Interlaminar Injections Research Articles

Comparable Overall Risk of Neurologic Adverse Events Following Cervicothoracic Interlaminar and Transforaminal Epidural Injections: An Analysis of 1.29 Million Patients.

Retrospective cohort study. To characterize the incidence and odds of neurologic adverse events following interlaminar (IL) and transforaminal (TF) cervicothoracic epidural spinal injections (CESI). CESI may be considered in the management of various cervical pathology. Adverse events, although rare, can be devastating and have been reported following both IL and TF injections. The literature is mixed with regard to the risk-profile of these two types of CESI, but is largely limited to case reports, single centered studies, and literature reviews, which may incompletely characterize the relative risk of these injections at a national level. All adult patients undergoing IL and TF-CESI were identified from a large, national, multi-insurance database. The incidence of any post-injection neurologic complication was reported per 1,000 patients. The odds of specific neurologic adverse events occurring within 48-hours following TF-CESI, relative to IL-CESI, were compared by multivariable logistic regression controlling for age, sex, and Elixhauser comorbidity index (ECI). A total of 1,073,215 IL-CESI patients and 220,597 TF-CESI patients were identified. The overall incidence of any neurologic complication following IL and TF-CESI occurred at a rate of 4.15 and 4.56 per 1,000 patients, respectively (P=0.889). TF-CESI was associated with higher odds ratio (OR) of nerve root injury (OR 1.69, P<0.001), but lower odds of epidural hematoma (OR 0.60, P=0.040), relative to IL-CESI. Conversely, no other neurologic adverse events were statistically different between approaches (P>0.05 for all). Following IL and TF-CESI, adverse events are relatively rare but not absent. Although the odds of the majority of individual neurologic adverse events were found to be similar, both approaches were independently associated with specific complications. Providers should therefore recognize that, at the national level, one CESI approach may not be universally associated with a lower risk of complications.

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.

Spinal Subdural Hematoma and Cauda Equina Syndrome Occurring After Interlaminar Injection in a Patient Receiving Anticoagulant Therapy

Spinal Subdural Hematoma and Cauda Equina Syndrome Occurring After Interlaminar Injection in a Patient Receiving Anticoagulant Therapy

Changes in the Utilization of Cervicothoracic Injections Between 2010 and 2020.

Descriptive epidemiologic study. To analyze trends and patient characteristics of those undergoing cervicothoracic transforaminal, interlaminar, and facet injections over time. Cervicothoracic transforaminal, interlaminar, and facet injections are considered for varied spinal pathologies. Evolving literature, changing physician preferences, insurance reimbursement policies, and patient factors may influence the utilization of such injections over time. Patients undergoing cervicothoracic transforaminal, interlaminar, and facet injections 2010-2020 were identified in the M151Ortho PearlDiver database using Current Procedural Terminology coding. Patient age, sex, Elixhauser Comorbidity Index, insurance plan (commercial, Medicaid, Medicare), and region of the country where the procedure was performed (Midwest, Northeast, South, and West) were extracted and assessed over study intervals based on prevalence per 100,000 covered lives. Cervicothoracic transforaminal, interlaminar, and facet injections were identified for 195,221 (11.3%), 951,191 (55.2%), and 575,228 (33.4%) patients, respectively. Patient characteristics for each injection type were defined. The annual number of injections performed per 100,000 covered lives decreased during the study period for transforaminal (17.1% decrease) and interlaminar (9.3% decrease) but increased for facet (3.7% increase) injections ( P <0.0001 for each). Stratifying by patient insurance type, administration of transforaminal, interlaminar, and facet injections per 100,000 covered lives was proportionally greatest for commercially insured patients (55%, 50%, and 45%, respectively), and proportionally smallest for Medicaid patients (10%, 13%, and 13%, respectively). Anesthesiology physicians performed the most injections, followed by physical medicine and rehabilitation physicians, with both provider types most frequently performing interlaminar injections, followed by facet and transforaminal injections. Annual cervicothoracic transforaminal and interlaminar injection utilization declined by 17.1% and 9.3% from 2010 to 2020, whereas facet injection administration increased by 3.7% over the same interval. Evolving practice patterns are important to consider in characterizing the overall landscape of spine care.

C-Arm Guided Epidural Steroid Injection: An Effective Treatment for Patients with Radiculopathy in Tertiary Level Hospital of Bangladesh

Introduction: Epidural steroid injections (ESI) have been utilized for over 50 years in the conservative therapy of prolapsed lumbar intervertebral discs. However, controversy persists regarding their effectiveness in reducing pain and improving function, with literature supporting and opposing them.&#x0D; Aim: To study the effectiveness of epidural steroid injection in treating pain caused by a prolapsed lumbar intervertebral disc and compare the effectiveness between caudal, transforaminal, and interlaminar injection routes.&#x0D; Materials and Methods: A total of 152 patients with back pain with Radiculopathy with a lumbar disc prolapse confirmed on MRI were included in the study. Their pre-injection Japanese Orthopedic Association Score (JOA) counted up. In this study, participants were enrolled using a simple randomization procedure (picking a card).in the Department of Physical Medicine &amp; Rehabilitation at BSMMU, Dhaka, from May 2020 to April 2021. Among 152 patients were intervenes as transforaminal (n=62), caudal (n=53), and interlaminar (n=25) approach with subsequently received epidural steroids as methylprednisone. Twelve individuals were dropped from the trial because they failed to show up for their scheduled therapy.&#x0D; Results: The prevalence increased dramatically, leading to a JOA Score at 12 months following injection via any of the three methods 53 (37.26%) via the caudal pathway, 62 (44.21%) via transforaminal, and 25 (18.53%) via interlaminar. At six months and 12 months post-injection, the transforaminal route was substantially more efficacious than the caudal (p=0.01) and interlaminar routes (p=0.03). Comparing the caudal and interlaminar methods yielded no statistically significant difference (p=0.36).&#x0D; Conclusion: In the current study, methylprednisone epidural injections effectively treat radiculopathy and back pain caused by a herniated lumbar disc. All three injection techniques are adequate, with the best result obtained by the transforaminal route.&#x0D; TAJ 2022; 36: No-1: 113-118

Effectiveness of Transforaminal, Interlaminar, and Caudal Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Network Meta-analysis

BACKGROUND: Epidural injection (EI) has been used to manage lower back and radicular leg pain caused by a herniated lumbar disc. There are 3 types of EI techniques currently being used: transforaminal (TFEI), interlaminar (ILEI), and caudal epidural injections (CEI). OBJECTIVES: To evaluate the comparative effectiveness of TFEI, ILEI, and CEI in reducing pain and improving function in patients with HLD. STUDY DESIGN: Systematic review and meta-analysis. METHODS: The PubMed, Embase, Cochrane Library, and Scopus databases were searched from the earliest records up to August 2022 for randomized controlled trials (RCTs) and non-RCTs. The standard mean differences (SMDs) in the changes in the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores were calculated from one week through one month posttreatment (short-term) and from 4 months through 6 months posttreatment (long-term). RESULTS: In total, 11 studies comprising 1,050 patients were included. Network meta-analysis showed that the improvement in the VAS scores was better with TFEI than with CEI (SMD = -1.16, 95% CI = -2.10 to -0.23). Ranking probability analysis showed that TFEI had the highest probability of being the best treatment for reducing pain and improving function in the short- and long-term evaluation periods. LIMITATIONS: Only a small number of previous studies were included in our analysis. Also, subgroup analysis according to the injection volume, material type, or pain onset could not be conducted. CONCLUSIONS: TFEI had the best potential of the 3 EI techniques to reduce pain and improve function in patients with a herniated lumbar disc. Further qualified trials comparing the effects of these 3 techniques are warranted to derive definitive conclusions. KEY WORDS: Disc herniation, back pain, radicular pain, epidural injection, transforaminal injection, interlaminar injection, caudal injection, lumbar spine

Efficacy and Complication Rate of Repeat Lumbar Interlaminar and Transforaminal Injections Within a Two-Month Period: A Retrospective Review

Efficacy and Complication Rate of Repeat Lumbar Interlaminar and Transforaminal Injections Within a Two-Month Period: A Retrospective Review

Complications of injections in conservative treatment of degenerative spine disease: a prospective unicentric study

BackgroundSpinal injection has been an accepted part of conservative therapy for degenerative diseases. The drugs used can cause side effects and severe complications. The aim of this study was to determine the occurrence of general side effects (GSE) and complications when performing consecutive different types of spinal injections and to evaluate pain reduction.MethodsProspective data evaluation of patients with degenerative spine disease at hospital admission, discharge, and six and 12 weeks after discharge. All patients received a specific injection protocol depending on their symptoms and radiological findings. The injections performed were dorsal sacroiliac joint injections, perineural injections, epidural interlaminar and epidural periradicular injections, and facet joint injections. Potential complications were categorized and recorded as GSE and complications. In addition, the Numerical Analog Scale (NAS) for pain, the Oswestry Disability Index (ODI) were evaluated.ResultsForty-eight patients were enrolled. There were 282 spinal injections performed. A total of 131 common treatment-related events were recorded. Depending on the type of injection, transient pain at the injection site (32.4–73.5%), radiating pain (9.4–34.7%), and nerve root irritation (2–18.4%) were the most common. One complication with postpuncture syndrome occurred with epidural-interlaminar injection. No persistent neurologic deficits occurred. The highest rate of GSE was observed with periradicular injections (relative frequency (RF) = 0.8), followed by epidural-interlaminar injections (RF = 0.65), least frequently with FJ injections (RF = 0.32). From the time of admission to discharge, NAS scores were significantly decreased and ODI score significantly improved at discharge (p < 0.001), but relapse occurred at the 12-week follow-up.ConclusionsVarious consecutive spinal injections for conservative treatment of degenerative spine diseases are safe and lead to a decrease in pain and improvement in quality of life. GSE are common, but not persistent. Although complications are rare, they can have serious consequences for the patient.

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

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

CORR Insights®: Microdiscectomy Is More Cost-effective Than a 6-Month Nonsurgical Care Regimen for Chronic Radiculopathy.

CORR Insights®: Microdiscectomy Is More Cost-effective Than a 6-Month Nonsurgical Care Regimen for Chronic Radiculopathy.

Епідуральне введення кортикостероїдів у лікуванні хронічного дискогенного болю в нижній частині спини

Актуальність. Біль у нижній частині спини залишається однією з найпоширеніших проблем хребетного стовпа та хронічних больових синдромів взагалі. Вона є частою причиною втрати працездатності, а витрати на неї вражають значністю сум. На сьогодні існують три напрямки лікування дискогенного болю — фізіотерапевтичний, медикаментозний і хірургічний. Інтервенційне лікування дискогенного болю шляхом уведення лікарських препаратів у епідуральний простір однаковою мірою можна віднести як до малоінвазивної хірургії, так і до активної таргетной терапії. Мета дослідження — вивчити динаміку больового синдрому в пацієнтів, які страждають від хронічного дискогенного болю в нижній частині спини, при використанні в їх лікуванні епідуральних стероїдних ін’єкцій. Матеріали та методи. У ретроспективне дослідження включено 74 пацієнти віком від 25 до 83 років (середній вік — 53,86 ± 14,27 року), пролікованих із 2015 по 2017 рік у клініці «Нейромед» м. Києва та Ужгородському обласному центрі нейрохірургії та неврології. У всіх досліджуваних після комплексного обстеження діагностовано терапевтично-резистентний хронічний дискогенний біль у нижній частині спини. Нами застосовувалося інтерламінарне та трансфорамінальне введення кортико­стероїдів під радіологічним контролем С-дуги. Всього було виконано 35 (47 %) трансфорамінальних епідуральних ін’єкцій, або блокад, і 39 інтерламінарних епідуральних блокад. За локалізацією проведені маніпуляції було розподілено наступним чином: на рівні L5-S1 — 36 (48 %), на рівні L4-L5 — 17 (23 %), на рівні L3-L4 — 12 (16 %) і на рівні L2-L3 — 9 (12 %). Больовий синдром оцінювався за 10-бальною візуально-аналоговою шкалою (ВАШ) перед маніпуляцією, через 7 і 30 днів після її проведення. Результати. Ускладнень не зареєстровано. Абсолютно всі пацієнти відзначали зниження больового синдрому. Більшість пацієнтів до маніпуляції характеризували свій біль як «дуже сильний, на межі з нестерпним» (7,01 ± 0,86 за ВАШ), а через тиждень після процедури більшість вже описували больові відчуття як «легкі, часом помірні» (3,68 ± 0,87 за ВАШ). Така тенденція зберігалася і через місяць після маніпуляції (1,98 ± 1,01 за ВАШ). Висновки. Епідуральне уведення кортикостероїдів є безпечним і ефективним способом лікування хронічного болю в нижній частині спини. Ця інтервенційна методика дозволяє істотно знизити інтенсивність страждання.

Fluoroscopically guided lumbar spine interlaminar and transforaminal epidural injections: inadvertent intravascular injection.

Inadvertent intravascular injection is a rare but catastrophic complication of lumbar epidural injections. To determine risk factors for inadvertent intravascular injection in fluoroscopically guided lumbar spine epidural injections. A total of 212 patients who presented for lumbar interlaminar or transforaminal injection were prospectively enrolled. Patient demographics, history of surgery, injection side, site and approach, and volume of contrast injected were recorded. There were 89 (42%) interlaminar and 123 (58%) transforaminal injections. For 36 (17%) patients, there had been surgery at the injected or adjacent lumbar level. There were 25 (12%) inadvertent intravascular injections, with an incidence of 2/93 (2%) for interlaminar and 23/119 (19%) for transforaminal injections. The patients with inadvertent intravascular injection were older (P = 0.017) and had prior surgery at or adjacent to the level of injection (P < 0.0001). Transforaminal approach had a higher intravasation rate than interlaminar injections, both when comparing the entire cohort (P = 0.0001) and only patients without prior surgery (P = 0.01). In multivariable logistic regression analysis, transforaminal injections (odds ratio [OR] 9.77, 95% confidence interval [CI] 2.14-44.6, P = 0.003) and prior surgery at or adjacent to the level of injection (OR 5.71, 95% CI 2.15-15.15, P < 0.001) were independently associated with increased risk of inadvertent intravascular injections. Inadvertent intravascular injection occurred in 12% of our lumbar injection cohort and is more common with transforaminal injections, in older patients, and with prior lumbar surgery at or adjacent to the level of injection.

Lumbar Epidural Contrast Spread Patterns for the Interlaminar Approach: Three-Dimensional Analysis Using Antero-Posterior, Lateral, and Contralateral Oblique Views.

To describe and analyze lumbar epidural contrast spread patterns in antero-posterior (AP), lateral, and contralateral oblique (CLO) views. Lumbar epidural contrast spread patterns after interlaminar injection were prospectively collected in AP, lateral, and several CLO views and analyzed for multiple variables; three-dimensional mapping was also performed. Epidural contrast patterns were prospectively analyzed in 28 subjects. The median volume of contrast injected was 2 mL; the AP view was more sensitive than the lateral view to detect foraminal uptake (13/28, 46%, 95% confidence interval [CI] = 27-66%, vs 7/28, 25%, 95% CI = 11-45% subjects). CLO view demonstrated the most consistent location for epidural contrast spread, with contrast contacting the ventral laminar margin in 28/28 (100%, 95% CI = 87-100%) patients. The most common location of contrast spread in the lateral view was at the facet joint lucency, with only 8/28 (29%, 95% CI = 13%-49%) subjects showing contrast contacting the spinolaminar junction. Lateral view was more sensitive than the CLO view in ventral epidural contrast spread detection. The extent and distribution of the spread did not bear any relationship to the volume injected or to the needle location in AP view. CLO view provides the most consistent landmark for lumbar epidural contrast spread, and lateral view is most suited to confirming ventral epidural spread. The AP view may be the most optimal for determining target access when considering access to the dorsal root ganglia; in an individual patient, the volume injected and needle location in AP view do not reliably predict target access. The volume to be injected and the need to re-access or obtain multisite access must be prospectively determined, based upon observation of the spread.

Cervical Interlaminar Epidural Injections In The Treatment Of Cervical Disc Herniation, Post Surgery Syndrome, Or Discogenic Pain: Cost Utility Analysis From Randomized Trials

Background: Neck pain is one of the major conditions attributing to overall disability in the United States. There have been multiple publications assessing clinical and cost effectiveness of multiple modalities of interventions in managing chronic neck pain. Even then, the literature has been considered sparse in relation to cervical interlaminar epidural injections in managing chronic neck pain. In contrast, cost utility studies of lumbar interlaminar injections, caudal epidural injections, cervical and lumbar facet joint nerve blocks, percutaneous adhesiolysis demonstrated costs of less than $3,500 for quality-adjusted life year (QALY). Objectives: To assess the cost utility of cervical interlaminar epidural injections in managing chronic neck and/or upper extremity pain secondary to cervical disc herniation, post-surgery syndrome in neck, and axial or discogenic neck pain. Study Design: Analysis based on 3 previously published randomized trials of the effectiveness of cervical interlaminar epidural injections assessing their role in disc herniation, cervical post-surgery syndrome, and axial or discogenic pain. Setting: A contemporary, private, specialty referral interventional pain management center in the United States. Methods: Cost utility of cervical interlaminar epidural injections with or without steroids in managing cervical disc herniation, cervical post-surgery syndrome, and cervical discogenic or axial neck back pain was conducted with data derived from 3 randomized controlled trials (RCTs) that included a 2-year follow-up, with inclusion of 356 patients. The primary outcome was significant improvement defined as at least 50% in pain reduction and disability status. Direct payment data from all carriers from 2018 was utilized for the assessment of procedural costs. Overall costs, including drug costs, were determined by multiplication of direct procedural payment data by a factor of 1.67 to accommodate for indirect payments respectively for disc herniation, discogenic pain, and cervical post-surgery syndrome. Results: The results of the 3 RCTs showed direct cost utility for one year of QALY of $2,412.31 for axial or discogenic pain without disc herniation, $2,081.07 for disc herniation, and $2,309.20 for post surgery syndrome, with an average cost per one year QALY of $2,267.57, with total estimated overall costs with addition of indirect costs of $3,475.38, $4,028.55, $3,856.36, and $3,785.89 respectively. Limitations: The limitation of this cost utility analysis includes that it is a single center evaluation. Indirect costs were extrapolated. Conclusion: This cost utility analysis of cervical interlaminar epidural injections in patients nonresponsive to conservative management in the treatment of disc herniation, post surgery syndrome and axial or discogenic neck pain shows $2,267.57 for direct costs with a total cost of $3,785.89 per QALY. Key words: Cervical interlaminar epidural injections, chronic neck pain, cervical disc herniation, cervical discogenic pain, post surgery syndrome, cost utility analysis, cost effectiveness analysis, quality-adjusted life years

DEPTH ASSESSMENT USING CONTRALATERAL OBLIQUE VIEW DURING CERVICAL INTERLAMINAR EPIDURAL STEROID INJECTIONS

Background: Recent literature has demonstrated that the contralateral oblique (CLO) view provides a more reliable angle in determining needle depth when compared to the lateral view during cervical interlaminar injections. Despite the utilization of CLO safety views, contrast patterns, and loss-of-resistance techniques, inherent risk of injury still remains. Additional safety measures must be assessed to provide clinicians with further safeguards to prevent procedural complications. Objective: The purpose of our study is to provide a reliable method of gauging needle depth insertion during cervical interlaminar injections by comparing the distance from the skin to the epidural space when measured on magnetic resonance imaging (MRI) and when measured intraoperatively. Methods: The study sample included 45 patients with cervical radiculopathy or cervical spinal stenosis. The distance from the skin to the epidural space was measured on cervical spine MRI and with the spinal needle intraoperatively. Primary analysis included the correlation between these distances, and whether differences in depth were influenced by injection level, needle tip location, or body mass index (BMI). Results: A significant correlation (r = .975, P &lt; .001) with an average difference of .03 mm (standard deviation, 2.99 mm) was found between MRI and procedural measurements. Neither injection level nor BMI had a significant influence on the difference in depth. Conclusion: When combined with traditional safety techniques, obtaining preprocedural MRI depth measurements can provide a reliable method in predicting the true needle depth to safely enter the epidural space. Because the majority of patients undergoing interlaminar cervical epidural steroid injections will have already obtained MRI, measuring the distance preprocedurally is a simple and practical method for physicians to implement. Key words: Cervical, fluoroscopy, radiculopathy, injection, contra-lateral oblique, contrast, safety, complications, spinal stenosis, radiation, interlaminar

Long-term comparative study between transforaminal and interlaminar epidural injection of steroids in lumbar radiculopathy due to single-level disc herniation

Background: Epidural steroid injection is commonly used in treating radicular pain secondary to lumbar disc prolapse, which is a common clinical condition. Two main techniques were suggested to deliver the steroids: interlaminar and transforaminal injections. Methods: From June 2013 to March 2016 we performed a prospective study on 40 patients between the ages of 19 and 55 yr. All the patients had low back pain and lower limb radiculopathy secondary to a single-level lumbar disc prolapse. The pupose of this study was to compare interlaminar and tranforaminal injection techniques regarding the short-term and long-term improvement of back pain, leg pain, and functional outcomes. On admission the patients were evaluated using a visual analogue scale (VAS) for back and leg pain, and the Oswestry Disability Index (ODI) for functional capacity. They were followed for a period of 47 to 49 wk (mean 48 wk), and clinical and functional outcomes were assessed using the same tools for evaluation. Results: We found that VAS and ODI improved in both the transforaminal and interlaminar groups both short and long term, but the only statistically significant improvement was in VAS for leg pain and the ODI in the transforaminal group. Conclusions: Epidural steroid injection is generally a safe procedure, but the transforaminal approach gives better results than the interlaminar approach in relieving radicular pain and improving functional outcome.

Transforaminal vs Interlaminar Epidural Steroid Injection for Acute-Phase Shingles: A Randomized, Prospective Trial

The acute phase of shingles is characterized by severe pain, and one of the complications of shingles known as postherpetic neuralgia (PHN) is associated with prolonged pain. Although factors predicting the development of PHN, as well as its preventative measures, have been investigated, there is no single treatment effective for PHN. Some studies showed effectiveness of epidural injection to alleviate pain associated with acute-phase shingles. In these studies, epidural injection was performed by interlaminar (IL) approach. However, transforaminal (TF) approach may be more effective as it enables injection of steroids and local anesthetics closer to the dorsal root ganglion where inflammation primarily occurs. There have not been any studies comparing the analgesic effects of epidural injection approaches for pain associated with acute-phase shingles. We compared the analgesic effects of IL and TF epidural injection approaches for pain associated with acute-phase shingles. We conducted a randomized prospective trial. Nara Medical University Hospital, Department of Anesthesiology. Forty patients with acute-phase shingles were randomly assigned to receive epidural steroid injections by TF or IL approaches. Patients were evaluated at the baseline, as well as at 1 month and 3 months after the treatment using the VAS and SF-36 scores. Patients with VAS score of over 40 at the 3-month follow-up were considered as having PHN, and the number of patients with PHN was compared between the IL and TF groups. Except the mental component of the SF-36 score and severity of skin rash, patient characteristics were not significantly different between the groups. VAS scores at 1 and 3-month follow-up were significantly lower than those at the baseline, and there was no difference between the groups. All SF-36 scores were not significantly different between groups at 1- and 3-month. There was no significant difference in the occurrence of PHN between the groups. We had a small sample size that did not reach the number of patients needed by the power analysis in the study. Then, our follow-up period of 3 months was relatively short. VAS scores, the SF-36 RCS and MCS scores improved in both groups, however, there was no difference in the analgesic effects of the IL and TF epidural steroid injections at 1 and 3 months for acute-phase shingles patients. Shingles epidural steroid injection interlaminar approach; transforaminal approach, fluoroscopic, postherpetic neuralgia, VAS, SF-36.

Major risks and complications of cervical epidural steroid injections: An updated review.

Background:Too many patients, with or without significant cervical disease, unnecessarily undergo cervical epidural steroid injections (CESIs). These include interlaminar (ICESI) and transforaminal ESI (TF-CESI) injections that are not Food and Drug Administration (FDA) approved, have no documented long-term efficacy, and carry severe risks and complications.Methods:Here we reviewed recent reports of morbidity and mortality attributed to the various types of CESIS. Major complications included; epidural hematomas, infection (abscess/meningitis), increased neurological deficits due to intramedullary (quadriparesis/quadriplegia), and intravascular injections (e.g., vertebral artery injections leading to cord, brain stem, and cerebellar strokes). The latter injections leading to strokes were typically attributed to the particulate steroid matter (e.g., within the methylprednisolone injection solution) that embolized into the distal arterial branches.Results:Complications of cervical CESI/TF-CESI injections producing epidural hematoma, new neurological deficits (intramedullary injections), or intravascular injections resulting in strokes to the cord, brain stem, and cerebellum are often underreported. Interestingly, several other cases involving adverse events of CESI/TF-CESI may now be found in the medicolegal literature.Conclusions:Cervical epidural injecions (e.g., CESI, ICESI, and TF-CESI) which are not FDA approved, provide no long-term benefit, and are being performed for minimal to no indications. They contribute to significant morbidity and mortality, including; epidural hematomas, infection, inadvertent intramedullary cord injections or cord, brain stem, and cerebellar strokes. Furthermore, these injections are increasingly required by insurance carriers prior to granting permission for definitive surgery, thus significantly delaying in some cases necessary operative intervention, while also subjecting patients at the hands of the insurance companies, to the additional hazards of these procedures.

Epidural interlaminar injections in severe degenerative lumbar spine: fluoroscopy should not be a luxury

ObjectiveTo assess technical efficacy, accuracy, and safety of epidural (interlaminar) injections performed blindly in patients with a severely degenerated lumbar spine.MethodsOver 12 consecutive months, 138 patients with a severe degenerative...

Abstract PR302

Background:In refractory pain, interventional procedures have been used successfully.(1) Objectives:To study and compare the efficacy of inter-laminar steroid injection and caudal epidural steroid injection in chronic radicular low back pain. Materials & Methods:After institutional ethics approval and written informed consent, a prospective, interventional assessor blinded study involving 60 patients (nmaster no.2, α error= 5%, power of study-80%). Aged 18-65years. Numeric rating scale (NRS) of radicular low back pain of 4 at rest for 12weeks in whom conservative therapy failed. Allocated either Group I (inter-laminar à conventional epidural injection in sitting position with 18G Tuohy’s needle consisting of 60mg Triamcinolone, 0.5ml of 0.5% Bupivacaine and 4ml of normal saline) or Group C (Caudalà fluoroscopy guided caudal epidural injection in prone position with 23G Quincke’s needle consisting of 80mg of Triamcinolone, 0.5ml of 0.5% Bupivacaine and 5.5ml of normal saline) by computer generated numbers. Intervention was done as a day care procedure under strict aseptic precautions and patient was discharged 2hours after observation. Cold fomentation was advised for 2 days. Analgesics in the form of Tapentadol, Paracetamol and gabapentin were continued. On day 3, they were referred to physiotherapist for back strengthening exercises. On the 1st, 3rd and 6th weeks after the procedure and they were assessed by NRS for pain, Rolland Morris low back pain and disability questionnaire, analgesic requirement and return to routine work. Results: Pain relief seen immediately after the procedure and at 1st week after the procedure were comparable in both groups but at the 3rd and 6th weeks after the procedure, Group C showed significantly better pain relief(Table 1)Table 1 -: ResultsConclusion: 1.Steroids administered by both conventional inter-laminar and fluoroscopic guided caudal techniques are effective for chronic radicular low back pain, 2.Over time, the effect of inter-laminar injection wears off while that of caudal injection stays consistent even at the 6th week, 3.Efficacy of caudal approach is better, 4.In absence of pain physician anaesthetist can treat low back pain.