Interlaminar Epidural Steroid Injection Research Articles

COMPARING THE CLINICAL OUTCOMES OF LUMBAR TRANSFORAMINAL VS INTERLAMINAR EPIDURAL STEROID INJECTIONS IN A REGISTRY COHORT

Epidural steroid injections are a safe and effective treatment for acute low back pain associated with radicular pain. Objective: The main objective of the study is to find the clinical outcomes of lumbar transforaminal vs interlaminar epidural steroid injections in a registry cohort. Methods: This prospective cohort study was carried out at Ghurki Trust Teaching Hospital, Lahore, over one year, from June 2023 to June 2024. A total of 185 patients were included in the study. Patients aged >18 years and presented with symptoms of lumbar radiculopathy due to lumbar disc herniation, spinal stenosis, or degenerative disc disease were included in the study. Results: The mean age of the TFESI group was 45.6 ± 10.3 years, while the ILESI group had a mean age of 46.2 ± 9.8 years (p = 0.67). The gender distribution was also comparable, with 55 males and 37 females in the TFESI group, and 58 males and 35 females in the ILESI group (p = 0.78). Baseline pain intensity (VAS score) and disability (ODI score) were similar between the two groups, with no significant differences in VAS (7.6 ± 1.1 vs. 7.5 ± 1.2, p = 0.58) or ODI (52.4 ± 10.2 vs. 51.9 ± 9.9, p = 0.71). In the TFESI group, 52.2% of patients had lumbar disc herniation, compared to 49.5% in the ILESI group (p = 0.69). Lumbar spinal stenosis was diagnosed in 32.6% of patients in the TFESI group and 34.4% in the ILESI group (p = 0.81). Conclusion: It is concluded that both lumbar transforaminal epidural steroid injections (TFESI) and interlaminar epidural steroid injections (ILESI) are effective in the management of lumbar radiculopathy, leading to significant reductions in pain and improvements in functional outcomes.

The annoyance of singultus: a case report of a rare adverse effect after epidural steroid injection

ObjectiveCervical epidural steroid injections (ESIs) can provide effective pain management for patients suffering from chronic neck pain due to various pathological changes of the cervical spine. There are several rare adverse effects reported from interventional pain procedures, including persistent hiccups (“singultus”). Based on a limited number of cases, we propose a modified treatment algorithm for this adverse outcome (Fig. 3).Case reportSingultus has been documented as an adverse effect of interventional pain procedures, including epidural steroid, facet joint, and sacroiliac joint injections. We describe the case of a general contractor who presented to our clinic with chronic neck pain and central canal stenosis. The patient received an uncomplicated lumbar ESI in the past and was recommended for a cervical interlaminar ESI. After an uneventful C6-C7 interlaminar ESI with dexamethasone, 1% lidocaine, and normal saline the patient developed singultus. Baclofen was sent to his pharmacy, but this was unsuccessful at alleviating his hiccups. The patient was subsequently started on chlorpromazine and found relief from his symptomatology.ConclusionPersistent hiccups after ESI or interventional pain procedures can be treated with conservative measures and non-pharmacologic methods, with escalation to therapy with baclofen, gabapentin, pregabalin, metoclopramide, chlorpromazine, other antipsychotic or antidopaminergic agents, and possible dual or triple therapy if further indicated.

FACTFINDERS FOR PATIENT SAFETY: Minimizing risks with cervical epidural injections

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to minimize risks associated with cervical epidural injections.Evidence in support of the following facts is presented.Minimizing Risks with Cervical Interlaminar Epidural Steroid Injections – 1) CILESIs should be performed at C6-C7 or below, with C7-T1 as the preferred access point due to the more generous dorsal epidural space at this level compared to the more cephalad interlaminar segments. This reduces the risk of the minor complication of dural puncture and the major complication of spinal cord injury due to inadvertent needle placement. 2) LF gaps are most prevalent in the midline cervical spine. This can result in diminished tactile feedback with loss of resistance (LOR), increasing the risk for inadvertent dural puncture or spinal cord injury. Based on current evidence, needle placement in the paramedian portion of the interlaminar space is safest to avoid LF gaps. 3) An optimal AP trajectory view and the physician's ability to discern engagement in the LF and subsequent LOR are crucial. Confirmation of minimal needle insertion depth relative to the ventral margin of the lamina with either a lateral or contralateral oblique (CLO) safety view is critical to minimize the risk of inadvertently inserting the needle too ventral. 4) There have been closed claims and case reports of patients who have suffered catastrophic neurologic injuries while receiving CILESIs under deep sedation. If sedation is administered, the least amount necessary should be utilized to ensure the patient can provide verbal feedback during the procedure. 5) CILESIs are an elective procedure; therefore, necessity and likelihood of benefit must be foremost considerations. Current guidelines recommend holding ACAP therapy before CILESIs due to the potentially catastrophic complications associated with epidural hematoma (EH) formation. However, there is also a risk of severe systemic complications with ceasing ACAP in specific clinical scenarios. The treating physician is obligated to determine if the procedure is indicated and can ultimately decide to delay the intervention or not perform the procedure if the benefit does not outweigh the risks.Minimizing Risks with Cervical Transforaminal Epidural Steroid Injections – the Role of Preprocedural Review of Advanced Imaging -- Variations in vascular anatomy may warrant a modified approach to CTFESI. Preprocedural review of cross-sectional imaging can provide critical information for safe injection angle planning specific to individual patients and may help to decrease the risk of unintended vascular events with potentially catastrophic outcomes.Safety of Multi-level or Bilateral Fluoroscopically-Guided Cervical Transforaminal Epidural Steroid Injections -- Safe performance of a CTFESI procedure requires the ability to detect inadvertent arterial injection. Contrast medium placed into the epidural space and/or along the exiting spinal nerves during an initial CTFESI may obscure the detection of inadvertent cannulation of a radiculomedullary artery by a subsequent CTFESI. While no available literature directly addresses the potential risk that exists with a multi-level or bilateral CTFESI, caution is still warranted.

Comparative analysis of contrast distribution in cervical epidural steroid injections utilizing a modified paramedian interlaminar approach with varied needle tip positions: A randomized controlledtrial.

Recent advancements in cervical interlaminar epidural steroid injections have given rise to the modified paramedian interlaminar (mPIL) approach. The objective of this study was to perform an analysis of the contrast spread pattern within the cervical epidural space, taking into account different needle tip positions in the mPIL approach. A total of 48 patients were included in the study and randomly assigned to either the medial or lateral group based on the needle tip's position in the anterior-posterior view. The primary outcome measured was the contrast flow under fluoroscopic visualization. As a secondary outcome, we analyzed the location of the needle tip position in both lateral and contralateral oblique views. Clinical effectiveness was assessed by measuring pain intensity and functional disability post-procedure. Significant disparities were noted in the ventral distribution of contrast between the medial and lateral groups. In the lateral images, needle tips in the lateral group were positioned more ventrally compared to those in the medial group. Both groups exhibited statistically significant improvements in neck and radicular pain, as well as functional status, 4 weeks after treatment, with no significant differences between them. Our results suggest that the ventral dispersion of contrast material during cervical interlaminar epidural steroid injections using the mPIL approach may vary depending on the needle tip location.

Ultrasound-Guided Cervical Selective Nerve Root Block versus Fluoroscopy-Guided Interlaminar Epidural Injection for Cervical Radicular Pain: A Randomized, Prospective, Controlled Study.

Ultrasound (US)-guided cervical selective nerve root block (CSNRB) procedures are increasingly being performed as an alternative to conventional fluoroscopy (FL)-guided epidural injections for the treatment of cervical radicular pain. The aim of this study was to compare the effectiveness of US-guided CSNRB versus FL-guided interlaminar cervical epidural steroid injection (IL-CESI) for cervical radicular pain. A total of 60 patients with cervical radicular pain due to a single-level disc herniation were randomized into either the FL or US group. The numeric rating scale, Short Form-36, and neck disability index were evaluated before treatment at months 1, 3, and 6 after treatment. Procedure time, complications, pain medication consumption, and patient satisfaction were also recorded. Patients experienced significant improvement in pain, disability, and quality of life scores up to 6 months after the procedure (p < 0.001). Treatment success rate was achieved in 56.6% of the IL-CESI group and 50% of the CSNRB group without any significant difference between the study arms (p = 0.617). US-guided CSNRB was shown to be as effective as the FL-guided IL-CESI in the treatment of cervical radicular pain, in addition to the absence of radiation exposure and requiring less procedure time.

190 Do Fractional Anisotropy and Apparent Diffusion Coefficient From Diffusion Tensor Imaging Correlate to Symptoms of Radiculopathy? A Case Series From BACPAC MRI

INTRODUCTION: Quantitative diffusion tensor imaging (DTI) parameters such as fractional anisotropy (FA) and apparent diffusion coefficient (ADC) are used to detect axonal pathology in nerve injuries. METHODS: Ganglia of the lumbar plexus nerves (L1-5) were input as seeds to track the nerve fibers using Constant Solid Angle reconstruction. Fiber tracts and values of FA and ADC were extracted along the lumbar plexus nerve profiles. Change in pain (VAS) and disability (ODI) after interlaminar epidural steroid injection at site of compression was compared to the changes in FA and ADC values. RESULTS: Five exams from three patients with bilateral L4-5 foraminal narrowing were included in this study. Two patients were imaged at two time points, three months apart. The average age of the cohort was 62.6 ± 5.3 years. Mean FA values were lowest at L3 (left: 0.32 ± 0.08; right: 0.35 ± 0.05) and L4 (left: 0.39 ± 0.06; right: 0.38 ± 0.03). Correspondingly, mean ADC values were highest at L3 (left: 0.0017 ± 0.0002; right: 0.0016 ± 0.0001) and L4 (left: 0.0.0013 ± 0.0001; right: 0.0015 ± 0.0002). For one patient, pain did not change in severity and ODI improved from severe to moderate disability after steroid injection: FA increased with no significant change in ADC. For another patient, pain increased from moderate to severe and ODI stayed the same after injection: FA decreased and ADC did not significantly change. CONCLUSIONS: The tractography generated from the segmentation model demonstrated lowest FA and highest ADC values corresponding to the level of compression. For patient outcomes, the FA values were observed to be more sensitive to changes in pain and disability compared to the ADC values.

ORAL OPIOID ANALGESICS VS SPINAL STEROID INJECTIONS IN THE TREATMENT OF LOW BACK PAIN: A COMPREHENSIVE SYSTEMATIC REVIEW

Introduction: Low back pain (LBP) affects a significant portion of the population worldwide, with distinct treatment needs for acute and chronic cases. Despite widespread opioid use, evidence for their efficacy in LBP remains uncertain, highlighting the need for alternative interventions. Minimally invasive procedures like epidural steroid injections offer potential relief for conditions like lumbar disc herniation, but their effectiveness is debated. To address these complexities, we conducted a comprehensive review encompassing various treatment modalities beyond medication, aiming to optimize outcomes and improve quality of life for individuals with LBP. Method: The researchers in this study followed the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines to ensure that their work met the required standards. This was done to ensure the precision and reliability of the conclusions derived from the research. Result: Our search produced 13 results. After looking at the titles and summaries, we found 8 papers that fit our criteria. At first, we excluded several articles because they were written in review style and case reports. But after reading the full papers carefully, we included four papers in our final analysis. These papers included retrospective analysis, a randomized, double blind, placebo controlled cross-over study, noninterventional, retrospective 12-week study using anonymized clinical practice data from the German Pain eRegistry, and a retrospective analysis of anonymized, propensity score–matched data. Conclusion: Favorable post-injection outcomes suggest the blind method for caudal epidural injections is safe and effective, suitable for patients not eligible for surgery or unresponsive to conservative treatments. Interlaminar epidural steroid injections effectively reduce VAS and ODI scores in patients with chronic low back pain and multi-level disc disease, but further research is needed to standardize administration protocols and optimize treatment outcomes, including addressing BMI's impact. The analgesic efficacy of periradicular meloxicam injections for acute/subacute low back pain, indicating a potential new treatment option, while real-world data suggest NBX oromucosal spray may be superior to typical oral LAO analgesics for severe peripheral NBP, pending confirmation in large RCTs.

The carbon footprint of epidural steroid injections: A pilot study.

Epidural steroid injections are common procedures in physical medicine and rehabilitation practice. However, their environmental impact has not been characterized. The primary aim is to estimate and compare the carbon footprint of two standard injection kits used to perform epidural steroid injections at a single academic institution. Secondary objectives were (1) to create a step-by-step guide for estimating the carbon footprint of materials and (2) to survey physicians on practice patterns and identify areas for improvement. Pilot study. Academic medical center. N/A. N/A. Carbon emissions measured in CO2 equivalents (CO2 eq). Using guidance from the Greenhouse Gas Protocol, the carbon footprint of the two kits was estimated by taking the sum of carbon emissions resulting from the production of the kit materials and the carbon emissions resulting from the waste disposal of the kit materials. The carbon footprint of the transforaminal epidural steroid injection (TFESI) kit was estimated at 1.328 kg CO2 eq. The carbon footprint of the interlaminar epidural steroid injection (ILESI) kit was estimated at 2.534 kg CO2 eq. For both kits, the carbon emissions resulting from the production of the kits were greater than the emissions resulting from disposal. The survey of interventionalists performing TFESI revealed all respondents required materials in addition to those provided in the standard epidural kit. Despite this, kit materials were typically wasted in 62% of respondents. Creating a methodology for quantifying carbon emissions is the first step to reducing carbon emissions. Once emissions are measured, the health care industry can determine the most effective strategies for reducing its impact. Our analysis has shown that it is feasible to perform emissions calculations and delineates a clear method with publicly available resources. Solutions to reduce epidural injection carbon footprint waste may include improved kit customization.

Comparing the clinical outcomes of lumbar transforaminal vs interlaminar epidural steroid injections in a registry cohort

BackgroundTransforaminal and interlaminar approaches are both common means of performing epidural steroid injection. Comparative effectiveness data on outcomes of these approaches is available but has yielded mixed results. ObjectiveCompare the effect of transforaminal vs interlaminar delivery of epidural steroids on patient-reported pain severity. DesignRetrospective Cohort Study. MethodsA retrospective review of prospectively collected interventional spine procedure registry data between December 2011 and July 2017 from a single academic medical center. Those who received epidural steroid injections and had prospectively collected index pain data (11-point Numeric Rating Scale [NRS]) recorded in the patient's chart prior to the procedure and at a 3 month follow up appointment were included. The outcome of interest was ≥50% reduction in pain as measured using a NRS for back and/or leg pain. To evaluate true predictive odds of success, multivariable logistic regression modeling was used to determine the odds of achieving improved pain. ResultsOf the 73 patients included in the study, 61 (84%) reported radicular pain, 49 (67%) reported back pain, and eleven (15%) had symptoms consistent with claudication, pain characteristics were not mutually exclusive. Fifty-one (70%) underwent transforaminal epidural steroid injection, while 22 (30%) underwent interlaminar injection. When claudication and radicular pain groups were combined into a single “leg pain” category (n = 66), 26/46 (57% 95% CI 41–71%) patients undergoing transforaminal and 6/20 (30% 95% CI 12–54%) patients undergoing interlaminar injections achieved ≥50% leg pain reduction on NRS (p = 0.048). Transforaminal epidural steroid injections were associated with higher odds of ≥50% reduction in leg pain in both the unadjusted model (OR 3.2, p = 00.034) and after adjustment for presence of radicular pain on presentation and the type of steroid used (OR 3.6, p = 0.042). ConclusionIn this clinical practice registry, patients treated with transforaminal epidural steroid injection were more likely to achieve ≥50% reduction in radicular or neurogenic/claudicatory leg pain compared to those treated with interlaminar epidural steroid injection.

Comparing Functional Efficacy of Transforaminal vs Interlaminar Epidural Steroid Injection for Lumbar Disc Disease!! Do We Really Need Transforaminal Epidural Route Injections?

ABSTRACT This study compared the functional efficacy of therapeutic transforaminal versus interlaminar epidural steroid injection. Adult patients were selected and randomized using an online research randomizer website and assigned into two groups and were given epidural injection either via transforaminal route or interlaminar route. The outcome was measured based on the Modified Japanese Orthopedic Association back index score (mJOA), Oswestry disability index (ODI), and visual analog scale (VAS) over a follow-up on 1st, 3rd, and 6th month postinjection period. It was found that there was no significant difference seen in m JOA, ODI, and VAS score at 1 month, 3 months, and 6 months between transforaminal and interlaminar epidural steroid injection. Pain management in the epidural route was comparable to the interlaminar route. Even though the transforaminal epidural route has the advantage of being a selective nerve route block, it has similar results as the interlaminar route at 6 months follow-up.

Contrast flow in CT-guided lumbar interlaminar epidural steroid injections: does needle position effect the laterality of contrast flow?

To evaluate the effect of needle position on the laterality of contrast flow in CT-guided lumbar interlaminar epidural steroid injections. A retrospective review of consecutive CT-guided interlaminar lumbar epidural steroid injections was performed. The terminal needle tip position (midline or lateral) and the laterality of epidural contrast were evaluated by two readers. Contrast flow pattern was classified as ipsilateral to needle trajectory, bilateral, or contralateral. Bilateral flow was further divided into asymmetric, symmetrical, or asymmetric to the contralateral side. Inter-reader agreement was calculated with the kappa statistic. The relationship of needle position to contrast laterality was calculated with the chi statistic. Pain scores were compared for bilateral and unilateral flows with a two-tailed T test for independent means. A total of 250 injections were included in 204 patients, with an age range of 24 to 93years. The most commonly injected level (145/250) was L4-L5. Agreement between the two readers was almost perfect and substantial (kappa 0.751-0.880). The majority of injections (154/250) demonstrated contrast flow ipsilateral to the needle trajectory, 90/250 demonstrated bilateral flow, and 6/250 had contralateral flow. Of the 90 cases with bilateral flow, 80% were performed with a midline terminal needle position (p < 0.001). There was no difference in immediate post-procedure pain scores between patients with ipsilateral or bilateral contrast flow. For interlaminar epidural steroid injections, a midline terminal needle tip position has a greater probability of producing bilateral contrast flow compared to a lateral terminal needle tip position.

The impact of vitamin D deficiency on treatment success of cervical interlaminar epidural steroid injection

ABSTRACT Objective: Our aim is to investigate the effect of vitamin D deficiency on treatment success of cervical interlaminar epidural steroid injection (ILESI) in patients with cervical disc herniation-related chronic radiculopathy. Patients and Methods: Fifty patients who had neck and unilateral extremity pain and received cervical ILESI were included. The patients were divided into two groups according to their serum 25 (OH) D levels as Group 1 (&gt;20 ng/mL) and Group 2 (

Parasagittal Interlaminar and Transforaminal Epidural Steroid Injections for Radicular Low Back Pain; Which is More Comfortable?

This study aimed to compare parasagittal interlaminar (PS) and transforaminal (TF) epidural steroid injections for unilateral L5 and S1 radicular lower back pain in terms of patient comfort, efficacy, safety, contrast enhancement, and radiation exposure. This was a prospective randomized single-blind study. A total of 59 participants were included in this study. The visual analog scale (VAS) and Oswestry Disability Index (ODI) were obtained. A comfort questionnaire was administered to all participants. The total fluoroscopy time and contrast distribution levels were recorded. Pre- and post-treatment VAS scores were similar between the groups. The ODI scores increased in favor of the PS group at week 2 (P < 0.041); however, there was no difference between the two groups at other times. The VAS and ODI scores improved significantly with treatment in both the groups (P < 0.001). Total fluoroscopy time was shorter in the PS group (P < 0.001). PS application was more comfortable (P < 0.001). While no complications were observed in the PS group, three complications occurred in the TF group. Anterior epidural contrast spread to three or more levels was observed in 57% of the participants in the PS group, whereas no spread to more than two levels was observed in the TF group. The PS epidural approach is superior to the TF approach in terms of a low incidence of side effects, less radiation exposure, better patient comfort, higher epidural contrast spread, and single-level needle access.

Safety outcomes and improvement in pain scores after radiologist-performed fluoroscopy-guided interlaminar cervical epidural steroid injection.

Image-guided spine injections are an important tool in the management of patients with a variety of spinal pathologies. Our practice offers radiologist-performed fluoroscopy-guided interlaminar cervical epidural steroid injection (ESI) routinely performed in the outpatient setting. The purpose of this study was to evaluate clinical outcomes and improvement in pain scores after radiologist-performed cervical ESI. An institutional database was used to retrospectively identify cervical injections performed between October 2016 and October 2022. All injections were performed at the C7-T1 level utilizing 1.0mL of 10mg/mL dexamethasone without epidural anesthetic. The Numerical Rating Scale (NRS) was used to assess pain improvement. Cervical MRI was reviewed to assess pre-injection cervical disease severity. Patient charts were reviewed for any post-injection complications. A total of 251 cervical injections in 186 patients met our inclusion criteria with mean clinical follow up of 28.5months (range 0.2 - 73.0months). No patients experienced any major complications after injection. Post-injection pain scores were available for 218 of 251 injections (86.9%) with mean follow-up of 11.8days (range 6 - 57days). There was a significant improvement in pain scores from a mean pre-injection NRS score of 5.2/10 to 3.0/10 (p < .0001). 117 patients (53.7%) reported ≥ 50% improvement after injection. Patients who had prior injection were more likely to report ≥ 50% pain improvement after subsequent injection (p = .012). Radiologist-performed fluoroscopy-guided interlaminar cervical ESI at the C7-T1 level is a safe and effective tool in the management of patients with cervical pathology.

Comparing the Effectiveness of Hands-on vs. Observational Training of Residents in Interlaminar Epidural Steroid Injections (ILESI) Using a High-Fidelity Spine Simulator.

Introduction The Accreditation Council for Graduate Medical Education (ACGME) requires that residents in the Physical Medicine and Rehabilitation (PM&R) residency observe or perform certain interventional procedures, one of which is an interlaminar epidural steroid injection(ILESI). While the traditional learning model relying heavily on observation is commonplace, it leaves the practice phase of learning to happen on real patients. High-fidelity simulation may be a worthwhile alternative as a training approach to increase physician comfort with the procedure and improve patient safety. Methods Current PM&R residents from two programs between their second and fourth year, inclusively, who lacked prior training experience in ILESI attended one hour of either: (1) an experimental arm of supervised hands-on training on a simulation deviceor (2) a control arm observing the procedures performed by an attending on the same device. Assignments were made based on resident schedule availability. Pre-training knowledge, training, and post-training knowledge were assessed at the Multidisciplinary Pain Clinic at Montefiore Medical Center. Participants were assessed on their procedural competence using an adapted version of a previously published grading checklist before the session. Participants also evaluated their confidence in performing the procedure prior to and after training. Data was analyzed using the Wilcoxon signed-rank test and the Wilcoxon rank-sum test. SAS Version 9.4 was used for analysis. Results Fifteen residents initially participated, but three residents dropped out at the 15-week follow-up. There was a significant increase in test scores in both arms immediately after the intervention (p=0.008 in control, p=0.016 in the experiment), with greater improvement shown in the hands-on training group (p=0.063). At the 15-week follow-up, there was no significant change in test scores in the control arm (p=0.969) while there was a decrease in the experiment arm (p<0.001). Conclusion Hands-on learning with high-fidelity simulation demonstrated more improvement for short-term motor-skill acquisition, while observational learning with repetition showed more benefits for long-term retention. Optimal procedural training should employ both educational modalities for best short- and long-term results.

An update on technical and safety practice patterns of interlaminar epidural steroid injections

IntroductionInterlaminar epidural steroid injections (ILESIs) are mainstay in the management of low back, neck and radicular pain and are a commonly performed pain management procedure in the United States. Our survey aims to provide an update in practice patterns of ILESIs among interventional pain physicians. MethodsWe distributed a 91-item survey nationwide to private and academic interventional pain physicians who perform epidural steroid injections (ESIs). The survey was distributed via REDCap with a series of questions inquiring about current practices in epidural steroid injections from March 2021 to March 2022. Cross sectional data from survey responses specific to ILESI-related practices were captured and synthesized. ResultsOf 103 complete survey responses, 96 physicians perform ILESIs (cervical, 87.5 %; thoracic, 82.3 %; lumbar 99 %). Nearly all surveyed physicians utilize fluoroscopy (98.1 %) over other modalities like MRI and ultrasound. For CIESIs, dexamethasone was the preferred steroid (52.4 %) over methylprednisolone (23.7 %); the converse was true for LIESIs in which methylprednisolone (44.2 %) was preferred over dexamethasone (32.6 %). The majority of providers performing ILESI's (91.7 %) preferred a Tuohy/Weiss needle while only a small fraction preferred the Quincke needle (7.2 %). Sedation practices were more varied with only about half of providers (47.6 %) offering medications. Furthermore, a great fraction of providers continue to use contrast for LIESIs (97.9 %) and CIESIs (89.6 %). DiscussionOur survey suggests that despite updated consensus recommendations, variability continues to exist in procedural practice patterns. Highlighting areas of variable adherence to current safety guidelines can assist with what is emphasized in the generation of future evidence-based guidelines. Though our survey was conducted in the context of the COVID-19 pandemic with resultant supply chain shortages, more research is needed to elucidate what variables may factor into why proceduralists may stray from guideline concordant care.

Epidural hematoma risks associated with ceasing vs maintaining anticoagulant and/or antiplatelet medications for cervical and thoracic interlaminar epidural steroid injections

BackgroundThere is a lack of substantiated evidence to support or refute the risks of ceasing vs maintaining anticoagulant and/or antiplatelet medications (ACAP) prior to cervical and thoracic interlaminar epidural steroid injections. The ACAP medication is frequently stopped pre-procedure due to concerns for potential bleeding complications, particularly epidural hematomas (EH). This article provides evidence regarding EH incidence in this population. MethodsData for this study was collected retrospectively on all patients from September 19, 2009–Jun 16, 2017 who were scheduled for an Interlaminar Cervical and/or Thoracic Epidural Steroid Injections (IL-CTESI) and were on an ACAP medication at the time a procedure was scheduled. All possible adverse outcomes were then retrospectively analyzed via extensive data mining of the electronic medical record system with special emphasis on EHs. Results591 IL-CTESI were performed on patients taking ACAP medications. In total, 351 patients ceased their ACAP medication prior to the procedure and 240 maintained ACAP medication. Our findings demonstrate that there were no clinically relevant incidents of EHs in either cohort. ConclusionsThis data gives critical insight into the post-procedural EH risk for patients who had continued or stopped taking their ACAP medications prior to their IL-CTESI. The results from this study suggest re-evaluating the potential post-procedural EH risks associated with continuing vs ceasing these medications.

Association between fatty infiltration in the cervical multifidus and treatment response following cervical interlaminar epidural steroid injection.

Recent attention has been directed towards fatty infiltration in the cervical extensor muscles for predicting clinical outcomes in several cervical disorders. This study aimed to investigate the potential association between fatty infiltration in the cervical multifidus and treatment response following cervical interlaminar epidural steroid injection (CIESI) in patients with cervical radicular pain. The data of patients with cervical radicular pain who received CIESIs between March 2021 and June 2022 were reviewed. A responder was defined as a patient with a numerical rating scale decrease of ≥ 50% from the baseline to three months after the procedure. The presence of fatty infiltration in the cervical multifidus was assessed, along with patient characteristics, and cervical spine disease severity. To assess cervical sarcopenia, fatty infiltration in the bilateral multifidus muscles was evaluated at the C5-C6 level using the Goutallier classification. Among 275 included patients, 113 (41.1%) and 162 (58.9%) were classified as non-responders and responders, respectively. The age, severity of disc degeneration, and grade of cervical multifidus fatty degeneration were significantly lower in responders. Multivariate logistic regression analysis revealed that pre-procedural symptoms (radicular pain with neck pain, odd ratio [OR] = 0.527, P = 0.024) and high-grade cervical multifidus fatty degeneration (Goutallier grade 2.5-4, OR = 0.320, P = 0.005) were significantly associated with an unsuccessful response to CIESI. These results suggest high-grade cervical multifidus fatty infiltration is an independent predictor of poor response to CIESI in patients with cervical radicular pain.

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

Transforaminal versus interlaminar CT-guided lumbar epidural steroid injections: prospective study of 237 patients with unilateral radicular pain and up to 5years of follow-up.

To compare the efficacy of the transforaminal approach (TFA) versus the interlaminar approach (ILA) for CT-guided epidural steroid injection (CTESI) in the treatment of persistent lumbosacral radicular pain (LRP > 6weeks) with long-term follow-up. Patients were prospectively assessed for pain by visual analogue scale (VAS) and functional disability (Oswestry Disability Index, (ODI)) before treatment, then 6weeks (6W), 6months (6M), and 5years (5Y) after CTESI. Overall, n = 237 patients (TFA, n = 71 and ILA, n = 166) were included, and 96 patients had 5years of follow-up. Both groups showed a statistically significant improvement in VAS and ODI values at 6W (TFA, n = 60 and ILA, n = 146, P < 0.001 for both), at 6M (TFA, n = 34 and ILA, n = 96, P < 0.001 for both), and at 5Y (TFA, n = 32 and ILA, n = 64, P < 0.001 for both). No significant differences were observed between the two approaches in VAS or ODI decreases at 6W (P = 0.38 and P = 0.33 respectively), 6M (P = 0.13 and P = 0.51 respectively), or 5Y (P = 0.15 and P = 0.57 respectively). No major complications were noted. Outcomes after CTESI by ILA approaches are similar to those by TFA for the treatment of persistent LRP.