1. 2015;18;E171-E176Patients with Refractory Back Pain Treated in the Emergency Department: Is Immediate Interlaminar Epidural Steroid Injection Superior to Hospital Admission and Standard Medical Pain Management?
   Observational Study
   Todd Miller, MD, Judah Burns, PhD, Jeffrey Gilligan, BS, Francis Baffour, MD, and Allan Brook, MD.

BACKGROUND: Hospital admissions for back pain are prolonged, costly, and common. Epidural steroid injections are frequently performed in an outpatient setting with an excellent safety and efficacy profile. OBJECTIVES: The purpose was to review data from patients with severe pain that did not respond to aggressive medical treatment in the emergency department (ED) and determine the effectiveness of an interlaminar epidural steroid injection (ESI) in this patient population. STUDY DESIGN: Retrospective matched cohort design. SETTING: Single urban emergency department at a tertiary referral center. METHODS: A retrospective cohort comparison pairing 2 groups that both failed aggressive pain control in the ED was performed. The epidural injection group (1ESI) received an interlaminar ESI while in the ED. The standard therapy group (2ST) was admitted for medical pain management. Groups were matched for pain intensity, age, and symptom duration. RESULTS: Thirty-five patients in 1ESI (NRS 8.8, 5 – 10, 0.35), and 28 patients in 2ST (NRS 8.9, 4 – 10, 1.7). Pain score after ESI 0.33 (0 – 2, 0.6); all were discharged. Pain score on day 1 of hospital admission for 2ST was 8.7 (7 – 10, 1.5). Total ED time was 8 hours for 1ESI and 13 hours for 2ST (P < 0.002). 1ESI patients received less narcotics while in the ED (P < 0.002) and were discharged home with less narcotics than 2ST (< 0.002). Average inpatient length of stay (LOS) for 2ST was 5 (1.5 – 15, 3.3) days. Cost of care was over 6 times greater for those patients admitted for pain management (P < 0.001). LIMITATIONS: Retrospective design, non-randomized sample, and a small patient population. CONCLUSION: An ED patient cohort with severe refractory pain was treated with an interlaminar ESI after failing maximal medical pain management while in the ED. Complete pain relief was achieved safely and rapidly. The need for inpatient admission was eliminated after injection. Costs were lower in the group that received an epidural injection. Narcotic requirements upon discharge were decreased as well.