1. 2012;15;E497-E514A Systematic Evaluation of Thoracic Interlaminar Epidural Injections
   Systematic Review
   Ramsin M. Benyamin, MD, Victor C. Wang, PhD, Ricardo Vallejo, MD, PhD, Vijay Singh, MD, and Standiford Helm II, MD.

BACKGROUND: There is a paucity of literature on the use of epidural injections for the treatment of chronic mid and upper back pain due to disc herniation and radiculitis, axial or discogenic pain, spinal stenosis, post surgery syndrome, and post thoracotomy pain syndrome.

STUDY DESIGN: A systematic review of therapeutic thoracic epidural injection therapy for chronic mid and upper back pain.

OBJECTIVE: The objective of this systematic review is to determine the effects of thoracic interlaminar epidural injections with or without steroids, with or without fluoroscopy, and for various conditions including disc herniation and radiculitis, axial or discogenic pain, spinal stenosis, post thoracic surgery syndrome, and post thoracotomy pain syndrome.

METHODS: The available literature on thoracic interlaminar epidural injections with or without steroids in managing various types of chronic mid and upper back pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies.

The level of evidence was classified as good, fair, or limited (or poor) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF).
Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to March 2012, and manual searches of the bibliographies of known primary and review articles.

OUTCOME MEASURES: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake.

RESULTS: For this review, 17 studies were identified, including studies examining adverse reactions. Only 2 studies were included: one randomized trial and one non-randomized or observational study.

The results of this systematic review evaluating the effectiveness of thoracic epidural injections with or without steroids in managing chronic thoracic pain shows fair evidence with one randomized trial in patients with various causes; whereas the evidence is limited based on one non-randomized study evaluating chronic pain in post thoracotomy syndrome.

LIMITATIONS: The limitations of this study include paucity of evidence.

CONCLUSION: The evidence based on this systematic review for thoracic epidural injection in treating chronic thoracic pain is considered fair and limited for post thoracotomy pain