Lumbosacral Transforaminal Epidural Injections Research Articles

Clinical Application of an Augmented Reality Navigation System for Transforaminal Epidural Injection: A Randomized Controlled Trial.

Objectives: Augmented reality (AR) navigation systems are emerging to simplify and enhance the precision of medical procedures. Lumbosacral transforaminal epidural injection is a commonly performed procedure for the treatment and diagnosis of radiculopathy. Accurate needle placement while avoiding critical structures remains a challenge. For this purpose, we conducted a randomized controlled trial for our augmented reality navigation system. Methods: This randomized controlled study involved 28 patients, split between a traditional C-arm guided group (control) and an AR navigation guided group (AR-NAVI), to compare procedure efficiency and radiation exposure. The AR-NAVI group used a real-time tracking system displaying spinal structure and needle position on an AR head-mounted display. The procedural time and C-arm usage (radiation exposure) were measured. Results: All patients underwent successful procedures without complications. The AR-NAVI group demonstrated significantly reduced times and C-arm usage for needle entry to the target point (58.57 ± 33.31 vs. 124.91 ± 41.14, p < 0.001 and 3.79 ± 1.97 vs. 8.86 ± 3.94, p < 0.001). Conclusions: The use of the AR navigation system significantly improved procedure efficiency and safety by reducing time and radiation exposure, suggesting a promising direction for future enhancements and validation.

Augmented Reality-Assisted Navigation System for Transforaminal Epidural Injection.

Multiple studies have attempted to demonstrate the benefits of augmented reality (AR)-assisted navigation systems in surgery. Lumbosacral transforaminal epidural injection is an effective treatment commonly used in patients with radiculopathy due to spinal degenerative pathologies. However, few studies have applied AR-assisted navigation systems to this procedure. The study aimed to investigate the safety and effectiveness of an AR-assisted navigation system for transforaminal epidural injection. Through a real-time tracking system and a wireless network to the head-mounted display, computed tomography images of the spine and the path of a spinal needle to the target were visualized on a torso phantom with respiration movements installed. From L1/L2 to L5/S1, needle insertions were performed using an AR-assisted system on the left side of the phantom, and the conventional method was performed on the right side. The procedure duration was approximately three times shorter, and the number of radiographs required was reduced in the experimental group compared to the control group. The distance from the needle tips to the target areas in the plan showed no significant difference between the two groups. (AR group 1.7 ± 2.3mm, control group 3.2 ± 2.8mm, P value 0.067). An AR-assisted navigation system may be used to reduce the time required for spinal interventions and ensure the safety of patients and physicians in view of radiation exposure. Further studies are essential to apply AR-assisted navigation systems to spine interventions.

Differential rates of intravascular uptake and pain perception during lumbosacral epidural injection among adults using a 22-gauge needle versus 25-gauge needle: a randomized clinical trial

BackgroundInadvertent intravascular injection has been suggested as the most probable mechanism behind serious neurological complications during transforaminal epidural steroid injections. Authors believe a smaller gauge needle may lead to less intravascular uptake and less pain. Theoretically, there is less chance for a smaller gauge needle to encounter a blood vessel during an injection compared to a larger gauge needle. Studies have also shown smaller gauge needle to cause less pain. The aim of the study was to quantify the difference between a 22-gauge needle and 25-gauge needle during lumbosacral transforaminal epidural steroid injection in regards to intravascular uptake and pain perception.MethodsThis was a prospective single blind randomized clinical trial performed at outpatient spine practice locations of two academic institutions. One hundred sixty-two consecutive patients undergoing lumbosacral transforaminal epidural injections from February 2018 to June 2019 were recruited and randomized to each arm of the study – 84 patients were randomized to the 22-gauge needle arm and 78 patients to 25-gauge arm. Each transforaminal injection level was considered a separate incidence, hence total number of incidence was 249 (136 in 22-gauge arm and 113 in 25-gauge arm). The primary outcome measure was intravascular uptake during live fluoroscopy and/or blood aspiration. The secondary outcome measure was patient reported pain during the procedure on the numerical rating scale.ResultsFisher exact test was used to detect differences between 2 groups in regards to intravascular uptake and paired t-tests were used to detect differences in pain scores. The incidence of intravascular uptake for a 22-gauge needle was 5.9% (95% confidence interval: 1.9 to 9.8%) and for a 25-gauge needle, 7.1% (95% confidence interval: 2.4 to 11.8%) [p = 0.701]. Average numerical rating scale scores during the initial needle entry for 22-gauge and 25-gauge needle was 3.46 (95% confidence interval: 2.94 to 3.98) and 3.13 (95% confidence interval: 2.57 to 3.69) respectively [p = 0.375].ConclusionsThe study showed no statistically significant difference in intravascular uptake or pain perception between a 22-gauge needle and 25-gauge needle during lumbosacral transforaminal epidural steroid injections.Trial registrationClinicalTrials.gov NCT04350307. Registered 4/17/2020. (Retrospectively registered).

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.

Safety and Efficacy of SX600 Administered by Lumbosacral Transforaminal Epidural Injection for Radicular Pain

Safety and Efficacy of SX600 Administered by Lumbosacral Transforaminal Epidural Injection for Radicular Pain

Induced lumbosacral radicular symptom referral patterns: a descriptive study

Background ContextLumbosacral radicular symptoms are commonly evaluated in clinical practice. Level-specific diagnosis is crucial for management. Clinical decisions are often made by correlating a patient's symptom distribution and imaging with sensory dermatomal maps. It is common for patients to describe non-dermatomal symptom patterns and for imaging to demonstrate pathology at levels not predicted by a dermatomal map. These observations suggest that the referred symptom distribution from lumbosacral nerve root provocation is different from dermatomal maps. This phenomenon has been demonstrated in the cervical spine but not in the lumbosacral spine. PurposeThe objective of this study was to characterize potential lumbosacral radicular symptom referral patterns induced during transforaminal epidural injections. Study Design/SettingThis is an observational descriptive study. Patient SampleThe patient sample included 71 consecutive patients with lumbosacral radicular pain undergoing lumbosacral transforaminal epidural injections at an outpatient interventional spine practice. Outcome MeasuresEach subject drew the location of provoked lumbosacral radicular symptoms on a pain diagram. Materials and MethodsSeventy-one consecutive patients undergoing 125 fluoroscopically guided lumbosacral transforaminal epidural injections at an outpatient interventional spine practice were included in the study. The described location of provoked symptoms was recorded (1) after final needle positioning, (2) after injection of up to 0.5 mL of contrast solution, and (3) after injection of up to a 1 mL test dose of 1% lidocaine. Each subject drew the location of provoked symptoms on a diagram. The provoked symptom diagrams for each lumbosacral segmental level were combined to create composite nerve root, level-specific, symptom referral pattern maps. ResultsOf the 125 injections, 87 provoked referred symptoms and were included in the analysis. Thirty-eight injections did not provoke referred pain symptoms and were excluded from further analysis. Four nerve roots were tested at L1 and eight were tested at L2. Because of the small number of subjects, composite diagrams and statistical analysis were not completed for these levels. Eleven nerve roots were analyzed at L3, 28 at L4, 34 at L5, and 11 at S1. Composite symptom referral pattern maps were created for levels L3, L4, L5, and S1. Although the symptom distribution occasionally followed the expected dermatomal maps, most often the referral was outside of the patterns expected for each level. The most common symptom referral pattern for levels L3–S1 was the buttock, the posterior thigh, and the posterior calf. ConclusionsThe level-specific provoked symptom distribution during lumbosacral transforaminal epidural injections is frequently different from that predicted by classic lumbosacral dermatomal maps. Referred pain to the buttock, the posterior thigh, or the posterior calf may come from L3, L4, L5, or S1 nerve root segmental irritation.

Ultrasound-Guided S1 Transforaminal Epidural Injection Using the In-Plane Approach and Color Doppler Imaging

Recently, several studies have investigated the effectiveness of the ultrasound-guided lumbosacral transforaminal epidural injection. However, the ultrasound-guided S1 transforaminal epidural injection using an out-of-plane approach, which was previously reported, may cause an intestinal injury or intravascular injection because the needle tip tends to be invisible in the out-of-plane approach. In this study, therefore, we report a new method of ultrasound-guided S1 transforaminal epidural injection using the in-plane approach and color Doppler. In addition, we also report the usefulness of color Doppler imaging for finding the S1 foramen and confirming the accuracy of the injection.

Retrospective cohort study of usage patterns of epidural injections for spinal pain in the US fee-for-service Medicare population from 2000 to 2014

ObjectiveTo assess the usage patterns of epidural injections for chronic spinal pain in the fee-for-service (FFS) Medicare population from 2000 to 2014 in the USA.DesignA retrospective cohort.MethodsThe descriptive analysis of...

Differential Rates of Inadvertent Intravascular Injection during Lumbar Transforaminal Epidural Injections Using Blunt-Tip, Pencil-Point, and Catheter-Extension Needles.

To quantify the incidence of inadvertent vascular penetration during lumbosacral transforaminal epidural injections using blunt-tip, pencil-point, and catheter-extension needles. This is a prospective, observational, consecutive cohort study. Two hundred consecutive patients undergoing lumbosacral transforaminal epidural injections at an academic outpatient spine center. Four hundred seventy-five fluoroscopically guided lumbosacral transforaminal epidural injections were performed on consecutively consenting patients by one interventional spine physician, using three different needle types. The presence or absence of vascular uptake was determined during contrast injection under live fluoroscopy. Vascular uptake of contrast was observed in 58 of the total 475 injections, for an overall incidence of 12.2%. By needle type, the incidence of inadvertent vascular uptake was 16.6% (26/157) in the pencil-point group, 15.6% (24/154) in the blunt-tip group, and 4.9% (8/164) in the catheter-extension group. The difference in rates is statistically significant between the catheter-extension needle group and both the pencil-point group (P = 0.0009) and blunt-tip group (P = 0.0024). A secondary analysis was performed to quantify the incidence of functional pitfalls between needle groups, with a significantly lower incidence in the pencil-point group compared to both the catheter-extension (P = 0.0148) and blunt-tip needle (P = 0.0288) groups. Blunt-tip and pencil-point needles have comparable risk of inadvertent vascular injection during lumbosacral transforaminal injections. Catheter-extension needles demonstrated a reduce incidence of vascular uptake, but also result in a significantly higher rate of functional pitfalls that limits their usefulness in routine practice.

Rates of lumbosacral transforaminal injections interpreted as intravascular: fluoroscopy alone or with digital subtraction

We investigated the rate of injections interpreted as intravascular during imaging of lumbosacral transforaminal epidural injections, using fluoroscopy alone or with digital subtraction. We evaluated 732 injections performed on 348 patients: 8.1% (59/732) and 10.5% (77/732) of injections were interpreted as intravascular during fluoroscopy and digital subtraction, respectively, p = 0.13. The odds ratio (95% CI) for interpreting injections as intravascular increased for both fluoroscopy and digital subtraction fluoroscopy, with: each year of age, 1.04 (1.01-1.07) and 1.03 (1.00-1.06), p = 0.011 and 0.024, respectively; sacral compared with lumbar injections, 10 (5-19) and 8 (5-15), p < 0.001 for both. The odds ratio for intravascular injection increased with three other variables during digital subtraction fluoroscopy: spinal stenosis, 5.1 (1.5-17.1), p = 0.009; failed back surgery syndrome, 4.3 (1.2-15.8), p = 0.025; compression fracture, 8.0 (1.6-39.4), p = 0.011.

Assessment of the Growth of Epidural Injections in the Medicare Population from 2000 to 2011

Background: Among the many diagnostic and therapeutic interventions available for the management of chronic pain, epidural steroid injections are one of the most commonly used modalities. The explosive growth of this technique is relevant in light of the high cost of health care in the United States and abroad, the previous literature assessing the effectiveness of epidural injections has been sparse with highly variable outcomes based on technique, outcome measures, patient selection, and methodology. However, the recent assessment of fluoroscopically directed epidural injections has shown improved evidence with proper inclusion criteria, methodology, and outcome measures. The exponential growth of epidural injections is illustrated in multiple reports. The present report is an update of the analysis of the growth of epidural injections in the Medicare population from 2000 to 2011 in the United States. Study Design: Analysis of utilization patterns of epidural procedures in the Medicare population in the United States from 2000 to 2011. Objectives: The primary purpose of this assessment was to evaluate the use of all types of epidural injections (i.e., caudal, interlaminar, and transforaminal in the lumbar, cervical, and thoracic regions) with an assessment of specialty and regional characteristics. Methods: This assessment was performed utilizing the Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) Master data from 2000 to 2011. Results: Epidural injections in Medicare beneficiaries increased significantly from 2000 to 2011. Overall, epidural injections increased 130% per 100,000 Medicare beneficiaries with an annual increase of 7.5%. The increases per 100,000 Medicare recipients were 123% for cervical/ thoracic interlaminar epidural injections; 25% for lumbar/sacral interlaminar, or caudal epidural injections; 142% for cervical/thoracic transforaminal epidural injections; and 665% for lumbar/ sacral transforaminal epidural injections. The use of epidurals increased 224% in the radiologic specialties (interventional radiology and diagnostic radiology) and 145% in psychiatric settings, whereas and physical medicine and rehabilitation physicians’ use of epidurals increased 520%. 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. Conclusions: Epidural injections in Medicare recipients increased significantly. The growth was significant for some specialties (radiology, physical medicine and rehabilitation, and psychiatry) and for certain procedures (lumbosacral transforaminal epidural injections). Key words: Spinal pain, interventional pain management, epidural injections, caudal epidural, lumbar epidural, cervical epidural, cervical transforaminal, lumbar transforaminal

The efficacy of lumbosacral transforaminal epidural steroid injections: A comprehensive literature review

There have been a number of recent studies showing the effectiveness of lumbosacral transforaminal steroid epidural injections used in the treatment of radicular pain. The studies include retrospective, prospective and randomized controlled studies. Thus, the data is valuable with regard to identifying evidence based recommendations that can be used for clinical practitioners. To review and critically evaluate literature focusing on the efficacy of lumbosacral transforaminal steroid injections. The goal of this review is to identify pertinent journal information that aids in the improvement of clinical care and guides future research by increasing the awareness of the efficacy of this procedure. A comprehensive literature review of the efficacy of lumbar sacral transforaminal epidural steroid injections. Medical databases were searched for key words of transforaminal lumbar sacral, anatomy, and efficacy of steroid injection using Pub Med, Medline, Cochrane databases and U.S. National Library of Medicine. Works cited lists were then searched and cross-referenced as well. Articles focusing solely on interlaminar and caudal steroid injections were excluded as were transforaminal studies focusing on the cervical spine. Also, articles were excluded that did not differentiate the type of technique with type of relief it produced. Papers focusing on the efficacy of lumbosacral transforaminal steroid injections were included in the data that followed the patient for three months or greater. In all there were 10 randomized trials, 4 retrospective studies and 8 prospective studies found. Among the 10 randomized control studies only 8 met inclusion criteria. All 8 of the randomized control studies included show a positive outcome in both the short term and long term results. There were a total of 9 prospective trials showing a positive short term and long term outcome and that used both CT guided injections as well as fluoroscopic injections. This systemic review included prospective, retrospective and randomized clinical trials showing that there was strong evidence for transforaminal injections in the treatment of lumbosacral radicular pain for both short term and long term relief.

Influence of needle type on the incidence of intravascular injection during transforaminal epidural injections: a comparison of short-bevel and long-bevel needles

Background context Vascular penetration and injection of corticosteroids into a vessel during lumbosacral transforaminal epidural injection is a suspected cause of myelopathy. Blunt needles have been suggested to avoid vascular penetration, but they are difficult to navigate. Another alternative to the standard long-bevel sharp needles is the short-bevel needles. Some have postulated that short-bevel needles are the best option for high-risk spine injections because they maintain navigation characteristics while potentially reducing the risk of complications. To date, no studies have been performed to either confirm or refute this. Purpose The purpose of this study was to determine if there is a difference in the incidence of vascular penetration during lumbosacral transforaminal epidural injections between short-bevel and long-bevel needles. Study design/setting This is a prospective, observational, in vivo study. Patient sample The sample comprises patients receiving lumbosacral transforaminal epidural injections at a university-based outpatient spine center. Outcome measure The outcome measure was the incidence of vascular contrast patterns observed under live fluoroscopy. Methods One interventional spine physician recorded contrast patterns observed during 158 fluoroscopically guided lumbosacral transforaminal epidural injections under live fluoroscopy using two different types of needle tips. Results Vascular injections were observed in 22 of the 158 injections, for an overall incidence of 13.9%. The incidence of vascular injections in the short-bevel group was 15.6% (10/64) and in the long-bevel group was 12.8% (12/94). This difference was not statistically significant (p=.6447). A secondary analysis was performed to determine if the needle gauge influenced the incidence of vascular injections, and again, there were no statistical differences in the overall rates of vascular injection. Conclusions In comparison with long-bevel needles, short-bevel needles do not reduce the risk of inadvertent vascular injection in lumbosacral transforaminal epidural injections.

The Effects of Epidural Betamethasone on Blood Glucose in Patients with Diabetes Mellitus

To determine the effects of lumbosacral transforaminal and caudal epidural betamethasone injections on blood glucose levels in diabetic subjects. The hypothesis is that epidural steroid injections result in transient elevation of blood glucose levels in diabetic subjects. This is a prospective, observational cohort. Twelve diabetic subjects (6 non-insulin-dependent and 6 insulin-dependent) receiving lumbosacral or caudal epidural betamethasone injections for neurogenic claudication or radicular pain were studied. Spinal level and approach were decided based on symptoms, pathology, and magnetic resonance imaging findings. Subjects recorded their finger stick blood glucose levels twice daily for 3 days before the injection, the day of the injection, and 3 days after the injection. A tertiary, university-based, spine center. Inclusion criteria included diabetic subjects (age 18 years) with the ability and willingness to monitor and report their blood glucose. Exclusion criteria included epidural steroid injections (ESIs) within the previous 2 months or peripheral corticosteroid injections within the previous 2 weeks. Nineteen subjects initially enrolled, and 12 successfully completed the study. After informed consent was obtained, subjects underwent fluoroscopically guided lumbosacral transforaminal ESIs (TFESIs) or caudal ESIs, using contrast to confirm targeted needle placement and to rule out vascular uptake. Subjects recorded morning and evening blood glucose (mg/dL) via glucometer. There was a 106 mg/dL average elevation in blood glucose level on the evening of the injection day. The blood glucose elevation remained statistically significant for 3 days after the injection (P < .002). Blood glucose remained elevated through postinjection day 2, though these elevations were not statistically significant. Lumbosacral transforaminal and caudal epidural betamethasone injections are associated with statistically significant elevations in blood glucose levels in diabetic subjects. This effect peaked on the day of the injection and lasted approximately 2 days.

Poster 244: Influence of Needle Type on the Incidence of Intravascular Injection During Lumbosacral Transforaminal Epidural Injections: A Comparison of Short Bevel and Long Bevel Needles

Objective: To determine if the incidence of intravascular injection differs between short bevel and long bevel needles during lumbosacral transforaminal epidural injections. Design: Prospective, observational comparison study. Setting: University spine center. Participants: 77 consecutive consenting patients scheduled to receive lumbar transforaminal epidural injections. Subjects had a mean age of 49.7 years (range, 21–91y), 43% were men and 57% women. Interventions: One physician performed 157 fluoroscopically-guided lumbosacral transforaminal epidural injections on the 77 study participants. For each injection the dynamic flow of contrast was observed under live fluoroscopy and the presence or absence of vascular patterns was recorded. Main Outcome Measures: The Fisher exact test was used to determine the significance of variance in the incidence of vascular contrast patterns observed in the injections performed with short bevel needles compared with long bevel needles. Results: Of the 157 injections, 58 were performed using short bevel (chiba point) needles and 99 using long bevel (quincke point) needles. Vascular injections were observed in 22 of the 157 injections for an overall incidence of 14.0%. The incidence of vascular injections with short bevel needles was 17.2% (10 out of 58) and with long bevel needles was 12.1% (12 out of 99). This difference was not statistically significant at P=0.364. Conclusions: Potential complications related to accidental intravascular penetration during transforaminal epidural injections has piqued interest in the relative safety of sharp versus blunt needles. This is the first study to report on the incidence of inadvertent intravascular injection with short bevel needles in comparison with long bevel needles, finding no difference in the incidence between these 2 needle types.

Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections

The incidence of vascular penetration during contrast confirmed fluoroscopically guided transforaminal lumbosacral epidural injections has been reported as 8.9% to 21.3% depending on the level of injection. Recently, intermittent fluoroscopy was shown to miss more than half of the vascular injections observed under live fluoroscopy. The number of misses increased when epidural and vascular contrast flow appeared simultaneously, even if the fluoroscopic image was taken during contrast injection. To date, no studies have documented the incidence of simultaneous epidural and vascular contrast injections. Also, most previous studies of vascular injections did not document use of live fluoroscopy during contrast injection, so the incidence of vascular injections may be higher than reported. To determine the incidence of simultaneous epidural and vascular contrast injection during lumbosacral transforaminal epidural injections. A prospective, observational, in vivo, study. Patients receiving lumbar transforaminal epidural injections at a university-based outpatient spine center. Incidence of epidural, vascular, and simultaneous epidural and vascular contrast patterns. One interventional spine physician and three fellows under his direct supervision recorded contrast patterns observed during 191 fluoroscopically guided lumbosacral transforaminal epidural steroid injections with injection of contrast observed under live fluoroscopy. The incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections was 8.9%. The incidence of a vascular injection alone was 4.2%, for a total vascular injection incidence of 13.1%. Subjects with a simultaneous epidural and vascular injection who returned for repeat injection had a statistically significant chance of a repeat simultaneous epidural and vascular injection when the injection was done at the same location. Fluoroscopy time was significantly increased, an average of 8.8 seconds, when a vascular injection was identified. There was no statistically significant correlation between the incidence of simultaneous epidural and vascular injection with subjects' age, sex, level of injection, side of injection, needle gauge, or diagnosis. Simultaneous epidural and vascular injection is twice as likely to occur as vascular injection alone. Use of intermittent fluoroscopy can miss the transient appearance of the vascular component of these injections, giving the false impression of successful contrast placement. In light of these results, live fluoroscopy is recommended during contrast injection for confirmation of lumbosacral transforaminal epidural injections.