Interlaminar Epidural Steroid Injection Research Articles

Factors Affecting Radiation Exposure during Lumbar Epidural Steroid Injection: A Prospective Study in 759 Patients.

ObjectiveTo estimate and compare radiation exposure and intervention time during lumbar epidural steroid injection (ESI) 1) under different practitioners and methods with continuous fluoroscopic monitoring, and 2) under one practitioner with different methods and monitoring.Materials and MethodsWe consecutively recruited 804 patients who underwent lumbar ESI and 759 patients who underwent 922 interventions were included for analysis in this investigation. Three different practitioners (a senior faculty member, junior faculty member, trainee) performed lumbar ESI using different methods (caudal, interlaminar, transforaminal). The senior faculty member performed lumbar ESI under two different methods of fluoroscopic monitoring (continuous [CM] and intermittent monitoring [IM]). The dose area product (DAP) fluoroscopy time, and intervention time during lumbar ESI were compared for 1) ESI methods and practitioners under CM, and 2) ESI methods and monitoring.ResultsWith CM, interaction between the effects of the practitioner and the intervention on DAP was significant (p < 0.001), but not fluoroscopy time (p = 0.672) or intervention time (p = 0.852). The significant main effects included the practitioner and intervention on DAP, fluoroscopy time, and intervention time with CM (p < 0.001). DAPs and fluoroscopy time for caudal, interlaminar, and transforaminal ESI were higher with CM than with IM (p < 0.001). Intervention time did not differ between CM and IM.ConclusionRadiation exposure is dependent on the practitioners and methods and within the established safety limits during lumbar ESIs under CM. With an experienced practitioner, IM leads to less radiation exposure than CM.

Method to Reduce the False-Positive Rate of Loss of Resistance in the Cervical Epidural Region.

Background. The cervical epidural space can be detected by the loss of resistance (LOR) technique which is commonly performed using air. However, this technique using air has been associated with a high false-positive LOR rate during cervical interlaminar epidural steroid injections (CIESIs). Objective. We investigated whether the detection of LOR with contrast medium might reduce the false-positive LOR rate on the first attempt. Methods. We obtained data retrospectively. A total of 79 patients were divided into two groups according to the LOR technique. Groups 1 and 2 patients underwent CIESI with the LOR technique using air or contrast medium. During the procedure, the injection technique (median or paramedian approach), final depth, LOR technique (air or contrast), total number of LOR attempts, and any side effects were recorded. Results. The mean values for the total number of LOR attempts were 1.38 ± 0.65 (Group 1) and 1.07 ± 0.25 (Group 2). The false-positive rate on the first attempt was 29.4% and 6.6% in Groups 1 and 2, respectively (P = 0.012). Conclusions. The use of contrast medium for LOR technique is associated with a lower rate of false-positivity compared with the use of air.

Fluoroscopically Guided Cervical Inter-Laminar Epidural Injections: Correlation Between Degree of Spinal Stenosis and Contrast Dispersal Pattern

Objectives: Cervical inter-laminar injections at C7-T1 have been routinely performed for many years as an effective means of palliating neck pain. The purpose of this study is to measure the extent of contrast spread following C7-T1 cervical inter-laminar epidural steroid injection (CIESI), and to correlate the upper extent of contrast spread with degree of cervical spinal stenosis. Methods: We retrospectively identified 41 consecutive patients over a six months’ time frame fulfilling the following inclusion criteria: (1) Had image guided CIESI at C7-T1, (2) Had PA and oblique epidurogram pre and post procedure, (3) Had procedural notes indicating the amounts injected and (4) Had an antecedent MRI. The epidurograms were reviewed for their extent of injectate spread. MRI studies were evaluated separately and blinded to the epidurograms. For each level the degree of cervical spine narrowing was noted. We correlated the extent of contrast spread with the level of maximal cervical narrowing. Results: Maximal contrast spread was up to the skull base and down to T4-T5; minimal extent was C6-C7 to T2. We found statistically significant correlation (2-tailed Pearson correlation r= 0.867, p<0.001) between the upper-most extent of contrast spread and the lowest level of significant central canal stenosis according to pre-procedure MRI. Conclusion: Following CIESI injectate will spread up as far as the cranio-cervical junction or near the lowest level where there is moderate degenerative central stenosis.

Serum Triamcinolone Levels Following Interlaminar Epidural Injection.

Lumbar interlaminar epidural steroid injections (ESIs) are one of the most commonly performed procedures in pain medicine, but little is known about the serum levels of steroids following injection into the epidural space. The primary objective of this study was to investigate the pharmacokinetics of fluoroscopy-guided epidural-administered triamcinolone acetonide in a cohort of patients with chronic low-back pain seeking treatment in a pain medicine clinic. The study cohort included 10 patients undergoing a fluoroscopically guided L4-L5 or L5-S1 lumbar interlaminar ESI at a pain medicine specialty clinic. Blood was collected prior to the ESI and on days 1, 2, 4, 6, 8, 14, 21, 28, 35, and 42 following the injection. The sample extract was analyzed by tandem mass spectrometry. The terminal elimination half-life of epidural-administered triamcinolone in a noncompartmental analysis was 523 hours. In the noncompartmental analysis, peak triamcinolone concentrations of 4.1 ng/mL were detected within 24 hours after administration. The pharmacokinetics of epidural-administered triamcinolone is consistent with previously observed adverse effects of the drug on endocrine function. The pharmacokinetics of other epidural-administered steroids should be determined and incorporated in clinical trials to investigate the potential associations between serum levels, clinical outcomes, and potential adverse endocrine effects.

Adverse Event Rates Associated with Transforaminal and Interlaminar Epidural Steroid Injections: A Multi-Institutional Study.

Transforaminal epidural steroid injections (TFESI) have demonstrated efficacy and effectiveness in treatment of radicular pain. Despite little evidence of efficacy/effectiveness, interlaminar epidural steroid injections (ILESI) are advocated by some as primary therapy for radicular pain due to purported greater safety. To assess immediate and delayed adverse event rates of TFESI and ILESI injections at three academic medical centers utilizing International Spine Intervention Society practice guidelines. Quality assurance databases from a Radiology and two physical medicine and rehabilitation (PM&R) practices were interrogated. Medical records were reviewed, verifying immediate and delayed adverse events. There were no immediate major adverse events of neurologic injury or hemorrhage in 16,638 consecutive procedures in all spine segments (14,956 TFESI; 1,682 ILESI). Vasovagal reactions occurred in 1.2% of procedures, more frequently (P = 0.004) in TFESI (1.3%) than ILESI (0.5%). Dural punctures occurred in 0.06% of procedures, more commonly after ILESI (0.2% vs 0.04%, P = 0.006). Delayed follow up on PM&R patients (92.5% and 78.5, next business day) and radiology patients (63.1%, 2 weeks) identified no major adverse events of neurologic injury, hemorrhage, or infection. There were no significant differences in delayed minor adverse event rates. Central steroid response (sleeplessness, flushing, nonpositional headache) was seen in 2.6% of both TFESI and ILESI patients. 2.1% of TFESI and 1.8% of ILESI patients reported increased pain. No long-term sequelae were seen from any immediate or delayed minor adverse event. Both transforaminal and ILESI are safely performed with low immediate and delayed adverse event rates when informed by evidence-based procedural guidelines. By demonstrating comparable safety, this study suggests that the choice between ILESI and TFESIs can be based on documented efficacy and effectiveness and not driven by safety concerns.

Cervical epidural steroid injections and spinal cord injuries

Background ContextCervical interlaminar and transforaminal epidural steroid injections have been increasingly performed as a medical interventional treatment for pain. PurposeThis study aimed to examine if there was increasing proportion of cervical spinal cord injured acute rehabilitation hospital admissions related to cervical epidural injections because of increased use of the procedure. Additionally, this study aimed to determine risk factors that may have made these patients known higher risk premorbidly. Study Design/SettingA retrospective chart review was carried out. Patient SampleThe sample was from a 2001 to 2008 spinal cord-related injuries admitted to Magee Rehabilitation (2,770). A total of 1,343 patients were classified as having acute spinal cord injuries (SCIs). Of these patients, seven cases of SCI occurred after cervical epidural injections. Outcome MeasuresChart data regarding characteristics of patients and proportion of SCI admissions to cervical epidural injections injuries were the outcome measures. MethodsParameters analyzed included age, sex, American Spinal Injury Association Impairment Scale on admission, mechanism of injury, presenting symptoms, time of onset, and risk factors. Proportion of SCI admissions to cervical epidural injections injuries was also analyzed. ResultsFrom the years 2001 to 2008, there were seven admissions for such injury with no change in the proportion of SCIs from cervical epidural injections relative to all SCIs. All were incomplete and mechanisms included anterior cord infarction (1), intraparenchymal injection (1), epidural abscess (2), contusion (1), epidural hematoma (1), and unknown (1). Presenting symptoms included hypotension, respiratory distress, chest pain, upper limb numbness, paresthesias, weakness, and fever. Symptom onset ranged from minutes to 72 hours after injection. ConclusionsAlthough there is an increased use of interventional spine procedures to treat pain, this did not increase the proportion of cervical epidural-related SCI admissions. Additional research is needed to advocate reporting complications in all clinical settings.

Comparison of Transforaminal and Parasagittal Epidural Steroid Injections in Patients With Radicular Low Back Pain.

Background:Epidural steroid injection (ESI), including transforaminal (TF) epidural injections and interlaminar (IL) epidural steroid injections are commonly performed procedures for the management of lumbosacral radicular pain. Parasagittal interlaminar (PIL) approach could enable higher ventral epidural spread, with fewer complications than TF.Objectives:This study aims to compare the effectiveness of PIL and TF ESI in relieving the pain and disability of patients with lumbosacral pain.Patients and Methods:This prospective study enrolled 64 patients, aged between 18 to 75 years, with a diagnosis of low back pain and unilateral lumbosacral radicular pain. The patients were randomized to receive fluoroscopically guided epidural injection, through either the PIL or TF approach. Patients were evaluated for effective pain relief [numerical rating scale (NRS) < 3] by 0 - 10 numeric rating scale (NRS) and functional improvement by the Oswestry Disability Index (ODI).Results:Effective pain relief [numeric rating scale (NRS) < 3] was observed in 77.3% (95% CI: 67‒90.5%) of patients in PIL group and 74.2% (95% CI: 62.4 - 89.4%) of patients in the TF group (P = 0.34), at 4 weeks. Mean NRS score was not significantly different between the PIL group compared to the TF group, at 4 weeks (P = 0.19). Number of patients with improved disability (measured by ODI < 20%) was not significantly different in PIL group (78% of cases) compared to the TF group (76% of cases), at 4 weeks (P = 0.21). There were no adverse effects observed in any of our patients.Conclusions:The PIL epidural injection is as effective as TF epidural injection in improving pain and functional status, in patients with chronic lumbosacral low back pain, due to disc degeneration.

Multicenter Survey of Attitudes and Perceptions of Pain Medicine Fellows Toward the Use of Lateral Versus Contralateral-Oblique Fluoroscopic View for Interlaminar Cervical Epidural Injection

For interlaminar cervical epidural steroid injections (CESI) the lateral fluoroscopic view (LAT) is often considered to improve needle localization. However, the contralateral-oblique view (CLO) is a useful alternative with potential advantages to improve identification of cervical anatomy and needle depth assessment. The authors explored the attitudes and perceptions of pain medicine fellows currently training in two ACGME-accredited pain medicine fellowship programs regarding the use of these two types of fluoroscopic views. The survey was conducted online following a request by e-mail. Of a total of 20 fellows who were contacted, there were 17 respondents who had experience with both techniques, and they were included for analysis. The response rate for participation was 95%. Whereas 70.6% respondents reported they were very certain about the assessment of anatomy with the CLO view, only 17.6% felt very certain with the LAT view. Compared with learning to perform interlaminar CESI using the LAT view only, the majority of fellows thought that using the CLO technique was easier to learn (P < 0.01) and offered better visualization of contrast dye spread pattern to confirm the cervical epidural space (P = 0.013). All respondents perceived that the likelihood of interlaminar CESI complications would be lower with CLO technique. Overall, 82.4% of respondents considered CLO visualization as a preferred technique for interlaminar CESI. Respondents stated that the likelihood of using the CLO technique as an independent physician was significantly higher than using only the LAT technique (P < 0.001), particularly for patients who are obese and have short necks. For interlaminar CESI, using the CLO is perceived to provide better definition of anatomy and yet is easier to learn. Trainees may become more confident in performing interlaminar CESI with the CLO. We encourage all fellowship programs to include the CLO technique for interlaminar CESI as part of the training.

Paraplegia following intercostal nerve neurolysis with alcohol and thoracic epidural injection in lung cancer patient.

The goal of cancer treatment is generally pain reduction and function recovery. However, drug therapy does not treat pain adequately in approximately 43% of patients, and the latter may have to undergo a nerve block or neurolysis. In the case reported here, a 42-year-old female patient with lung cancer (adenocarcinoma) developed paraplegia after receiving T8-10 and 11th intercostal nerve neurolysis and T9-10 interlaminar epidural steroid injections. An MRI results revealed extensive swelling of the spinal cord between the T4 spinal cord and conus medullaris, and T5, 7-11, and L1 bone metastasis. Although steroid therapy was administered, the paraplegia did not improve.

Patients with Refractory Back Pain Treated in the Emergency Department: Is Immediate Interlaminar Epidural Steroid Injection Superior to Hospital Admission and Standard Medical Pain Management?

Background: Hospital admissions for back pain are prolonged, costly, and common. Epidural steroid injections are frequently performed in an outpatient setting with an excellent safety and efficacy profile. Objectives: The purpose was to review data from patients with severe pain that did not respond to aggressive medical treatment in the emergency department (ED) and determine the effectiveness of an interlaminar epidural steroid injection (ESI) in this patient population. Study Design: Retrospective matched cohort design. Setting: Single urban emergency department at a tertiary referral center. Methods: A retrospective cohort comparison pairing 2 groups that both failed aggressive pain control in the ED was performed. The epidural injection group (1ESI) received an interlaminar ESI while in the ED. The standard therapy group (2ST) was admitted for medical pain management. Groups were matched for pain intensity, age, and symptom duration. Results: Thirty-five patients in 1ESI (NRS 8.8, 5 – 10, 0.35), and 28 patients in 2ST (NRS 8.9, 4 – 10, 1.7). Pain score after ESI 0.33 (0 – 2, 0.6); all were discharged. Pain score on day 1 of hospital admission for 2ST was 8.7 (7 – 10, 1.5). Total ED time was 8 hours for 1ESI and 13 hours for 2ST (P &lt; 0.002). 1ESI patients received less narcotics while in the ED (P &lt; 0.002) and were discharged home with less narcotics than 2ST (&lt; 0.002). Average inpatient length of stay (LOS) for 2ST was 5 (1.5 – 15, 3.3) days. Cost of care was over 6 times greater for those patients admitted for pain management (P &lt; 0.001). Limitations: Retrospective design, non-randomized sample, and a small patient population. Conclusion: An ED patient cohort with severe refractory pain was treated with an interlaminar ESI after failing maximal medical pain management while in the ED. Complete pain relief was achieved safely and rapidly. The need for inpatient admission was eliminated after injection. Costs were lower in the group that received an epidural injection. Narcotic requirements upon discharge were decreased as well. Key words: Low back pain, epidural steroid injection, emergency department, hospital admission

Acupuncture in patients with a vertebral compression fracture: a protocol for a randomized, controlled, pilot clinical trial.

Objectives:A vertebral compression fracture (VCF) is characterized by back pain and fracture of a vertebral body on spinal radiography. VCFs of the thoraco lumbar spine are common in the elderly. In general, appropriate analgesics should be prescribed to reduce pain and, thus, promote early mobilization. The ideal treatment approach for VCFs has not been determined. In Korea, acupuncture and herbal medication have been used to treat VCFs for many years. There is empirical evidence that acupuncture might benefit patients with a VCF. However, no randomized, controlled, clinical trials evaluating the efficacy and the safety of acupuncture for treating a VCF have been published. Therefore, we designed a randomized, controlled, pilot, clinical trial to obtain information for the design of a further full scale trial.Methods:A five week protocol for a randomized, controlled, pilot, clinical trial is presented. Fourteen patients will be recruited and randomly allocated to two groups: a control group receiving interlaminar epidural steroid injections once a week for three weeks, and an experimental group receiving interlaminar epidural steroid injections plus acupuncture treatment (three acupuncture sessions per week for three weeks, nine sessions in total). The primary outcomes will be the pain intensity (visual analogue scale and PainVisionTM system). The secondary outcome measurements will be the answers on the short form McGill pain questionnaire and the oswestry disability index. Assessments will be made at baseline and at one, three, and five weeks. The last assessment (week five) will take place two weeks after treatment cessation. This study will provide both an indication of feasibility and a clinical foundation for a future large scale trial. The outcomes will provide additional resources for incorporating acupuncture into existing treatments, such as nonsteroidal anti-inflammatory medications, narcotics and vertebral augmentation. This article describes the protocol.

Complication Rates for Fluoroscopic Guided Interlaminar Lumbar Epidural Steroid Injections Performed by Certified Registered Nurse Anesthetists in Diverse Practice Settings

What is the complication rate for Certified Registered Nurse Anesthetists (CRNAs) performing fluoroscopic guided lumbar epidural steroid injections (LESIs)? CRNA pain practitioners responded to questionnaires regarding their education level, experience, and practice locations. Participants also collected data on number of fluoroscopic guided LESIs performed and each of 20 complications for a 6-month period, and answered a poll regarding satisfaction with the data collection process. Participants represented urban (23%) and rural (77%) practices; as well as office/clinic (31%) hospital (62%) and mixed (7%) practice settings. Both Masters (62%) and Doctoral prepared (38%) CRNAs participated. Their experience in performing fluoroscopic guided LESIs ranged from 1 to 17 years and 50 to 12,000 procedures. Rate of occurrence for each complication was below 1%. Participants had higher rates of bruising and vasovagal reactions than other complications. No paralysis or death occurred. Neither practice setting nor experience level was related to complication rates. Participants expressed interest in participating in additional studies of complication rates. CRNAs were able to safely and effectively perform fluoroscopic guided LESIs with complication rates similar to physician rates cited in the literature. Additional study of definitions of complications and CRNA complication rates for other pain management procedures is recommended.

Incidence of Inadvertent Intravascular Injection during CT Fluoroscopy-Guided Epidural Steroid Injections.

Inadvertent intravascular injection during epidural steroid injection can result in complications and has been investigated previously with conventional fluoroscopy, but not CT fluoroscopy. The purpose of this study was to determine the incidence of intravascular injections recognized during CT fluoroscopy-guided epidural steroid injection. We retrospectively reviewed 575 consecutive CT fluoroscopy-guided epidural steroid injections. Procedures were assessed to determine the incidence of intravascular injection. Cases positive for intravascular injection were classified on the basis of anatomic location, distance from the needle tip, washout pattern, and presence of combined epidural and vascular injection. Cases were also graded as either venous or arterial by using a 5-point scale. Intravascular injection was observed in 26% of cervical transforaminal epidural steroid injections (7/27), 9% of cervical interlaminar epidural steroid injections (4/47), 8% of lumbar transforaminal epidural steroid injections (22/275), and 2% of lumbar interlaminar epidural steroid injections (4/222). Vessels were most commonly identified close to the needle, but in 30% of cases, they were visualized in the anterior paraspinal soft tissues remote from the needle. Washout was most commonly delayed (86%), though rapid washout occurred in 14% of cases. Simultaneous epidural and vascular injections occurred in 32% of cases. Most visualized vessels were venous, but 2 cases were classified as probably arterial. Intravascular injections can be detected with CT fluoroscopy. The incidence in our study was similar to that in previous reports using conventional fluoroscopy. Technical factors such as the "double-tap" on CT fluoroscopy following contrast injection, assessment for discordance between injected and visualized contrast volume, and maintenance of an appropriate FOV facilitate the detection of such events.

Evaluation of Anxiety in Procedure-Naive Patients During Cervical and Lumbar Epidural Steroid Injection Procedures

The lack of studies that identify patient and procedural risk factors for increased levels of anxiety during spine injections represents a major barrier to the development of safe tailored sedation practices. We measured and compared anxiety in procedure-naive patients undergoing a cervical or lumbar interlaminar epidural steroid injection to identify predictors of patient movement and vasovagal responses in the periprocedural period. This prospective observational cohort study was conducted with injection-naive patients presenting for a routine cervical or lumbar epidural steroid injection. The primary outcome measure was the Spielberger State Trait Anxiety Inventory (STAI) score. Participants also reported anxiety using the Numeric Rating Scale in the periprocedural period. The Wilcoxon rank sum test was used to compare STAI scores; Numeric Rating Scale values were compared using Friedman test. Post hoc tests were corrected for 12 comparisons using the Bonferroni method. We found no group differences in age, gender, marital status, Visual Analog Scale pain score, duration of pain symptoms, or utilization of health care resources for pain symptom management. The mean STAI score was 43 ± 8 in the cervical group (n = 140) and 44 ± 9 in the lumbar group (n = 140) (P = 0.35), a low level of anxiety. There were no between-group differences in anxiety at any point during the periprocedural period. A vasovagal response was identified in 10% of the cervical group and in 3% of the lumbar group (P = 0.04). No group differences in anxiety were seen between cervical and lumbar groups. Anxiety levels were not associated with patient movement or vasovagal symptoms. Our results suggest that the practice of routine prevention or treatment of injection-related anxiety in the procedure-naive general population with a duration of pain less than 6 months and without a history of an anxiety disorder should be reevaluated.

Hemiparesis and Facial Sensory Loss following Cervical Epidural Steroid Injection

Interlaminar cervical epidural steroid injections (ic-ESI) are safe and effective treatment options for the management of acute and chronic radiculopathy, spinal stenosis, and other causes of neck pain not responding to more conservative measures. However, the procedure inherently lends itself to possible spinal cord injury (SCI). Though reports of such events have been documented, the clinical presentation of patients with needle puncture SCI varies. In part, this may be due to anatomic considerations, as symptoms may be dependent on the cervical level intruded, as well as the volume and type of injectate used. Many cases go unreported and therefore the true incidence of cord injections during ic-ESI is not known. Cervical epidurals can be performed by the transforaminal or interlaminar approach. It is generally accepted that ic-ESI is safer than transforaminal epidurals. There are numerous reports of arterial invasion or irritation with the latter despite an inherently greater risk of cord puncture with the former. The likelihood of cord interruption rises when ic-ESIs are performed above C6-C7 as there is a relatively slim epidural layer compared to lower cervical epidural zones. Though most cases of devastating outcomes, such as hemiplegia and death, have been reported during cervical transforaminal epidural injections and rarely with ic-ESI, it is important to understand the symptoms and potential pitfalls of performing any cervical epidural injection. Cervical epidural malpractice claims are uncommon, but exceed those of steroid blocks at all the levels combined, demonstrating the need for improved awareness of potential complications in ic-ESI. Here, we will describe an unusual presentation of a spinal cord injection during an ic-ESI procedure. Key words: Cervical epidural, spinal cord, hemiparesis

Particulate versus non-particulate steroids for lumbar transforaminal or interlaminar epidural steroid injections: an update.

Lumbar transforaminal and interlaminar epidural steroid injections are widely used to treat patients with radicular pain and radiculopathy [1]. These lumbar spine procedures are reported to be clinically effective for short-term and long-term pain relief by some studies [2–5]. However, a relative lack of randomized and controlled clinical trials and as well as variability of the employed study methods were noted [6]. Thus, some controversy concerning the effectiveness of lumbar transforaminal and interlaminar epidural steroid injections still remains [6, 7]. Moreover, it should be emphasized that these indications and use are often performed on an off-label basis. The question arises whether just formal approval is lacking or whether extensive medical literature provides sufficient evidence-based efficacy and safety data for this off-label use. An image-guided therapeutic injection of both the cervical and lumbar spine is a minimally invasive technique, however rare serious adverse events such as brainstem, cerebellum and cervical, thoracic and lumbar spinal cord infarction have occurred [8–26]. The present article discusses serious complications associated with epidural steroid injections after injections at the level of the lumbosacral spine.

Transforaminal Versus Interlaminar Approaches to Epidural Steroid Injections: A Systematic Review of Comparative Studies for Lumbosacral Radicular Pain

Background: The superiority of transforaminal epidural steroid injections (TFESI) vs. interlaminar epidural steroid injections (ILESI) for treating unilateral lumbosacral radicular pain (LSRP) is unproven. Objective: To assess studies comparing TFESI to ILESI for unilateral LSRP for pain relief and functional improvement. Study Design: Systematic review of comparative studies. Methods: A systematic literature search was conducted using the Cochrane Central Register of Controlled Trials, PubMed, and Scopus databases for trials reported in English. Studies meeting the Cochrane Review criteria for randomized trials and the AHCQ criteria for observational studies were included. Evidence was graded using the USPSTF classification. Results: Five (prospective) and 3 (retrospective) studies were included assessing 506 patients. Statistical analysis was calculated only utilizing the 5 prospective studies and consisted of 249 patients with an average of 3.2 months follow-up. In the short-term (2 weeks), there was a 15% difference favoring TFESI vs. ILESI for pain relief. There was no efficacy difference at one or 6 months. Combined pain improvements in all 5 prospective studies revealed &lt; 20% difference between TFESI and ILESI (54.1% vs. 42.7%). There was slightly better functional improvement in ILESI groups (56.4%) vs. TFESI groups (49.4%) at 2 weeks. Combined data showed slight differences (TFESI 40.1% and ILESI 44.8%). Limitations: The limitations of this systematic review include the relative paucity of comparative studies. Conclusions: The findings show that both TFESI and ILESI are effective in reducing pain and improving functional scores in unilateral LSRP. In the treatment of pain, TFESI demonstrated non-clinically significant superiority to ILESI only at the 2-week follow-up. Based on 2 studies, ILESI demonstrated non-clinically significant superiority to TFESI in functional improvement. Key words: Radiculopathy, epidural steroids, transforaminal, interlaminar, systematic review

Pneumocephalus after lumbar epidural steroid injection: a case report and review of the literature.

Pneumocephalus may occur after inadvertent injection of air into the subarachnoid space while performing epidural anesthesia using a loss-of-resistance technique with air in the syringe. We report a case of pneumocephalus after an interlaminar epidural steroid injection using the loss-of-resistance to air technique. In this report, we examine the etiology, the expected course of symptoms, and resolution, as well as treatment, of pneumocephalus following a systematic literature review.

Epidural steroid injection: a need for a new clinical practice guideline.

Epidural steroid injection: a need for a new clinical practice guideline.

Concordant Provocation as a Prognostic Indicator During Interlaminar Lumbosacral Epidural Steroid Injections

Background: Interlaminar epidural steroid injection is a well-established intervention for the treatment of radicular pain. Pain is commonly reported during the injection into the epidural space; this provocation is typically either concordant or discordant with the patient’s baseline pain. It is not well known how this provocation pain relates to treatment outcomes. Objective: To determine the relationship between concordant versus discordant provocation during interlaminar epidural steroid injection and its effects on pain reduction at follow-up. Study Design: Secondary analysis of a single center, prospective randomized double-blind study. Methods: Interlaminar epidural steroid injections under fluoroscopic guidance were performed on 48 patients with radicular lumbosacral pain. After injection with 80 mg methylprednisolone and 2 mL of normal saline at a single level, patients were asked to report if pain was provoked, and whether the pain was concordant or discordant with their baseline pain. The primary outcome measure was self-rated percentage of pain reduction from baseline at 2-week follow-up. Secondary outcomes included improvement in activity level and decreased analgesic consumption. Results: Provocation was observed in 37 out of 48 patients (77%). This was further classified as concordant (22/37, 60%) or discordant (15/37, 40%) pain. The concordant group achieved a significant decrease in self-reported pain as compared to the discordant group at 2-week followup (61%, t = 2.45, P &lt; 0.01). There were also significantly more patients in the concordant group who reported 75% pain reduction as compared to the discordant group (X = 6.44, df(1), P &lt; 0.05). There were no significant differences between concordant and discordant groups in regard to improvements in activity level (X = 2.56) and decreased analgesic use (X = 3.28). Limitations: The secondary analysis did not examine long-term outcomes. Conclusions: The concordant group demonstrated significantly higher pain reduction as compared to the discordant group. There were no significant differences between the 2 groups in terms of improved function or reduced analgesic requirements. Concordant provocation during interlaminar epidural injection may be a predictor of outcome. Key words: Lumbar epidural steroid injection, steroids, interlaminar injection, lumbar, lumbosacral, provocation, pressure paresthesia, low back pain