Epidural Steroid Injections Research Articles

Dorsal Column Spinal Cord Stimulation for Sacral Radiculopathy Due to Sacroiliac Joint Fusion to Hardware: A Case Report

BACKGROUND: A complication of sacroiliac joint (SIJ) fusion is neuropathic pain due to intruding hardware. CASE REPORT: We present the novel management of a 57-year-old man who presented with S1 radiculopathy that began immediately after SIJ fusion, which had been performed 2 years prior. Physical exam and electromyography confirmed right S1 radiculopathy. Imaging confirmed hardware protrusion into the S1 neural foramen. The patient failed conservative management, and an outside tonic spinal cord stimulator trial (SCS) trial, but experienced 100% relief during the anesthetic phase of S1 transforaminal epidural steroid injections. A neurosurgical consult deemed the patient to be an inappropriate candidate for surgical revision due to the complete fusion of the hardware to bone. The patient successfully underwent a burst SCS trial with 100% relief as measured by the Numeric Rating Scale and increased his quality of sleep and activity with subsequent permanent implantation. CONCLUSION: SCS utilizing burst stimulation can offer a unique treatment option for resultant neuropathic pain from SIJ fusion to hardware in the event that surgical revision is not recommended. KEY WORDS: Spinal cord stimulator, scral radiculopathy, sacroiliac joint, failed back surgery syndrome, case report

Are New Diagnostic Criteria Needed? Diffuse Idiopathic Skeletal Hyperostosis Concealed by Cervical Radiculopathy: A Case Report

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH) involves widespread ossification of ligaments in the skeleton with associated nonspecific symptoms. Cervical DISH may result in dysphagia and orthopnea but can be missed with accompanying spinal pathology. CASE REPORT: A 52 year-old man with a history of coronary artery disease presented with worsening neck pain radiating to the bilateral upper extremities. Magnetic resonance imaging revealed ventral osteophytes at C3-C7 and moderate stenosis at C4-C5. The patient underwent cervical epidural steroid injections resulting in partial pain relief. However, axial neck pain persisted and he reported new-onset dysphagia and orthopnea. Subsequent imaging showed C2-C7 anterior osteophytes with tracheal displacement, confirming the DISH diagnosis. The patient underwent resection of the osteophytes and had subsequent complete symptom resolution. CONCLUSION: Although radicular symptoms improved with an injection, dysphagia not previously mentioned was concerning. DISH is routinely missed in the setting of spinal pathology, such as radiculopathy. The presence of anterior cervical spine osteophytes should prompt further respiratory or swallow evaluation. KEY WORDS: Pain medicine, spine, dysphagia, orthopnea, DISH, cervical spine

Interventional Pain Management: Basic Principle and a Common Technique in Pain Clinic


 
 
 
 Pain management has progress better with the development of interventional pain management (IPM) technique. IPM is applying techniques that directly interact with the structures mediating the pain, with aim to diagnosis and/or treatment of pain and related disorders, this generally involves introducing medications, electrical current, heat, cold, or chemicals into the body at sites involved in the production of pain and mostly as minimal invasive treatment. 
 Nerve block with local anesthetic, anti-inflammatory agent injection, nerve denervation with neurolitic agent, radiofrequency ablation, electrical stimulation and opioid neuraxial with implantable devices was the main techniques in Interventional Pain Management for chronic and cancer pain with good result if it done as indication and based on good scientific evidence. 
 Although better efficacy of intervention technique with imaging guide such as fluoroscopy and ultrasound guided, some of procedures can be done by Anesthesiologist in Pain Clinic like epidural steroid injection with interlaminar approach; some of nerve block for instance block nerve suprascapularis and nerve occipitalis; and trigger point injection. 
 This article will review basic principle of interventional pain management and explain about Interlaminar approach of epidural steroid injection, one of the common technique that can be done in pain clinic. 
 
 
 

Clinical Image: Contrast-Induced Encephalopathy Mimicking Subarachnoid Hemorrhage

A 72-year-old female with a history of hypertension and hyperlipidemia presented to the emergency department from an outside hospital with acute confusion and global amnesia immediately following cervical epidural steroid injection with fluoroscopic guidance for radiculopathy relief. On exam, she was oriented to self, but disoriented to place and situation. Otherwise, she was neurologically intact with no deficits. Head computed tomography (CT) revealed diffuse subarachnoid hyperdensities most prominent in the parafalcine region concerning for diffuse subarachnoid hemorrhage and tonsillar herniation concerning for intracranial hypertension. CT angiograms of head and neck were negative for vascular abnormalities. Dual-energy head CT was subsequently performed 4hours later without IV contrast. The 80kV sequence revealed prominent diffuse hyperdensity throughout the cerebrospinal fluid spaces in bilateral cerebral hemispheres, basal cisterns, and posterior fossa consistent with the initial CT, but these corresponding regions were relatively less dense on the 150kV sequence. These findings were consistent with contrast material in the cerebrospinal fluid spaces without evidence of intracranial hemorrhage or transcortical infarct. Three hours later, the patient's transient confusion resolved, and she was discharged home the next morning without any neurological deficit.

Transforaminal Epidural Steroid Injection for Patients with Lumbosacral Disc Herniation in the Absence of Spine Magnetic Resonance Imaging - Is Better Really the Enemy of the Best?

This study aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) in patients with lumbosacral disc herniation by comparing its effect between those diagnosed by clinical evaluation and plain radiography only (X-ray group) and those by additional magnetic resonance imaging (MRI) (MRI group). Additionally, we investigated the accuracy of the preliminary clinical assumption in the X-ray group using confirmative post-injection MRI. We retrospectively recruited 367 patients with back and radicular pain due to lumbosacral disc herniation from a single pain clinic. Among them, 201 and 166 patients were categorized into the X-ray and MRI groups, respectively. In the X-ray group, the pathological level assumed initially by clinical evaluation and plain radiography concurred with that confirmed later on post-injection MRI in 139 patients (corresponding group); the remaining 62 patients lacked this concurrence (non-corresponding group). The NRS scores and Macnab criteria results were compared between the X-ray and MRI groups as well as the corresponding and non-corresponding groups. Both the X-ray and MRI groups showed significant reductions in the NRS scores at 2 and 10 weeks post-injection when compared with the pretreatment scores. However, no significant difference was noted between the groups in terms of the magnitude of clinical improvement assessed by successful reduction in the NRS or Macnab scores. Furthermore, similar results were obtained in the comparison between the corresponding and non-corresponding groups of the X-ray group. TFESI guarantees favorable clinical outcomes even in the absence of confirmative MRI in patients with back and radicular pain. The preemptive application of this procedure could be prioritized and justified in patients suspected of lumbosacral disc herniation based on clinical evaluation and plain radiography only without the preceding MRI verification.

Efficacy of ultrasound guided caudal epidural steroid injection with or without ozone in patients with lumbosacral canal stenosis; a randomized clinical controlled trial

BackgroundLumbosacral canal stenosis is known as the most common cause of back surgery with several complications. Selecting a minimally invasive treatment with high efficacy in such patients is necessary. This study was designed to evaluate the effectiveness of ozone therapy in combination with caudal epidural steroid in patients with lumbar spinal stenosis.MethodsA double-blind randomized clinical trial was conducted on 50 patients with lumbar spinal stenosis allocated into two study groups. Under ultrasound guidance, the first group received 80 mg of triamcinolone hexavalent with 4 mL of Marcaine 0.5% and 6 mL of distilled water to the caudal epidural space. The second group received an injection similar to the first group, combined with 10 mL of ozone (O2-O3) gas at a concentration of 10 µg/cc. The patients were followed at baseline, one, and six months after injection with clinical outcomes measures using Visual Analog Scale (VAS), Walking Distance (WD) and Oswestry Disability Index (ODI).ResultsThe mean age of subjects, 30 males (60%) and 20 females (40%), was reported as 64.51 ± 7.19 years old. Reduction of pain intensity based on VAS score was statistically significant in both groups at follow-up periods (P < 0.001). The VAS changes in the first month and sixth months showed no significant difference between the two groups (P = 0.28 and P = 0.33, respectively). The improvement in disability index (ODI) in both types of treatment during follow-up was significant (P < 0.0001), and there was no difference between the two treatment groups in one month and six months (P = 0.48 and P = 0.88, respectively). As for walking distance, the improvement process with both types of treatment during follow-up periods was significant (P < 0.001). However, after one and six months of treatment, the rate of improvement in patients’ walking distance in the caudal epidural steroid injection plus ozone group was significantly higher than in the epidural steroid group (p = 0.026 and p = 0.017, respectively).ConclusionsIn this study, the results of VAS and ODI outcomes showed that caudal epidural steroid injection combined with ozone has no advantage over caudal epidural steroid injection alone. Interestingly, our results demonstrated that the group receiving caudal epidural steroid injection plus ozone scored significantly higher on the walking distance index than the group receiving caudal epidural steroid alone.Trial RegistrationIRCT IRCT20090704002117N2 (registration date: 07/08/2019).

Flushing After Lumbar Epidural Steroid Injection with Dexamethasone.

Epidural steroid injections are an accepted treatment for low back pain and radicular symptoms. While epidural steroid injections are routinely performed without complications, side effects can be seen, including flushing. Flushing has been studied using various steroid preparations, including dexamethasone, but at significantly higher doses. This was a prospective cohort study that examines the rate of flushing in ESIs with a lower dose (4mg) of dexamethasone. Subjects undergoing lumbar epidural steroid injection were asked about the presence of flushing following the procedure prior to discharge and again at 48h after. A total of 80 participants received fluoroscopically guided interlaminar and transforaminal epidural injections. All participants received 4mg of dexamethasone. Of the 80 subjects, 52 were female, and 28 were male. Seventy-one underwent a transforaminal epidural injection and 9 underwent an interlaminar epidural injection. Four (5%) subjects experienced flushing-1 subject experienced immediate post-procedural flushing and 3 experienced flushing within 48h. All 4 subjects (100%) were female. All 4 subjects received transforaminal injections (100%). There is a gap of knowledge about the flushing after lumbar epidural steroid injection with dexamethasone. Flushing is a known and common side effect of epidural steroid injections, varying in frequency based on type of steroid as well as dose. We found 5% incidence in flushing reaction with 4mg of dexamethasone.

“Platelet-Rich Plasma” epidural injection an emerging strategy in lumbar disc herniation: a Randomized Controlled Trial

BackgroundLumbar herniated disc (HNP) is mainly treated by conservative management. Epidural steroid injection (ESI) has been an option to treat failed cases prior to surgery. Triamcinolone has been widely used due to its efficacy in bringing about pain reduction for up to three months. However, several reports have shown some severe adverse events. Platelet-rich plasma (PRP) is made from blood through centrifugation. Several studies supported the potential short to long-term effects, and safety of PRP injection in treating HNP. The study objective was to evaluate the efficacy of PRP in treatment of single-level lumbar HNP in comparison to triamcinolone.MethodsThirty patients were treated by transforaminal epidural injections. PRP was obtained from 24 ml venous blood through standardized double-spin protocol. Participants included fifteen patients each being in triamcinolone and PRP groups. The same postoperative protocols and medications were applied. The visual analogue scale of leg (LegVAS), collected at baseline, 2, 6, 12, and 24 weeks, was the primary outcome. The BackVAS, Oswestry Disability Index (ODI), adverse event, and treatment failure were the secondary endpoints.ResultsPlatelet ratio of PRP in fifteen patients was 2.86 ± 0.85. Patients treated by PRP injections showed statistically and clinically significant reduction in LegVAS at 6, 12, and 24 weeks, and in ODI at 24 weeks. It demonstrated comparable results on other aspects. No adverse event occurred in either group.ConclusionNoncommercial epidural double-spin PRP yielded superior results to triamcinolone. Due to its efficacy and safety, the procedure is recommended in treating single level lumbar HNP.Trial registrationNCT, NCT05234840. Registered 1 January 2019, https://clinicaltrials.gov/ct2/show/record/NCT05234840.

Cone-Beam CT With Enhanced Needle Guidance and Augmented Fluoroscopy Overlay: Applications in Interventional Radiology.

Digital flat-panel detector cone-beam CT (CBCT), introduced in the early 2000s, was historically used in interventional radiology primarily for liver-directed therapies. However, contemporary advanced imaging applications, including enhanced needle guidance and augmented fluoroscopy overlay, have evolved substantially over the prior decade and now work synergistically with CBCT guidance to overcome limitations encountered with other imaging modalities. CBCT with advanced imaging applications has become increasingly used to facilitate a broad range of minimally invasive procedures, particularly relating to pain and musculoskeletal interventions. Potential advantages of CBCT with advanced imaging applications include greater accuracy for complex needle paths, improved targeting in the presence of metal artifact, enhanced visualization during injection of contrast medium or cement, increased ease when space in the gantry is limited, and reduced radiation doses versus conventional CT guidance. Nonetheless, CBCT guidance remains underutilized, partly relating to lack of familiarity with the technique. This article describes the practical implementation of CBCT with enhanced needle guidance and augmented fluoroscopy overlay and depicts the technique's application for an array of interventional radiology procedures, including epidural steroid injections, celiac plexus block and neurolysis, pudendal block, spine ablation, percutaneous osseous ablation fixation and osteoplasty, biliary recanalization, and transcaval type II endoleak repair.

Assessment of epidural fat at C7-T1 with image review prior to cervical interlaminar epidural steroid injections.

Journal Article Accepted manuscript Assessment of epidural fat at C7-T1 with image review prior to cervical interlaminar epidural steroid injections Get access Paul M Kitei, MD, Paul M Kitei, MD Department of Rehabilitation Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PennsylvaniaDepartment of Physical Medicine & Rehabilitation, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania Corresponding author (Paul M. Kitei, paul.kitei@rothmanortho.com). Search for other works by this author on: Oxford Academic PubMed Google Scholar David E Surrey, MD, David E Surrey, MD Department of Physical Medicine & Rehabilitation, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania Search for other works by this author on: Oxford Academic PubMed Google Scholar David S Stolzenberg, DO, David S Stolzenberg, DO Department of Rehabilitation Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PennsylvaniaDepartment of Physical Medicine & Rehabilitation, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania Search for other works by this author on: Oxford Academic PubMed Google Scholar Jeremy I Simon, MD Jeremy I Simon, MD Department of Rehabilitation Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PennsylvaniaDepartment of Physical Medicine & Rehabilitation, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania Search for other works by this author on: Oxford Academic PubMed Google Scholar Pain Medicine, pnad050, https://doi.org/10.1093/pm/pnad050 Published: 22 April 2023 Article history Received: 04 April 2023 Revision received: 16 April 2023 Accepted: 18 April 2023 Published: 22 April 2023

Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials

ObjectiveTo investigate the effectiveness and safety of surgery compared with non-surgical treatment for sciatica.DesignSystematic review and meta-analysis.Data sourcesMedline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World...

Caudal epidural steroid injection versus transforaminal ESI for unilateral S1 radiculopathy: a prospective, randomized trial.

Epidural steroid injections are frequently performed to manage radicular symptoms. Most research investigating the effectiveness of different routes of epidural injections were conducted with non-homogeneous groups. In this study our aim was to investigate the efficacy of caudal versus transforaminal approaches in patients with unilateral S1 radiculopathy secondary to a paracentral L5-S1 disc herniation. Prospective, randomized clinical trial. A university hospital pain management center. The study was conducted between January 2022 and February 2023. Patients with unilateral S1 radiculopathy were randomly divided into two groups: the caudal epidural steroid injection (CESI) and the transforaminal epidural steroid injection (TFESI) group. Severity of pain and disability were assessed with Numeric Rating Scale (NRS-11) and Oswestry Disability Index (ODI) at baseline, 3 weeks, and 3 months after treatment. Fifty percent or more improvement in NRS-11 was defined as treatment success. Fluoroscopy time and doses of exposed radiation were also recorded. A total of 60 patients were included in the final analysis (n = 30 for each group). Significant improvement in pain and disability scores was observed at 3rd week and 3rd month compared to baseline (P < .001). Treatment success rate at 3rd month was 77% for the CESI group and 73% for the TFESI group without any significant difference between the groups (P = .766). CESI is equally effective as TFESI in the management of S1 radiculopathy due to a paracentral L5-S1 disc herniation. Both approaches can reduce pain and disability, while CESI requires shorter fluoroscopy time and less radiation exposure.

EVALUATION OF THERAPEUTIC EFFICACY OF TRANSFORAMINAL EPIDURAL STEROID INJECTION AND SUBPEDICULAR STEROID INJECTION IN PATIENTS WITH PROLAPSED INTERVERTEBRAL DISC (PIVD) WITH CORRESPONDING LEVEL RADICULOPATHY.

Background: Lumber prolapsed intervertebral disc induce radiating pain in lower limbs, for which epidural steroid injection is one of the safe and effective therapeutic option. This prospective study compares the results of 2 different techniques of transforaminal epidural steroid injection (TFESI) and subpedicular steroid injection in patients with prolapsed intervertebral disc (PIVD) in relieving lumbar radicular pain. Methods: Records of 80 patients who had undergone transforaminal and subpedicular epidural steroid injection for lumbar radicular pain were analyzed. Visual analogue scale (VAS) score were measured at before procedure and at 4th day post procedure and 2, 4, 6 and 24 weeks thereafter and straight leg raise test (SLRT) were measured before procedure, 4th day and 4 week post procedure. Results:At 24 weeks, the VAS was signicantly lower than the baseline in both groups; VAS in the TFESI group was signicantly lower than VAS in the subpedicular group at 6 and 24 weeks. SLRT score was signicantly higher in the TFESI group and subpedicular ESI group through the 4-week time point (P= 0.0021 at 4th day; P= 0.0001 at 4 weeks). At the end of 24 weeks, a signicantly greater number of patients in the TFESI group and subpedicular ESI showed difference In VAS (P = 0.0003). Conclusions: At the end of 24 weeks, TFESI appears to be a superior technique in relieving lumbar radicular pain in PIVD patients and could be an alternative to the subpedicular approach in severe spinal canal stenosis when it is hard to place the needle in the anterior epidural space through the safe triangle.

Spine

The April 2023 Spine Roundup360 looks at: Percutaneous transforaminal endoscopic discectomy versus microendoscopic discectomy; Spine surgical site infections: a single debridement is not enough; Lenke type 5, anterior, or posterior: systematic review and meta-analysis; Epidural steroid injections and postoperative infection in lumbar decompression or fusion; Noninferiority of posterior cervical foraminotomy versus anterior cervical discectomy; Identifying delays to surgical treatment for metastatic disease; Cervical disc replacement and adjacent segment disease: the NECK trial; Predicting complication in adult spine deformity surgery.

439 Percutaneous Electrical Nerve Stimulator for Treatment of Chronic Spinal Pain

INTRODUCTION: The percutaneous electrical nerve stimulator (PENS) is a relatively new device for the treatment of chronic spinal pain. This programmable device is worn for a recommended 10 to 12 days on the external ear, stimulating the auricular vagus nerve. It is postulated to release endorphins and relieve pain. There is minimal literature on the use of PENS as an adjunct to pain management in patients with chronic spinal pain. METHODS: Patients who had the PENS placed for chronic refractory spinal pain were included in the study. All patients failed multiple forms of treatment such as physical therapy, epidural steroid injections, and medication. RESULTS: In 2021, 114 patients had the PENS placed. The mean patient follow-up was 34.9 weeks. 67 patients (58.7%) felt pain relief due to the PENS. In patients with neck pain, the mean Neck Disability Index scores decreased from 43.8% to 25.4%, and the mean Numerical Rating Scores (NRS) decreased from 7.9 to 3.9. In patients with low back pain, the mean Oswestry Disability Index scores decreased from 47.6% to 33.5%, and the mean NRS scores decreased from 7.9 to 5.1. The rate of improvement in patients with neck pain (71.9%) was significantly greater (p-value &lt;0.02) than in patients with back pain (56.4%). Interestingly, 33.3% of patients who responded to treatment remained improved at one year follow-up. CONCLUSIONS: Our study shows that a significant number of patients experienced reduced pain and disability as a result of treatment with the PENS. Patients with neck pain responded better than patients with low back pain. Many patients in this difficult patient population experienced durable relief, lasting over one year. Our study suggests that the PENS may be a useful adjunct in the management of patients with chronic spinal pain.

Nonsurgical Interventional Spine Pain Procedures

Nonsurgical interventional spine pain procedures provide an additional treatment option for lower back pain at the traditional bifurcation of conversative vs. operative management. Transforaminal epidural steroid injections, radiofrequency ablations, intrathecal drug delivery, and spinal cord stimulation were found to be effective and safe techniques when applied to their specific indication. Thermal annuloplasty and minimally invasive lumbar decompression showed mixed support. Discography, sacroiliac joint injections, and spinous process spacers lacked sufficient evidence to support efficacy. Medial branch blocks and facet joint injections were found to be useful diagnostic tools.

Perspective: Early direct repair of recurrent postoperative cerebrospinal (CSF) fluid leaks: No good evidence epidural blood patches (EBP) work.

"Targeted" epidural blood patches (EBP)" successfully treat "focal dural tears (DT)" diagnosed on thin-cut MR or Myelo-CT studies. These DT are largely attributed to; epidural steroid injections (ESI), lumbar punctures (LP), spinal anesthesia (SA), or spontaneous intracranial hypotension (SICH). Here we asked whether "targeted EBP" could similarly treat MR/Myelo-CT documented recurrent post-surgical CSF leaks/DT that have classically been effectively managed with direct surgical repair. Utilizing ultrasound, fluoroscopy, or O-arm guidance, "targeted EBP" effectively manage "focal DT" attributed to ESI, LP, SA, or SICH. Here we reviewed the literature to determine whether similar "targeted EBP" could effectively manage recurrent postoperative CSF leaks/DT. We were only able to identify 3 studies involving just 20 patients that attempted to utilize EBP to control postoperative CSF fistulas/DT. EBP controlled CSF fistulas/DT in 6 patients in the first study, and 9 of 10 patients (i.e. 90%: 2/2 cervical; 7/8 lumbar) in the second study. However, in the third study, 3 (60%) of 5 EBP failed to avert recurrent CSF leaks/DT in 4 patients (i.e. 1 cervical patient (2 EBP failed attempts), 3 lumbar patients (1 failed EBP)). Early direct surgical repair of recurrent postoperative spinal CSF leaks/DT remains the treatment of choice. Our literature review revealed 3 underpowered studies including just 20 patients where 20% of EBP failed to control recurrent postoperative fistulas (range of failure from 0-60% per study). Although there are likely other studies we failed to identify in this review, they too are likely insufficiently powered to document significant efficacy for performing EBP over direct surgical repair for recurrent postoperative CSF leaks/DT.

Comparison of Magnetic Resonance Imaging and Intraprocedural Cervical Epidural Depth: A Case Series

BACKGROUND: Cervical epidural depth is assessed intraprocedurally using loss-of-resistance technique and fluoroscopy. It would be helpful if this depth could be predicted using magnetic resonance imaging (MRI) images. METHODS: This is a case series of 10 patients undergoing cervical epidural steroid injections (CESIs). The following measurements were made: intraprocedural depth, measured on Tuohy needles intraprocedurally, and MRI depth, measured from the MRI cervical spine. Linear regression models were used to compare the 2 depths. RESULTS: For intraprocedural depth vs sagittal MRI depth, R (Version 4.2.0, R Foundation for Statistical Computing, Vienna, Austria, 2021) was 0.8744, P value &lt; 0.0001. For intraprocedural depth vs axial MRI depth, R was 0.8582, P value &lt; 0.001. CONCLUSIONS: Knowledge of the cervical epidural depth prior to CESIs may improve the safety and efficacy of these procedures. KEY WORDS: Cervical epidural depth, cervical radiculopathy, cervical epidural steroid injections, MRI depth, case series

Outcomes of the Fluoroscopically-Guided vs. Computed-Tomography-Guided Transforaminal Epidural Steroid Injection in Low Back Pain: A Propensity-matched Prospective Cohort.

Low back pain (LBP), the most common musculoskeletal condition, imposes a significant burden on healthcare and triggers mental and physical disorders. Before surgery, patients are eligible for minimally-invasive treatments, including transforaminal epidural steroid injection (TFESI). We aimed to compare fluoroscopically- and CT-guided TFESI in patients with subacute (4-12 weeks) and chronic (≥12 weeks) LBP. In this prospective cohort study, 121 adults with subacute or chronic LBP were recruited. Using propensity score matching (PSM), we created two age, sex, and body mass index (BMI) matched groups of fluoroscopically- and CT-guided TFESI, each including 38 patients. The outcomes of interest were the Oswestry disability index (ODI) and numerical rating scale (NRS), which were measured in all patients before the procedure and at the three-month follow-up. Then, the ODI and NRS mean changes were compared between Fluoroscopy and CT groups using repeated measures ANOVA. All analyses were performed with IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, NY, USA). Of the total 76 matched patients with a mean (SD) age of 66.22 (13.49), 81 (66.9%) were female. ODI and NRS scores significantly decreased from baseline to the three-month follow-up in both treatment groups. The ODI score mean change from baseline to follow-up compared between the two groups was insignificant (fluoroscopy vs. CT mean difference (95% CI): 1.092 (-0.333-2.518), P = 0.131). Similarly, the NRS score mean change from baseline to follow-up compared between the two groups was insignificant (fluoroscopy vs. CT mean difference (95% CI): -0.132 (-0.529-0.265), P = 0.511). Fluoroscopically- and CT-guided TFESI show similar therapeutic effectiveness in patients with subacute and chronic LBP.

Preoperative Epidural Steroid Injection Does Not Increase Infection Risk Following Posterior Cervical Surgery.

Retrospective cohort study. The purpose of this study was to characterize infection risk of preoperative epidural steroid injection (ESI) in patients undergoing posterior cervical surgery. ESI is a helpful tool for alleviating pain and is often used as a diagnostic tool prior to cervical surgery. However, a recent small-scale study found that ESI prior to cervical fusion was associated with an increased risk of postoperative infection. Patients from 2010-2020 with cervical myelopathy, spondylosis, and radiculopathy who underwent posterior cervical procedure including laminectomy, laminoforaminotomy, fusion, or laminoplasty were queried from the PearlDiver database. Patients who underwent revision or fusion above C2 or who had a diagnosis of neoplasm, trauma, or pre-existing infection were excluded. Patients were divided on whether they received an ESI within 30 days prior to the procedure and subsequently matched by age, gender, and preoperative comorbidities. Chi-squared analysis was used to calculate risk of postoperative infection within 90 days. Logistic regression controlling for age, sex, ECI, and operated levels was conducted within the unmatched population to assess infection risk for injected patients across procedure subgroups. Overall, 299417 patients were identified with 3897 having received a preoperative ESI and 295520 who did not. Matching resulted in 975 in the injected group and 1,929 in the control group. There was no significant difference in postoperative infection rate in those who received an ESI within 30 days preoperatively and those who did not (3.28% vs. 3.78%, OR=0.86, 95% CI: 0.57-1.32, P=0.494). Logistic regression accounting for age, gender, ECI, and levels operated demonstrated that injection did not significantly increase infection risk in any of the procedure subgroups. The present study found no association between preoperative ESI within 30 days prior to surgery and postoperative infection in patients undergoing posterior cervical surgery.