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Low-back pain (LBP) is a common pain syndrome with a reported prevalence of over 70 per cent in industrialised countries [1]. Between 15 and 45 per cent of LBP can be attributed to lumbar facet joint origin [2]. First-line therapy often consists of a conservative, multi-modal approach (pharmacological management, non-steroidal anti-inflammatory drugs, physiotherapy), before progressing to diagnostic and/or therapeutic interventional procedures targeting the facet joint specifically. European Guidelines do not recommend the use of intra-articular (IA) corticosteroid (CS) facet joint injections for the management of non-specific chronic LBP [3]. Correspondingly, Cochrane Review guidelines for LBP injection therapy state there is insufficient evidence to support the use of IA CS for subacute (<6 weeks) and chronic (<12 weeks) conditions. However, they conclude that injection therapy should not be ruled out entirely, as subgroups of patients may respond positively to specific types of injection therapy [4].
Viscosupplementation (which utilises IA injections of Sodium Hyaluronate (SH)) has been proven to provide significant long-term therapeutic benefit for degenerative change within synovial joints, demonstrating significantly longer temporal reduction of pain and a greater degree of functional improvement when compared with CS injection [5]. Furthermore, no reports of serious or long-term adverse effects have been documented.
Fuchs et al. evaluated the efficacy and safety of IA SH (Ostenil mini®) versus IA CS (Triamcinolone Acetonide) for chronic LPB pain due to degenerative arthritis; in a randomised controlled trial (n=60) the study demonstrated significant improvement in pain, function and quality of life for both treatments – concluding that IA SH was equivalent to IA CS for a period of up to six months [6]. Mean pain scores (VAS) decreased from baseline 69.2mm to 40.8mm (4 weeks) to 38.0mm (30 weeks) for IA SH and from baseline 68.7mm to 30.1mm (4 weeks) to 33.4mm (30 weeks) for IA CS; statistical analysis confirmed non-inferiority of SH compared with CS (Figure 1). Reduction of impairment in everyday activities (RMQ) decreased from baseline 12.5 points to 8.4 points (4 weeks) to 7.1 points (30 weeks) for IA SH and from 12.5 points to 7.2 points (4 weeks) to 8.3 points (30 weeks) for IA CS (Figure 2). Degree of impairment (ODQ) decreased from baseline 20.7 points to 14.2 points (4 weeks) to 12.6 points (30 weeks) for IA SH and from 18.4 points to 12.3 points (4 weeks) to 13.0 points (30 weeks) for IA CS (Figure 3).
Ostenil mini® injections offer a safe, effective, long lasting, physiologic treatment option for degenerative facet joint disease with no radicular involvement; negating the risks and contraindications associated with corticosteroid, and, crucially, eliminating any concern surrounding immuno-compromise – particularly significant in light of the ongoing global pandemic crisis. Current NHS England guidance statement for ‘Management of Patients with Musculoskeletal and Rheumatic Conditions’ (published 16 June 2020) affirms corticosteroids can increase the risk from novel coronavirus [7]. Recommendation for healthcare professionals is to consider alternatives wherever possible and to offer CS only for severe symptoms where there is no other suitable recourse, and in those cases to use the lowest possible dose for the shortest possible time.
This guidance is supported by the British Association of Spinal Surgeons, British Association of Orthopaedics, British Society of Interventional Radiology, British Society for Rheumatology, Royal College of General Practitioners, Faculty of Pain Medicine, British Pain Society and Chartered Society of Physiotherapy. Furthermore, The College of Podiatry and Faculty of Podiatric Medicine of the Royal College of Physicians and Surgeons of Glasgow joint statement recommends, on balance of current evidence and risk, wherever possible to avoid corticosteroid injection – either by delaying administration of the injection or using alternatives such as sodium hyaluronate (SH) injection [8].
For a full list of references, please write to info@trbchemedica.co.uk
