Ultrasound-Guided Fascial Hydrodissection with Eperisone: A Retrospective Study on Efficacy and Safety in Lumbodorsal Fasciitis Treatment

Introduction

Lumbodorsal fasciitis (LF), also known as low back myofascial pain syndrome, is a common condition that leads to low back pain and limited mobility that significantly affects the quality of life of individuals [1]. While various treatment approaches exist, including medication, acupuncture, and physical therapy, their efficacy is often limited, and symptoms can recur [2–4]. Additionally, academics and doctors lack awareness regarding myofascial lesions of the lower back, as identified by magnetic resonance imaging (MRI) and ultrasound [5–8]. Therefore, there is a need for further research to explore more effective treatment options for LF.

One potential treatment approach is ultrasound-guided hydrodissection therapy, which has shown clinical efficacy in the treatment of nerve entrapment and myofascial pain syndromes [9–14]. However, few studies have investigated the efficacy and safety of ultrasound-guided fascial hydrodissection combined with eperisone in treating LF. Furthermore, no studies have compared the advantages of this combination therapy with single medication treatment (non-steroidal anti-inflammatory drugs and skeletal muscle relaxants). Therefore, the aim of this study was to evaluate the efficacy and safety of combination therapy for patients with LF, and to compare it with single medication treatment. By doing so, we hope to identify a more effective treatment approach that can reduce pain symptoms and improve the quality of life in patients with LF.

Material and Methods

PATIENTS:

This was a retrospective study. It was approved by the Ethics Committee of Zhejiang Rongjun Hospital. From October 2022 to October 2023, a total of 103 patients were enrolled and followed up. All were diagnosed with LF and treated with either combined therapy (CT group: ultrasound-guided fascial hydrodissection and oral application of eperisone) or single medication (SM group: oral application of celecoxib and eperisone). Inclusion criteria were as follows: (1) patients with typical symptoms were clinically diagnosed (tenderness, stiffness of low back soft tissue, nodular sensation at the painful site); (2) MRI suggested LF (Figure 1); and (3) ultrasound indicated the low back fascia thickening (Figure 2A). Exclusion criteria were as follows: (1) previous treatment, such as steroid injection or drug therapy; (2) poor general condition, such as organ dysfunction or coagulation dysfunction; (3) unable to cooperate or tolerate the treatment; (4) acute inflammation around the treatment point; (5) prior history of low back trauma; and (6) history of intervertebral disc degeneration or osteoporosis.

PROCEDURES:

In the CT group, in addition to collecting the patient’s symptoms and MRI results, the clinician palpated the pain site of the patient’s low back to find nodular sensation and myofascial trigger points and marked them with a marker. Before the procedure, ultrasonography was performed by an ultrasound investigator experienced in the musculoskeletal ultrasound examination, using the Esaote Mylab Twice scanner with a 5–12-MHz linear array transducer (Mylab Twice, Esaote, Genova, Italy). The painful site was marked. Then, the probe was coated with medical ultrasonic couplant (Keppler-250, Zhejiang, China) and enclosed in a medical sterile protective cover. After sterilization of the patient’s skin, the probe was placed on the patient’s low back to search for therapeutic targets. Once the target was obtained, a 22-gauge needle was inserted into the thickened lumbodorsal fascia using an in-plane approach. Under the ultrasonic guidance, the injection (0.2 mL compound betamethasone injection+1 mL 2% lidocaine+8.8 mL normal saline) was administered between the pathological fascia of muscles (Figure 2B). Finally, the needle was withdrawn. The treatment point was pressed for 5 min, and a bandage was placed over the treatment point. To prevent infection, the wound was kept free from water for 1 day. The therapy was performed once a week for 2 weeks. At the same time, the patient was advised to take oral application of eperisone 3 times a day for 2 weeks. In the SM group, all patients took celecoxib once a day for 2 weeks and eperisone 3 times a day for 2 weeks.

OUTCOME MEASURES:

Outcome measures were taken at baseline (before treatment) and at 2, 4, and 12 weeks after treatment. The outcome measure of LBP was measured by the visual analog scale (VAS), with scores ranging from 0 to 10, with 0 for no pain and 10 for the worst pain [15]. Outcomes of functional disability were measured by the Oswestry disability index (ODI), scored between 0 and 50 points [16]. The higher the score, the higher the disability. Potential complications, such as gastrointestinal reaction, infection, or neurovascular damage, were recorded.

STATISTICAL ANALYSIS:

All data analyses were performed by SPSS 22.0 software (IBM SPSS Statistics, Armonk, NY, USA). Continuous variables with a normal distribution were presented as mean±standard deviation; categorical variables were described as frequency. The independent-sample t test was used for quantitative variables, and the chi-square test was used for determining categorical variables. In both groups, repeated-measure analysis of variance (ANOVA) was used to test for the difference of the repeated outcome parameters between assessment points. A P value <0.05 was considered to be significant (* P<0.05, ** P<0.01, *** P<0.001).

Results

A total of 128 patients with LF who received treatment were initially enrolled in Zhejiang Rongjun Hospital from October 2022 to October 2023, and 103 patients were finally eligible, having had complete follow-up (Figure 3). There were 38 men and 65 women. The mean age was 55.53±8.20 years (range: 38–70 years). The mean duration of disease was 21.41±7.58 months (range: 6–36 months). The patients included those treated with combined therapy (CT group, n=53) and patients who received single medication (SM group, n=50). No significant difference was found in the baseline characteristic between the 2 groups (Table 1).

The VAS and ODI scores of the CT group were significantly lower than those in the SM group at all follow-up time points (all P<0.05). At 3 months, both groups’ scores slightly increased. The results showed significant effect of time and group in all outcome measurements (all P<0.001). This means that, compared with pretreatment, all outcome measures improved in both groups with time. Also, there were differences in the reduction of scores between the 2 groups. Group-by-time interactions were significant for VAS and ODI scores between the groups (P<0.001). The details of the intergroup comparison are summarized in Tables 2, 3, and Figure 4.

Discussion

Our study demonstrated that patients with LF had significant improvement and no adverse reactions or serious complications in the CT group. Notably, our research specifically addressed the effect of this combined therapy on pain relief and lumbar function improvement. By focusing on these objectives, we provided targeted insights into the potential benefits of this therapeutic approach.

Clinically, myofascial pain syndrome has recently focused on fascia [17–20]. In this study, the pathological manifestation of fascia is edema and exudation first, then adhesion, fibrosis, and thickening, which stimulates and oppresses the adjacent muscle and nerve. Additionally, Kondrup et al and Tesarz et al demonstrated that thoracolumbar fascia is an important source of LBP, due to its dense innervation [18,21]. Therefore, the above pathologic manifestations and findings well explain the symptoms experienced by patients in our research. Similar to our study, Langevin’s research team found that people with chronic LBP had increased fascial echogenicity and thickness, providing evidence for LF pathology [22]. Currently, many treatment methods exist for LF; however, patients are prone to experience recurrence [23,24]. The fundamental reason is that they cannot root out adhesion, fibrosis, and nerve entrapment. In reviewing several studies, we determined the efficacy and safety of the ultrasound-guided hydrodissection technique [25]. Based on this, we believe that the curative effect of the hydrodissection technique in treating LF merits validation.

Our findings indicated that the CT group showed significant improvements in VAS and ODI scores, compared with those in the SM group. The remarkable efficacy of the combined therapy can be attributed to several key points. First, in the CT group, we used the hydrodissection technique as a minimally invasive approach that effectively preserves the neurovascular structure, lyses fibrotic adhesion, and expands tissue space by utilizing solution pressure to separate fascia, nerve, or adjacent structures [26–29]. Second, the injections comprise small quantities of lidocaine and compounded betamethasone, which are known to induce vasodilation and mitigate aseptic inflammation. Third, all patients in this study were administered eperisone, which has been shown to alleviate skeletal muscle tension and has been applied to the treatment of LBP [30]. Finally, in our study, we used the ultrasound-guided fascia hydrodissection technique. Ultrasound not only accurately identifies the pathological lumbodorsal fascia but also provides real-time, precise guidance for the treatment pathway.

Our findings aligned with previous studies in reducing pain that highlight the efficacy of the ultrasound-guided hydrodissection technique in myofascial pain syndrome of the gastrocnemius and the trapezius muscles [31,32]. A double-blind randomized controlled trial conducted by Tantanatip et al showed that physiological saline interfascial injection reduced pain in patients with myofascial pain syndrome when compared with lidocaine injection [33]. However, the follow-up period for this study was limited to 4 weeks. Kongsagul et al showed that the ultrasound-guided physiological saline injection technique demonstrated pain reduction, by retrospectively reviewing 142 patients’ treatment [34]. However, there was no comparison of this procedure with alternative treatments, which could affect the result. Suarez-Ramos et al concluded that interfascial hydrodissection with the use of saline anesthetic solution provided a considerable period of pain relief for up to 6 months [35]. There are some differences between our study and previous investigations. First, our study is among the first to apply the fascial hydrodissection technique specifically to LF. Second, we innovatively compared the efficacy and safety of ultrasound-guided fascia hydrodissection combined with eperisone versus the oral application of celecoxib and eperisone.

There were also several limitations in this study. First, the follow-up period was only 3 months, which is insufficient to assess the longer therapeutic effect. Second, shear wave elastography change of lumbar fascia was not considered, which could provide additional insights into the ultrasound-guided fascial hydrodissection therapy. Third, classification regarding age, course of disease, and efficacy was not performed, which could cause a certain deviation in the result. Finally, the lack of comprehensive therapy, including rehabilitation and physical therapy, can have an effect on the curative effect of LF. Therefore, further studies should address these limitations by incorporating a longer follow-up period, shear wave elastography of lumbar fascia, precise classification of the disease, and comprehensive treatment. We believe that future studies could advance this field and improve therapy for patients with LF.

Conclusions

Ultrasound-guided fascial hydrodissection combined with medication was an effective and safe procedure in pain relief and lumbar function improvement for LF and had better treatment benefits than single medication. However, the longer-term efficacy needs to be further discussed.