Lumbar Transforaminal Injections Research Articles

Lumbar Transforaminal Injection of Steroids versus Platelet-Rich Plasma for Prolapse Lumbar Intervertebral Disc with Radiculopathy: A Randomized Double-Blind Controlled Pilot Study.

Double-blind randomized controlled pilot study. The purpose of this study was to compare outcomes of steroids with autologous platelet-rich plasma (PRP) administered by lumbar transforaminal injection (LTI) in patients with lumbar radiculopathy. Degenerative disc disease of the lumbar spine is one of the most common conditions managed by spine surgeons in routine practice. Once conservative management fails, LTI is diagnostic and often therapeutic. Steroids are the gold standard drug used for LTI but have limitations and side effects. In this single-center double-blind randomized controlled pilot study, 46 patients were recruited and randomized by the lottery method. The Visual Analog Scale (VAS) for leg pain, modified Oswestry Disability Index (mODI), and Short-Form 12 (SF-12) were assessed at 1 week, 3 weeks, 6 weeks, 6 months, and 1 year. Both groups were comparable in terms of demographics, preprocedure VAS scores, mODI, and SF-12 scores (p=0.52). At the 1-week follow-up, the steroid group had significantly better improvement than the PRP group (p=0.0001). At the 3-week follow-up, both groups showed comparable outcomes; however, the PRP group had better symptom improvement. At 6 weeks and 6 months, the PRP group had better outcomes (VAS, p<0.0001; ODI, p=0.02; SF-12, p=0.002). Moreover, 17 and 16 patients in the steroid and PRP groups underwent repeat LTI with steroids or surgery because of pain recurrence during follow-up. At 1 year, no difference in outcomes was observed. PRP may be a useful alternative to steroids for LTI in lumbar radiculopathy. Although improvement was delayed and 1-year outcomes were comparable, the 6-week and 6-month outcomes were better with PRP than with LTI. Multiple PRP injections may be beneficial because of its autologous nature. However, further studies with a larger number of participants, longer follow-up, and repeat LTIs are warranted to draw definite conclusions.

Artificial Intelligence Co-Authorship: Perspectives on Scientific Accuracy and Responsibility

Dear Editors, Amidst the rapid advancements in artificial intelligence tools, we have read the editorials published in your journal on the subject of “artificial intelligence and academic articles” with great interest [1, 2]. First and foremost, we would like to express our gratitude for fostering an essential platform for discourse on this current topic. Thank you for creating a significant environment for discussion. The rapid advancements emerging in artificial intelligence tools undoubtedly promise significant contributions not only in various fields but also in the realm of science. However, just as in scientific progress, it is clear that the opportunities supporting science and enabling its advancement are also evolving. For instance, had we sent this letter to your journal thirty years ago, we might have needed to send it through postal mail. Alternatively, if our writing had been published in your journal twenty years ago, we could have read it in hard copy rather than in an online environment. Similarly, had we been practising medicine hundreds of years ago, we wouldn't have had the capability to do anything for patients that we can easily treat today with the aid of ultrasound guidance in the operating room. It is highly likely that in the future, thanks to artificial intelligence tools, many tasks will become significantly more efficient and practical. From this perspective, we believe that incorporating artificial intelligence tools into the realm of science is a necessity. However, as you have also pointed out in your editorial articles [1, 2], we believe that the inclusion of artificial intelligence tools as authors in academic research is a significant topic of debate. Based on our current knowledge and perspective, we believe this situation may not be entirely appropriate. We believe that one of the most crucial points of contention regarding the inclusion of artificial intelligence tools as authors in academic research is the concept of “accuracy”. Artificial intelligence provides us with information it finds on the internet. Whether these sources are genuinely obtained from reputable journals cannot be definitively determined. This poses a significant challenge in ensuring the accuracy of such contributions. This also suggests that articles written by artificial intelligence may not be sufficiently reliable. For instance, when we input “the lumbar transforaminal injection method” into ChatGPT, it provides a lot of information on the topic. However, when asked for references, it responds with, “The information I provide is based on a vast dataset of text from a wide range of sources available on the internet, including books, websites, research papers, and more.” Indeed, it can also retrieve information from virtual and/or fake accounts. In essence, as of now, artificial intelligence lacks a truth filter similar to that of a human. While artificial intelligence facilitates rapid access to information, the uncertainty arising from data unreliability raises doubts about the information it presents. Furthermore, we believe that artificial intelligence cannot share an equal level of responsibility with human authors for the information it provides. For these reasons, we are of the opinion that the responsibility for confirming the accuracy of information presented by AI applications lies entirely with the human authors, and we believe that artificial intelligence applications should not be listed as authors in articles. Yours Sincerely,

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.

Update of a Study of Not Ceasing Anticoagulants for Patients Undergoing Injection Procedures for Spinal Pain

To determine prevalence rates of hemorrhagic complications in patients who either ceased or continued anticoagulants during interventional pain procedures. A total of 1,936 consecutive patients were prospectively monitored during a total of 12,723 injection procedures. The prevalence of hemorrhagic complications was tallied for a variety of procedures performed on patients who ceased or continued various anticoagulants. No hemorrhagic complications occurred in any patient who continued anticoagulants. Sufficiently large sample sizes were obtained to conclude that, in patients who continued warfarin or clopidrogel during lumbar transforaminal injections and for lumbar facet procedures, the zero prevalence of complications had 95% confidence intervals of 0% to 0.3%. This prevalence was significantly lower than the risk of medical complications in patients who ceased warfarin. Lumbar transforaminal injections and lumbar facet injections have a very low rate of hemorrhagic complications when patients continue to take anticoagulants.

Three-Dimensional Imaging Angiography (3DIA) vs Fluoroscopy To Reveal Intravascular Injection During Lumbar Transforaminal Steroid Injection: A Retrospective Study

Demonstrate of accidental intravascular injection during lumbar transforaminal anterior epidural steroid injection (TAESI) performed with three-dimensional imaging angiography (3DIA) and fluoroscopy.We assessed 20 (9 males and 11 females) patients (with a total of 40 levels) whose images were received with simultaneously 3DIA and fluoroscopy-guided TAESI between January 2016 and September 2016 as retrospective. Injections were carried out in the lumbar fourth intervertebral space bilaterally and performed in the same way all of the cases.The mean age and body mass index of the patients were 47.9±2.72 years and 26.95±1.21, respectively. There were 10 patients with disc herniation, seven patients with spinal stenosis, and three patients with failed back surgery syndrome. In 3D imaging, vascular escape was detected in the 7 levels (17.5%) which were thought to be no escape in the fluoroscopy imaging.In chronic lumbar radiculopathy patients, intravascular escapes may occur during the fluoroscopic TAESI procedure. To avoid intravascular injections during TAESI procedure, it may be appropriate to use different imaging methods that can give more detailed results such as 3D angiography.

The Effectiveness of Lumbar Transforaminal Injection of Steroid for the Treatment of Radicular Pain: A Comprehensive Review of the Published Data

To determine the effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain. Comprehensive systematic review. The primary outcome of interest was the proportion of individuals with reduction of pain by ≥50%. Additional outcomes of interest were a more-than-two-point reduction in pain score, patient satisfaction, functional improvement, decreased use of pain medication, and avoidance of spinal surgery. For patients with disc herniations, using the criterion of ≥50% reduction in pain, success rates across included studies (range) were 63% (58-68%) at one month, 74% (68-80%) at three months, 64% (59-69%) at six months, and 64% (57-71%) at one year. For patients with lumbar spinal stenosis, success rates across included studies (range) were 49% (43-55%) at one month, 48% (35-61%) at three months, 43% (33-53%) at six months, and 59% (45-73%) at one year, but there was a lack of corroboration from appropriately controlled studies. There is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. There is a lack of high-quality evidence demonstrating their effectiveness for the treatment of radicular pain due to spinal stenosis, though small studies suggest a possible benefit. Lumbar transforaminal injection of nonparticulate steroids is as effective as injections with particulate steroids.

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.

Strategies to Minimize Risk in Lumbar Transforaminal Injections: Imaging and Injectate.

Strategies to Minimize Risk in Lumbar Transforaminal Injections: Imaging and Injectate.

Regarding the paper published 'Ultrasound-guided lumbar transforaminal injection through interfacet approach'.

Regarding the paper published 'Ultrasound-guided lumbar transforaminal injection through interfacet approach'.

Ultrasound-guided lumbar transforaminal injection through interfacet approach.

Ultrasound-guided lumbar transforaminal injection through interfacet approach.

Anticoagulant and Antiplatelet Management for Spinal Procedures: A Prospective, Descriptive Study and Interpretation of Guidelines.

Epidural hematoma rarely complicates interventional spine procedures. While anticoagulant and antiplatelet drugs increase bleeding risk, cessation may precipitate serious thromboembolic events. The Spine Intervention Society (SIS) and American Society of Regional Anesthesia and Pain Medicine (ASRA) put forth guidelines that dissent with regard to management of hemostatically active agents during commonly performed spinal injections. To validate an antiplatelet/anticoagulant management table based on modifications of the SIS 2013 and ASRA 2015 guidelines. Prospective descriptive study. Patients undergoing interventional spine injections from a interventional physiatrist's practice. A Modified SIS 2013-ASRA 2015 Antiplatelet & Anticoagulant (MSAAA) guideline table was devised and adopted. Patients undergoing interventional spine procedures were monitored for bleeding events. Of 4,253 injection sites, 197 (4.6%) were performed in 74 patients on antiplatelet/anticoagulants. No clinically evident bleeding events were observed in patients on antiplatelet/anticoagulant medications for lumbar transforaminal epidural (N = 90), posterior-approach facet joint (N = 62), lumbar intradiscal (N = 11), lumbar sympathetic (N = 3), and sacroiliac (N = 5) injections or in 26 radiofrequency neurotomy procedures. One in 2,026 (0.05%, 95% confidence interval = 0.00-0.31%) interlaminar epidural injections (cervical, thoracic, lumbar, and caudal) suffered epidural hematoma. This patient was not on an antiplatelet/anticoagulant drug. No patient in 191 cervicothoracic and 723 lumbar transforaminal injections experienced bleeding complications. Continuing antiplatelet and anticoagulant medications for intermediate- to low-risk interventional spine procedures may be advisable. The MSAAA table may be a reasonable guideline reference for managing antiplatelet and anticoagulant drugs.

The Risks of Continuing or Discontinuing Anticoagulants for Patients Undergoing Common Interventional Pain Procedures.

Guidelines have been published that recommend discontinuing anticoagulants in patients undergoing interventional pain procedures. The safety and effectiveness of these guidelines have not been tested. The present study was performed to determine if continuing or discontinuing anticoagulants for pain procedures is associated with a detectable risk of complications. An observational study was conducted in a private practice in which some partners continued anticoagulants while other partners routinely discontinued anticoagulants. No complications attributable to anticoagulants were encountered in 4,766 procedures in which anticoagulants were continued. In 2,296 procedures in which anticoagulants were discontinued according to the guidelines, nine patients suffered serious morbidity, including two deaths. Lumbar transforaminal injections, lumbar medial branch blocks, trigger point injections, and sacroiliac joint blocks appear to be safe in patients who continue anticoagulants. In patients who discontinue anticoagulants, although low (0.2%) the risk of serious complications is not zero, and must be considered when deciding between continuing and discontinuing anticoagulants.

Effect of High-Volume Injectate in Lumbar Transforaminal Epidural Steroid Injections: A Randomized, Active Control Trial

Background: There have been many studies proving the effectiveness of lumbar transforaminal epidural steroid injections (TFESIs) for the treatment of radicular pain. Dexamethasone has been suggested as an alternative to particulate steroids. However, no controlled trials have investigated the effect of different injected volumes for a same dose of dexamethasone. Objective: To compare the effects of a high-volume injectate with those of a low-volume injectate using the same dose of dexamethasone for 2 groups in lumbar TFESI. Study Design: A prospective, randomized, active control trial. Setting: The outpatient clinic of a single academic medical center. Methods: A total of 66 patients were randomized to receive lumbar transforaminal epidural dexamethasone injections with either a low-volume injectate (3mL, N = 30) or a high-volume injectate (8mL, N = 32). The primary outcome measures for this study were the incidence of the patients achieving meaningful pain relief and a reduction on the Visual Analogue Scale (VAS, range 0 – 100) at 4 weeks after the procedure. The definition of “meaningful pain relief” was ≥ 50% from baseline. The secondary outcomes included the Roland-Morris Disability Questionnaire (RMDQ, range 0 – 24) score and adverse effects. The outcomes were assessed 4 weeks after the procedure. Results: Four weeks after the procedure, in the DL8 group, the incidence of achieving meaningful pain relief was higher compared with DL3 group (19, 59.4% vs. 9, 30%, P = 0.024). Both groups demonstrated a significant improvement in their VAS and RMDQ scores (P &lt; 0.05). The VAS of the high-volume injectate group (DL8) was significantly lower than that of the low-volume injectate group (DL3) (33.3 ± 25 vs. 46.3 ± 25, P = 0.036). There was no significant difference in the RMDQ score between the 2 groups. Limitations: We enrolled a small number of patients and did not assess the long-term outcomes. Conclusions: Injectate at a volume of 8 mL was more effective than injectate at a volume of 3 mL for radicular pain in a lumbar transforaminal steroid injection, although both of the injectates contained the same dose of dexamethasone. Key words: Dexamethasone, disc herniation, epidural injection, lumbar, radiculopathy

Randomized Double-Blind Controlled Trial Comparing the Effectiveness of Lumbar Transforaminal Epidural Injections of Particulate and Nonparticulate Corticosteroids for Lumbosacral Radicular Pain.

To compare equivalent doses of a nonparticulate (dexamethasone) with a particulate (betamethasone) corticosteroid in lumbar transforaminal epidural steroid injections (TFESIs) in terms of pain, function, and complications. Fifty-six patients presenting with debilitating radicular pain were randomized in a double-blind controlled trial to receive a lumbar transforaminal injection of either dexamethasone 7.5 mg (n = 29) or betamethasone 6.0 mg (n = 27). A pain clinic and physical medicine and rehabilitation department in two academic hospital centres. Data were collected at 1-, 3-, and 6-month follow-ups. The primary outcome was pain reduction on a visual analog scale (VAS) at 3 months. Secondary outcomes were functional improvement, as measured by the Oswestry Disability Index (ODI), and number and type of complications. No differences on the VAS, analyzed either as a continuous (P = 0.209) or categorical variable (≥50% (P = 0.058) or ≥75% (P = 0.865) improvement) and ODI (P = 0.181) were found between the two groups at 3 months. At 6 months, improvement of ODI score was at the limit of statistical significance in favor of dexamethasone (P = 0.050). Multivariate regression analysis, adjusting for potential confounding variables, showed that differences on the ODI became statistically significant at the 6 month follow-up, also in favor of dexamethasone (adjusted P = 0.003). No serious complications were observed in either group. According to this study, pain relief and functional improvement are similar for both dexamethasone and betamethasone at 3 months. Considering its safety profile, dexamethasone could be considered as first choice for TFESI. However, given that the study was underpowered, more research is needed to support a recommendation of systematically using dexamethasone in TFESI.

Percutaneous Adhesiolysis Procedures in the Medicare Population: Analysis of Utilization and Growth Patterns from 2000 to 2011

Background: Multiple reviews have shown that interventional techniques for chronic pain have increased dramatically over the years. Of these interventional techniques, both sacroiliac joint injections and facet joint interventions showed explosive growth, followed by epidural procedures. Percutaneous adhesiolysis procedures have not been assessed for their utilization patterns separately from epidural injections. Study Design: An analysis of the utilization patterns of percutaneous adhesiolysis procedures in managing chronic low back pain in the Medicare population from 2000 to 2011. Objective: To assess the utilization and growth patterns of percutaneous adhesiolysis in managing chronic low back pain. Methods: The study was performed utilizing the Centers for Medicare and Medicaid Services (CMS) Physician Supplier Procedure Summary Master of Fee-For-Service (FFS) Data from 2000 to 2011. Results: Percutaneous adhesiolysis procedures increased 47% with an annual growth rate of 3.6% in the FFS Medicare population from 2000 to 2011. These growth rates are significantly lower than the growth rates for sacroiliac joint injections (331%), facet joint interventions (308%), and epidural injections (130%), but substantially lower than lumbar transforaminal injections (665%) and lumbar facet joint neurolysis (544%). Limitations: Study limitations include lack of inclusion of Medicare Advantage patients. In addition, the statewide data is based on claims which may include the contiguous or other states. Conclusion: Percutaneous adhesiolysis utilization increased moderately in Medicare beneficiaries from 2000 to 2011. Overall, there was an increase of 47% in the utilization of adhesiolysis procedures per 100,000 Medicare beneficiaries, with an annual geometric average increase of 3.6%. Key words: Interventional techniques, chronic spinal pain, epidural steroid injections, percutaneous adhesiolysis, post surgery syndrome, spinal stenosis

A Systematic Review of the Effectiveness of CT-Guided, Lumbar Transforaminal Injection of Steroids

To determine the effectiveness and safety of computerized tomography (CT) guided, lumbar transforaminal injection of steroids in the treatment of radicular pain. Systematic review of published literature. Two reviewers independently assessed 19 publications on the effectiveness and safety of CT-guided, lumbar transforaminal injection of steroids. For effectiveness, the primary outcome was the success rate for relief of pain. For safety, the radiation exposure involved and the nature of complications were determined. Much of the literature fails to provide evidence. Two studies reported decreases in mean or median pain scores but no other data. Two studies reported success rates of between 34% and 62% for achieving 50% relief of pain at between 1 and 6 months after treatment. CT-guided injections may involve greater radiation exposure than does fluoroscopy-guided injections and do not avoid catastrophic spinal cord injury. The evidence-base for CT-guided lumbar transforaminal injection of steroids is meagre. This intervention is not more effective than fluoroscopy-guided injections and is not demonstrably safer.

Efficacy of therapeutic fluoroscopy-guided lumbar spine interventional procedures

PurposeTo evaluate the benefit of fluoroscopy-guided lumbar spine interventional procedures in treatment of low back pain. MethodsThis prospective descriptive study was performed on 60 patients with back/radicular pain after showing no improvement with conservative treatment. ResultsOne hundred and two injection sessions were done (average 1.7 injection per patient). Caudal and lumbar transforaminal injections were effective in 55.9% and 78.5%, respectively. Facet and sacroiliac interventions were effective in 28.3% and 10%, respectively. Complications occurred in 20% of the procedures. ConclusionLumbar injections improved pain/disability related to discogenic lumbar spinal diseases. Efficacy of facet and sacroiliac injections is limited.

The Effectiveness of Lumbar Transforaminal Injection of Steroids: A Comprehensive Review with Systematic Analysis of the Published Data

To determine the effectiveness of lumbar transforaminal injection of steroids in the treatment of radicular pain. Comprehensive review of the literature with systematic analysis of all published data. Four reviewers independently assessed 39 publications on the effectiveness of lumbar transforaminal injection of steroids. Each reviewer determined if a publication provided any valid information on effectiveness. Assessments were compared, and the data of each publication were evaluated in terms of the rigor with which they were produced and the evidence they provided of effectiveness. The primary outcome sought was the success rate for relief of pain. Improvement in secondary outcomes was noted if reported. For miscellaneous conditions, the available evidence is limited and is neither compelling nor conclusive. For disc herniation, the evidence is sufficiently abundant to show that lumbar transforaminal injection of steroids is not universally effective but, nevertheless, benefits a substantial proportion of patients, and is not a placebo. Success rates are higher in patients with contained herniations that cause only low-grade compression of the nerve. In a substantial proportion of patients with lumbar radicular pain caused by contained disc herniations, lumbar transforaminal injection of corticosteroids is effective in reducing pain, restoring function, reducing the need for other health care, and avoiding surgery. The evidence supporting this conclusion was revealed by comprehensive review of all published data and found to be much more compelling than it would have been if the literature review had been of the limited scope of a traditional "systematic review" of randomized, controlled trials only.

Ultrasound-Guided Lumbar Transforaminal Injections

Preclinical feasibility study. Evaluation and validation of ultrasound-guided lumbar transforaminal injections. Lumbar transforaminal injections are routinely implemented in the interventional management of spinal radicular pain. Typically, these injections are administered under fluoroscopy or computed tomography. Although radiological guidance provides anatomical precision and accuracy, it is associated with radiation exposure and cannot be performed during outpatient visits or at bedside. Ultrasound-guided techniques have been previously described; however, the methodological generalizability remained unknown and validation against routine fluoroscopy has never been conducted on multiple spinal levels. We addressed the procedural accuracy of ultrasound-guided lumbar transforaminal injections and proposed anatomically sound approach. Fluoroscopic validation was performed. Of the 50 planned injections, 46 procedures were performed. L5/S1 foraminal access was impossible in 4 cases (8%). Fluoroscopy confirmed the correct foraminal placement in all 46 injections (100%). The contrast-spread pattern was intraforaminal in 42 cases (91.3%) and extraforaminal (nerve root) in 4 cases (8.7%). When intraforaminal pattern was detected on anteroposterior image, lateral fluoroscopy demonstrated ventral epidural flow in all occasions. In 3 cases, intravascular injection was detected (6.5%). Ultrasound-guided lumbar transforaminal injections are accurate and feasible in the preclinical setting.

Re: Comparison of the Effectiveness of Lumbar Transforaminal Epidural Injection with the Particulate and Nonparticulate Corticosteroids in Lumbar Radiating Pain: Table 1

Dear Editor, We read the article by Park, Lee, and Kim with regard to particulate and nonparticulate steroids in lumbar transforaminal injection [1] with much interest. We have previously audited our own practice to examine the efficacy of different steroid preparations on pain scores and functional outcomes and would like to outline them to add to the current article. Our objective was to compare the efficacy of particulate and nonparticulate steroid preparations in lumbar sleeve nerve root injections and their effect on patient functional outcomes. We designed a postal survey, which was sent to 39 patients who had undergone sleeve …