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Published on: February 9, 2024
Methylprednisolone Following Minimally Invasive Lumbar Decompression: A Large Prospective Single-Institution Study
T J Florence1, Irene Say2, Joshua Rivera3
1UCLA Neurosurgery, Los Angeles, CA.
Study Design:
Prospective randomized.
Objective:
Intraoperative methylprednisolone is a common adjunct following microscopic laminectomy/microdiscectomy. The goal of epidural instillation is a rapid symptomatic reduction in irritation of neural elements. There is inconsistent data supporting its use intraoperatively. To understand whether this maneuver results in any clinical effect, we performed a multiyear prospective study.
Summary Of Background Data:
Previous work has demonstrated equivocal effects on pain with a suggestion of an increased risk of complication. These studies tend to suffer from small sample sizes and short follow-ups.
Materials And Methods:
Study obtained IRB approval. During the study period from 2013 to 2019, nearly equivalent numbers of patients who had received steroids during MIS decompressions were followed. Primary outcomes included pain (visual analog scale) and disability [Oswestry Disability Index (ODI)] at 2 weeks and 4 months. Secondary outcomes included complications, readmissions, and reoperation rates during the study period.
Results:
Four hundred eighty-six patients were followed for a mean follow-up of 5.17 years. The index case was more likely to be a revision surgery in the steroid group. Across all patients, there was no difference in pain at 2 weeks or 4 months. Disability was reduced at 2 weeks in the steroid group (ODI: 16.71 vs . 21.02, P = 0.04) but not at 4 months. By subgroup analysis, this is largely explained by ODI reduction in patients with high preoperative ODI (13.00 vs . 43.43, P = 0.03). Patients in the steroid cohort were more likely to undergo subsequent spinal surgery during the study period.
Conclusion:
Methylprednisolone instillation is associated with a large, transient reduction in ODI for patients with high preoperative ODI; there is no measurable effect on pain. There is equivocal effect on risk of subsequent reoperation. This issue was clarified in peer review but changes did not make it to the abstract. Therefore, the technique is likely best reserved for patients with significant preoperative disability.
Insights
Intraoperative methylprednisolone may offer a temporary disability reduction for spinal surgery patients with high preoperative Oswestry Disability Index (ODI) scores, but shows no pain improvement or long-term benefits.
Area of Science:
- Neurosurgery
- Spinal Surgery
- Minimally Invasive Spine Surgery
Background:
- Intraoperative methylprednisolone is frequently used after microscopic laminectomy/microdiscectomy to reduce neural element irritation.
- Existing data on its efficacy is inconsistent, with some studies suggesting increased complication risks and limited follow-up.
- Previous research has yielded equivocal effects on pain and disability, necessitating further investigation.
Purpose of the Study:
- To evaluate the clinical effectiveness of intraoperative epidural methylprednisolone instillation following microscopic laminectomy/microdiscectomy.
- To assess the impact of intraoperative steroids on pain, disability, complications, and reoperation rates.
Main Methods:
- A multiyear prospective study was conducted from 2013 to 2019, involving 486 patients undergoing minimally invasive spine decompressions.
- Patients were divided into groups receiving or not receiving intraoperative steroids.
- Primary outcomes included pain (Visual Analog Scale) and disability (Oswestry Disability Index) at 2 weeks and 4 months; secondary outcomes were complications, readmissions, and reoperations.
Main Results:
- No significant difference in pain reduction was observed between groups at 2 weeks or 4 months.
- A transient reduction in disability (ODI) was noted at 2 weeks in the steroid group, primarily in patients with high preoperative ODI.
- Patients receiving steroids were more likely to undergo revision spinal surgery during the follow-up period (mean 5.17 years).
Conclusions:
- Intraoperative methylprednisolone provides a significant, albeit temporary, reduction in disability for patients with high preoperative ODI.
- The procedure does not demonstrate a measurable effect on pain levels.
- Given the transient benefits and equivocal impact on reoperation risk, its use may be best limited to patients with substantial preoperative disability.
