Lumbar Transforaminal Epidural Injections Research Articles

Functional Outcomes of Fluoroscopy-Guided Intra-articular Steroids in Lumbar Facet Arthropathy: A Retrospective Comparative Study of Dexamethasone Versus Triamcinolone Acetonide.

Introduction Mechanical low back pain frequently originates from the lumbar facet joint (LFJ). Axial low back discomfort can result from osteoarthritis in the LFJ. Depending on the severity of LFJ degeneration, the effect of intra-articular (IA) LFJ corticosteroid injection may vary. For LFJ discomfort, IA block with steroids and local anaesthetics has also been utilised, with varying degrees of success. The main objective of this study was to assess the efficacy of IA steroid injections dexamethasone vs. triamcinolone acetonide for the treatment of LFJ syndrome and to compare functional outcome in terms of Visual Analog Scale(VAS) score, Modified Oswestry Disability Index(MODI) score, and short-form McGill Pain Questionnaire between the two groups. Methodology Dexamethasone 8 mg or triamcinolone acetonide 40 mg was given intra-articularly to27 patients comprising group A and 33 patients comprising group B, respectively (total 60 patients). Before intervention and at one, three, and six months, observation was conducted using the VAS score, short-form McGill pain questionnaire, and MODI score. Results There was a significant difference between both the groups after the procedure with pain alleviation and functional improvement, more in the group that received triamcinolone acetonide. A significant difference was observed in all three parameters that assessed pain with differences more pronounced at six months. Conclusion Pain reduction and clinical outcomes were better among the group that received triamcinolone acetonide. Injection of a steroid alone is associated with its own side effects. When a lumbar transforaminal epidural injection is used to treat radiculopathy in the lumbar area, particulate medication (triamcinolone) is more effective than non-particulate medication (dexamethasone) with no known drug-related complications.

Lumbar Transforaminal Epidural Platelet Rich Plasma Injections: The Novel Modality for the Treatment of Low Back Pain

Background: Low back is a common health problem, it causes significant morbidity that limits the economic productivity, the use of platelet rich plasma has been shown to be effective in cosmetic surgical procedures and help accelerate wound healing in trauma and joint injuries. Platelet rich plasma injections use each individual patient’s own healing system to improve musculoskeletal problems. We therefore investigated the use of lumbar transforaminal epidural platelet rich plasma injections for the treatment of low back pain patients. Methods: We evaluated a pain numerical rating scale for a total of 210 patients with low back pain at the level of L3-4-5, immediately prior to the procedure, the patients completed the pain numerical rating scale score were 0 no pain and 10 the worst pain, a successful categorical outcome were defined as reduction in pain by at least 50%, we also evaluated an assessment of immediate post procedure numerical rating scale at 2 weeks and we measure the successful outcomes at 2 months. Results: Immediate NRS response was weakly associated with 2-month outcomes, Patients that responded at 2 weeks were more likely to be responders at 2 months than those who were non-responders at 2 weeks. Conclusion: Immediate post-TFE PRP pain relief does not strongly predict longer term effectiveness in pain relief or functional recovery. Response in pain relief or functional recovery at 2 weeks is more strongly associated with 2-month outcomes.

Ultrasound-guided transforaminal epidural injection with fluoroscopy confirmation for the treatment of unilateral lumbar radiculopathy: A randomized controlled non-inferiority study

BackgroundUltrasound (US)-guided injections for chronic pain has multiple advantages over traditional radiologic method. The study was performed to exam the clinical outcomes of lumbar transforaminal epidural injection (LTFEI) between US and fluoroscopy (FL) guidance for lumbar radiculopathy (LRP). MethodsA total of 164 patients with LRP were randomly assigned into US and FL group to receive LTFEI in a 1:1 ratio. Pain relief and functional disability were assessed by numeric rating scale (NRS) and Modified Oswestry Disability Questionnaire (MODQ) scores before treatment, 1 month and 3 months post-intervention. Contrast spread pattern, fluoroscopic image number and complications were also recorded. The primary outcome was accurate rate of contrast dispersing into lumbar epidural space, and non-inferiority margin was predefined at −15 %. ResultsThe accuracy of LTFEI was 90.2 % and 91.5 % in US and FL group, and the lower limit of the 95 %CI of mean difference between two modalities (−4.9 % (95 %CI: −12.8 %, 3.1 %)) was above the non-inferiority margin. Procedure time in US group (531.90 ± 67.12 s) was shorter than FL group (904.20 ± 120.20 s) (p < 0.05), while radiation dosage in the US group was lower than in the FL group (3047.20 ± 569.53 vs. 8807.50 ± 1039.10 μGy m2, p < 0.001). Both groups didn’t differ in pain reduction (F = 1.050, p = 0.306) and functional improvement (F = 0.103, p = 0.749) during follow-up period. No severe complications occurred in both groups. ConclusionsUS-guided LTFEI confirmed by FL was not inferior to conventional FL method in terms of accurate rate of lumbar epidural contrast dispersion. Effective pain relief and functional ability improvement were comparable between two modalities, and US technique had advantages of less radiation exposure and possible facilitation of avoiding critical vessels around intervertebral foramen.

Relationship between needle depth for lumbar transforaminal epidural injection and patients' height and weight using magnetic resonance imaging.

BackgroundOptimal needle depth in transforaminal epidural injection (TFEI) is determined by body measurements and is influenced by the needle entry angle. Physician can choose the appropriate needle length and perform the procedure more effectively if depth is predicted in advance.MethodsThis retrospective study included patients with lumbosacral pain from a single university hospital. The skin depth from the target point was measured using magnetic resonance imaging transverse images. The depth was measured bilaterally for L4 and L5 TFEIs at 15°, 20°, and 25° oblique angles from the spinous process.ResultsA total of 4,632 measurements of 386 patients were included. The lengths of the left and right TFEI at the same level and oblique angle were assessed, and no statistical differences were identified. Therefore, linear regression analysis was performed for bilateral L4 and L5 TFEIs. The R-squared values of height and weight combined were higher than the height, weight, and body mass index (BMI). The following equation was established Depth (mm) = a – b (height, cm) + c (weight, kg). Based on the equation, maximal BMI capable with a 23G, 3.5-inch, Quincke-type point spinal needle was presented for three different angles (15°, 20°, and 25°) at lumbar levels L4 and L5.ConclusionsThe maximal BMI that derived from the formulated equation is listed on the table, which can help in preparations for morbid obesity. If a patient has bigger BMI than the one in the table, the clinician should prepare longer needle than the usual spinal needle.

Predictive value of immediate pain relief after lumbar transforaminal epidural injection with local anesthetics and steroids for single level radiculopathy

ObjectiveTo assess the predictive value of immediate pain-relief after CT-guided transforaminal epidural steroid injection (TFESI) including local anesthetics for longer-term pain relief and patients’ global impression of change (PGIC) after 4 weeks.Materials and methodsOne hundred ninety-three patients (age 55.4 ± 14.9) with single-level discogenic lumbar radiculopathy and subsequent TFESI were included. Pain scores were recorded before (NRS0), 15 min (NRS15min), and 4 weeks (NRS4w) after treatment using a numerical-rating-scale (NRS; 0, no pain; 10, intolerable pain). Additionally, the PGIC was assessed after 4 weeks. Two fellowship-trained musculoskeletal radiologists evaluated nerve compression of the injected level and contrast dispersion. Spearman’s rank and point-biserial correlation were applied to assess associations between outcome variables and demographics/imaging findings. A p-value < 0.05 was considered to be statistically significant.ResultsThere was a significant positive correlation between immediate pain-relief and longer-term pain-reduction (r = 0.24, p = 0.001) with an odds ratio of 2.0 (CI: 1.1–3.6). A good short-term response (NRS15min ≥ 50% reduction) was associated with a persistent longer-term good response (NRS4w ≥ 50% reduction) in 59.7% (CI: 50.9–68.0%) of patients. There was no association between short-term pain-relief and PGIC after 4 weeks (p = 0.18). Extent and location of nerve compression and contrast dispersion during TFESI did not correlate with longer-term pain-relief (all p ≥ 0.07).ConclusionOur results indicate a significant positive correlation between immediate post-procedural and longer-term pain relief after TFESI in patients with lumbar radiculopathy; however, no effect of short-term pain relief is seen on PGIC after 4 weeks. Patients with good longer-term outcome (≥ 50% pain reduction) are twice as likely to have already shown good immediate pain reduction after TFESI.

A comparative evaluation of kambin’s triangle approach versus safe triangle approach for lumbar transforaminal epidural injection in patients with lumbar radiculopathy - A prospective, randomized, double blind study

Background: Epidural injection of steroid and local anaesthetic is a common modality for management of radicular pain. Transforaminal approach is preferred for epidural injection in case of radiculopathy.&#x0D; Aims and Objectives: To compare the effect of the Kambin’s triangle and subpedicular approaches of transforaminal epidural injection (TFEI) in patients of lumbar radiculopathy.&#x0D; Materials and Methods: Forty patients with lumbar radicular pain were enrolled and randomly assigned to each group (Group K for Kambin’s triangle approach and Group S for subpedicular approach). All procedures were performed under fluroscopic guidance. The frequency of complications during the procedure and the effect of TFEI at 2 and 4 weeks after the procedure between the two groups were compared. Short-term outcomes were measured using a visual Analog scale (VAS). Multiple logistic regression analyses were performed to evaluate the relationship between possible outcome predictors and the therapeutic effect.&#x0D; Result: VAS was improved 2 weeks after the injection and continued to improve until 4 weeks in both groups. There were no statistical differences in changes of VAS between these two groups. Spinal nerve pricking occurred in one case of the subpedicular and in none of the cases of the Kambin’s triangle approach (p&lt;0.05).&#x0D; Conclusion: Kambin’s triangle approach is as efficacious as the subpedicular approach for short-term effect and offers considerable advantages (i.e., less spinal nerve pricking during procedure). So, Kambin’s triangle approach may be an alternative method for TFEI in cases where needle tip positioning in the anterior epidural space is difficult.

Spinal nerve signal intensity on Dixon T2-weighted water-only sequence: an important outcome predictor after lumbar transforaminal epidural injection.

To evaluate the role of Dixon T2-weighted water-fat separation technique in predicting the outcome of lumbartransforaminal epidural injections (TFESIs). Patients who underwent TFESI of a single spinal nerve within 3 months after magnetic resonance imaging (MRI) exam between August 2018 and April 2020 were identified. The patients were classified into positive or negative outcome groups based on the response to the TFESI procedure. Two musculoskeletal radiologists measured the signal intensity of the injected side spinal nerves, contralateral side spinal nerves, and subcutaneous fat on axial Dixon T2-weighted water-only images, and the diameter of spinal nerve on axial Dixon T2-weighted in-phase images of the pre-procedural MRI. The measured values of the injected side spinal nerves were compared between the two groups and with the contralateral side spinal nerve. A total of 94 patients were included, 76 in the positive outcome group and 18 in the negative outcome group. The mean signal intensity and the nerve-to-fat signal ratio of the injected side spinal nerve were significantly higher in the positive outcome group than in the negative outcome group (793.78 vs. 679.19, p = 0.016; 4.21 vs. 3.28, p = 0.003). In the positive outcome group, the diameter of the spinal nerve was significantly higher on the injected side than on the contralateral side (6.91 mm vs. 6.37 mm, p = 0.016). The mean signal intensity and the nerve-to-fat signal ratio of the spinal nerve on axial Dixon T2-weighted water-only images can help predict patient response to the TFESI. • Applying the Dixon technique to lumbar spine MRI can help predict patient response to the TFESI procedure. • An increased nerve-to-fat signal ratio and mean spinal nerve signal intensity on axial Dixon T2-weighted water-only images predicted favorable TFESI outcomes.

Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines

BACKGROUND: Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE: To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS: The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and recommendations were provided. RESULTS: In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives. The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness. The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness. Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness. The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS: The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS: These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations. KEY WORDS: Chronic spinal pain, interventional techniques, epidural procedures, caudal epidural, lumbar interlaminar epidural, cervical interlaminar epidural, thoracic interlaminar epidural, lumbar transforaminal epidural, percutaneous adhesiolysis DISCLAIMER: These guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a “standard of care.” There was no external funding in the preparation of this manuscript.

Role of transforaminal epidural injections or selective nerve root blocks in the management of lumbar radicular syndrome - A narrative, evidence-based review

ObjectiveLumbar radicular Syndrome (LRS) is a common spinal pathology and is attributed to complex interplay of mechanical, inflammatory and immunological processes. Epidural injection of steroids has a significant therapeutic role in mitigating the inflammatory component of LRS. Trans-foraminal approach under image guidance enables a targeted drug delivery. The current narrative review discusses the various aspects related to lumbar trans-foraminal epidural injection of steroid (LTFIS). MethodsAn elaborate search on PubMed, Google and Medline databases was made using keywords “lumbar selective nerve root block”, “lumbar trans-foraminal epidural steroid injection”, “selective nerve root block in lumbar disc prolapse”, “trans-foraminal epidural steroid injection in lumbar prolapse”, “selective nerve root block in lumbar radiculopathy”, and “trans-foraminal epidural steroid injection in lumbar radiculopathy” The articles were selected based on specific inclusion criteria. ResultsOur search identified 539 articles. All articles discussing alternate procedures, LTFIS in other pathologies, diagnostic roles of LTFIS, not pertaining to concerned questions, in non-English language and duplicate articles were excluded. Review articles, randomised controlled trials or level 1 studies were given preference. Overall, 108 articles were included. Being a focussed narrative review, further screening [Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) or Methodological Index for non-randomized studies (MINORS) criteria] was not performed to select articles. Based on the evidence, LTFIS is an effective and useful treatment modality. It is offered to patients with lumbar disc herniation (LDH) presenting with persistent, unilateral, radiculopathy after a course of conservative measures for around 6 weeks’ duration. It has been reported to yield better results than caudal or inter-laminar epidural injections. The anti-inflammatory and nociceptive signal stabilization actions of steroids, as well as mechanical effects of washout of inflammatory mediators and neural lysis contribute to its efficacy. The three different approaches include sub-pedicular, retro-neural and retro-discal. The procedure is performed under image guidance using a water-soluble contrast under fluoroscopy. The four described radiculogram patterns include “arm”, “arrow”, “linear” and “splash”. Computerised tomography, ultrasonography and magnetic resonance imaging are other modalities, which may be helpful in performing LTFIS. The use of particulate versus non-particulate steroids is controversial. ConclusionThe overall success rate of SNRB is reported to be 76–88%. The majority of benefits are observed during immediate and early post-injection period. Clinical factors including duration and severity of symptoms, and radiological factors like presence of osteophytes, location, size and type of disc prolapse influence outcomes. The radiculogram “splash” pattern is associated with poor outcomes.

Three-dimensional architecture of the neurovascular and adipose zones of the upper and lower lumbar intervertebral foramina: an epoxy sheet plastination study.

Kambin's triangle and the safe triangle are common posterolateral approaches for lumbar transforaminal endoscopic surgery and epidural injection. To date, no consensus has been reached on the optimal transforaminal approach, in particular its underlying anatomical mechanism. The aim of this study was to investigate the 3D architecture of the neurovascular and adipose zones in the upper and lower lumbar intervertebral foramina (IVFs). Using the epoxy sheet plastination technology, 22 cadaveric lumbar spines (12 female and 10 male, age range 46-89 years) were prepared as a series of transverse (11 sets), sagittal (8 sets), and coronal (3 sets) slices with a thickness of 0.25 mm (6 sets) or 2.5 mm (16 sets). The high-resolution images of the slices were scanned and analyzed. The height, area, and volume of 30 IVFs from T12-L1 to L4-5 were estimated and compared. This study was performed in accord with the authors' institutional ethical guidelines and approved by the institutional ethics committees. The findings were as follows. 1) The 3D boundaries of the lumbar IVF and its subdivisions were precisely defined. 2) The 3D configuration of the neurovascular and adipose zones was different between the upper and lower lumbar IVFs; zoning in the upper lumbar IVFs was much more complex than that in the lower lumbar IVFs. 3) In general, the infraneural adipose zone gradually tapered and rotated from the inferoposterolateral aspect to the superoanteromedial aspect. 4) The average height, area, and volume of the IVF gradually increased from the upper to the lower lumbar spine. Within a lumbar IVF, the volumes below and above the inferior border of the dorsal root ganglia were similar. This study highlights differences of fine 3D architecture of neurovascular and adipose tissues between the upper and lower lumbar IVFs, with related effects on the transforaminal approaches. The findings may contribute to optimization of the surgical approaches to and through the IVF at different lumbar spinal levels and also may help to shorten the learning curve for the transforminal techniques.

A Video of Ultrasound-Guided S1 Transforaminal Epidural Injection Using Color Doppler: Technical Reports.

Lumbosacral radicular pain with or without radiculopathy is a fairly common clinical condition. In such cases, lumbosacral transforaminal epidural injection (TFEI) is one of the most commonly performed interventions. Recent studies have explored the effectiveness of ultrasound (US)-guided lumbosacral TFEI. Most of these studies have focused on lumbar TFEI via an in-plane approach. S1 TFEI can also be easily performed, since the S1 foramen is more superficial than the lumbar foramen. However, most studies regarding US-guided sacral TFEI use an out-of-plane technique. Therefore, in this report we present a video of US-guided S1 TFEI via an in-plane approach.

Synovial Cysts Confounding Access to the Dorsal S1 Neural Foramen in Transforaminal Epidural Steroid Injections.

The S1 dorsal foramen is the route for 30% of lumbar transforaminal epidural injections; it is therefore important to identify structures impeding S1 foraminal access. The study objective was to characterize the imaging findings, prevalence, and anatomic origin of synovial cysts presenting within the S1 neural foramen. A case series (N = 14) established imaging characteristics of S1 synovial cysts. Imaging studies of 400 patients undergoing epidural injections were reviewed for lesions compromising S1 foraminal access. Cadaveric dissections defined the relationship of the inferior recess of the L5-S1 facet to the S1 dorsal foramen. Elderly patients (mean age = 76) exhibited S1 synovial cysts. Synovial cysts were typically 1-2 cm in diameter, hyperintense on sagittal T2 weighted magnetic resonance images (MRIs), fluid-density on computed tomography, and dorsal to the S1 spinal nerve. Sixty percent of cysts exhibited complex MRI signal characteristics (thick wall, internal structure). Tarlov cysts, in contrast, were larger, lobular, and exhibited pure fluid intensity. Lesions impeded access to the S1 dorsal foramina in 5% of reviewed imaging studies (16 Tarlov cysts, three synovial cysts, one conjoint S1-S2 nerve root). The multifidus muscle was interposed between the L5-S1 facet inferior recess and the S1 dorsal foramen on dissection specimens; severe atrophy of the ipsilateral multifidus was noted on imaging in 17/18 synovial cysts. The S1 neural foramina should be inspected on sagittal MRI, when available, for confounding lesions before performing S1 epidural injections. Tarlov cysts are more common than synovial cysts; the latter are seen in elderly patients with severe multifidus atrophy.

Comparison Immediate and Acute Adverse Effects Following Transforaminal Epidural Steroid Injections with Dexamethasone and Diluted Triamcinolone

Background: Transforaminal epidural steroid injections (both lumbar and cervical) are used in many treatments. The use of this method in the control and treatment of radicular pain is intensively expanding. In this method, and for the purpose of implementing the injection process, the needle is inserted from the posterolateral of the spine and steroids injected.&#x0D; Steroids include a wide range of medications, many of which are used in modern medicine. Research on these drugs is still underway. The use of Dexamethasone in lumbar transforaminal epidural injections and the study of complications caused by it have been less studied. In some previous studies, use of this steroid for lumbar transforaminal epidural injections has been mentioned.&#x0D; Methods: The present study was conducted in Shohada-e-Tajrish Hospital in Tehran. Patients over 18 years of age who were afflicted with Lumbar stenosis Foraminal (Diagnosis by MRI) and had associated with Radio Kevlar pain were selected. These patients are divided into two groups of 14. In a group, 2.5 cc dexamethasone 8 mg / cc diluted with 2.5 cc distilled water was injected. In the second group, 2.5 cc triamcinolone 40 mg / cc was injected with 2.5 cc distilled water in a volume of 5 cc. In order to evaluate and compare the effects of these two steroids on the patients, the results of the questionnaire were evaluated by statistical techniques and software SPSS 21.&#x0D; Results: The results showed that the use of dexamethasone had far more successful effects than another drug. However, the above conclusion is a relative conclusion and absolute expression is not possible. Pharmaceutical manifestations are the result of patient reactions. Thus, doing similar research and comparing drug performance should be put on the agenda of various research and medical teams.&#x0D; Conclusion: Use of Dexamethasone had far more successful effects than Triamcinolone on epidural steroid injections.

Ultrasound-Guided Lumbar Transforaminal Epidural Injections; A Single Center Fluoroscopic Validation Study.

To investigate the success rate (technical precision) of ultrasound-guided lumbar transforaminal epidural steroid injection, which was validated by conventional fluoroscopic technique. A total of 20 patients with unilateral single-level lumbar foraminal disc protrusion causing radiculopathy were enrolled. Using transforming route, the needle location was determined by an axial (transvers) view of the ultrasound with fluoroscopic confirmation. We determined the needle placement accuracy of ultrasound- guided lumbar transforaminal injections approach. The accuracy of ultrasound-guided interventions was 90% as confirmed by fluoroscopy. There were 2 failed cases at the L4-L5 level in the US-guided. The success rate in L5-S1 level was 100%, in L4-L5 level was 80% and in L3-L4 level was 100%. No complications were noted. Ultrasound-guided lumbar transforaminal epidural injections are accurate and feasible in clinical setting with an accuracy of 90% and no complications.

The Influence of Local Anesthesia Depth on Procedural Pain During Fluoroscopically Guided Lumbar Transforaminal Epidural Injections: A Randomized Clinical Trial.

The aim of the study was to evaluate the influence of the depth of local anesthesia application on procedural pain during lumbar transforaminal epidural steroid injection. Sixty-eight patients were enrolled who were scheduled for single-level, unilateral fluoroscopically guided lumbar transforaminal epidural steroid injection. Patients were randomly allocated to receive either subcutaneous local anesthesia (group S) or deep local anesthesia (group D) for transforaminal epidural steroid injection. The data related to pain and technical performance during the procedure was compared. In addition, the incidence of injection site soreness was assessed 2 wks after transforaminal epidural steroid injection. Sixty-seven patients completed all assessments (group S, n = 33; group D, n = 34). There was no significant difference in procedural pain and discomfort level between the groups (P = 0.151, P = 0.183, respectively). Patients in group D showed lower behavioral pain scores (P = 0.017). There was no significant difference in the numbers of needle manipulations, fluoroscopy time, and radiation dose during the procedure between the groups. Two patients in group S and three in group D complained of injection site soreness after transforaminal epidural steroid injection for a few days, but there was no significant difference in its incidence (P = 0.667). Deep local anesthesia to reduce procedural pain during transforaminal epidural steroid injection seems to have no significant clinical benefit compared with conventional subcutaneous local anesthesia. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Reduce procedural pain by considering clinical factors of the patient during fluoroscopically guided lumbar transforaminal epidural injections.Upon completion of this article, the reader should be able to: (1) Understand the potential impact of procedural pain on the performance of transforaminal epidural steroid injections; (2) Distinguish cutaneous nociceptive afferents from nociceptive afferents in muscle; and (3) Explain the factors to reduce procedural pain during fluoroscopically guided lumbar transforaminal epidural injections. Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The short and midterm outcomes of lumbar transforaminal epidural injection with preganglionic and postganglionic approach in lumbosacral radiculopathy: a systematic review and meta-analysis.

The purpose of this study was to compare clinical outcomes after preganglionic versus ganglionic epidural steroid injection (ESI) using a systematic review and network meta-analysis. A systematic review and meta-regression was performed to compare postoperative outcomes between the two difference injection techniques. Relevant randomized controlled trials were identified from Medline and Scopus up to September 24, 2016. Sixteen out of 598 studies were eligible; 3, 2, and 3 studies were included in the pooling of outcomes including effectiveness, visual analog score (VAS), and complications (nerve root, injury, dural puncture, and intraneural injection). Preganglionic ESI has a 2.38 (95% CI 1.12, 5.04) times statistically significantly higher chance of effectiveness when compared to ganglionic ESI. There were differences in pain VAS and complications in lumbar radiculopathy, but these displayed no statistical significance. This meta-analysis indicated that preganglionic ESI has a statistically significantly higher chance of effectiveness when compared to ganglionic ESI. In terms of pain score and complications, there were no statistically significant differences between the two groups. These results were generally homogeneous and with little publication bias, thus should be generalizable.

The Effect of Skin Pressure on Needle Entry Point Accuracy During Fluoroscopically Guided Lumbar Transforaminal Epidural Injections: A Randomized Clinical Trial.

The aim of this study was to investigate the effect of skin pressure on needle entry point accuracy during fluoroscopically guided lumbar transforaminal epidural injection. This study is a prospective randomized clinical trial; 64 patients with a body mass index of 25 kg/m or greater were enrolled. For patients in the pressing group, the operator marked the needle entry point on the patient's back while pressing the patient's skin with the tip of an indicator. For patients in the nonpressing group, the tip of the indicator was gently positioned on the patient's skin. The data related to technical performance and radiation exposure during the procedure were compared. Sixty patients (nonpressing group, n = 30; pressing group, n = 30) were analyzed. There were more attempts to reposition the needle (n) and increased procedure time (in seconds) in the pressing group (median, 5 vs. 4 [P = 0.019]; 400.0 vs. 358.5 [P = 0.033]). The fluoroscopy time (in seconds) and the kerma-area product (in cGy cm) were also significantly longer and greater in the pressing group, respectively (median, 63.5 vs. 50.5 [P = 0.038]; 416.3 vs. 318.6 [P = 0.014]). This study shows that practitioners should not press the skin with a radiopaque indicator when determining the needle entry point by fluoroscopy during lumbar transforaminal epidural injection.

Ultrasound-guided Versus Fluoroscopy-controlled Lumbar Transforaminal Epidural Injections: A Prospective Randomized Clinical Trial.

Recently, most lumbar spine injections have been administered under ultrasound (US) guidance; however, there is no standard method for US-guided lumbar transforaminal epidural injection (TFEI). In this study, we evaluated the accuracy, effect on pain relief, and safety of US-guided lumbar TFEI. A total of 80 patients with low back pain and radicular pain were enrolled. The patients were randomly assigned to either the fluoroscopy (FL) group or the US group. The FL-guided approaches were performed under standardized procedures using the C-arm, whereas the US-guided injections were performed with an US device with a linear probe, and were verified by FL. The needle tip reached the lateral side of the lamina in the axis view and the middle of the adjacent facet joints in the parasagittal view. Afterward, the needle was advanced slightly deeper until the loss-of-resistance test was positive. The success ratio of the US-guided interventions was 85%. The operation time in the US group (518±103 s) was shorter than the FL group (929±228 s) (P<0.05). In addition, the radiation dosage in the US group (2640±906 μGy m²) was lower than in the FL group (8992±2132 μGy m²). There was no significant difference in pain relief between the US and FL groups. No serious complication was observed in any of the patients in either group. Lumbar TFEI under US guidance was feasible, safe, and required less radiation to achieve the same benefit as the FL-guided interventions.

Ultrasound-guided fluoroscopic-verified lumbar transforaminal epidural injection: A clinical evaluation of technique

Background: Fluoroscope guidance method is the gold standard for performing lumbar transforaminal epidural steroid injections (TFESIs), but it is not devoid of adverse effects such as exposure to radiation and need to wear heavy lead aprons. Ultrasound (US)-guided techniques are being evaluated recently but methodological acceptability and reproducibility remain unknown. So after reviewing literatures, studing the us scan of lumber region, we have performed these injection safely and methodologial manner and describing in this study. Duration of Study: The duration of this study was six months, from May 01, 2016, to November 31, 2016. Study Design: This was a prospective, open-label, clinical, pilot study. Materials and Methods: A total of twenty patients with low back pain and radiculopathy were enrolled in this study. A US-guided novel technique was used to perform TFESI. A needle was placed under the guidance of US, and then verified with fluoroscope for dye spread. Then, predecided mixture of drugs were injected. Patients were monitored for number of attempts for localization of transforaminal space, number of adjustment, time taken for needle insertion in transforaminal space, radiation dosage, if the cortex of bone touched by the needle, and whether any complication occurred. Results: The number of attempts for localization of transforaminal space in 85% was one and two in 15% of the patients, number of adjustment per attempt was 5.3, and the average time taken for TFESI in patients in one-attempt group was 973 ± 93 s and 1506 ± 65 s in two-attempt group. Average exposure time of fluoroscope per person was 17.5 ± 2.5 s only. Bone was contacted in 75% of cases and no complications were noted. Conclusion: Lumbar TFESI can be safely and effectively performed under US guidance but fluoroscopic confirmation is required to rule out intravascular and intrathecal spread of the contrast at this stage. However, US guidance has reduced radiation exposure to significant level in this study.

Efficacy of Epidural Injections in Managing Chronic Spinal Pain: A Best Evidence Synthesis

Background: Epidural injections have been used since 1901 in managing low back pain and sciatica. Spinal pain, disability, health, and economic impact continue to increase, despite numerous modalities of interventions available in managing chronic spinal pain. Thus far, systematic reviews performed to assess the efficacy of epidural injections in managing chronic spinal pain have yielded conflicting results. Objective: To evaluate and update the clinical utility of the efficacy of epidural injections in managing chronic spinal pain. Study Design: A systematic review of randomized controlled trials of epidural injections in managing chronic spinal pain. Methods: In this systematic review, randomized trials with a placebo control or an active-control design were included. The outcome measures were pain relief and functional status improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Best evidence synthesis was conducted based on the qualitative level of evidence (Level I to V). Data sources included relevant literature identified through searches of PubMed for a period starting in 1966 through August 2015; Cochrane reviews; and manual searches of the bibliographies of known primary and review articles. Results: A total of 52 trials met inclusion criteria. Meta-analysis was not feasible. The evidence in managing lumbar disc herniation or radiculitis is Level II for long-term improvement either with caudal, interlaminar, or transforaminal epidural injections with no significant difference among the approaches. The evidence is Level II for long-term management of cervical disc herniation with interlaminar epidural injections. The evidence is Level II to III in managing thoracic disc herniation with an interlaminar approach. The evidence is Level II for caudal and lumbar interlaminar epidural injections with Level III evidence for lumbar transforaminal epidural injections for lumbar spinal stenosis. The evidence is Level II for cervical spinal stenosis management with an interlaminar approach The evidence is Level II for axial or discogenic pain without facet arthropathy or disc herniation treated with caudal or lumbar interlaminar injections in the lumbar region; whereas it is Level II in the cervical region treated with cervical interlaminar epidural injections. The evidence for post lumbar surgery syndrome is Level II with caudal epidural injections and for post cervical surgery syndrome it is Level II with cervical interlaminar epidural injections. Limitations: Even though this is a large systematic review with inclusion of a large number of randomized controlled trials, the paucity of high quality randomized trials literature continues to confound the evidence. Conclusion: This systematic review, with an assessment of the quality of manuscripts and outcome parameters, shows the efficacy of epidural injections in managing a multitude of chronic spinal conditions. Key words: Chronic pain, spinal pain, epidural injections, local anesthetic, steroids, interlaminar epidural injections, caudal epidural injections, transforaminal epidural injections