Epidural Steroid Research Articles

ID: 212778 Minimally Invasive Interspinous Process Decompression for Elderly Patient With L1-L2 Lumbar Stenosis

Lumbar spinal stenosis (LSS) is the progressive narrowing of the spinal canal. In the USA, the prevalence of LSS in those older than 60 is 47% making it one of the most common causes of lower back pain (1). Diagnosis is multifaceted and based on history, physical exam, and imaging studies. LSS with neurogenic claudication characteristically presents as pain relieved by sitting and worse with standing (2). The initial management of LSS consists of physiotherapy and anti-inflammatory medications followed by epidural steroid injections. When conservative treatment fails, the most common surgical management is decompressive laminectomy with or without fusion (3). Open spinal surgery, however, is not without risks given that the majority of LSS patients are elderly and have multiple comorbidities. An effective procedure in relieving symptomatic LSS is minimally invasive interspinous process decompression which entails an interspinous spacer that is implanted under local anesthesia (4).

ID: 206837 Novel "Reverse-C" Positioning for Transforaminal Epidural Injections in Scoliosis

A 65-year-old female with a history of levoscoliosis presented to the clinic with right sided low back pain (LBP) radiating to her right lower extremity. Pt reported a history of multiple epidural steroid injections (ESI) which resulted in minimal relief. Imaging revealed severe neuro-foraminal stenosis (right worse than left) mainly due to degenerative disc disease and scoliosis. Novel “reverse-C” positioning during transforaminal steroid injections was shown to open the right-sided neuro-foramen, especially with fluoroscopy before and after, increasing chances for a successful injection.

ID: 214900 Utilizing Double Needle Technique to Mitigate Risk of Infection During Transforaminal Epidural Steroid Injection

Introduction: The double needle (two-needle) technique is widely used while performing intradiscal steroid injections. The technique provides increased control during placement of the needle in the desired location. Superior, the double needle technique also theoretically provides protection and infection control against potential seeding of pathogens in the intradiscal space. The technique is preferred even without much scientific data as the proposed benefit adds a layer of protection to the intradiscal space and vertebral discs which are notoriously difficult to treat for infections due to minimal blood supply in the area.

ID: 201068 A Curious Case of Intractable Yawning After Lumbar Epidural Steroid Injection

We present a case of seizures manifesting as intractable yawning in a patient who developed pneumocephalus after epidural steroid injection, and how bedside Lorazepam clarified the diagnosis.

ID: 216922 Lumbar Medial Branch Nerve Stimulation With SPRINT Demonstrating No Pacemaker Interference: A Case Report

A 93-year-old male with significant cardiac history including CAD, aortic valve stenosis s/p TAVR, symptomatic bradycardia, paroxysmal atrial fibrillation, second degree AV block on anticoagulation with an implanted Biotronik cardiac pacemaker was evaluated for chronic low back pain. Patient previously completed conservative modalities and multiple interventional procedures including epidural steroid injections and lumbar medial branch blocks with minimal relief. He was not a surgical candidate. The risks and potential benefits of SPRINT peripheral nerve stimulation (PNS) were discussed given his age, cardiac history, and ongoing anticoagulation. Currently, SPRINT is contraindicated in patients with active cardiac implanted devices including pacemakers and defibrillators.

P.147 Exploring the bacterial hypothesis of low back pain: a prospective cohort study

Background: Occult bacterial infection is a proposed etiology of low back pain (LBP). However, a causative link between LBP and bacteria remains unconfirmed. Herein, we determined the incidence of occult discitis in patients receiving surgery for LDH. Methods: Study Design: prospective cohort study. Inclusion criteria: consecutive adult patients undergoing discectomy for symptomatic LDH. Exclusion criteria: prior epidural steroid use, prior spinal surgery, and antibiotic use within 2 weeks of surgery. Tissue samples: Four nuclear tissue and ligamentum flavum (control) samples were obtained per patient using stringent aseptic protocol. Samples underwent 16S-PCR and culturing. Results: Eighty-one patients were enrolled (mean age 43.3±13.3 years). All (100%) of tissue samples were negative by 16S PCR and no virulent species were detected. Nuclear and ligament cultures were both negative in 51 (62.9%) cases. Cultures were positive for nuclear tissue only, ligament only, or both in 14.8%, 12.3%, and 9.9% of cases, respectively. Fifteen of 20 (75%) disc positive samples grew a single colony of an indolent species. Conclusions: The findings of this prospective cohort study of consecutive patients receiving surgery for LDH do not support the theory of occult discitis. All samples were 16S-PCR negative, and most cultures were negative or grew a single colony suggestive of contamination.

ID: 216501 Subdural Contrast Spread in the Contralateral Oblique View During Epidural Steroid Injection

Introduction/Description: For accessing the cervical epidural space, the contralateral oblique (CLO) view under fluoroscopy at 50 degrees (CLO50) has been described as a safe and effective view for obtaining epidural access with some studies suggesting it is superior to the lateral and anteroposterior (AP) views for correct needle tip placement [1]. Because false loss of resistance can still occur using this approach, contrast medium needs to be injected prior to medication administration to ensure correct placement. It is important to recognize spread patterns within the meningeal layers to distinguish between proper placement into the epidural space and unintended spread into the subdural or intrathecal space.

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

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

Epidural Steroid Injections and the Risk of Osteoporosis in Lumbar Spondylosis Patients: A Nationwide Population-Based Cohort Study

BACKGROUND: Epidural steroid injections (ESIs) involve the administration of steroids and local anesthetics into the spinal epidural space, and they are performed by inserting a needle between the ligamentum flavum and dura. This procedure is suitable for patients with lumbosacral radiculopathy secondary to disc herniation or postsurgical radicular pain. The relief period of the analgesic medications may be prolonged by > 6 weeks, resulting in nonsurgical management becoming a suitable option. However, the negative effect of ESIs on bone mineral density has been reported. OBJECTIVES: We aimed to clarify the association between ESIs and osteoporosis risk by analyzing a nationwide population database. STUDY DESIGN: This study is a nationwide retrospective cohort study. SETTING: Data on 1 million cases randomly selected from the 2000 Registry for Beneficiaries of the National Health Insurance Research Database (NHIRD) were collected. METHODS: In total, 4,957 patients who were diagnosed with lumbar spondylosis and received ESIs between 2000 and 2013 were identified from the NHIRD. Subsequently, another 4,957 patients with lumbar spondylosis were randomly selected from the same database and frequency matched by age, gender, and index year with the patients who received ESIs. RESULTS: The mean age of the patients were 50.3 ± 17.1 years. The incident rates of osteoporosis in the ESI and non-ESI groups were 7.95 and 7.01 per 1,000 person-years, respectively. Osteoporosis risk was significantly higher in the ESI cohort than in the non-ESI cohort (absolute standardized hazard ratio = 1.23, 95% confidence interval = 1.05-1.45, P = 0.01). The risk factors for osteoporosis were old age, being female, and undergoing ESIs. Osteoporosis risk was significantly higher in the ESI cohort than in the non-ESI cohort in the male, lowest-urbanization-level (fourth level), other-occupations, and comorbidity-free subgroups. LIMITATIONS: The NHIRD did not provide information on osteoporosis-related scales, renal function, blood pressure, smoking habit, pulmonary function, daily activities, and dosage of injected steroids. CONCLUSIONS: For patients diagnosed with lumbar spondylosis, ESIs are associated with a high osteoporosis risk. Thus, this therapy should be recommended with caution, especially for patients with correlated risk factors (e.g., high risk of osteoporotic fracture, low socioeconomic status, and retired or unemployed status). KEY WORDS: Lumbar spondylosis, epidural steroid injection, osteoporosis, urbanization level

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.

Full endoscopic spine surgery

BackgroundWith a dramatic increase in elderly population worldwide, the prevalence of degenerative spine disease is steadily rising. Even though the entire spinal column is affected the problem is more commonly seen in the lumbar, cervical spine and to some extent the thoracic spine. The treatment of symptomatic lumbar disc or stenosis is primarily conservative with analgesics, epidural steroids and physiotherapy. Surgery is advised only if conservative treatment is ineffective. Conventional open microscopic procedures even though are still a gold standard, have the disadvantages of excessive muscle damage and bone resection, epidural scarring along with prolonged hospital stay and increased need of postoperative analgesics. Minimal access spine surgeries minimize surgical access related injury by minimizing soft tissue and muscle damage and also bony resection thus preventing iatrogenic instability and unnecessary fusions. This leads to good functional preservation of the spine and enhances early postoperative recovery and early return to work. Full endoscopic spine surgeries are one of the more sophisticated and advanced form of MIS surgeries. PurposeFull endoscopy has definitive benefits over conventional microsurgical techniques. These include better and clear vision of the pathology due to presence of irrigation fluid channel, minimal soft tissue and bone trauma, better and relatively easy approach to deep seated pathologies like thoracic disc herniations and a possibility to avoid fusion surgeries. The purpose of this article is to describe these benefits, give an overview of the two main approaches - transforaminal and interlaminar, their indications, contraindications and their limitations. The article also describes about the challenges in overcoming the learning curve and its future prospectives. ConclusionFull endoscopic spine surgery is one of the fastest growing technique in the field of modern spine surgery. Better intraoperative visualization of the pathology, lesser incidence of complications, faster recovery time, less postoperative pain, better relief of symptoms and early return to activity are the main reasons behind this rapid growth. With better patient outcomes and reduced medical costs, the procedure is going to be more accepted, relevant and popular procedure in future.

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).

“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.

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.

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...