Lumbar Interlaminar Epidural Steroid Injections Research Articles

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.

Comparison of interlaminar and transforaminal epidural steroid injection for lumbosacral radiculopathy

Background: Low back pain due to Intervertebral disc herniation, intervertebral disc degeneration without disc herniation are the most common diagnosis of chronic persistent low back and lower extremity symptoms. Epidural steroid injections (ESI) are one of the most common interventional techniques for managing low back pain with or without lower extremity radiation Aims and objectives: Comparison of the effectiveness of lumbar Interlaminar and Transforaminal epidural steroid injections in managing various types of chronic low back pain. Material and methods: A total of 60 patients with history of lumbosacral radicular pain (≥3 months with VAS score ≥50) and magnetic resonance imaging (MRI) of the lumbar spine showing the exact disc level protrusion, who met the inclusion criteria were selected. With simple purposive sampling techniques, all patients were randomly divided into two groups. Group I Received 4 ml of 0.25% bupivacaine with 8mg dexamethasone through fluoroscopy guided interlaminar epidural route  and Group T Received 2ml of 0.25% bupivacaine with 4mg dexamethasone through transforaminal route. Baseline assessment was completed just before the randomization and then follow up SLRT and VAS score recordings were taken - post 1 week, 1 month and 3 months after the procedure. 

Persistent Hiccups as a Potential Complication after Interlaminar Epidural Steroid Injection Should be Included in the Consent Form: A Case Discussion

Persistent hiccups or Singultus (duration more than 48 hours) are a rare complication after epidural steroid injections. The literature on this subject is limited to a few case reports, and the exact mechanism is still unknown. This case, to our knowledge, reports the first case of persistent hiccups following an interlaminar lumbar epidural steroid injection of non-Particulate type.

Lumbar interlaminar epidural steroid injections for chronic low back- and lower extremity-pain in Sjogren's syndrome: A case report.

Introduction and importancePeripheral nervous system involvement is very common in Sjogren's syndrome (SS); however, polyradiculopathy has been reported rarely in association with SS, and predominantly chronic forms have been described. Here, we reported a case from our Neurosurgery Department in Intan Medika KIM Hospital, Bangka Island, Pangkalpinang, Indonesia; as Academic Health System of Universitas Padjadjaran.Case presentationA 32-year-old woman, diagnosed with Sjogren's syndrome that was characterized by anti-nuclear, anti-Ro, anti-La and anti dsDNA-antibodies positives since 3 years ago; consulted to our department for a chronic low back with a radicular pain in both lower limbs from the gluteal area to both feet together with numbness, hyperstesis and allodynia. The pain was evaluated by the visual analogue scale (VAS) score of 8; we then performed cervico-lumbal computed tomography (CT) scan that demonstrated multiple protruded discs of the cervical- and lumbar-spine.Clinical discussionPain was treated with lumbar interlaminar epidural steroid injections as a safe technique that allows relieving patient symptoms; after 10 min, the patient experienced an improvement in her pain with reduced scores to 0–1 in VAS, as well as a significant improvement on her quality of life later on.ConclusionThe use of lumbar interlaminar epidural steroid injections for an alternative therapeutic for neuropathic pain in SS gives a satisfactory result in terms of improvement of pain as well as a significant improvement on patients' quality of life.

Efficacy of epidural injection of steroid in treatment of lumber disc prolapse: article review

"Chronic low back and lower extremity pain is mainly caused by lumbar disc herniation (LDH) and radiculitis. Various surgery and nonsurgical modalities, including epidural injections, have been used to treat LDH or radiculitis. Caudal epidural injection of local anesthetics with or without steroids is one of the most commonly used interventions in managing chronic low back and lower extremity pain. To describe the indications, rationale, techniques, alternatives, contraindications, complications, and efficacy of lumbar and caudal epidural corticosteroid injections. Interventions: Three reviewers with formal training and certification in evidence-based medicine searched the literature on non–image guided lumbar interlaminar epidural steroid injections. A larger team of seven reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented. A systematic literature search was performed, in the Medline Case reports and retrospective and prospective studies were extensively reviewed to provide detailed descriptions of the clinical features of lumbar and caudal epidural corticosteroid injections. Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE , and manual searches of bibliographies of known primary and review articles. Epidural corticosteroid injections are commonly requested treatments for patients with various low-back or lower-extremity pain syndromes (or both). Most of the reports on the use of this type of treatment are retrospective and noncontrolled. These studies indicate benefit; however, the prospective controlled studies provide varied results about the efficacy of lumbar and caudal epidural corticosteroid injections. In conclusions: In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical practice, these procedures should be restricted to the rare settings where fluoroscopy is not available."

Efficacy of epidural steroid injection in management of lumbar disc lesion

Background and aim Low back pain and radiculopathy are the main annoying complaints in patients with degenerative disc diseases. Epidural steroid injection (ESI) has a role to reduce pain and improve disability by decreasing inflammatory process at the nerve root caused by herniated disc. This study was done to evaluate the efficacy of lumbar ESI regarding the improvement of pain and functional outcome. Patients and methods This study was a prospective randomized study on 30 patients, aged between 30 and 65 years with low back pain and lumbar radiculopathy secondary to lumbar disc prolapse with no absolute indication for surgery. The patients were treated by lumbar epidural injection of steroids. Patients were divided randomly into two groups: group 1 included 15 patients subjected to lumbar interlaminar ESI, and group 2 included 15 patients subjected to lumbar transforaminal ESI. Patients were evaluated using visual analog scale (VAS) score for pain and the Oswestry Disability Index (ODI) for functional capacity. They were followed up after 4 weeks, and clinical and functional outcomes were assessed using the same tools for evaluation. Results The mean VAS for the 30 patients improved by 58.33% (P Conclusion We found by the end of the study that the ESI is a safe and effective procedure in alleviating radicular pain and improvement of functional outcome, but the transforaminal approach gives better results than the interlaminar approach.

Current Trends in Steroid Dose Choice and Frequency of Administration of Epidural Steroid Injections: A Survey Study

Epidural steroid injections (ESI) are commonly used to treat refractory radicular spinal pain. Although evidence suggests that an increasing cumulative dose of exogenous corticosteroid may be harmful, knowledge of current practice patterns is limited regarding the choice of dose and frequency of epidural steroid injections (ESIs). Describe current practice trends in the dose selection and frequency of administration of transforaminal ESIs (TFESIs) and interlaminar ESIs (ILESIs). Cross-sectional survey study. Not applicable. Three hundred fourteen physician members of the Spine Intervention Society (SIS). From May to June 2018, an online survey was distributed to 5907 physician members of the SIS. Not applicable. Corticosteroid dose used by practitioners and the number of annual ESIs administered per patient. Three hundred fourteen physicians responded to the survey. For single cervical or lumbar injections of dexamethasone, most physicians (56.0%) reported using 10 mg; 17% of physicians reported use of doses greater than 10 mg, with 6% using a dose of 20 mg per injection level. The most common particulate corticosteroid dose used during both cervical and lumbar ILESIs was 80 mg (cervical = 55.4%, lumbar = 54.7%). During cervical and lumbar ILESIs, 17% and 12.7% of physicians reported using doses greater than 80 mg, respectively. Almost 10% of physicians reported performing cervical TFESIs with particulate steroids. Forty percent of physicians reported allowing four ESIs at a given spinal segmental level per year (cervical/thoracic/lumbosacral). A small percentage of physicians reported allowing more than six ESIs annually (6%) and >10 injections annually (1%). There is considerable variability among this large cohort of interventionists with regard to corticosteroid dose selection and epidural steroid injection frequency. A small proportion of respondents reported Mulitsociety Pain Workgroup guideline-discordant use of particulate steroids during cervical TFESIs. These findings demonstrate a need for additional research regarding both the reasons for such variation in care and the reasons for guideline-discordant practice in a subset of physicians. IV.

A Contemporary Medicolegal Analysis of Outpatient Interventional Pain Procedures: 2009-2016.

Closed malpractice claim studies allow a review of rare but often severe complications, yielding useful insight into improving patient safety and decreasing practitioner liability. This retrospective observational study of pain medicine malpractice claims utilizes the Controlled Risk Insurance Company Comparative Benchmarking System database, which contains nearly 400,000 malpractice claims drawn from >400 academic and community medical centers. The Controlled Risk Insurance Company Comparative Benchmarking System database was queried for January 1, 2009 through December 31, 2016, for cases with pain medicine as the primary service. Cases involving outpatient interventional pain management were identified. Controlled Risk Insurance Company-coded data fields and the narrative summaries were reviewed by the study authors. A total of 126 closed claims were identified. Forty-one claims resulted in payments to the plaintiffs, with a median payment of $175,000 (range, $2600-$2,950,000). Lumbar interlaminar epidural steroid injections were the most common procedures associated with claims (n = 34), followed by cervical interlaminar epidural steroid injections (n = 31) and trigger point injections (n = 13). The most common alleged injuring events were an improper performance of a procedure (n = 38); alleged nonsterile technique (n = 17); unintentional dural puncture (n = 13); needle misdirected to the spinal cord (n = 11); and needle misdirected to the lung (n = 10). The most common alleged outcomes were worsening pain (n = 26); spinal cord infarct (n = 16); epidural hematoma (n = 9); soft-tissue infection (n = 9); postdural puncture headache (n = 9); and pneumothorax (n = 9). According to the Controlled Risk Insurance Company proprietary contributing factor system, perceived deficits in technical skill were present in 83% of claims. Epidural steroid injections are among the most commonly performed interventional pain procedures and, while a familiar procedure to pain management practitioners, may result in significant neurological injury. Trigger point injections, while generally considered safe, may result in pneumothorax or injury to other deep structures. Ultimately, the efforts to minimize practitioner liability and patient harm, like the claims themselves, will be multifactorial. Best outcomes will likely come from continued robust training in procedural skills, attention paid to published best practice recommendations, documentation that includes an inclusive consent discussion, and thoughtful patient selection. Limitations for this study are that closed claim data do not cover all complications that occur and skew toward more severe complications. In addition, the data from Controlled Risk Insurance Company Comparative Benchmarking System cannot be independently verified.

Evaluation of Chronic Back Pain Improvement after Single Dose of Epidural Steroid Plus Lignocaine Injection in both Genders at a Tertiary Care Hospital, Karachi

Objective: To evaluate chronic back pain improvement after single dose of epidural steroid plus  li-  gnocaine injection in both sexes.&#x0D; Methods: A consecutive cases series of 65 patients having age of ³18  to 80 years and of both sexes from one institution were retrospectively studied. The study was conducted from January 2011 to July It was designed to evaluate the pain improvement after single dose of epidural steroid plus li- gnocaine injection with lumbar interlaminar technique in chronic back pain patients. Patients were di- vided into two groups, to assess the effectiveness of pain relief  following  the  injection  in  between  different age groups with Magnetic Resonance Imaging (MRI), evidence of lumber disc prolapse and non-responder to oral medication were included. Those having  red-flags  (neurosurgical  deficit)  for  surgical intervention were excluded from  the  study.  Chronic  back  pain  patients  were  treated  with  single dose of lumbar interlaminar epidural steroid  plus  lignocaine  injection.  Follow-up  visits  were  carried out to assess pain reduction by patient perception as well as decrease requirement of oral medication.&#x0D; Result: Out of all 65 patients, 28 were male. Mean age of 50.04 ± 14.26 range 18-80 years. After the epidural steroid plus lignocaine injection, all patients of both the groups  showed  decrease  in  pain  severity, evidenced by both patient perception  and  decrease  requirement  for  oral  medication.  There  was no gender difference. Two patients needed second injection  after  interval  of  6  months.  One  fe- male developed spinal anaesthesia after the injection, who recovered within 1 week.&#x0D; Conclusion: This study concludes that epidural  injection  of  steroid  plus  lignocaine  is  effective  and  safe in relieving chronic back pain in both sexes.

Inadvertent Intrafacet Injection during Lumbar Interlaminar Epidural Steroid Injection: A Comparison of CT Fluoroscopic and Conventional Fluoroscopic Guidance

Inadvertent intrafacet injection can occur during interlaminar epidural steroid injection, resulting in a false-positive loss of resistance and nontarget injection of medication. The purpose of this investigation was to compare the observed rates of this phenomenon during lumbar interlaminar epidural steroid injection performed by using conventional fluoroscopic and CT fluoroscopic guidance. We retrospectively reviewed 349 lumbar interlaminar epidural steroid injections performed by using conventional fluoroscopy or CT fluoroscopic guidance to determine the observed rates of inadvertent intrafacet injection with each technique. Cases of inadvertent intrafacet injection were classified as either recognized or unrecognized by the proceduralist at the time of the procedure. Multivariate logistic regression was used to determine the independent effect of imaging guidance technique, age, and sex. The rate of inadvertent intrafacet injection was observed to be 7.5% in the CT fluoroscopic group and 0.75% in the conventional fluoroscopy group. All 16 cases identified from CT fluoroscopic procedures were recognized during the procedure; the single case identified from conventional fluoroscopy procedures was not recognized prospectively. The type of imaging guidance showed a statistically significant effect on the detection of the phenomenon (OR for conventional fluoroscopy versus CT fluoroscopy = 0.10, P = .03) that was independent of differences in age or sex. Inadvertent intrafacet injection is identified during CT fluoroscopic-guided interlaminar epidural steroid injection at a rate that is 10-fold greater than the same procedure performed under conventional fluoroscopy guidance.

The Effectiveness and Risks of Fluoroscopically Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data.

To determine the effectiveness and risks of fluoroscopically guided lumbar interlaminar epidural steroid injections. Systematic review of the literature with comprehensive analysis of the published data. Three reviewers with formal training in evidence-based medicine searched the literature on fluoroscopically guided lumbar interlaminar epidural steroid injections. A larger team consisting of five reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented. The primary outcome assessed was pain relief. Other outcomes such as functional improvement, reduction in surgery rate, decreased use of opioids/medications, and complications were noted, if reported. The evidence on each outcome was appraised in accordance with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system of evaluating evidence. The search yielded 71 primary publications addressing fluoroscopically guided lumbar interlaminar epidural steroid injections. There were no explanatory studies and all pragmatic studies identified were of low quality, yielding evidence comparable to observational studies. The body of evidence regarding effectiveness of fluoroscopically guided interlaminar epidural steroid injection is of low quality according to GRADE. Studies suggest a lack of effectiveness of fluoroscopically guided lumbar interlaminar epidural steroid injections in treating primarily axial pain regardless of etiology. Most studies on radicular pain due to lumbar disc herniation and stenosis do, however, report statistically significant short-term improvement in pain.

The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data.

To determine the effectiveness and risks of non-image-guided lumbar interlaminar epidural steroid injections. Systematic review. Three reviewers with formal training and certification in evidence-based medicine searched the literature on non-image-guided lumbar interlaminar epidural steroid injections. A larger team of seven reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented. The primary outcome assessed was pain relief. Other outcomes such as functional improvement, reduction in surgery rate, decreased use of opioids, and complications were noted, if reported. The evidence was appraised in accordance with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system of evaluating evidence. The searches yielded 92 primary publications addressing non-image-guided lumbar interlaminar epidural steroid injections. The evidence supporting the effectiveness of these injections for pain relief and functional improvement in patients with lumbar radicular pain due to disc herniation or neurogenic claudication secondary to lumbar spinal stenosis is limited. This procedure may provide short-term benefit in the first 3-6 weeks. The small number of case reports on significant risks suggests these injections are relatively safe. In accordance with GRADE, the quality of evidence is very low. In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, non-image-guided lumbar interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical practice, these procedures should be restricted to the rare settings where fluoroscopy is not available.

The Impact of Body Mass Index on Fluoroscopy Time During Lumbar Epidural Steroid Injection; A Multicenter Cohort Study.

This study aimed to assess the relationship between BMI and fluoroscopy time during lumbar epidural steroid injections (LESIs) performed for lumbosacral radicular pain. Multicenter retrospective cohort study. Three academic, outpatient pain treatment centers. Patients who underwent fluoroscopically guided LESI. Mean and standard deviation (SD) fluoroscopy time were compared between patients with normal (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2) BMI. Statistical significance was set at P=0.01 due to multiple comparisons. A total of 2,930 procedure encounters were included, consisting of 598 interlaminar LESIs and 2,332 transforaminal LESIs. Fluoroscopy time was significantly longer in the obese patients compared to normal and overweight patients during interlaminar LESI (P < 0.01). Fluoroscopy time was significantly longer with each increasing BMI category in during transforaminal LESI (P < 0.01). These relationships remained when a trainee was involved (P < 0.01; P<0.01), during repeat injections (P < 0.01; P < 0.01), and during bilateral transforaminal LESIs (P < 0.01). While longer fluoroscopy times were required in high BMI categories during L5-S1 transforaminal LESI (P < 0.01), there was no relationship between fluoroscopy time and BMI during L4-L5 and S1 transforaminal LESI (P = 0.02; P = 0.13). Fluoroscopy time during interlaminar LESI compared to transforaminal LESI was significantly lower within all BMI categories (all P<0.01). The findings of this study indicate that fluoroscopy time is increased during interlaminar LESIs and during L5-S1 transforaminal LESIs in patients who are obese. These relationships are not affected by injection number, performance of bilateral injections, or trainee involvement. Further study is needed to determine if this increase in fluoroscopy time is indicative of a clinically significant associated increase in radiation dose.

Serum Triamcinolone Levels Following Interlaminar Epidural Injection.

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

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

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

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

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

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

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

Concordant Pressure Paresthesia During Interlaminar Lumbar Epidural Steroid Injections Correlates with Pain Relief in Patients with Unilateral Radicular Pain

Background: Transforaminal and interlaminar epidural steroid injections are commonly used interventional pain management procedures in the treatment of radicular low back pain. Even though several studies have shown that transforaminal injections provide enhanced short-term outcomes in patients with radicular and low back pain, they have also been associated with a higher incidence of unintentional intravascular injection and often dire consequences than have interlaminar injections. Objectives: We compared 2 different approaches, midline and lateral parasagittal, of lumbar interlaminar epidural steroid injection (LESI) in patients with unilateral lumbosacral radiculopathic pain. We also tested the role of concordant pressure paresthesia occurring during LESI as a prognostic factor in determining the efficacy of LESI. Study Design: Prospective, randomized, blinded study. Setting: Pain management center, part of a teaching-community hospital in a major metropolitan US city. Methods: After Institutional Review Board approval, 106 patients undergoing LESI for radicular low back pain were randomly assigned to one of 2 groups (53 patients each) based on approach: midline interlaminar (MIL) and lateral parasagittal interlaminar (PIL). Patients were asked to grade any pressure paresthesia as occurring ipsilaterally or contralaterally to their “usual and customary pain,” or in a distribution atypical of their daily pain. Other variables such as: the Oswestry Disability Index questionnaire, pain scores at rest and during movement, use of pain medications, etc. were recorded 20 minutes before the procedure, and on days 1, 7, 14, 21, 28, 60, 120, 180 and 365 after the injection. Results: Results of this study showed statistically and clinically significant pain relief in patients undergoing LESI by both the MIL and PIL approaches. Patients receiving LESI using the lateral parasagittal approach had statistically and clinically longer pain relief then patients receiving LESI via a midline approach. They also had slightly better quality of life scores and improvement in everyday functionality; they also used less pain medications than patients receiving LESI using a midline approach. Furthermore, patients in the PIL group described significantly higher rates of concordant moderate-to-severe pressure paresthesia in the distributions of their “usual and customary pain” compared to the MIL group. In addition, patients who had concordant pressure paresthesia and no discordant pressure paresthesia (i.e., “opposite side or atypical”) during interventional treatment had better and longer pain relief after LESI. Two patients from each group required discectomy surgery in the one-year observation period. Limitations: The major limitation of this study is that we did not include a transforaminal epidural steroid injection group, since that is one of the approaches still commonly used in contemporary pain practices for the treatment of low back pain with unilateral radicular pain. Conclusions: This study showed that the lateral parasagittal interlaminar approach was more effective than the midline interlaminar approach in targeting low back pain with unilateral radicular pain secondary to degenerative lumbar disc disease. It also showed that pressure paresthesia occurring ipsilaterally during an LESI correlates with pain relief and may therefore be used as a prognostic factor. Key words: lumbar epidural steroid injection, interlaminar injection, low back pain, unilateral radicular pain, midline interlaminar approach, lateral parasagittal interlaminar approach, pressure paresthesia, quality of life, everyday functionality

Digital subtraction angiography does not reliably prevent paraplegia associated with lumbar transforaminal epidural steroid injection

Digital subtraction angiography (DSA) has been touted as a radiologic adjunct to minimize complications during interventional neuraxial procedures where it is imperative to identify vascular compromise. We present a case of instantaneous paraplegia following lumbar TFESI wherein a local anesthetic test dose, as well as DSA was used as adjuncts to fluoroscopy. An 80 year-old male with chronic L5 radiculopathic pain was evaluated at a University Pain Management Center. Two previous lumbar interlaminar epidural steroid injections provided transient pain relief, and decision was made to perform right-sided L5-S1 TFESI with a 5 inch, 22-gauge Quincke type spinal needle with a curved tip.

Analysis of dispersion of lumbar interlaminar epidural injectates

It is recognized that because most lumbar disc herniations occur posterior to the vertebrae, inflammation arises primarily in the anterior epidural space at the site of the disc herniation [1]. Therefore, deposition of steroids in the anterior epidural space directly at the site of inflammation has been the preferred treatment [2]. Until recently, the transforaminal approach has been considered to be the most target-specific, with the least volume necessary to reach the primary site of pathology (the anterior epidural spaces), compared to interlaminar approaches [3,4]. However, the transforaminal approach presents a higher risk of severe adverse events for patients. We have clearly confirmed through an imaging study, whether or not lumbar interlaminar epidural injectates are able to reach the anterior epidural space. After informed, written consent was obtained, 43 patients who suffered from lower back pain without radiculopathy due to degenerative disc disease or internal disc disruption were enrolled in an Institutional Review Board-approved, prospective, controlled, single-blinded study. The male to female ratio was 1 : 2, and the mean age was 61.9 years. Lower back pain in all study patients was treated with lumbar interlaminar epidural steroid injections (LIESIs). Patients with extruded disc rupture, severe spinal stenosis with neurogenic claudication, severe spondylolisthesis and history of spinal surgery or intervention, such as percutaneous vertebroplasty or kyphoplasty, were excluded in order to minimize the influence of anatomical deformities that could affect the dispersion pattern of lumbar interlaminar epidural injectates. The study patients were randomly divided into four groups (A, B, C and D) according to the total volume of injectate administered. Injectates were composed of 0.5% lidocaine, 20 mg of triamcinolone, and radiocontrast dye (Isovist-240, Schering) and were administered as follows: Group A received 5 ml (3 ml of 0.5% lidocaine, 20 mg of triamcinolone [0.5 ml], and 1.5 ml of radiocontrast dye), Group B received 7.5 ml (5 ml of 0.5% lidocaine, 20 mg of triamcinolone, and 2 ml of radiocontrast dye), and Group C received 10 ml (7 ml of 0.5% lidocaine, 20 mg of triamcinolone, and 2.5 ml of radiocontrast dye). To clarify the effect of position change on the dispersion of the injectates, Group D received 7.5 ml (5 ml of 0.5% lidocaine, 20 mg of triamcinolone, and 2 ml of radiocontrast dye) and assumed a supine position soon after the procedure until the computed tomography (CT) scan was taken. After 20 minutes, all patients were re-scanned from the upper endplate level of the L1 body to the S2 body level, using CT to a thickness of three millimeters. The physicians divided each vertebra into two compartments; an upper and a lower. One intervertebral disc was regarded as one compartment. Therefore, the total number of compartments was 16; from the L1 upper endplate level to the S1 upper body level (Fig. 1). Fig. 1 Rescanned CT image taken 20 minutes after completion of the LIESI. Regions from the upper endplate of L1 to the midportion of S1 are divided into 16 compartments (A: anterior epidural space, B: posterior epidural space). The results show that there were no statistical differences between Groups A, B, and C in the degree of dispersion of the injectates anteriorly and posteriorly in the epidural space (P > 0.05) and that there were no statistical differences between Groups B and D (P > 0.05). However, in all of the groups, the degree of dispersion of the injectates within the posterior epidural space was greater than that within the anterior epidural space. No patient in this study experienced any infection, headache, intravascular injection, reaction to the contrast material and steroid, or subarachnoid injection. However, the present study has some limitations. In particular, the lack of control group to allow for comparison and assessment of the clinical effectiveness of the experimental groups is something that should be rectified in future studies. If a control group, such as an lumbar transforaminal epidural injectates (LTESIs) group, had been included in the study and the clinical effectiveness of the intervention groups had been compared with the control group, the authors would be able to determine more precisely the clinical usefulness of LIESI, although the amount of injectate that can reach the anterior epidural space would remain unknown. Second, it is possible that the small sample size may have increased the probability of type II errors (i.e. failing to detect a difference when there is one). Third, all procedures were performed by a single physician, therefore the results of the present study reflect the experience of one practitioner and may not be generalized. Although this study does have some limitations and flaws, to our knowledge, this is the first report verifying clearly through an imaging study, the dispersion patterns of lumbar interlaminar epidural injectates, while simultaneously considering the impact of time. In conclusion, although the authors cannot state precisely the amount of lumbar interlaminar epidural injectate that can reach the anterior epidural space, we know that more than 5 ml of injectate for the LIESIs can reach the anterior epidural space well. The effect of the patient's posture bears little relation to the degree of dispersion of the injectates.