocrine response. The reduction in use of postoperative
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opioid analgesia also presents steroid administration as an attractive pathway. Foulkes et al. 13 emphasize the

reduced incidence of over-sedation, respiratory depression and postoperative complications observed in their
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cohorts. Of course, there are a number of ongoing concerns regarding steroid use. Aljabi et al. suggest that due

to the immunosuppressive effects of steroids, delayed healing, increased risk of infection and increased risk of
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reherniation are likely to become more prevalent issues in practice 8. Whilst the majority of studies report near
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negligible rates of infection, these concerns mandate that further studies on the topic extend their follow-up

periods to beyond what is currently accepted within the literature. Indeed, some study groups have utilized

prophylactic antibiotic use to overcome the risk of clinical infection, although this poses the question as to

whether this is appropriate antibiotic stewardship. Complications in terms of site injection and long-term

adverse effects have also not been followed up adequately.

Limitations of this systematic review

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This systematic review is constrained by several limitations. With respect to the literature, a number of studies

incorporated in the analyses failed to adequately report key outcomes. The paucity of data with respect to

long-term follow-up is a point of concern; given this review focusses on landmark studies from previous eras

of investigation, it is unlikely that modern clinical practice and patient outcomes are accurately reflected.

Ongoing evolution of peri- and postoperative care is likely to have had an effect on patient recovery in this

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regard. No statistical analyses of functional disability or adverse effects of steroid administration were carried

out, as these parameters were not well reported by the included studies. Further, our statistical tests also

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revealed high heterogeneity, as reflected by I2 values >75 in all key study outcomes bar VAS at one month.

This is likely due to the large variability in surgical techniques, steroid formulations and patient

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characteristics.

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CONCLUSIONS

As the population continues to age, spinal surgeries will become increasingly prevalent and costly if
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postoperative management remains suboptimal. Therefore, the implementation of intelligent surgical

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management pathways will, in turn, become more important in future practice. Intra- /perioperative epidural
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administration of steroids offers significant benefits in terms of pain control, reduction in length of hospital

stay and use of postoperative opioid analgesics. Before steroids are routinely employed by spinal surgeons,
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however, significantly more data are required from modern operating theatres and studies. A particular

emphasis must be placed on standardized study protocols, surgical techniques, steroid formulations and data
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recording to accommodate less variability in results and more thorough analysis of key patient outcomes.
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ACKNOWLEDGEMENTS

None
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APPENDIX

Search terms/search strategy

1. anesthesia, epidural/

2. injections, epidural/

3. analgesia, epidural/

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4. epidural steroid*.tw.

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5. 1 or 2 or 3 or 4

6. lumbar spine surgery.tw

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7. spine surgery.tw

8. intervertebral disk/su

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9. lumbar vertebrae/su
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10. diskectomy/

11. laminectomy/
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12. 6 or 7 or 8 or 9 or 10 or 11

13. 5 and 12
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Figure legends

Figure 1 - Forest plot demonstrating meta-analysis of postoperative pain at 24 hours via Visual Analogue

Scale (VAS) scores

Figure 2 - Forest plot demonstrating meta-analysis of postoperative pain at 1 month via Visual Analogue

Scale (VAS) scores

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Figure 3 - Forest plot demonstrating meta-analysis of length of stay/hospital stay time

Figure 4 - Forest plot demonstrating meta-analysis of postoperative steroid use

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Figure 5 - Forest plot demonstrating meta-analysis of total adverse events

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Table 1 - Study and MANUSCRIPT
clinical characteristics

First Author, Year Location Study design Follow- Cohort Age (mean Males Operative Steroid Administration
up number +/- standard total procedures formulation route
(total) deviation or (%) (dose +
mean/range) medication if
Control + stated)
Steroid(s)
Abrishamkar Iran Prospective 2 66 36.4 ± 10.27 46.96% Single level LM 40mg MP EPI implant
(2011) Double-blind weeks 36.7 ± 9.99 acetate

PT
RT AND 1cc Bupivacaine
35.3 ± 11.14 (0.5%)
1cc Saline

RI
Aljabi (2015) UAE Prospective 1 150 42 (18-60) 49.33% Single level MD 80mg MP EPI
RT month 45 (21-53) acetate
Saline

SC
Bahari (2010) Ireland Prospective 2 100 39.2 54.00% Single level MD 1cc 10mg TAC EPI
Blinded RCT months 39.3 AND acetonide + 1cc
42.7 AND Bupivacaine
41.8 (0.5%)

U
TAC acetonide +
AN
Saline
Bupivacaine +
1cc Saline
2cc Saline
M

Davis (1990) USA Prospective 4 days 86 44.4 ± 12.19 61.62% LM 80mg MP EPI
Matched 42.5 ± 10.73 acetate
control No treatment
D

(control)
TE

Diaz (2012) Canada Prospective 1 year 201 50 ± 3 46.76% MD or LM MP acetate + EPI

Double-blind 53 ± 3 MS
RCT MP acetate
MS
EP

Placebo
Dikmen (2005) Turkey Prospective 3 years 31 NR NR Single level LM 2mg/10cc EPI
RT and discectomy Morphine +
C

Saline
8mg/10cc
AC

Dexamethasone
+ Saline
(Needham
paste)

Foulkes (1990) USA Prospective 8 days 45 43.4 (24-71) 68.89% Hemi-LM or MD 16mg EPI
44.3 (26-87) Dexamethasone
No treatment
(control)
Hulbert (1999) USA Prospective 3 60 NR NR Discectomy or MP acetate + EPI
Double-blind months decompression MS (Needham
RCT paste)
Saline
Jirarattanaphochai Thailand Prospective 3 103 51 ± 13 46.60% LM and 80mg/0.375% EPI
(2007) Double-blind ACCEPTED 53
months MANUSCRIPT
± 10 foraminotomy; 30cc MPSS +
RCT spinal Bupivacaine
fusion/pedicular Saline
screw fixation
Lavyne (1992) USA Prospective 3 78 42 67.85% Single level MD 40mg MP EPI
weeks 38.8 acetate
Saline
Lotfinia (2007) Iran Prospective 96 150 38.92 ± 0.66 44.67% Single level LM 40mg/3cc MP EPI
Double-blind hours 38.16 ± 0.16 and discectomy acetate + Saline
placebo RCT AND 2cc 0.5%

PT
37.20 ± 0.51 Bupivacaine +
2cc Saline
4cc Saline

RI
McNeil (1995) USA Prospective 48 166 NR NR Decompressive 50ml Saline EPI
Randomized hours LM 5mg/10cc
blinded Morphine

SC
comparative 40mg MP + 5mg
Morphine
40mg/10cc MP

U
Mirzai (2002) Turkey Prospective 12 44 39.5 ± 10.0 56.81% LM and 20cc 0.9% Saline IM EPI
Blinded RCT hours 39.1 ± 6.3 discectomy 40mg MP + 20cc
AN
0.25%
Bupivacaine
Modi (2009) Korea Prospective 1 year 57 30.14 ± 8.15 80.70% Single level 40mg MP EPI
M

Randomized 29.82 ± 7.16 discectomy and acetate

prospective flavotomy No treatment
case control (control)
D

Pobereskin (2000) UK Prospective 24 93 NR NR Not specified 20mg TAC EPI

TE

Randomized hours 40mg TAC

No treatment
(control)
EP

Rasmussen (2008) Denmark Prospective 2 years 200 40.9 (18-62) 61.00% Discectomy 40mg/1cc MP EPI
Randomized 44 (18-66) acetate
control study No treatment
(control)
C

Shin (2015) Korea Randomized 6 97 NR NR Percutaneous 40mg TAC + 4cc EPI

AC

control study months endoscopic MD Saline

5cc Saline
Abbreviations: RT (randomized trial), LM (Laminectomy), MD (Microdiscectomy), MP (methylprednisolone), TAC (triamcinolone), MS
(morphine sulphate), MPSS (methylprednisolone sodium succinate), EPI (epidural), IM (intramuscular), IV (intravenous)
 ACCEPTED MANUSCRIPT
Table 2 - Quality assessment using the MOOSE checklist

Study - Author and year Clear definition Clear definition Independent Sufficient No selective Important Study quality
of study of outcomes assessment of duration of loss during confounders level
population and outcome outcome follow-up follow-up and prognostic
assessment parameters factors
identified
Abrishamkar (2011) Y Y Y N, 14d Y N 4
Aljabi (2015) Y Y Y Y, 1m Y Y 6

PT
Bahari (2010) Y Y U Y, 2m Y Y 5
Davis (1990) Y Y Y N, 4d Y N 4
Diaz (2012) Y Y Y Y, 1y Y Y 6

RI
Dikmen (2005) Y Y U Y, 3y Y N 5
Foulkes (1990) Y Y U N, 8d Y N 3

SC
Hulbert (1999) Y Y Y Y, 3m Y N 5

Jirarattanaphochai Y Y U Y, 3m Y Y 5
(2007)

U
Lavyne (1992) Y Y U N, 3w Y N 3
Lotfinia (2007) Y Y Y N, 96h Y N 4
AN
McNeil (1995) Y Y Y N, 48h Y Y 5
Mirzai (2002) Y Y Y N, 12h Y N 4
Modi (2009) Y Y U Y, 1y Y Y 5
M

Pobereskin (2000) Y Y Y N, 24h Y N 5

Rasmussen (2008) Y Y Y Y, 2y Y Y 6
Shin (2015) Y Y Y Y, 6m Y Y 6
D

Abbreviations: Y (Yes), N (No), U (undetermined/not provided)

TE
C EP
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT
• 17 RCTs were included in this meta-analysis
• Steroids were shown to be superior in terms of VAS outcome at 24 hours
• At 1 month, all steroids illustrated superiority in terms of VAS outcome
• Steroids also reduced hospital stay and postoperative opioid analgesia

PT
RI
U SC
AN
M
D
TE
C EP
AC