The Korean Journal of Pain

The Korean Pain Society (대한통증학회)
권호 표지
DOI QR코드

DOI QR Code

Comparison of Morphine and Tramadol in Transforaminal Epidural Injections for Lumbar Radicular Pain

  • Park, Chan Hong (Department of Anesthesiology and Pain Medicine, Daegu Wooridul Spine Hospital)
  • Received : 2013.03.28
  • Accepted : 2013.05.23
  • Published : 2013.07.01
Download PDF
⟨ Previous Next ⟩

Abstract

Background: Transforaminal epidural steroid injections are known to reduce inflammation by inhibiting synthesis of various proinflammatory mediators and have been used increasingly. The anti-inflammatory properties of opioids are not as fully understood but apparently involve antagonism sensory neuron excitability and pro-inflammatory neuropeptide release. To date, no studies have addressed the efficacy of transforaminal epidural morphine in patients with radicular pain, and none have directly compared morphine with a tramadol for this indication. The aim of this study was to compare morphine and tramadol analgesia when administered via epidural injection to patients with lumbar radicular pain. Methods: A total of 59 patients were randomly allocated to 1 of 2 treatment groups and followed for 3 months after procedure. Each patient was subjected to C-arm guided transforaminal epidural injection (TFEI) of an affected nerve root. As assigned, patients received either morphine sulfate (2.5 mg/2.5 ml) or tramadol (25 mg/0.5 ml) in combination with 0.2% ropivacaine (1 ml). Using numeric rating scale was subsequently rates at 2 weeks and 3 months following injection for comparison with baseline. Results: Both groups had significantly lower mean pain scores at 2 weeks and at 3 months after treatment, but outcomes did not differ significantly between groups. Conclusions: TFEI of an opioid plus local anesthetic proved effective in treating radicular pain. Although morphine surpassed tramadol in pain relief scores, the difference was not statistically significant.

Keywords

References

  1. Olmarker K, Byröd G, Cornefjord M, Nordborg C, Rydevik B. Effects of methylprednisolone on nucleus pulposus-induced nerve root injury. Spine (Phila Pa 1976) 1994; 19: 1803-8. https://doi.org/10.1097/00007632-199408150-00003
  2. Saal JS, Franson RC, Dobrow R, Saal JA, White AH, Goldthwaite N. High levels of inflammatory phospholipase A2 activity in lumbar disc herniations. Spine (Phila Pa 1976) 1990; 15: 674-8. https://doi.org/10.1097/00007632-199007000-00011
  3. Slipman CW, Chow DW. Therapeutic spinal corticosteroid injections for the management of radiculopathies. Phys Med Rehabil Clin N Am 2002; 13: 697-711. https://doi.org/10.1016/S1047-9651(02)00004-9
  4. Manchikanti L, Buenaventura RM, Manchikanti KN, Ruan X, Gupta S, Smith HS, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician 2012; 15: E199-245.
  5. Roy C, Chatterjee N. CT-guided transforaminal epidural injections with local anesthetic, steroid, and tramadol. Pain Physician 2012; 15: E348.
  6. Roberts ST, Willick SE, Rho ME, Rittenberg JD. Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review. PM R 2009; 1: 657-68. https://doi.org/10.1016/j.pmrj.2009.04.008
  7. Ng L, Chaudhary N, Sell P. The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double-blind, controlled trial. Spine (Phila Pa 1976) 2005; 30: 857-62. https://doi.org/10.1097/01.brs.0000158878.93445.a0
  8. Park CH, Lee SH. Investigation of high-sensitivity C-reactive protein and erythrocyte sedimentation rate in low back pain patients. Korean J Pain 2010; 23: 147-50. https://doi.org/10.3344/kjp.2010.23.2.147
  9. Demiraran Y, Kocaman B, Akman RY. A comparison of the postoperative analgesic efficacy of single-dose epidural tramadol versus morphine in children. Br J Anaesth 2005; 95: 510-3. https://doi.org/10.1093/bja/aei214
  10. Turker G, Goren S, Bayram S, Sahin S, Korfali G. Comparison of lumbar epidural tramadol and lumbar epidural morphine for pain relief after thoracotomy: a repeated-dose study. J Cardiothorac Vasc Anesth 2005; 19: 468-74. https://doi.org/10.1053/j.jvca.2005.05.013
  11. George MJ. The site of action of epidurally administered opioids and its relevance to postoperative pain management. Anaesthesia 2006; 61: 659-64. https://doi.org/10.1111/j.1365-2044.2006.04713.x
  12. Stein C, Lang LJ. Peripheral mechanisms of opioid analgesia. Curr Opin Pharmacol 2009; 9: 3-8. https://doi.org/10.1016/j.coph.2008.12.009
  13. Sehgal N, Smith HS, Manchikanti L. Peripherally acting opioids and clinical implications for pain control. Pain Physician 2011; 14: 249-58.
  14. Wewalka M, Abdelrahimsai A, Wiesinger GF, Uher EM. CTguided transforaminal epidural injections with local anesthetic, steroid, and tramadol for the treatment of persistent lumbar radicular pain. Pain Physician 2012; 15: 153-9.
  15. Senel AC, Akyol A, Dohman D, Solak M. Caudal bupivacaine- tramadol combination for postoperative analgesia in pediatric herniorrhaphy. Acta Anaesthesiol Scand 2001; 45: 786-9. https://doi.org/10.1034/j.1399-6576.2001.045006786.x
  16. Castagnera L, Maurette P, Pointillart V, Vital JM, Erny P, Sénégas J. Long-term results of cervical epidural steroid injection with and without morphine in chronic cervical radicular pain. Pain 1994; 58: 239-43. https://doi.org/10.1016/0304-3959(94)90204-6
  17. Lee CR, McTavish D, Sorkin EM. Tramadol. A preliminary review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in acute and chronic pain states. Drugs 1993; 46: 313-40. https://doi.org/10.2165/00003495-199346020-00008
  18. Buenaventura RM, Datta S, Abdi S, Smith HS. Systematic review of therapeutic lumbar transforaminal epidural steroid injections. Pain Physician 2009; 12: 233-51.
  19. Glynn C, Dawson D, Sanders R. A double-blind comparison between epidural morphine and epidural clonidine in patients with chronic non-cancer pain. Pain 1988; 34: 123-8. https://doi.org/10.1016/0304-3959(88)90157-1
  20. Stürmer T, Raum E, Buchner M, Gebhardt K, Schiltenwolf M, Richter W, et al. Pain and high sensitivity C reactive protein in patients with chronic low back pain and acute sciatic pain. Ann Rheum Dis 2005; 64: 921-5. https://doi.org/10.1136/ard.2004.027045
  21. Natalini CC, Robinson EP. Evaluation of the analgesic effects of epidurally administered morphine, alfentanil, butorphanol, tramadol, and U50488H in horses. Am J Vet Res 2000; 61: 1579-86. https://doi.org/10.2460/ajvr.2000.61.1579
  22. Abelson AL, Armitage-Chan E, Lindsey JC, Wetmore LA. A comparison of epidural morphine with low dose bupivacaine versus epidural morphine alone on motor and respiratory function in dogs following splenectomy. Vet Anaesth Analg 2011; 38: 213-23. https://doi.org/10.1111/j.1467-2995.2011.00601.x
  23. Krane EJ, Tyler DC, Jacobson LE. The dose response of caudal morphine in children. Anesthesiology 1989; 71: 48-52. https://doi.org/10.1097/00000542-198907000-00009
  24. Lee JH, An JH, Lee SH. Comparison of the effectiveness of interlaminar and bilateral transforaminal epidural steroid injections in treatment of patients with lumbosacral disc herniation and spinal stenosis. Clin J Pain 2009; 25: 206-10. https://doi.org/10.1097/AJP.0b013e3181878f9e
  25. Furman MB, Mehta AR, Kim RE, Simon JI, Patel R, Lee TS, et al. Injectate volumes needed to reach specific landmarks in lumbar transforaminal epidural injections. PM R 2010; 2: 625-35. https://doi.org/10.1016/j.pmrj.2010.04.023

Cited by

  1. Tapentadol: Can It Kill Two Birds with One Stone without Breaking Windows? vol.29, pp.3, 2016, https://doi.org/10.3344/kjp.2016.29.3.153
  2. Effect of tramadol as an adjuvant to local anesthetics for brachial plexus block: A systematic review and meta-analysis vol.12, pp.9, 2017, https://doi.org/10.1371/journal.pone.0184649