Lumbosacral Transforaminal Epidural Steroid Injections Research Articles

Results of lumbar transforaminal epidural steroid injections based on the physician referral source

BackgroundMany patients who receive lumbosacral transforaminal epidural steroid injections (TFESIs) are referred for the injection from a physician who does not perform the procedure. PurposeTo compare success rates of fluoroscopically guided lumbosacral TFESIs in patients who had a clinical evaluation and recommendation for the injection by a fellowship-trained spine specialist who routinely performs ESIs (Group A), vs those who had a clinical evaluation by a fellowship-trained spine specialist who referred the patient for the procedure to be done by a different physician (Group B). Study design/settingRetrospective, observational, in vivo study of consecutive patients. Patient. SamplePatients undergoing lumbosacral TFESIs at a single outpatient academic spine center. Outcome. MeasuresNumeric Rating Scale (NRS) pain score improvement. MethodsCurrent procedural terminology (CPT) codes were used to search all consecutive patients who received a lumbosacral TFESI between September 2019 and September 2020. All patients with pre- and post-injection NRS pain scores within 60 days of the injection were included in the analysis. ResultsA total of 230 TFESIs were analyzed, 151 in Group A, and 79 in Group B. The primary outcome was defined as > 50% improvement in the NRS pain score. 39% [95% CI: 33, 45%] of all patients who received a lumbosacral TFESI achieved a successful outcome. There were better results in Group A with a 47% [95% CI: 39, 55%] success rate compared to a 23% [95% CI: 14, 32%] success rate in Group B. Group A also had a higher proportion of patients who achieved at least 80% pain relief (26% [95% CI: 19, 33%]) compared to Group B (10% [95% CI: 3, 17%]). History of prior surgery did not significantly affect outcomes. ConclusionThis retrospective study demonstrated a higher success rate from lumbosacral TFESIs when patients were referred for the injection by a physician who performs ESIs.

The association of payer type and opioid use on functional improvement at short-term follow-up after lumbosacral transforaminal epidural steroid injection: Results of a large registry study

BackgroundLumbosacral transforaminal epidural steroid injection (LTFESI) is a commonly performed intervention for treating radicular pain. While factors that predict pain improvement after LTFESI have been evaluated, minimal literature exists regarding predictors of functional improvement. PurposeTo identify factors that are associated with functional improvement at short-term follow-up after LTFESI. Study designRetrospective review of prospectively collected registry data. Patient samplePatients undergoing LTFESI at an academic spine center who completed an Oswestry Disability Index (ODI) questionnaire both pre-procedure and one to three weeks post-procedure. Outcome measuresThe outcomes of interest were the proportions of patients who experienced a minimal clinically important difference (MCID) in function defined as ​≥ ​30% improvement in ODI score, as well as ​≥ ​10-point and ≥15-point improvement in ODI score. MethodsLogistic regression analysis was performed to examine the associations of predictor variables to the ODI responder/non-responder outcome variable. The predictor variables for the analysis included: age, baseline ODI score, Charleston Comorbidity Index (CCI), payer type, prior lumbosacral spine surgery, pre-injection opioid use, two-level injections, bilateral injections, repeat injection, trainee presence during injection, immediate numerical rating scale (NRS) change post-injection. An odds ratio (OR) and its 95% confidence intervals (CIs) were calculated. ResultsA total of 606 patients were included in the analysis. More than half of the patients (56.8%) reported a ≥7.1% improvement in ODI score, and about 30% reported a ≥30% improvement in ODI score. Approximately 36% and 20% of the patients reported ≥10-point and ≥15-point reductions in ODI score, respectively. Medicaid and Medicare payer type and pre-injection opioid use were significantly associated with a lower likelihood of ≥30%, and ≥15-point improvements in ODI, after adjusting for the other factors (p ​< ​0.05). ConclusionsWhen using various common definitions of MCID for ODI score improvement, Medicaid, Medicare, and pre-injection opioid use were identified as factors that are negatively associated with functional improvement at short-term follow-up after LTFESIs.

The Impact of Vitamin D Deficiency to Treatment Success of Transforaminal Epidural Steroid Injection

Transforaminal epidural steroid injection (TFESI) is an interventional technique used to relieve disc herniation related back and radicular pain. Although few studies have investigated the factors predicting positive outcomes after TFESI, there is no data concerning the possible relationship between pre-procedure serum 25-hydroxyvitamin D (25(OH)D) levels and the response to TFESI. To investigate the effect of vitamin D deficiency to treatment success of fluoroscopy-guided transforaminal epidural steroid injection. A retrospective assessment. A university hospital interventional pain management center. Nine hundred forty-eight patients received lumbosacral TFESI between January 2018 and December 2019 in a university hospital pain management center and were examined retrospectively for eligibility. Clinical and demographic data; magnetic resonance imaging (MRI); pre-procedure laboratory tests, including serum 25(OH)D; pain scores at baseline, third week, and third month follow-ups were collected. A total of 83 patients were recruited and divided into 2 groups with respect to vitamin D status. The number of patients with serum 25(OH)D level below 20 ng/mL was 57 and the number of patients with serum 25(OH)D level above 20 ng/mL was 26. Treatment success rates were significantly lower in vitamin D deficient group at third week and third month (P: 0.006, P: 0.01). Retrospective nature and the absence of functional outcomes. Vitamin D deficiency is associated with a lower probability of meaningful pain relief following TFESI. It may worth assessing serum vitamin D level prior to this intervention, although prospective investigation is necessary.

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).

Comparing pain relief and functional improvement between methylprednisolone and dexamethasone lumbosacral transforaminal epidural steroid injections: a self-controlled study.

BackgroundPrevious studies have shown varying results between lumbosacral transforaminal epidural steroid injections (TFESIs) performed with particulate versus non-particulate corticosteroids. The purpose of this study was to investigate the difference in pain relief and functional improvement between particulate and non-particulate lumbosacral TFESIs in patients who had undergone both injections, sequentially.MethodsThis was a self-controlled, retrospective study of 20 patients who underwent both a methylprednisolone and a dexamethasone TFESI to the same vertebral level and side. Primary outcomes included pain relief according to the visual analogue scale (VAS) and functional improvement determined by a yes/no answer to questions regarding mobility and the activities of daily living. Post-injection data was recorded at 2, 3, and 6 months.ResultsA decrease in VAS scores of –3.4 ± 3.0 (mean ± standard deviation), –3.1 ± 3.1, and –2.8 ± 3.4 was seen for the methylprednisolone group at 2, 3, and 6 months, respectively. Similar decreases of –3.9 ± 3.5, –3.4 ± 2.8, and –2.3 ± 3.4 were seen in the dexamethasone group. There was no significant difference in pain relief at any point between the two medications. The percentage of subjects who reported improved function at 2, 3, and 6 months was 65%, 51%, and 41%, respectively, for the methylprednisolone group and 75%, 53%, and 42% for the dexamethasone group.ConclusionsThese findings support the use of non-particulate corticosteroids for lumbosacral TFESIs in the context of documented safety concerns with particulate corticosteroids.

Lumbar Radicular Pain Response to First Injection with Non-particulate Steroid.

IntroductionRecent studies on the use of transforaminal epidural steroid injection (TFESI) to treat lumbar radicular pain have highlighted controversies pertaining to the choice of corticosteroid agent utilized in lumbosacral TFESI, in terms of both safety and efficacy. The primary objective was to characterize the radicular pain response after a first transforaminal injection with dexamethasone. The secondary objective was to document the response of those who failed to respond to a dexamethasone injection when particulate steroid was utilized for a second injection.MethodsIt was a retrospective study of 94 consecutive patients undergoing transforaminal injection for lumbosacral radicular pain. At two-week follow-up, patients rated their pain response on a clinically oriented five-point survey. First injection non-responders were given a second injection with particulate steroid and again completed the survey.ResultsApproximately one-third (N = 31/94) of patients received no meaningful relief from a single injection with dexamethasone. No patients achieved lasting and complete pain relief after a single injection. Of initial non-particulate steroid non-responders, approximately two-thirds (N = 19/28) demonstrated a notable or complete response to a second injection with particulate steroid.ConclusionsWe are now able to better inform patients with regard to their anticipated pain response to an initial dexamethasone injection. Only one-third of patients realized more significant and lasting relief after a single injection. Of those who did not demonstrate a more meaningful response, a second injection with particulate steroid resulted in more pronounced pain relief in two-thirds of patients.

Factors Predicting Favorable Short-Term Response to Transforaminal Epidural Steroid Injections for Lumbosacral Radiculopathy.

Background and Objectives: The purpose of this retrospective study was to identify predictors of short-term outcomes associated with a lumbosacral transforaminal epidural steroid injection (TFESI). Materials and Methods: The medical records of 218 patients, who were diagnosed with lumbosacral radiculopathy and treated with a TFESI, were reviewed in this retrospective study. A mixture of corticosteroid, lidocaine, and hyaluronidase was injected during TFESI. Patients with >50% pain relief on the numerical rating scale compared with the initial visit constituted the good responder group. Demographic, clinical, MRI, and electrodiagnostic data were collected to assess the predictive factors for short-term outcomes of the TFESI. Results: A multivariate logistic regression analysis demonstrated that a shorter duration of symptoms and a positive sharp wave (PSW)/fibrillation (Fib) observed in electrodiagnostic study (EDx) increased the odds of significant improvement 2–4 weeks after the TFESI. Conclusions: Shorter duration of symptoms and PSW/Fib on EDx were predictors of favorable short-term response to TFESI.

Does obesity have an impact on the radiation exposure during lumbosacral transforaminal epidural steroid injections? Retrospective study

Aim: To find out whether obesity or injection level have an impact on the amount of radiation exposure during fluoroscopy-guided lumbosacral transforaminal epidural steroid injections (TFESIs).Material and Methods: Patients aged 19-65 years who underwent lumbosacral transforaminal epidural steroid injection were retrospectively reviewed. Eighty-three patients with a mean age of 42.7±13.2 (19-65) years with signs and symptoms of unilateral lumbar radicular pain due to single level disc herniation were included. Subjects were categorized as normal weighted (18.5≤body mass index (BMI) ≤ 24.9), overweighed (25≤BMI30) and obese (BMI≥30) according to World Health Organization BMI criteria. All patients were given unilateral TFESIs, including39 (47%) L5, and 44 (53%) S1 level. Radiation exposure dose and procedure time was automatically measured by fluoroscope.Results: Radiation dosage increased significantly with increasing BMI (p=0.0001). No statistically significant differences were found when three groups’ procedure durations and NRS scores were compared (>0.05). The radiation dosages and procedure durations between the two different injection levels (L5 and S1) were not found to be statistically significant (>0.05). Conclusion: Obesity is associated with increased radiation exposure independent of procedure duration and the injection level.

Adverse events associated with fluoroscopically guided lumbosacral transforaminal epidural steroid injections

Background contextAlthough the types and incidence of adverse events (AEs) associated with transforaminal epidural steroid injection (TFESI) have been described, no study has used a systematic standardized questionnaire to solicit AEs from patients to capture an accurate range and incidence of complications. PurposeThe aim was to systematically identify the types and incidence of AEs associated with TFESI. Additionally, this study evaluated demographic and clinical factors that may predict a higher risk of an AE. Study design/SettingThis was a retrospective cohort study from a multiphysician academic PM&R clinic. Patient samplePatients, aged 19 to 89, who underwent a fluoroscopically guided TFESI for lumbosacral radicular pain between 2004 and 2007 were included. Outcome measuresThe relationship of AEs with gender, age, trainee presence, steroid type, preprocedure visual analog scale (VAS) pain score, systolic blood pressure, fluoroscopy time, and corticosteroid injectate volume was analyzed. MethodsAdverse event data were collected using a survey both immediately and at 24 to 72 hours after TFESI. Statistical analysis was performed using the chi-square, Fisher exact, or Wilcoxon rank sum two-sided tests. Logistic regression analysis was also performed. C.P. is the owner of Rehabilitation Institute of Chicago Physiatric Log & Analysis System computer software. ResultsIn 1,295 consecutive patients undergoing 2,025 TFESI procedures, immediate AEs and delayed AEs occurred after 182 (9.2%) and 305 (20.0%) injections, respectively. The most common immediate AEs were: vasovagal reaction (4.2%) and interrupted procedure from intravascular flow (1.7%). Common delayed AEs included: pain exacerbation (5.0%), injection site soreness (3.9%), headache (3.9%), facial flushing/sweating (1.8%), and insomnia (1.6%). Significant associations were identified between AEs and gender, age, preprocedure VAS, steroid type, and fluoroscopy time. Trainee involvement in the procedure did not impact the complication rate. ConclusionsFluoroscopically guided lumbosacral TFESI is associated with a similar rate of minor AEs both immediately and 24 to 72 hours after procedure that are typical of other axial corticosteroid injections. Permanent AEs were not found in this sample. The most common AEs associated with TFESI include vasovagal episodes, procedure interruption from intravascular flow, pain exacerbation, injection site soreness, headache, and insomnia.

Poster 460 Fluoroscopically Guided Lumbosacral Transforaminal Epidural Steroid Injections: Adverse Events and Predictive Factors

PM&RVolume 6, Issue 9S p. S347-S347 Saturday Poster Presentations - Poster Hall Poster 460 Fluoroscopically Guided Lumbosacral Transforaminal Epidural Steroid Injections: Adverse Events and Predictive Factors Zachary McCormick MD, Zachary McCormick MD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorChristopher Plastaras MD, Christopher Plastaras MD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorCynthia Garvan PhD, Cynthia Garvan PhD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorDonald S. Macron MD, Donald S. Macron MD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorAnand Joshi MD, MHA, Anand Joshi MD, MHA The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorGary P. Chimes MD, PhD, Gary P. Chimes MD, PhD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorWesley L. Smeal MD, Wesley L. Smeal MD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorJoshua D. Rittenberg MD, Joshua D. Rittenberg MD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorDavid J. Kennedy MD, David J. Kennedy MD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this author Zachary McCormick MD, Zachary McCormick MD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorChristopher Plastaras MD, Christopher Plastaras MD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorCynthia Garvan PhD, Cynthia Garvan PhD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorDonald S. Macron MD, Donald S. Macron MD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorAnand Joshi MD, MHA, Anand Joshi MD, MHA The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorGary P. Chimes MD, PhD, Gary P. Chimes MD, PhD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorWesley L. Smeal MD, Wesley L. Smeal MD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorJoshua D. Rittenberg MD, Joshua D. Rittenberg MD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this authorDavid J. Kennedy MD, David J. Kennedy MD The Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL, United StatesSearch for more papers by this author First published: 29 September 2014 https://doi.org/10.1016/j.pmrj.2014.08.832Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume6, Issue9SSeptember 2014Pages S347-S347 RelatedInformation

Factors Associated With Pain Reduction After Transforaminal Epidural Steroid Injection for Lumbosacral Radicular Pain

ObjectiveTo identify demographic and clinical factors associated with pain improvement after a lumbosacral transforaminal epidural steroid injection (TFESI) for the treatment of radicular pain. DesignRetrospective cohort study. SettingOutpatient center. ParticipantsAdults (N=188) who underwent a fluoroscopically guided TFESI for lumbosacral radicular pain. InterventionsNot applicable. Main Outcome MeasuresPain reduction from preinjection to 2-week follow-up was measured by visual analog scale (VAS). Patients were grouped by those who experienced no pain relief or worsened pain (≤0%), pain relief but <50% relief (>0%–<50%), or significant pain relief (≥50%) on the VAS. ResultsThe mean duration of pain prior to injection was 45.8±81 weeks. The mean time to follow-up after TFESI was 20±14.2 days. Significantly more patients who experienced ≥50% pain relief at follow-up reported higher preinjection pain on the VAS (P=.0001) and McGill Pain Inventory Questionnaire (P=.0358), reported no worsening of their pain with walking (P=.0161), or had a positive femoral stretch test (P=.0477). No significant differences were found between VAS pain reduction and all other demographic and clinical factors, including a radiologic diagnosis of disk herniation versus stenosis or other neural tension signs on physical examination. ConclusionsGreater baseline pain on the VAS and McGill Pain Inventory, a history of a lack of worsening pain with walking, and a positive femoral stretch test predict a greater likelihood of pain reduction after TFESI for lumbosacral radicular pain at short-term follow-up. Greater baseline pain on the McGill Pain Inventory and a lack of worsening pain with walking predict a magnitude of >50% pain reduction.

Lumbosacral transforaminal epidural steroid injections are equally effective for treatment of lumbosacral radicular pain in the obese compared to non-obese population: A pilot study1

Current evidence suggests that lumbosacral transforaminal epidural steroid injection (TFESI) is an effective treatment for lumbosacral radicular pain. However, practitioners may be reluctant to attempt this intervention in obese patients because of a perceived reduction in the chance of providing pain relief due to the increased technical difficulty of TFESI in individuals with a larger body habitus. No study to date has compared the effectiveness of TFESI in groups stratified by BMI. We report pilot data addressing whether lumbosacral transforaminal epidural steroid injection is as effective in treating lumbosacral radicular pain in the obese and overweight population as it is in the non-overweight population. This study consisted of 9 normal weight (18.5 < BMI < 25), 9 overweight (25 < BMI < 30), and 6 obese (BMI > 30) patients who presented with lumbosacral radicular pain and received a TFESI. For each group, percent reduction in pain and the proportion of individuals with a 50% or greater reduction in pain 2-4 weeks after TFESI was determined. Comparing the overweight and obese groups to the normal weight group, no significant differences were found in the percent improvement in pain after TFESI (p=0.7154, p=0.4566) or in the proportion of each group with a 50% or greater reduction in lower back pain after TFESI (p=0.2968). Our pilot data indicates that lumbosacral TFESI is as effective in providing short-term relief of lumbosacral radicular pain in obese and overweight patients as it is in non-overweight patients. However, our sample size was not large enough to find a significant difference at a power of 80%. We plan to perform a larger prospective study to confirm the findings of this study. Case-control study, Level II-2.

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.

Contrast Flow Selectivity During Transforaminal Lumbosacral Epidural Steroid Injections

Background: Lumbosacral transforaminal epidural steroid injections (LS-TFESIs) are an accepted procedure used in the comprehensive, conservative care for lumbar disc pathology and/or spinal stenosis induced low back pain with a radicular component. Historically, the terminology used to describe the transforaminal technique of instilling medications into the epidural space and/or exiting structures has varied. These procedures have also been referred to as either diagnostic or therapeutic selective nerve root blocks (SNRBs). Although this procedure is typically used to “selectively” treat isolated pathology, the “SNRB” terminology suggests that one can selectively diagnose or treat a specific nerve root as a pain generator by anesthetizing or blocking it. It has been recently demonstrated that L4 and L5 SNRBs are often non-“selective” by investigating the extent of epidural contrast flow patterns after injecting 1.0 mL of contrast. Our study attempts to identify the minimum injectate volume at which LS-TFESIs may still be considered “selective” with no injectate extending to either the adjacent (superior and/or inferior) levels or to the contralateral side. Objective: Quantitatively evaluate contrast flow level selectivity noted during fluoroscopically guided lumbosacral transforaminal epidural steroid injections (LS-TFESIs). Study Design: Prospective, nonrandomized, observational human study. Methods: Thirty patients (female = 10, male = 20) undergoing LS-TFESIs were investigated. After confirming appropriate spinal needle position with biplanar imaging, 4.0 mL of nonionic contrast was slowly injected. Fluoroscopic images were recorded at 0.5 mL increments. These biplanar contrast flow images were evaluated to determine which 0.5 mL volume increment was no longer specific for the injected level. In particular, we documented when contrast extended either to a superior or inferior spinal segment or crossed the midline spine to the contralateral side. Results: After injecting 0.5 mL of contrast, 30% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. After injecting 1.0 mL of contrast, 67% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. After injecting 1.5 mL of contrast, 87% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. After injecting 2.5 mL of contrast, 90% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. Conclusions: Diagnostic LS-TFESI or SNRB blocks limiting injectate to a single, ipsilateral segmental level cannot reliably be considered diagnostically selective with volumes exceeding 0.5mL. Injectate volumes greater than 0.5mL are consistently non-selective and cannot be used reliably for diagnostic block procedures in the epidural space. Key words: Epidural steroid injections, selective nerve root block, transforaminal, contrast flow

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.

Pain reproduction during lumbosacral transforaminal epidural steroid injection does not affect outcome

Pain reproduction during lumbosacral transforaminal epidural steroid injection does not affect outcome

PR_103: Pain Reproduction During Lumbosacral Transforaminal Epidural Steroid Injection Does Not Affect Outcome

Objective: To assess if reproduction of a patient’s radicular pain during fluoroscopically guided lumbosacral transforaminal epidural steroid injection (TFESI) is of prognostic value as to which patients would show favorable results. Design: Retrospective chart review of consecutive patients who underwent fluoroscopically guided TFESI for treatment of low back radicular pain. Pain rating on an 11-point pain intensity numeric rating scale (NRS) was recorded before, immediately following, and at follow-up (2−3wk) to the procedure.

Incidence of intravascular penetration in transforaminal lumbosacral epidural steroid injections.

A prospective, observational, human, in vivo study. To evaluate the incidence of vascular penetration during fluoroscopically guided, contrast-enhanced, transforaminal lumbar epidural steroid injections (ESIs) and determine whether a "flash" (blood in the needle hub) or aspiration of blood can be used to predict a vascular injection. Incorrectly placed, intravascular lumbosacral spinal injections result in systemic medication flow that misses the desired target. No previous studies evaluate the incidence of vascular injections in transforaminal ESIs, nor the ability of flash to predict a vascular injection. The incidence of flash or positive blood aspiration and the incidence of fluoroscopically confirmed vascular spread were prospectively observed in 670 patients treated with lumbosacral fluoroscopically guided transforaminal ESIs. Presence of a flash or positive aspiration was documented. Contrast was injected to determine whether the needle tip was intravascular. Seven hundred sixty-one transforaminal ESIs were included. The overall rate of intravascular injections was 11.2%. There was a statistically significant higher rate of intravascular injections (21.3%) noted with transforaminal ESIs performed at S1 (n = 178), compared with those at the lumbar levels (8.1%, n = 583). Using flash or positive blood aspirate to predict intravascular injections was 97.9% specific, but only 44.7% sensitive. There is a high incidence of intravascular injections in transforaminal ESIs that is significantly increased at S1. Using a flash or blood aspiration to predict an intravascular injection is not sensitive, and therefore a negative flash or aspiration is not reliable. Fluoroscopically guided procedures without contrast confirmation are instilling medications intravascularly and therefore not into the desired epidural location. This finding confirms the need for not only fluoroscopic guidance but also contrast injection instillation in lumbosacral transforaminal ESIs.