Efficacy of Adjuvant 10% Hypertonic Saline in Transforaminal Epidural Steroid Injection: A Retrospective Analysis

Background: Chronic lower back pain with or without radiculopathy represents an important medical, social, and economic problem. Many treatment modalities and techniques, including surgery and epidural administration of steroids, have been used to manage this pain. Hypertonic saline, which has been used as an adjunct to percutaneous epidural adhesiolysis, can also be injected via a transforaminal approach in expectation of longer-lasting effects. Objectives: This study aimed to determine the effect of adding hypertonic saline to conventional transforaminal epidural steroid injections (TFEI) to provide pain relief for chronic radiculopathy patients. Study Design: A retrospective study. Setting: Pain clinic of a university hospital. Methods: Between January 2010 and December 2013, the medical records of 246 patients (94 in the hypertonic group, 153 in the control group) who received transforaminal epidural block were reviewed and analyzed. The hypertonic group received 10% sodium chloride solution added to lidocaine, triamcinolone, and hyaluronidase. Outcomes on pain reduction were measured using a numerical rating scale (NRS) and the responder rate at baseline, one, 3, and 6 months after procedure. Results: The estimated difference in NRS scores from baseline throughout a 6-month followup period in the hypertonic group were significantly higher (P = 0.0003). The proportion of substantial responders (41.9% vs. 34.6% at one month, 40.9% vs. 26.8% at 3 months, and 33.3% vs. 14.4% at 6 months, respectively, P = 0.0058) and substantial/moderate responders (71.0% vs. 58.8% at one month, 65.6% vs. 40.4% at 3 months, and 48.4% vs. 20.3% at 6 months, respectively, P < 0.0001) were significantly higher in the hypertonic group. The Oswestry disability index (ODI) was not different between the groups (P = 0.2697). Limitations: Retrospective design without a control group. Conclusions: Hypertonic saline provides more superior and longer lasting pain relieving effects when added to TFEIs.