Abstract

Title: Comparing the Efficacy of Epidural Monotherapy to Combined Epidural Pulsed Radiofrequency in Mitigating Chronic Lower Back Pain At 1 Month: A Systematic Review and Pooled Analysis.

Authors: Uzay Cagatay1 , Jonathan Elias1 , Fatima Mossolem MS1,2 , Jay Patel1 , Seth Spicer MS1,2 , Richard Jermyn DO1 1Rowan-Virtua School of Osteopathic Medicine, Stratford, NJ 2 Futures Forward Research Institute, Toms River, NJ

Background: Using transforaminal epidural steroid injection (TFESI) has been the standard treatment in the alleviation of chronic lower back pain (CLBP). Recent studies utilizing pulsed radiofrequency (PRF) have shown potential in alleviating lower back pain. There have yet to be any systematic reviews comparing the administration of TFESI alone against utilizing TFESI in combination with PRF to mitigate chronic lower back pain at the 1-month mark. We hypothesize that TFESI + PRF therapy could be beneficial due to their additive effects, as TFESI reduces inflammation, while PRF modulates pain signal transmission.

Methods: The systematic review and pooled analysis followed the 2020 PRISMA guidelines. Seven online databases were surveyed (Pubmed, Embase, Scopus, Rowan-Virtua School of Osteopathic Medicine Library, Cochrane, Web of Science, Google Scholar). The analysis included randomized controlled trials (RCTs) in which patients received TFESI alone or TFESI and PRF. Pain level was measured using the visual analog scale (VAS) or the numeric rating scale (NRS). Three RCTs fit the inclusion criteria for the review, yielding 193 distinct evaluations. VAS and NRF were analyzed 1-month post-treatment in the two groups.

Results: There was no statistical significance (p = 0.37) between utilizing TFESI alone, or in combination with PRF. However, the results may be clinically significant as there was a notable difference in mean effect size with a difference of Cohen’s d = 0.79, in favor of TFESI + PRF.

Discussion: TFESI utilizing PRF provided statistically similar pain reduction compared to TFESI alone, but there still may be potential in this combinatorial treatment. A limitation of our study is the relatively small sample size of 193 patients. To solidify our findings, there is a need for additional RCTs with larger sample sizes, to better determine statistical significance of such a treatment. Reducing pain recurrence in these patients may lower opioid prescriptions from family medicine physicians, lowering the possibility of patient opioid dependence. This will ultimately reduce the burden on family medicine physicians.

Conclusion: Our systematic review suggests that there is potential in a combination therapy of TFESI with PRF to treat CLBP as there is a clinically significant improvement in NRS and VAS Scores at the 1 month mark. Statistical significance was not achieved with the currently available sample size and RCTs.