Interlaminar Epidural Injections Research Articles

Comparison of fluoroscopy guided inter-laminar epidural platelet-rich plasma versus steroid injection in patients with lumbar radicular pain

Background: Radicular back pain is one of the prevalent causes for low back pain. Objective: The aim of work is to compare the efficacies of fluoroscopic guided inter-laminar epidural injection of platelet-rich plasma (PRP) and epidural steroids in improving lumbar radicular pain. Settings and Design: This study was a prospective randomized controlled clinical trial. Methods: Forty-eight patients were enrolled in this study and divided into two groups. Steroid group (S); A 24 patient, that received fluoroscopic guided inter-laminar epidural injection of 1ml methylprednisolone (40mg/ml) + 4 ml normal saline and platelet rich Plasma group (p); A 24 patients, that received fluoroscopic guided inter-laminar epidural injection of 4.5 ml PRP + 0.5 ml PRP activator (calcium gluconate). Patients were followed up at one week, 4 weeks, and 3 months after the procedure. Results: No differences between study groups as regard pain scores at pretreatment, after 1 and 4 weeks and 3 months of treatment and disability scores at pretreatment, after 4 weeks and 3 months of treatment.

Comparison of pain relief of the cervical radiculopathy between high thoracic erector spinae plane block and cervical epidural injection.

The high thoracic erector spinae plane block (ESPB) has been used for the management of chronic shoulder pain or arthroscopic shoulder surgery. No study has evaluated the analgesic efficacy of ESPB in patients with cervical radiculopathy although it is a favored and easy technique compared to neuraxial block. The purpose of this study was to compare the treatment outcome of cervical radiculopathy using high thoracic ESPB or cervical interlaminar epidural injection (CEPI). This study included 82 patients with neck and arm pain who received CEPI (CEPI group) using 4 ml of 0.1% ropivacaine or high thoracic ipsilateral ESPB (ESPB group) at the T2 or T3 level using 20 ml of 0.1% ropivacaine 20 ml. The degree of pain relief and disability were assessed using an 11-point numerical scale (NRS) and neck disability index (NDI), respectively. The CEPI and ESPB groups demonstrated an equal number of patients with excellent pain relief (NRS reduction ≥ 50%). Significant reduction of NRS was found in both groups, and the effect of time was statistically significant in the groups (P < 0.001). The number of patients who showed an excellent improvement in NDI (NDI reduction ≥ 30%) was 20 (48.8%) and 22 (53.7%) in the CEPI and ESPB groups, respectively. Both the CEPI and ESPB demonstrated significant relief in neck and arm pain with improvement in disability.

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.

The Influence of COVID-19 on Utilization of Epidural Procedures in Managing Chronic Spinal Pain in the Medicare Population.

A retrospective cohort study of utilization patterns and variables of epidural injections in the fee-for-service (FFS) Medicare population. To update the utilization of epidural injections in managing chronic pain in the FFS Medicare population, from 2000 to 2020, and assess the impact of COVID-19. The analysis of the utilization of interventional techniques also showed an annual decrease of 2.5% per 100,000 FFS Medicare enrollees from 2009 to 2018, contrasting to an annual increase of 7.3% from 2000 to 2009. The impact of the COVID-19 pandemic has not been assessed. This analysis was performed by utilizing master data from the Centers for Medicare and Medicaid Services, physician/supplier procedure summary from 2000 to 2020. The analysis was performed by the assessment of utilization patterns using guidance from Strengthening the Reporting of Observational Studies in Epidemiology. Epidural procedures declined at a rate of 19% per 100,000 Medicare enrollees in the FFS Medicare population in the United States from 2019 to 2020, with an annual decline of 3% from 2010 to 2019. From 2000 to 2010, there was an annual increase of 8.3%. This analysis showed a decline in all categories of epidural procedures from 2019 to 2020. The major impact of COVID-19, with closures taking effect from April 1, 2020, through December 31, 2020, will be steeper and rather dramatic compared with April 1 to December 31, 2019. However, monthly data from the Centers for Medicare and Medicaid Services is not available as of now. Overall declines from 2010 to 2019 showed a decrease for cervical and thoracic transforaminal injections with an annual decrease of 5.6%, followed by lumbar interlaminar and caudal epidural injections of 4.9%, followed by 1.8% for lumbar/sacral transforaminal epidurals, and 0.9% for cervical and thoracic interlaminar epidurals. Declining utilization of epidural injections in all categories was exacerbated to a decrease of 19% from 2019 to 2020, related, in part, to the COVID-19 pandemic. This followed declining patterns of epidural procedures of 3% overall annually from 2010 to 2019.

Predictive factors for favorable short-term response to interlaminar epidural block for cervical radiculopathy.

We sought to identify clinical predictors of favorable short-term outcomes associated with cervical interlaminar epidural injection (CIEI). Previous studies investigating the predictive factors of CIEI efficacy have shown inconsistent results. Gaining information on the possible response determinants of CIEI is necessary for appropriate treatment selection and outcomes prediction in the treatment of cervical radiculopathy. We analyzed the clinical data of 72 patients who received fluoroscopic-guided CIEI using the paramedian approach for cervical radiculopathy to identify the predictive factors for short-term outcomes of CIEI. Demographic characteristics, history of neck surgery, diagnosis, initial numeric rating score, duration of symptoms, Douleur Neuropathique 4 (DN4) questions, painDETECT questionnaire, neck disability index, and ventral epidural spread of contrast medium were assessed. Treatment success was defined as at least a 50% reduction in the numeric rating score after CIEI and was designated as a good response. The short-term success rate of CIEI for cervical radiculopathy was 55.56%. Multivariate logistic regression analysis established that spinal stenosis (odds ratio 0.183; P = 0.012), a longer duration of > 24weeks of symptoms (odds ratio 0.206; P = 0.026), and combined positive results for the DN4 and painDETECT (odds ratio, 0.019; P = 0.008) decreased the odds ratio of a good response, 2-3weeks after CIEI. CIEI provides a significant short-term outcome in patients with cervical radiculopathy. However, CIEI efficacy may be negatively affected in patients with spinal stenosis, the presence of a chronic state, and a possible neuropathic pain component.

Retrodural space of Okada in the posterior ligamentous complex region: clinical and anatomical findings relevant to lumbar interlaminar epidural injection

BackgroundThe retrodural space of Okada is a potential space posterior to the ligamentum flavum that allows communication with the bilateral facet joints. However, the actual anatomy of this space has...

118. Trends in lumbar transforaminal and interlaminar injection utilization from 2010-2019

BACKGROUND CONTEXT Lumbar transforaminal and interlaminar injections are considered for varying lumbar pathologies. Reported studies, physician practices, insurance authorization and other factors may influence the utilization of such procedures over time. PURPOSE To analyze trends in lumbar transforaminal and interlaminar spinal injection utilization and associated factors over time. STUDY DESIGN/SETTING A descriptive epidemiologic study. PATIENT SAMPLE 2010-2019 PearlDiver M91Ortho dataset. OUTCOME MEASURES Transforaminal and interlaminar lumbar injections per 100,000 patients in the dataset. METHODS Patients undergoing transforaminal and interlaminar spinal injections were identified based on CPT coding. Patient age, sex, Elixhauser Comorbidity Index (ECI), insurance plan (commercial, Medicaid, Medicare), region of the country where procedure was performed (midwest, northeast, south, west) and average number of injections per patient within a year were abstracted, assessed and tracked over the years studied based on prevalence per 100,000 covered lives. RESULTS In total, transforaminal injections were identified for 426,039 patients, while interlaminar injections were identified in 501,228 patients. For transforaminal injections, the average utilization rate per 100,000 patients decreased between 2010 and 2019 from 160.81 to 76.36. For interlaminar injections, the average utilization per 100,000 patients decreased over the period from 200.53 to 77.56. This decrease in overall injections was greatest for those with commercial and Medicare coverage (53.40% and 66.50%, respectively), with a smaller drop amongst those with Medicaid coverage (32.39%). Over the years, the average age of the injection recipients increased (transforaminal recipients 57.48 to 59.68 years old, interlaminar recipients 57.20 to 60.49 years old, both p < 0.0001). Conversely, the number of injections per patient per year decreased (transforaminal 2.16 to 2.10, interlaminar 2.05 to 1.94, both p < 0.0001). These changes were associated with a shift to more transforaminal relative to interlaminar injections over the years of the study (44.5% to 49.6% transforaminal). Overall, injections were performed most frequently by anesthesiology/pain medicine specialists (who performed less transforaminal than interlaminar inactions), followed distantly by physical medicine and rehabilitation specialists (who performed more transforaminal than interlaminar injection), and those of other specialties performed many fewer injections. CONCLUSIONS Transforaminal and interlaminar spinal epidural injections were shown to decrease by an overall 52.37% from 2010 to 2019. Changes in demographics of those undergoing such injections and practice patterns are important to consider in the picture of overall spine service utilization. Variations in injection utilization trends by patient insurance plan raise questions regarding disparities in care. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Lumbar transforaminal and interlaminar injections are considered for varying lumbar pathologies. Reported studies, physician practices, insurance authorization and other factors may influence the utilization of such procedures over time. To analyze trends in lumbar transforaminal and interlaminar spinal injection utilization and associated factors over time. A descriptive epidemiologic study. 2010-2019 PearlDiver M91Ortho dataset. Transforaminal and interlaminar lumbar injections per 100,000 patients in the dataset. Patients undergoing transforaminal and interlaminar spinal injections were identified based on CPT coding. Patient age, sex, Elixhauser Comorbidity Index (ECI), insurance plan (commercial, Medicaid, Medicare), region of the country where procedure was performed (midwest, northeast, south, west) and average number of injections per patient within a year were abstracted, assessed and tracked over the years studied based on prevalence per 100,000 covered lives. In total, transforaminal injections were identified for 426,039 patients, while interlaminar injections were identified in 501,228 patients. For transforaminal injections, the average utilization rate per 100,000 patients decreased between 2010 and 2019 from 160.81 to 76.36. For interlaminar injections, the average utilization per 100,000 patients decreased over the period from 200.53 to 77.56. This decrease in overall injections was greatest for those with commercial and Medicare coverage (53.40% and 66.50%, respectively), with a smaller drop amongst those with Medicaid coverage (32.39%). Over the years, the average age of the injection recipients increased (transforaminal recipients 57.48 to 59.68 years old, interlaminar recipients 57.20 to 60.49 years old, both p < 0.0001). Conversely, the number of injections per patient per year decreased (transforaminal 2.16 to 2.10, interlaminar 2.05 to 1.94, both p < 0.0001). These changes were associated with a shift to more transforaminal relative to interlaminar injections over the years of the study (44.5% to 49.6% transforaminal). Overall, injections were performed most frequently by anesthesiology/pain medicine specialists (who performed less transforaminal than interlaminar inactions), followed distantly by physical medicine and rehabilitation specialists (who performed more transforaminal than interlaminar injection), and those of other specialties performed many fewer injections. Transforaminal and interlaminar spinal epidural injections were shown to decrease by an overall 52.37% from 2010 to 2019. Changes in demographics of those undergoing such injections and practice patterns are important to consider in the picture of overall spine service utilization. Variations in injection utilization trends by patient insurance plan raise questions regarding disparities in care.

Does Paramedian Approach Preferentially Secure Optimal Drug Delivery Onto Ventral Epidural Space and Subsequent Superior Clinical Efficacy Over a Dorsal Midline Approach During Cervical Interlaminar Epidural Injection?

There is paucity in the literature directly comparing the clinical results between the paramedian and the midline interlaminar cervical epidural injections. To compare the proportion of ventral epidural spread of injectate and consequent clinical outcome between the paramedian and midline approach during interlaminar epidural injection in patients with axial neck and/or interscapular pain triggered from the underlying cervical spine pathologic condition. Retrospective study. Primary pain clinic and spine hospital. Two hundred and twenty-three patients with axial neck and/or interscapular pain due to cervical problem underwent interlaminar epidural injection through either a paramedian approach (PM group, n = 93) or a midline approach (ML group, n = 130). We compared the portion of ventral epidural filling, Numeric Rating Scale (NRS), and McNab criteria between both groups. The NRS and McNab criteria were also separately compared between the ventrally spread (VS) group and non-ventral spread (non-VS) group inside each PM and ML group, respectively, at 2 weeks and 10 weeks post-injection. The PM group showed a significantly higher proportion of ventral spread, successful NRS reduction, and satisfactory McNab criteria than the ML group at 10 weeks. In the PM group, the VS group showed the same results as above compared to the non-VS group. A retrospective analysis based on the relatively short-term follow-up period clinical results. The paramedian approach showed the better direct injectate transfer over the ventral epidural space and subsequently superior clinical efficacy for the patients suffering from axial neck and/or interscapular pain secondary to cervical spine problems.

A Comparative Systematic Review and Meta-Analysis of 3 Routes of Administration of Epidural Injections in Lumbar Disc Herniation

The Best Practices in Pain Management from the U.S. Department of Health and Human Services (HHS) describes interventional techniques as part of a continuum. Epidural injections are commonly utilized modalities in managing low back and lower extremity pain. Epidural injections were initially administered in 1901 where the first descriptions of caudal epidural with local anesthetic for low back pain appeared. Since then, multiple developments have occurred. Currently, epidural injections are provided by caudal, interlaminar, and transforaminal approaches. The comparative effectiveness of each modality has been studied. However, comparative assessment has been sparse. To assess the efficacy of 3 routes of administration of epidural injections for lumbar disc herniation. A systematic review and meta-analysis of randomized controlled trials (RCTs) of transforaminal, interlaminar and caudal epidural injections in managing chronic low back and lower extremity pain due to lumbar disc herniation. RCTs with a placebo control or an active control design, performed under fluoroscopic guidance, with at least 6 months of follow-up are included. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Data extraction and methodological quality assessment were performed. Evidence was summarized utilizing principles of best evidence synthesis. A total of 21 trials were included. Of these, 7 studied caudal epidural injections, whereas transforaminal epidural injections were studied in 12 trials, and lumbar interlaminar epidural injections were studied in 10 trials, which all met inclusion criteria. Based on qualitative and quantitative analysis, which included conventional dual-arm and single-arm analysis for interlaminar epidural injections, and single-arm analysis for caudal and transforaminal epidural injections, and the approach to the epidural space, there is Level I evidence for local anesthetic and steroids, Level II for local anesthetic alone for transforaminal and interlaminar approaches, and Level II for the caudal approach with steroids or local anesthetic alone for short- and long-term relief. There is a paucity of literature with intermediate or long-term relief of at least 6 months with appropriate outcome parameters. Conventional dual-arm meta-analysis was feasible only for interlaminar epidural injections. Epidural injections with local anesthetic and steroids showed Level I evidence for transforaminal and interlaminar approaches, whereas with local anesthetic alone Level II evidence was demonstrated. In contrast, caudal epidural injections showed Level II evidence with local anesthetic with steroids or local anesthetic alone.

One-year results from a randomized comparative trial of targeted steroid injection via epidural catheter versus standard transforaminal epidural injection for the treatment of unilateral cervical radicular pain

ObjectivesThe objective of this study was to evaluate the long-term effectiveness of catheter-directed cervical interlaminar epidural steroid injection with triamcinolone compared with cervical transforaminal steroid injection with dexamethasone for the...

Postdural Puncture Headache Related to Procedure: Incidence and Risk Factors After Neuraxial Anesthesia and Spinal Procedures.

Postdural puncture headache (PDPH) is a potential complication of certain neuraxial anesthesia and spinal procedures, and some risk factors for PDPH have been identified. However, there have been no detailed analyses of rates and risk factors of PDPH after various spinal and neuraxial anesthesia procedures. Patient data from January 1, 2015, to December 31, 2017, were retrospectively analyzed. The patients underwent dural puncture procedures (spinal anesthesia, lumbar puncture [spinal tap], lumbar cerebrospinal fluid [CSF] drainage) or nondural puncture procedures (transforaminal epidural injection, interlaminar epidural injection, epidural catheterization with patient-controlled analgesia for delivery). PDPH incidence and risk factors were evaluated. For dural puncture procedures, PDPH incidence was 2.96%, and risk factors were younger age, female sex, and lumbar puncture. Larger needle gauge was a risk factor according to Student t-test but not during logistic regression analysis. PDPH incidence was higher after lumbar puncture using a 22 G Tuohy needle (4.63%) than after lumbar CSF drainage using an 18 G Tuohy needle (3.05%). For nondural puncture procedures, PDPH incidence was 0.53% and did not differ between procedure types; no risk factors were identified. PDPH incidence and risk factors depended on the type of neuraxial anesthesia and spinal procedures. PDPH incidence after lumbar puncture using a 22 G Tuohy needle was higher than that after lumbar CSF drainage using an 18 G Tuohy needle, suggesting that catheter insertion may reduce PDPH risk. In non-dural puncture procedures, PDPH risk did not differ according to type of procedure, and no risk factors were found.

An Operator's Experience of the Loss-of-Resistance Technique in Epidural Injections: An Observational Study.

A successful interlaminar epidural injection relies on correct epidural space needle placement. Most interlaminar epidural steroid injection (ESI) procedures are performed with a blind technique known as loss-of-resistance (LOR) without an imaging guide. This study aims to evaluate the success rate of the LOR technique in interlaminar epidural steroid injection under fluoroscopic control. Patients who underwent interlaminar ESI owing to a history of at least 3 months of chronic low back and leg pain not responding to medications and physical therapies were included in an observational trial. Participants' age was between 27 and 88 years, and they had an American Society of Anesthesiologists physical status of I-III. The patients were placed in a prone position, and a Tuohy needle was introduced at the level of the L5-S1 interlaminar foramen using fluoroscopic image with an anteroposterior view. A lateral view was obtained when the LOR was felt. The procedures that achieved epidural spread by contrast agent in the first attempt were deemed successful. Those that did not and those that had false positive LOR were regarded as unsuccessful. Interlaminar ESİ was administered to 150 patients. The procedure's success and failure rates were 76% (114 patients) and 24% (36 patients), respectively. A total of 58.3% (21 patients) of patients who underwent an unsuccessful procedure had a false LOR, whereas 41.6% (15 patients) of the same group exhibited other causes. Sex, age, and body mass index (BMI) showed no statistical significance in terms of procedural success. There were statistically significant differences in the distance between the skin and the epidural space according to the body mass index groups. The LOR technique identified the epidural space in most epidural procedures. However, in some cases, LOR was shown to be inadequate. Therefore, we suggest that the LOR technique must be supported by imaging such as fluoroscopy during epidural injections.

Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines

BACKGROUND: Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE: To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS: The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and recommendations were provided. RESULTS: In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives. The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness. The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness. Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness. The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS: The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS: These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations. KEY WORDS: Chronic spinal pain, interventional techniques, epidural procedures, caudal epidural, lumbar interlaminar epidural, cervical interlaminar epidural, thoracic interlaminar epidural, lumbar transforaminal epidural, percutaneous adhesiolysis DISCLAIMER: These guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a “standard of care.” There was no external funding in the preparation of this manuscript.

Declining Utilization and Inflation-Adjusted Expenditures for Epidural Procedures in Chronic Spinal Pain in the Medicare Population

BACKGROUND: Despite epidurals being one of the most common interventional pain procedures for managing chronic spinal pain in the United States, expenditure analysis lacks assessment in correlation with utilization patterns. OBJECTIVES: This investigation was undertaken to assess expenditures for epidural procedures in the fee-for-service (FFS) Medicare population from 2009 to 2018. STUDY DESIGN: The present study was designed to assess expenditures in all settings, for all providers in the FFS Medicare population from 2009 to 2018 in the United States. In this manuscript: • A patient was described as receiving epidural procedures throughout the year. • A visit was considered to include all regions treated during the visit. • An episode was considered as one treatment per region utilizing primary codes only. • Services or procedures were considered as all procedures including bilateral and multiple levels. A standard 5% national sample of the Centers for Medicare and Medicaid Services (CMS) physician outpatient billing claims data for those enrolled in the FFS Medicare program from 2009 to 2018 was utilized. All the expenditures were presented with allowed costs and adjusted to inflation to 2018 US dollars. RESULTS: Total expenditures were $723,981,594 in 2009, whereas expenditures of 2018 were $829,987,636, with an overall 14.6% increase, or an annual increase of 1.5%. However, the inflation-adjusted rate was $847,058,465 in 2009, compared to $829,987,636 in 2018, a reduction overall of 2% and an annual reduction of 0.2%. Inflation-adjusted per patient annual costs decreased from $988.93 in 2009 to $819.27 in 2018 with a decrease of 17.2% or an annual decline of 2.1%. In addition, inflation-adjusted costs per procedure decreased from $399.77 to $377.94, or 5.5% overall and 0.6% annually. Per procedure, episode, visit, and patient expenses were higher for transforaminal epidural procedures than lumbar interlaminar/caudal epidural procedures. Overall, costs of transforaminal epidurals increased 27.6% or 2.7% annually, whereas lumbar interlaminar and caudal epidural injections cost were reduced 2.7%, or 0.3% annually. Inflation-adjusted costs for transforaminal epidurals increased 9.1% or 1.0% annually and declined 16.9 or 2.0% annually for lumbar interlaminar and caudal epidural injections. LIMITATIONS: Expenditures for epidural procedures in chronic spinal pain were assessed only in the FFS Medicare population. This excluded over 30% of the Medicare population, which is enrolled in Medicare Advantage plans. CONCLUSIONS: After adjusting for inflation, there was a decrease of expenditures for epidural procedures of 2%, or 0.2% annually, from 2009 to 2018. However, prior to inflation, the increases were noted at 14.6% and 1.5%. Inflation-adjusted costs per patient, per visit, and per procedure also declined. The proportion of Medicare patients per 100,000 receiving epidural procedures decreased 9.1%, or 1.1% annually. However, assessment of individual procedures showed higher costs for transforaminal epidural procedures compared to lumbar interlaminar and caudal epidural procedures. KEY WORDS: Chronic spinal pain, epidural procedures, caudal epidural, lumbar interlaminar epidural, cervical interlaminar epidural, thoracic interlaminar epidural, lumbar transforaminal epidural procedures, Medicare expenditures

Evaluation of Contrast Flow Patterns with Cervical Interlaminar Epidural Injection: Comparison of Midline and Paramedian Approaches.

Background and objectives: The purpose of this study was to compare and to analyze contrast spread patterns between the paramedian and midline approaches to cervical interlaminar epidural injection (CIEI). Materials and Methods: We retrospectively enrolled 84 CIEI cases that had been performed for unilateral cervical spinal pain from April 2019 to April 2020. After 3 mL of contrast had been injected into the epidural space, fluoroscopic images were obtained. The CIEI was divided into a midline (Group M, n = 42) and a paramedian (Group P, n = 42) approach by anteroposterior imaging. The P Group was classified into a more medial (Group Pm, n = 26) and a more lateral (Group Pl, n = 16) group. Using ImageJ on an anteroposterior image, we assessed the grayscale brightness ratio of the ipsilateral or contralateral side of the vertebral body as well as the intervertebral disc space one level just above the needle location. We identified the dispersion of contrast into the ventral epidural space. Results: The grayscale brightness ratio was significantly higher in Group P than in Group M (p < 0.001). The incidence of ventral epidural spread in Group M was 57.1% versus 88.1% in Group P, which was significantly different (p = 0.001). Conclusions: The fluoroscopic CIEI finding in the paramedian approach predominantly showed an excellent delivery of the injectate to the ipsilateral side in comparison to the contralateral side. This showed a greater advantage in delivery toward ventral epidural space as compared to the midline approach.

Analysis of Subdural Injection During Lumbar Interlaminar Epidural Injection in Failed Back Surgery Syndrome.

Persistent or recurrent back and leg pain following spinal surgery, known as failed back surgery syndrome (FBSS), significantly limits daily life activities. A lumbar epidural injection can reduce adhesions, inflammation, and nerve compression, although the epidural space can be distorted due to dura mater and epidural tissues changes after spinal surgery. This study analyzed subdural injection during lumbar epidural injection in FBSS patients. We retrospectively analyzed data from 155 patients who received a lumbar interlaminar epidural injection to manage FBSS. We grouped the patients based on the injected contrast medium appearance in the subdural (group S) or epidural spaces (group E) in fluoroscopic contrast images. Demographic, clinical, surgical and fluoroscopic data were recorded and evaluated, as were the pain scores before and after injection. There were 59 patients (38.1%) in the subdural group. Injection distance from the surgery level differed between the groups. Risk of subdural injection at level 1 distance from the surgery level had an odds ratio of 0.374, and at level ≥2, it was 0.172, when compared to level 0. Subdural incidence differed with the distance from surgical site. Physicians should strive to reduce subdural incidence when the injection is planned at surgery site in FBSS.

Ultrasound-guided interventions during pregnancy for lumbosacral pain unresponsive to conservative treatment: A retrospective review.

Current conventional therapeutic strategies for lumbosacral pain during pregnancy are usually inadequate and data regarding interventional analgesic procedures feasible in pregnant women is scarce. We decided to retrospectively review our experience of ultrasound-guided pain management procedures in pregnant women with lumbosacral pain unresponsive to conservative treatment. Twenty women in the second trimester of pregnancy with lumbosacral pain developed during pregnancy unresponsive to conservative treatments who underwent the following ultrasound-guided pain interventions were included: sacroiliac joint, caudal epidural, interlaminar epidural, and trigger point injections. All patients were followed up until early postnatal period using Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores. All but one patient achieved satisfactory pain control throughout the pregnancy with a single injection. Significant declines in ODI and VAS scores was attained within the first 2 weeks and first week of intervention, respectively, which was maintained thereafter until early postnatal period. Injections used for effective interventional pain management in nonpregnant populations seem to represent an effective and safe method also for pregnant women when performed under ultrasound guidance, with rapid onset and enduring duration of action until the time of delivery.

Effect of low-dose lidocaine on objective upper extremity strength and immediate pain relief following cervical interlaminar epidural injections: a double-blinded randomized controlled trial

BackgroundLow-dose lidocaine is a common diluent for analgesia following cervical interlaminar epidural steroid injection (CIESI). Concerns with this practice exist. A single-arm cohort reported that 20% of patients develop postprocedural...

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Background: Chronic neck pain is reportedly considered the fourth leading cause of disability. Cervical interlaminar epidural injections are among the commonly administered nonsurgical interventions for managing chronic neck pain, secondary to disc herniation and radiculitis, spinal stenosis, or chronic neck pain of discogenic origin. Objectives: To systematically review the differences in the effectiveness of cervical epidural injections with local anesthetics with or without steroids for the management of chronic neck pain. Study Design: Systematic review and meta-analysis. Methods: A comprehensive search of the literature of randomized controlled trials (RCTs) that compared epidural injections with local anesthetic with or without steroids was performed, including a search of PubMed, EMBASE, and Cochrane databases for all years up to May 2019. Meta-analysis was done for pain relief based on the Numeric Rating Scale, functional status based on the Neck Disability Index, and opioid intake dosage. Results: Four studies met the inclusion criteria. A total of 370 patients were divided into 2 groups: the experimental group received cervical epidural injection with steroid and local anesthetic, and the control group received injection with local anesthetic only. Regrading pain relief, no significant difference was observed between both groups (weighted mean difference [WMD], –0.006; 95% confidence interval (CI), –0.275 to 0.263; P = 0.963; I2 = 0.0% at 12 months). There was also no significant difference in the improvement of the functional status (WMD, 0.159; 95% CI, –1.231 to 1.549; P = 0.823; I2 = 9.8% at 12 months). Similarly, there was no significant difference in opioid dosage (WMD, –0.093; 95% CI, –5.952 to 5.766; P = 0.975; I2 = 0.0% at 12 months). Limitations: Only a few studies on this premise were found in the literature. There was also a lack of heterogeneity of the included RCT studies. Conclusions: The addition of steroids to anesthetic injectates was not associated with better pain and functional score outcomes compared with anesthetic injectate alone in patients with chronic neck pain. Key words: Chronic neck pain, cervical radiculopathy, cervical disc disease, spinal stenosis, facet joint pathology, cervical epidural injections, steroid injections, local anesthetic injections, systematic review, meta-analysis, randomized control trial

Role of transforaminal epidural injections or selective nerve root blocks in the management of lumbar radicular syndrome - A narrative, evidence-based review

ObjectiveLumbar radicular Syndrome (LRS) is a common spinal pathology and is attributed to complex interplay of mechanical, inflammatory and immunological processes. Epidural injection of steroids has a significant therapeutic role in mitigating the inflammatory component of LRS. Trans-foraminal approach under image guidance enables a targeted drug delivery. The current narrative review discusses the various aspects related to lumbar trans-foraminal epidural injection of steroid (LTFIS). MethodsAn elaborate search on PubMed, Google and Medline databases was made using keywords “lumbar selective nerve root block”, “lumbar trans-foraminal epidural steroid injection”, “selective nerve root block in lumbar disc prolapse”, “trans-foraminal epidural steroid injection in lumbar prolapse”, “selective nerve root block in lumbar radiculopathy”, and “trans-foraminal epidural steroid injection in lumbar radiculopathy” The articles were selected based on specific inclusion criteria. ResultsOur search identified 539 articles. All articles discussing alternate procedures, LTFIS in other pathologies, diagnostic roles of LTFIS, not pertaining to concerned questions, in non-English language and duplicate articles were excluded. Review articles, randomised controlled trials or level 1 studies were given preference. Overall, 108 articles were included. Being a focussed narrative review, further screening [Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) or Methodological Index for non-randomized studies (MINORS) criteria] was not performed to select articles. Based on the evidence, LTFIS is an effective and useful treatment modality. It is offered to patients with lumbar disc herniation (LDH) presenting with persistent, unilateral, radiculopathy after a course of conservative measures for around 6 weeks’ duration. It has been reported to yield better results than caudal or inter-laminar epidural injections. The anti-inflammatory and nociceptive signal stabilization actions of steroids, as well as mechanical effects of washout of inflammatory mediators and neural lysis contribute to its efficacy. The three different approaches include sub-pedicular, retro-neural and retro-discal. The procedure is performed under image guidance using a water-soluble contrast under fluoroscopy. The four described radiculogram patterns include “arm”, “arrow”, “linear” and “splash”. Computerised tomography, ultrasonography and magnetic resonance imaging are other modalities, which may be helpful in performing LTFIS. The use of particulate versus non-particulate steroids is controversial. ConclusionThe overall success rate of SNRB is reported to be 76–88%. The majority of benefits are observed during immediate and early post-injection period. Clinical factors including duration and severity of symptoms, and radiological factors like presence of osteophytes, location, size and type of disc prolapse influence outcomes. The radiculogram “splash” pattern is associated with poor outcomes.