Interlaminar Group Research Articles

EFFICACY OF FULL-ENDOSCOPIC INTERLAMINAR AND TRANSFORAMINAL DISCECTOMY FOR LUMBER DISC HERNIATION.

To evaluate the clinical efficacy of full-endoscopic interlaminar and transforaminal lumbar discectomy to treat LDH. A total of 93 patients with LDH who underwent fully-endoscopic lumbar interlaminar/transforaminal discectomy were retrospectively collected. Patients were divided into a Transforaminal group (n=41) and an Interlaminar group (n=52). Clinical efficacy was evaluated by visual analogue scale (VAS), the Oswestry disability index (ODI), and the modified MacNab scoring system. Of the 93 patients, involving segments in LDH referred to L3-4, L4-5, and L5-S1. The fluoroscopy times in the Interlaminar group were smaller than that of the Transforaminal group. We found no obvious significances between the Transforaminal and Interlaminar groups regarding operation time, incision length, postoperative landing time, hospitalization, and incision healing time. Postoperative VAS and ODI scores notably improved at follow-up. Besides, almost 90% LDH patients achieved excellent/good outcomes. The full-endoscopic visualization technique via interlaminar and transforaminal approaches safely and effectively treat LDH. Level of Evidence III, Retrospective Study.

Retrospective analysis of cervical transforaminal versus interlaminar epidural steroid injections

BackgroundSeveral studies have compared outcomes from lumbar epidural steroid injections (ESIs) based upon technique (transforaminal (TF) vs interlaminar (IL) vs caudal). However, little on this topic has been reported in the cervical spine, and results have been conflicting. PurposeTo compare success rates of fluoroscopically-guided cervical TFESIs vs ILESIs. Study design/settingRetrospective, observational, in vivo study of consecutive patients at outpatient Physical Medicine & Rehabilitation clinics at a single academic spine center. Patient sampleConsecutive patients who received a cervical TF or IL ESI between January 2010 and October 2018. Outcome measuresNRS pain scores within 60 days of the ESI. MethodsCurrent procedural terminology (CPT) codes were used to search all consecutive patients at a single outpatient academic spine center who received a cervical TF or IL ESI between January 2010 October 2018. All patients with pre and post injection NRS pain scores within 60 days of the injection were included in the analysis. ResultsA total of 178 ​TF and 185 ILESIs were analyzed. Success was defined as ≥ 50% improvement in NRS pain score. 52% [95% CI: 47 – 57%] of all patients receiving a cervical ESI achieved a successful outcome. There was a strong trend towards better results in the ILESI group with 59% [95% CI: 52 – 66%] of patients achieving at least 50% pain relief compared to 46% [95% CI: 39 – 53%] in the TF group. A higher proportion of patients in the IL group obtained at least 80% pain relief (37% [95% CI: 30 – 44%]) compared to those in the TF group (17% [95% CI: 11 – 23%]). Post-procedure median NRS pain scores, and improvement in median NRS pain scores were better in the ILESI group compared to the TFESI group (p<0.001). ConclusionThis retrospective study demonstrated better results in the cervical ILESI group compared to the cervical TFESI group.

Lumbar discectomy in post epidural steroid treated patients for disc prolapse

Aim: In spine surgery, it is common practice to thoroughly exhaust all conservative measures before surgery. With the increasing popularity of injection procedures, significant number may still require surgery post epidural steroid infiltration (ESI). We aim to study the incidence of such patients who eventually go in for surgery after a failed ESI. We also studied and compared the functional outcomes of transforaminal (TF) versus interlaminar (IL) procedures in intervertebral disc prolapse (IVDP) patients. Materials and Methods: 150 patients with lumbar disc prolapsed were subjected to epidural steroid infiltration after 6 weeks of failed conservative management, of which 101 underwent IL and 49 TF procedure according to surgeon's preference, and followed up for 6 weeks. Those with persisting (or worsening) Visual analogue scale (VAS), Modified Oswestry diability index (ODI) and with progressive neurological deficits, underwent lumbar discectomy and all were followed up for 6 months.Results: Out of 150 patients, 45 patients underwent discectomy (30 %) after total 6 months follow up, and out of the remaining 105 patients, 40 (81.6%) from TF group and 65 (64.4%) from IL group improved. In total, 62% of females went to surgery, Minimal disability in ODI score was seen in 77.8% in surgery group and 98.1% in epidural group at final follow up.Conclusion: Our study observed a much smaller crossover rate (30%) to surgery, and a significant difference in outcomes of the two injection methods and concludes that TF is a better procedure than IL.

Comparison of post-operative wound pain between interlaminar and transforaminal endoscopic spine surgery: which is superior?

Prospective cohort study PURPOSE: The objective is to compare post-operative wound pain in patients treated by endoscopic surgery between interlaminar and transforaminal approach at lumbar region. There are two common approaches for endoscopic lumbar spine surgery, interlaminar and transforaminal approach. The wound size of these two approaches is about the same. However, post-operative wound pain may differ according to the entrance area. We conducted a prospectively cohort study including all patients underwent full endoscopic lumbar spine surgery by single surgeon between January 2016 to October 2019. Wound pain using visual analog scale (VAS) at post-operative day 1 and day 14 were collected. VAS back pain, VAS leg pain, Oswestry Disability Index (ODI), modified McNab criteria and complications were also collected. There were 313 patients included in the study. There was no significant difference in VAS wound pain between interlaminar and transforaminal group. Interestingly, subgroup analysis in interlaminar group found statistically significant higher VAS for wound pain at post-operative day 1 when significant bone resection was done by power burr. VAS back-leg pain and ODI have improved significantly between pre-operative and last follow up in both approaches. Wound pain from endoscopic spine surgery is minimal. This study found no difference in wound pain between endoscopic interlaminar and transforaminal approach. Both approaches show favorable clinical outcomes with few serious complications rate. Further study with long term follow up is needed.

Comparative Effectiveness of Parasagittal Interlaminar and Transforaminal Cervical Epidural Steroid Injection in Patients with Cervical Radicular Pain: A Randomized Clinical Trial

Cervical epidural steroid injections (ESI) are performed either by interlaminar (IL) or transforaminal (TF) approaches; however, there is controversy over which is better for safety and efficacy. This clinical trial aimed to compare the effectiveness of the parasagittal IL and TF approaches for cervical ESI in patients who were suffering from cervical radicular pain. A prospective randomized assessor-blind study. The study took place at a single pain clinic within a tertiary medical center in Seoul, Republic of Korea. This prospective randomized, assessor-blind trial included 80 patients with cervical radicular pain. We randomly assigned patients to the TF or parasagittal IL approach for cervical ESI. The effectiveness of the 2 groups was compared based on pain intensity using the Numeric Rating Scale (NRS-11) at 1 and 3 months. The Neck Disability Index (NDI), Medication Quantification Scale (MQS), and responders at 1 and 3 months between the 2 groups were compared. The pain intensity of both groups significantly reduced after 1 and 3 months after each procedure (P < 0.001). Two-way repeated measures of analysis of variance showed no significant interaction between group and time for cervical radicular pain (P = 0.266), although NRS-11 pain score was lower in the TF group than the parasagittal IL group after 1 month (P = 0.010). NDI, MQS, and successful responders were not different between the 2 groups at 1 and 3 months after the procedure. We observed 7 cases (18.4%) of vascular visualization in the TF group, although no serious complications were found in either group. This study had no placebo control group and limited follow-up time. Parasagittal IL ESI may be recommended over the TF ESI in reducing cervical radicular pain, considering both clinical effectiveness and safety.

Learning Curve and Early Results of Interlaminar and Transforaminal Full-Endoscopic Resection of Lumbar Disc Herniations.

BackgroundFull-endoscopic spinal surgery is an evolving technique. A laborious learning phase is inevitable due to the complexity of the orientation and instrumentation. The goal of the present study is to evaluate a single surgeon’s learning curve and early outcomes in full-endoscopic resection of lumbar disc herniations.MethodsThis was a prospective non-controlled single-surgeon cohort study. In 54 patients with 57 herniations, 41 interlaminar and 16 transforaminal resections were performed. Surgery time, severity of adhesive process in the spinal canal, complication rates and clinical outcomes (VAS, ODI, custom questionnaire, recurrence and re-operation rate) were assessed.ResultsIn the interlaminar group, operative time has decreased from 60 ± 20 min in the first 20 operations to 45 ± 14 min in the following 17 (p=0.023). In the transforaminal group, operative time has decreased from 60 ± 16 min in the first 7 operations to 41 ± 12 min in following 9 (p=0.023). Severe adhesive process in spinal canal was associated with duration of symptoms greater than 2 years, longer surgery and higher risk of surgical complications. Four recurrent disc herniations were re-operated using full-endoscopic technique. VAS, ODI and pain medications significantly decreased in both groups and in re-operated patients.ConclusionThe plateau of the learning curve and good short-term clinical results of full-endoscopic interlaminar and transforaminal surgery may be achieved after twenty operations, given extensive previous experience in microsurgery. Risk of complications at the learning phase may be decreased by excluding the patients with symptoms lasting over two years.

Comparative study between transforaminal epidural selective nerve root block versus interlaminar epidural in the treatment of lumbar radicular leg pain

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Sciatic neuralgia is a result of nerve root oedema because of the inflammatory, immunological and mechanical factors. Steroid injections play an important role in the management of sciatic radiculopathy. Steroids act by reducing the oedema around the nerve roots and decreasing pain. Locally administered steroids have the advantage of reduced dosage and targeted delivery around the nerve roots. This forms the basis of epidural steroid injections. This can be given around the nerve root in the transforaminal space or in the interlaminar space. There is a paucity of literature comparing the two techniques of epidural steroid injections. We have done a randomized comparative trial, to compare the effectiveness of the two modalities of injection in the management of a single level unilateral foraminal disc herniation.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Patients were randomized in two groups Group A: Transforaminal epidural (SNRB) and Group B: interlaminar epidural. Same dose of steroid was used in each group.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Immediate post injection, 2 week and 1 month transforaminal epidural (SNRB) was better compare to interlaminar epidural however at the end of 3 months the difference was not significant (p=0.08).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Both transforaminal and interlaminar epidural injection are effective form of treatment in mild to moderate grade of disc disease. Both the technique provide short lasting relief in the symptoms associated with disc pathology, however pain management is better in transforaminal group compared to interlaminar group. Thus these techniques can be considered for delaying surgery and providing intermitant relief. &lt;/p&gt;

Decompression of lumbar canal stenosis with a bilateral interlaminar versus classic laminectomy technique: a prospective randomized study.

OBJECTIVEThe aim of this study was to compare the radiological and clinical results of bilateral interlaminar canal decompression and classic laminectomy in lumbar canal stenosis (LCS).METHODSTwo hundred eighteen patients with LCS were randomized to surgical treatment with classic laminectomy (group 1) or bilateral interlaminar canal decompression (group 2). Low-back and leg pain were evaluated according to the visual analog scale (VAS) both preoperatively and postoperatively. Disability was evaluated according to the Oswestry Disability Index (ODI) preoperatively and at 1 month, 1 year, and 3 years postoperatively. Neurogenic claudication was evaluated using the Zurich Claudication Questionnaire (ZCQ) preoperatively and 1 year postoperatively. The two treatment groups were compared in terms of neurogenic claudication, estimated blood loss (EBL), and intra- and postoperative complications.RESULTSPostoperative low-back and leg pain declined as compared to the preoperative pain. Both groups had significant improvement in VAS, ODI, and ZCQ scores, and the improvements in ODI and back pain VAS scores were significantly better in group 2. The average EBL was 140 ml in group 2 compared to 260 ml in group 1. Nine patients in the laminectomy group developed postoperative instability requiring fusion compared to only 4 cases in the interlaminar group (p = 0.15). Complications frequency did not show any statistical significance between the two groups.CONCLUSIONSBilateral interlaminar decompression is an effective method that provides sufficient canal decompression with decreased instability in cases of LCS and increases patient comfort in the postoperative period.

Radiation Exposure during Percutaneous Endoscopic Lumbar Discectomy: Interlaminar versus Transforaminal

Objective Percutaneous endoscopic lumbar discectomy (PELD) relies heavily on fluoroscopy guidance; therefore, medical staff exposure to radiation has become an important issue. The purpose of this study was to determine the radiation dose and the amount of time to which the surgeons are exposed during PELD and to compare both parameters in the transforaminal (TF) and interlaminar (IL) approaches. Although they are considerably different, they may be wrongly considered together. Methods A retrospective evaluation of the last 20 PELD performed by the authors is presented. Patients were distributed in 2 groups. Six (1F, 5M) patients were submitted to IL-PELD and 14 (6F, 8M) to TF-PELD. Fluoroscopy reports were obtained from patients' records, all performed with the same C-Arm device and software mode. Groups were compared using unpaired t-test. Results The IL group showed an average radiation exposure of 8.37 ± 4.21 mGy and duration of 11.1 ± 5.45 seconds, while the TF group showed an average radiation exposure of 28.92 ± 7.56 mGy and duration of 42 ± 16.64 seconds. The p-value for radiation was 0.0000036, and for time it was 0.00027. Conclusions Interlaminar PELD requires a lower radiation dose and a shorter amount of exposure than TF-PELD. Studies that concern radiation required for minimally-invasive spine surgeries should consider the PELD approaches separately.

Inyección epidural de betametasona en el síndrome radicular lumbosacro: evaluación de su eficacia por abordajes interlaminar y transforaminal

espanolRESUMEN Introduccion: La betametasona es un esteroide utilizado en las inyecciones epidurales, de reciente incorporacion en Uruguay. Objetivos: Evaluar la eficacia de la inyeccion epidural de betametasona administrada por los abordajes interlaminar parasagital y transforaminal en pacientes con dolor radicular lumbosacro unilateral cronico, utilizando el Inventario Abreviado de Dolor. Material y metodo: Estudio prospectivo aleatorizado que compara la administracion de betametasona por ambos accesos, interlaminar parasagital y transforaminal. El IAD se aplico previamente y al mes de las inyecciones epidurales. La intensidad del dolor se midio por la Escala Visual Numerica (EVN) obtenida de la pregunta 6 del IAD y el Indice de Intensidad. Tambien se midio la interferencia funcional producida por el dolor mediante el Indice de Interferencia. Se establecio como respuesta satisfactoria un descenso de 2 puntos en la EVN basal al mes de los procedimientos, definiendo a estos pacientes como respondedores. Se utilizo la prueba t de Student y de Chi cuadrado para el analisis estadistico, tomando un valor de p EnglishABSTRACT Introduction: Betamethasone is a frequently used steroid for epidural injection, recently incorporated in the Uruguayan pharmaceutical market. Aims: The aim of this study is to evaluate the efficacy of parasagittal interlaminar and transforaminal epidural betamethasone in unilateral lumbosacral radicular syndrome, utilizing the Brief Pain Inventory (BPI). Material and method: Is a prospective study comparing parasagittal interlaminar and transforaminal epidural betamethasone. Patients with chronic unilateral lumbosacral radicular pain were included. The BPI was administered before and one month after epidural injections. Pain intensity was measured by the Visual Numeric Scale (VNS, question 6 of the BPI) and the Intensity Score. Interference of pain in daily activities was measured by the Interference Score. Satisfactory responses to injections were considered with a 2 points reduction in VNS. The statistical evaluation was performed by paired an unpaired T test to continuous data and Chi Square to evaluate proportions. A p value less than 0.05 was considered statistically significant. Results: Fifty four patients were treated with epidural betamethasone. In 29 the parasagittal interlaminar route was utilized while 25 were treated by the transforaminal route. A 20 % reduction in baseline VNS was observed with the interlaminar route and 36 % reduction with transforaminal approach. Intensity and Interference Scores were also reduced. This reductions were statistically significant when comparing to baseline data (paired t test) but differences between groups were not significant (unpaired t test). However the number of positive responses as defined above was greater in the transforaminal group, 64 % versus 38 % in the interlaminar group, statistically significant difference using the Chi Square analysis (p=0.01). In patients with positive responses, interlaminar and transforaminal betamethasone produce clinical and statistically significant reductions in pain intensity and interference, without difference between groups. Conclusion: Epidural betamethasone produced a reduction in pain intensity and interference utilizing the BPI, by the two routes utilized to access the epidural space. Although no statistically differences were observed in this reductions between groups, the frequency of positive responses were higher when the drug is administered by the transforaminal route. Epidural interlaminar parasagittal betamethasone injection is a reasonable alternative to the transforaminal route, without the neurologic complications described utilizing this technique.

Outcomes of discectomy by using full-endoscopic visualization technique via the interlaminar and transforaminal approaches in the treatment of L5-S1 disc herniation: An observational study.

The purpose of this retrospective study was to assess the clinical outcomes of discectomy by using full-endoscopic visualization technique via the interlaminar approach versus the transforaminal approach under general anesthesia in the treatment of L5-S1 disc herniation.Sixty patients with L5-S1 disc herniation were non-randomly recruited and assigned into two groups. One group (thirty patients) underwent discectomy by using full-endoscopic visualization technique via the interlaminar approach under general anesthesia, while the other group (thirty patients) underwent discectomy by using full-endoscopic visualization technique via the transforaminal approach under general anesthesia. The operative time, fluoroscopy time, and perioperative complications were recorded. The visual analog scale (VAS) score for leg and back pain and Oswestry disability index (ODI) score were evaluated preoperatively and at 3, 6, and 18 months postoperatively.The mean operative time and fluoroscopy time in the interlaminar group were significantly shorter compared with those in the transforaminal group. The mean VAS and ODI postoperative scores were significantly improved over the preoperative scores in both groups. According to the MacNab classification system, more than 90.0% of the patients achieved an excellence/good rating in both groups. An intraoperative epineurium injury occurred in both groups. The total recurrence rate during 18 months follow-up was 3.3% in the interlaminar group and 0% in the transforaminal group.It is efficient and safe to perform discectomy by using full-endoscopic visualization technique via both interlaminar and transforaminal approaches under general anesthesia in patients with L5-S1 disc herniation. Discectomy performed by using full-endoscopic visualization technique via the interlaminar approach requires a shorter operative time and suffers less radiation exposure than the transforaminal approach.

Debridement and Internal Fixation from a Single Posterior Approach for the Treatment of Lumbosacral Tuberculosis

To evaluate the application and therapeutic effects of debridement from a single posterior approach for bone grafting and internal fixation treatment of lumbosacral tuberculosis. From January 2010 to December 2016, 96 patients with lumbosacral tuberculosis were treated by single posterior debridement and internal fixation with bone graft. Among these patients, there were 9 cases involving the L3-L4 segment, 57 involving L4-L5, and 30 involving L5-S1. Interlaminar debridement was applied in 60 cases and transforaminal debridement was applied in 36 cases. Evaluation of therapeutic effects included the Prolo scale and visual analogue scale. The kyphotic angle and height loss of the vertebral body in the affected region of the lumbosacral segment were measured radiologically. All patients were followed up for 12-24 months. In the interlaminar group, the mean preoperative, postoperative, and final kyphotic angles were-24.1 ± 5.5°,-34.6 ± 5.6°, and-32.1 ± 5.1°, respectively. In contrast, those in the transforaminal group were-25.1 ± 5.9°,-35.0 ± 6.6°, and-33.3 ± 5.9°, respectively. There was significant improvement of the postoperative angle compared with the preoperative angle. The result of the modified Prolo scale was 93.8%. According to the visual analogue scale, the preoperative and postoperative scales were 7.8 and 2.7, indicating a significant alleviation of pain. Debridement from single posterior approach is an effective technique for the internal fixation of lumbosacral regional spinal tuberculosis. An appropriate selection of indications, careful evaluation of radiology, and thorough debridement were the key to a successful operation.

Advantages of a Microsurgical Translaminar Approach (Keyhole Laminotomy) for Upper Lumbar Disc Herniation

To prevent risk of iatrogenic instability after surgery for upper lumbar disc herniation, we adapted a microsurgical translaminar approach (keyhole laminotomy), which allows less destructive laminotomy. We compared results of translaminar and interlaminar approaches. The study enrolled 48 patients who underwent single-level discectomy in the upper lumbar spine (L1-2 or L2-3). Patients were allocated to 2 groups: a translaminar group (n= 20) or an interlaminar group (n= 28). Mean patient age was 57.04 ± 12.77 years, and median follow-up duration was 3.5 years (range, 1.0-7.0 years). Clinical and radiologic data were retrospectively reviewed. Baseline characteristics, including age, sex, surgical level, and preoperative symptoms, were nonsignificantly different. At 1 year after surgery, improvement in leg pain as determined by visual analog scale was nonsignificantly different. Improvement in visual analog scale for back pain was significantly greater in the translaminar group compared with interlaminar group (mean 4.00 ± 1.56 vs. 2.45 ± 2.01, P < 0.001). Surgical outcome was not different between groups. Mean decrease in disc height at operated level was not significantly different between groups. Mean increase in segmental range of motion at surgical levels was significantly greater in the interlaminar group (-3.38 ± 4.03° vs. 1.10 ± 3.03°, P= 0.010), and mean recovery of total lumbar lordosis was significantly greater in the translaminar group (9.80 ± 5.96° vs. 0.43 ± 8.45°, P= 0.021). The translaminar approach provides a safe and effective alternative to the classic interlaminar approach for upper lumbar disc herniation.

Comparison of the efficacy of caudal, interlaminar, and transforaminal epidural injections in managing lumbar disc herniation: is one method superior to the other?

BackgroundEpidural injections are performed utilizing 3 approaches in the lumbar spine: caudal, interlaminar, and transforaminal. The literature on the efficacy of epidural injections has been sporadic. There are few high-quality randomized trials performed under fluoroscopy in managing disc herniation that have a long-term follow-up and appropriate outcome parameters. There is also a lack of literature comparing the efficacy of these 3 approaches.MethodsThis manuscript analyzes data from 3 randomized controlled trials that assessed a total of 360 patients with lumbar disc herniation. There were 120 patients per trial either receiving local anesthetic alone (60 patients) or local anesthetic with steroids (60 patients).ResultsAnalysis showed similar efficacy for caudal, interlaminar, and transforaminal approaches in managing chronic pain and disability from disc herniation. The analysis of caudal epidural injections showed the potential superiority of steroids compared with local anesthetic alone a 2-year follow-up, based on the average relief per procedure. In the interlaminar group, results were somewhat superior for pain relief in the steroid group at 6 months and functional status at 12 months. Interlaminar epidurals provided improvement in a significantly higher proportion of patients. The proportion of patients nonresponsive to initial injections was also lower in the group for local anesthetic with steroid in the interlaminar trial.ConclusionsThe results of this assessment show significant improvement in patients suffering from chronic lumbar disc herniation with 3 lumbar epidural approaches with local anesthetic alone, or using steroids with long-term follow-up of up to 2 years, in a contemporary interventional pain management setting.

Analysis of efficacy differences between caudal and lumbar interlaminar epidural injections in chronic lumbar axial discogenic pain: local anesthetic alone vs. local combined with steroids.

Study Design: Comparative assessment of randomized controlled trials of caudal and lumbar interlaminar epidural injections in chronic lumbar discogenic pain.Objective: To assess the comparative efficacy of caudal and lumbar interlaminar approaches of epidural injections in managing axial or discogenic low back pain.Summary of Background Data: Epidural injections are commonly performed utilizing either a caudal or lumbar interlaminar approach to treat chronic lumbar axial or discogenic pain, which is pain exclusive of that associated with a herniated intervertebral disc, or that is due to degeneration of the zygapophyseal joints, or due to dysfunction of the sacroiliac joints, respectively. The literature on the efficacy of epidural injections in managing chronic axial lumbar pain of presumed discogenic origin is limited.Methods: The present analysis is based on 2 randomized controlled trials of chronic axial low back pain not caused by disc herniation, radiculitis, or facet joint pain, utilizing either a caudal or lumbar interlaminar approach, with a total of 240 patients studied, and a 24-month follow-up. Patients were assigned to receive either local anesthetic only or local anesthetic with a steroid in each 60 patient group.Results: The primary outcome measure was significant improvement, defined as pain relief and functional status improvement of at least 50% from baseline, which was reported at 24-month follow-ups in 72% who received local anesthetic only with a lumbar interlaminar approach and 54% who received local anesthetic only with a caudal approach. In patients receiving local anesthetic with a steroid, the response rate was 67% for those who had a lumbar interlaminar approach and 68% for those who had a caudal approach at 12 months. The response was significantly better in the lumbar interlaminar group who received local anesthetic only, 77% versus 56% at 12 months and 72% versus 54% at 24 months.Conclusion: This assessment shows that in patients with axial or discogenic pain in the lumbar spine after excluding facet joint and SI Joint pain, epidural injections of local anesthetic by the caudal or lumbar interlaminar approach may be effective in managing chronic low back pain with a potential superiority for a lumbar interlaminar approach over a caudal approach.

Epidural steroid injection in patients with lumbosacral radiculopathy in Abuja, Nigeria

Objective:This prospective-controlled observational study looked at well-matched patients with spinal pain and radicular symptoms, caused by lumbar intervertebral disc herniation to compare the short-term clinical outcome of transforaminal and interlaminar epidural steroid injection (ESI) in a resource challenged tertiary institution in Nigeria.Materials and Methods:49 patients with radicular symptoms who were matched for age, symptom duration, magnetic resonance imaging findings, and pre-injection revised Oswentry Disability Index (ODI) score and Visual Analogue Scale (VAS) were assigned into ESI technique. The ODI and VAS score were analyzed immediately after an injection and upon follow-up (average 178.5 days), also with the need for repeated injections and surgical interventions over a 1-year follow-up interval.Result:In the transforaminal group (25 patients), there was a statistically significant improvement in the ODI scores from before the injection (ODI mean 62.4) to immediately after the injection (ODI mean 24.4, P < 0.01), and upon follow-up (ODI mean 20.8, P < 0.01). 9 patients (18.4%) required 1 or 2 repeated injections, 3 (6.1%) patients underwent surgery and 2 (4%) patients lost to follow-up. In the interlaminar group (24 patients), there was a statistically significant improvement in the ODI scores from before the injection (ODI mean 60.7) to immediately after the injection (ODI mean 30.1, P < 0.01), but not upon follow-up (ODI mean 43.2, P = 0.09). 11 (22.4%) patients required 1 or 2 repeated injection, 4 (8%) patients underwent surgery and 3 (6.1%) patients were lost to follow-up. There is an average of 2 fold improvement of transforaminal ESI over interlaminar ESI in a 40 point scale of ODI score on follow-up, which was statistically significant (P < 0.01). The VAS showed similar pattern with the ODI scores in the study.Conclusion:Transforaminal ESI to treat symptomatic lumbar disc herniation resulted in better short-term pain improvement and fewer long-term surgical interventions compared to interlaminar ESI.

Interlaminar Versus Transforaminal Epidural Steroids for the Treatment of Subacute Lumbar Radicular Pain: A Randomized, Blinded, Prospective Outcome Study

Background: There is uncertainty in the literature over the relative effectiveness of lumbar epidural interlaminar (IL) steroid injection versus transforaminal (TF) steroid injection for lumbar radiculopathy. Most studies to date have been retrospective, or technically focused. Objective: To complete a randomized, blinded, prospective outcome study of the short-term benefit for IL versus TF epidural steroids for the treatment of subacute lumbar radicular pain. Study design: Prospective, randomized, blinded, subacute efficacy trial. Setting: Tertiary care pain management center, major metropolitan city, United States Methods: After institutional review board approval, 42 age-matched patients with similar lower back pain and unilateral radicular symptoms were enrolled and randomized in a patient and evaluating physician blinded trial to IL or TF epidural steroids from 2007 through 2009. Prior to intervention and 10-16 days after injection, each participant was evaluated by questionnaire and physical exam by an independent physician. All injections were performed by the same physician. Thirty-eight participants completed the study, 18 in the IL group and 20 in the TF group. Four participants required a repeat injection, and 2 participants crossed over to the alternative injection type (IL to TF). Results: Overall, physical exam, diagnostic testing, disability, activity, depression measures, and opioid pill use were similar between the 2 groups, both pre-injection baseline and postinjection improvement. In primary outcomes, the post-injection follow-up Numeric Rating Scale (NRS) was more greatly reduced in the TF group. The NRS decreased from 7.0 ± 1.9 to 3.9 ± 3.1 (mean values +/- standard deviation) in the IL group and 6.4 ± 2.1 to 1.7 ± 1.4 in the TF group. The Oswestry Disability Index was reduced from 37.5 ± 12.6 to 19.0 ± 16.7 in the IL group and 38.3 ± 6.4 to 21.6 ± 16.8 in the TF group. In secondary outcomes, the depression scale was reduced from 4.39 ± 3.22 to 2.28 ± 3.20 in the IL group and 4.10 ± 1.94 to 1.65 ± 1.63 in the TF group. Walking tolerance was increased from 8.1 ± 4.6 blocks to 10.6 ± 4.4 in the IL group and 8.9 ± 5.3 blocks to 11.8 ± 4.2 in the TF group. Limitations: The study did not examine long-term outcomes. A single experienced interventionalist performed all injections. Conclusion: Results suggest that patients may experience greater subjective relief, at least initially, from TF epidural steroid injections over IL. However, more objective, and likely subacute, therapeutic effects are similar. Key words: epidural, steroids, interlaminar, transforaminal, lumbar, lumbosacral, radicular, low back pain

Interlaminar versus Transforaminal Epidural Steroid Injections for the Treatment of Symptomatic Lumbar Spinal Stenosis

Lumbar spinal stenosis is a common condition that causes axial low back pain, radicular pain, and neurogenic claudication. Epidural steroid injections are commonly used for the treatment of radicular symptoms and neurogenic claudication associated with symptomatic lumbar spinal stenosis. No prior study has evaluated whether transforaminal or interlaminar epidural steroid injections produce better clinical outcomes. Retrospective case control study. For each technique, 19 patients were retrospectively identified who received their first fluoroscopically guided epidural steroid injection for radicular and neurogenic claudication symptoms caused by lumbar spinal stenosis over a 12-month interval. All patients had corresponding MRI findings and had failed previous non-invasive therapies. Outcomes included the visual analog scale (VAS, 0-10 scale) immediately before the injection, immediately after the injection, and upon follow up at 4-6 weeks. Surgery rates and number of repeat injections over a 3 year period were also analyzed. The patient groups were matched for age and level of stenosis on MRI. There was no statistically significant difference between the two groups in pre injection to follow up VAS scores (P=0.919). The difference between number of repeat injections between the interlaminar and transforaminal groups was not statistically significant (0.91-mean 2.47 and 2.58, respectively). Both the interlaminar and transforaminal groups experienced statistically significant improvement in VAS scores from before the injection to after the injection, and on follow up. Low numbers underwent surgery (11% in the interlaminar group vs 15% in the transforaminal group, not significant, P=0.63). In the current study, neither transforaminal nor interlaminar steroid injections resulted in superior short term pain improvement or fewer long term surgical interventions or repeat injections when compared with each other.

Comparison of the Effectiveness of Interlaminar and Bilateral Transforaminal Epidural Steroid Injections in Treatment of Patients With Lumbosacral Disc Herniation and Spinal Stenosis

The purpose of this study is to compare the effectiveness of interlaminar (IL) and bilateral transforaminal (TF) epidural steroid injections (ESIs) for pain reduction in patients with axial back pain resulting from herniated intervertebral disc (HIVD) and spinal stenosis (SS). Patients reporting axial back pain without radiation continuing over 3 months, which resulted from lumbosacral SS or HIVD were recruited and assigned to either the IL or TF technique group. The degree of pain and patient satisfaction were evaluated by the Numerical Rating Scale (NRS), the Patient Satisfaction Index (PSI), and the Roland 5-point pain score, which were administered at pretreatment, 2 weeks, 2 months, and 4 months after ESI. Both the TF and IL ESIs accomplished significant pain reduction in HIVD and SS from 2 weeks to 4 months after treatment. SS showed a more significant reduction in the Roland 5-point pain score and obtained more successful NRS results using the TF technique as compared with the IL technique. HIVD did not show any differences between the techniques. Bilateral TF epidural injection allowed the higher concentration of injectates to be delivered into ventral epidural space bilaterally. The IL approach can be more affected by tissue fibrosis, scarring, or hypertrophy, which is more prominently featured in SS than in HIVD; these prevent the injectate delivered via the posterior route from spreading to the ventral epidural space. Consequently, in patients with SS, bilateral TF produces better results than IL.