Nerve Root Injections Research Articles

Initial evaluation of pain relief efficacy of ultrasound-guided selective nerve root injection with corticosteroid in the treatment of cervical disc herniation

Objective: To evaluate the pain relief efficacy of selective nerve root injection with corticosteroid under ultrasound’s guidance in the treatment of the cervical disc herniation and its complications. Subject and method: The study was conducted with 20 cervical disc herniation patients in the Center of Multidisciplinary Consultation and Treatment, 108 Military Central Hospital from February 2021 to May 2021. All included patients were examined and performed the first injection, then observed for 2 hours after the procedure. The second injection would be indicated if the first one was not able to relieve 50% of pain at each time points of study. The time points of study were T0, T1, T2, T3 according to before, at a time, and after intervention 2 weeks and 4 weeks. The researched outcomes were vital signs, general status, Numeric Rating Scale (NRS, for pain assessment), and complications. Result: The average age of subjects was 54.75 ± 12.07 years old. Gender ratio (male/female) was 1.22. The most common herniated level was C5-C6 (90%), mainly right orientation (67%). The most frequent compressed nerve root was C6 right (67%). The NRS score at the time points after intervention significantly reduced, and this favorable outcome steadily maintained (p<0.05). The most popular complication was the parasympathetic reflex (10%), it gradually disappeared with conservative care. There was no severe complication. Conclusion: The selective nerve root injection with corticosteroid under ultrasound’s guidance in the treatment of cervical disc herniation is the acceptably safe and effective management.

Establishing a common language for lumbar transforaminal epidural steroid injections.

Patients presenting to spine surgeons for lumbar radiculopathy often undergo initial conservative treatment including medications, therapy, and lumbar transforaminal epidural steroid injections. Despite a growing number of spinal injections performed, there is a lack of available data regarding the occurrence of wrong-site injections. However, when examined, the discrepancies between ordering level and level of epidural steroid injection performed are immense. To aid with this issue, we propose that instead of ordering a lumbar transforaminal epidural steroid injections at a given level, it should be ordered to address a specific nerve root with laterality. This has the potential to reduce wrong-site procedures and improve patient outcomes. Retrospective chart review of 60 patients at a private orthopaedic spine practice under the care of spine surgeons or physician assistants over a 1-year period. The progress note, injection order form, procedure note, and procedural fluoroscopy were reviewed. If there were inconsistencies between one or more of these steps, it was deemed a failure. Results were analyzed to assess for any differences in outcomes between the two groups. We calculated our sample size prior to the study and powered it at 90%; descriptive statistics, Chi-square, Fisher's exact test, Student's t-test, and Wilcoxon rank sum tests were used where appropriate utilizing SAS v9.4. Thirty-seven patients (37/60, 61.6%) were considered a failure. There were no failures when ordering an S1 nerve root injection. We identified one wrong-site procedure and one wrong-level order that was identified and corrected by the interventionalist. There were multiple inconsistencies identified at various steps in the injection ordering process. This indicates a need to standardize the language used in this process to avoid wrong-site procedures. There were no inconsistencies in ordering an S1 injection, likely because this injection could only be ordered at the nerve root. It is also critical to utilize and save a localization film to ensure accuracy and accountability. We propose indicating the affected nerve root in all cases rather than the level of disc pathology would avoid confusion.

Crossing the Cervico-Thoracic Junction in Long Posterior Cervical Fusions Reduces Caudal Adjacent Segment Pathology.

Study Design:Retrospective case control.Objectives:The purpose of this study is to compare clinical outcomes and rates of symptomatic caudal adjacent segment pathology (ASP) in posterior cervical fusions (PCF) constructs with end-instrumented vertebrae in the cervical spine (EIV-C) to PCF constructs that end in the proximal thoracic spine (EIV-T).Methods:Retrospective review of 1714 consecutive cervical spinal fusion cases was done. Two groups were identified: 36 cervical end-instrumented vertebra patients (age56 ± 10 yrs) and 53 thoracic EIV patients (age 57 ± 9 yrs). Symptomatic ASP was defined as revision surgery or nerve root injection (or recommended surgery or injection) at the adjacent levels.Results:EIV-C patients had a significantly higher rate of caudal-level symptomatic ASP requiring intervention compared with EIV-T patients (39% vs 15%, p = 0.01). The development of caudal-level ASP was highest at C7 (41%), followed by C6 (40%). The overall complication rate and surgical revision rates, however, were similar between the groups. Neck Disability Index outcomes at 2 years postop were significantly better in the EIV-T group (24.5 vs. 34.0, p = 0.05).Conclusions:Long PCF that cross the C-T junction have superior clinical outcomes and reduced rates of caudal breakdown, at the expense of longer fusions and higher EBL, with no increase in the rate of complications. Crossing the C-T junction affords protection of the caudal adjacent levels without adding significant operative time or morbidity.

Surgical microdiscectomy vs steroid nerve root injection for sciatica up to 1yr; the nerves trial

Surgical microdiscectomy vs steroid nerve root injection for sciatica up to 1yr; the nerves trial

Ultrasound-Guided Lumbar Spine Injection for Axial and Radicular Pain: A Single Institution Early Experience.

Study DesignClinical audit via retrospective review of a database.PurposeTo report an early experience using ultrasound-guided lumbar spinal injection for axial and radicular pain in an Asian multiethnic cohort.Overview of LiteratureUltrasound-guided spine injection therapy is a comparatively new technique in the management of axial and radicular pain from degenerative lumbar spinal conditions, which may be a reasonable alternative to conventional fluoroscopic or computed tomography-guided injection.MethodsA retrospective review was conducted, involving all patients who underwent ultrasound-guided lumbar spine injection therapy at a single institution over 1 year. Patients were evaluated by two interventionists, who then performed standardized ultrasound-guided lumbar facet joint and pararadicular spinal injections.ResultsThere were 42 patients treated at our Sports Medicine Centre; with 27 patients (64.3%) receiving facet joint injections and 18 patients (42.9%) receiving nerve root injections. The majority (90.5%) of patients experienced an improvement of >30% in pain intensity at 3 months post-injection, using the Numerical Rating Scale pain score (p<0.001); with 40 patients (95.2%) reporting a reduction in Oswestry Disability Index score (p<0.001). No complications were reported.ConclusionsOur initial experience confirms the safety, feasibility, and effectiveness of ultrasound-guided lumbar spinal injection for the treatment of axial and radicular pain in an Asian multiethnic cohort.

Can we Rotate the Head Safely During Cervical Nerve Root Injection?

Objectives: Trans-foraminal epidural injections have been used successfully to aid in the management of cervicobrachialagia. The aim of this study was to assess the cross sectional area of the vertebral artery during transforaminal cervical nerve root injections (TFCNRI) when the head is typically rotated and to compare with the neutral position cross sectional area. We hypothesize that head rotation does not lead to a change of vertebral artery calibre at the neural foramen, thus this technique can be performed relatively safely during TFCNRI. Material and Methods: A pilot study involving a retrospective review of 16 computed tomography guided TFNRI was performed and cross sectional area of vertebral artery with head tilted and head in neutral position was performed. Results: There was no correlation between the degree of head rotation and change in the area of the ipsilateral or contralateral vertebral artery. Conclusion: We suggest that head can safely be rotated to varied degrees while performing TFCNRI.

Cervicogenic Headache

Cervicogenic headache is a secondary headache that occurs due to referred pain from the cervical region, perceived in the trigeminal nerve distribution. It is a rare entity which is often seen in patients following whiplash injuries belonging to the early 30s age group. The pain generators are facet joints, atlanto-occipital joint, intervertebral discs, neck muscles, and cervical nerves from various pathologies. Clinically, it is a side-locked headache worsened by abnormal neck postures and neck strain. The flexion–rotation test is positive in most cases. Diagnosis is made based on the ICHD-3 criteria. The mainstay of treatment involves physical therapy for 6 weeks along with psychological therapy and pain medications. Interventional pain therapy options include cervical epidural steroid injections, trigger point injections, selective nerve root injections, and radiofrequency thermal neurolysis.

Cervical Ultrasound Utilization in Selective Cervical Nerve Root Injection for the Treatment of Cervical Radicular Pain: a Review

This paper aims to review the available literature addressing the safety, accuracy, and efficacy of ultrasound-guided injections for cervical radicular pain. Ultrasound-guided injections remain a “partially blind technique” due to the inability to visualize relevant structures and the distribution of injectate. There remains a need for adequately powered studies evaluating the safety, accuracy, and effectiveness of ultrasound-guided steroid injections in the cervical spine. Fluoroscopy remains the best evidence-based image-guidance modality for injections into the cervical epidural space to treat cervical radicular pain. If ultrasound guidance is planned for treatment of cervical radicular pain, the authors recommend concomitant use of fluoroscopy guidance. Given the risk of inaccurate needle placement, physicians should retain fluoroscopic images prior to contrast injection to document the proper vertebral segment and final needle tip position. As epidural flow cannot be fully visualized with ultrasound, it is recommended to use fluoroscopy and, if needed, digital subtraction imaging to confirm the absence of intravascular injection. At a minimum, images should be saved post-contrast injection to document epidural flow.

Effectiveness of selective transforaminal nerve root injection of triamcinolone with ropivacaine for lumbar radicular leg pain

Background: Selective Nerve Root Block using steroid is a proven technique for management of lumbar radiculopathy. The aim of the study was to determine the effectiveness of selective nerve root block in lumbar radiculopathy. Methods: A prospective observational study was conducted for duration of one year in patients diagnosed with lumbar radiculopathy. Patients with leg pain, positive straight leg raising test and single level disc prolapse were included in the study. The procedure was performed under fluoroscopic guidance and Visual Analogue Pain rating scale was used for assessment pre-injection, immediate post injection 1 month, 3months and 6 months post injection. Results: Total 30 patient with mean age of 37.7± 9.31 years were included in the study. In 18 patients, this pain reduction was obtained immediately and in a further 8 patients within 4 days. In 4 patients, the nerve root block did not show a sufficient pain reduction. Conclusions: Selective transforaminal Nerve Root Block in lumbar radiculopathy significantly reduces Visual Analogue Pain Score post injection.

Characteristics of Patients and Treatment Recommendations from a Multidisciplinary Spinal Tumor Program

Spinal tumors arise frequently for patients with advanced cancer and optimal management involves consideration of neurologic, oncologic, mechanical, and systemic features. We describe characteristics of patient and treatment recommendations from a multidisciplinary spinal tumor board at one institution. A multidisciplinary spinal tumor program including radiation oncology, neuroradiology, orthopedic surgery, neurosurgery, and palliative care providers convened weekly to review complex spine cases and formulate a consensus plan. Patient and tumor characteristics were abstracted from electronic medical record with IRB approval, and treatment recommendations descriptively summarized. Between April 2017 and February 2019, 622 cases were reviewed, representing 438 unique patients. The median age was 62 years (range 21-92), comprising 52.5% men (n=230). In total, 31% (n=236) patients were deceased at last follow up. Most patients (91.8%) had metastatic disease, most commonly, breast (15.2%, n=67), NSCLC (14.8%, n=65), prostate (11.6%, n=51), renal cell (9.1%, n=40), or sarcoma (6.4%, n=28). 4.3% of patients had primary CNS tumors (n=19), and 2.5% had benign findings after pathology review, including 2 with infection. Radiation treatment was recommended in 52% of cases, including conventional EBRT in 34% (n=210) and SBRT in 18% (n=111). Surgical intervention was recommended for 26.2% (n=163) of patients. Vertebroplasty/kyphoplasty, biopsy, nerve root injection, or cryoablation was recommended for 15.9% (n=99), 9.3% (n=58), 0.8% (n=5), and 3.7% (n=23) of cases, respectively. Primary palliative care or medical oncology evaluation was recommended in 4.5% (n=28) and 5.3% (n=33). Additional imaging was requested for 16.6% (n=103), and 4% (n=25) cases had no further intervention recommended. Multidisciplinary care characterized 30% (n=189) of treatment recommendations, involving coordination of care of at least 2 (n=181) or 3 (n=8) disciplines for further local therapy or intervention. Multidisciplinary input is integral to the optimal care of spinal tumor patients. The risk of death for this patient population highlights the need to prioritize modalities that optimize overall quality of life in the context of a patient’s individual prognosis.

Paravertebral Collateral Arteries in Patients with Carotid Stenosis: Is There a Safe Space for Transforaminal Cervical Nerve Root Injections?

Image-guided cervical nerve root injections can cause serious complications including spinal cord infarction. This risk may be increased in patients with carotid stenosis who develop collateral arteries. The aim of this study is to describe the prevalence, and anatomical location, of arterial collateral vessels in relation to the optimal needle tip position in cervical nerve root injections. This retrospective study included 25 patients who had > 70% stenosis on a carotid CT angiogram. For each foramen the position of collateral arteries and the most anterior point of the facet joint were recorded, as Cartesian coordinates, by two independent observers. Descriptive statistics were used to analyse and present the results. 14 patients had unilateral and 11 had bilateral stenoses. A total of 85 collaterals were identified at all levels, the most common being C2/3. The median distance from collateral to optimal needle tip placement was 9.6mm (95% CI median: 6.7-12.4, IQR: 5.6-15.6). The minimum distance was 2.9mm. Inter-observer reliability was "substantial" (ICC 0.78, 95% CI 0.71-0.83). Collateral arteries were common in our cohort of patients with carotid artery stenosis and half lay within 10mm of the optimal position for transforaminal cervical nerve root injection.

Assessment of the utility of the National Health Service England Low Back and Radicular Pain Pathway: analysis of patient reported outcomes.

Lumbar disc herniation causing radiculopathy is a common reason for referral to spinal out-patient clinics. At our centre following routine referral, patients wait a mean of 109 weeks for a consultation with a spinal surgeon. A pathway in keeping with the National Health Service England Low Back and Radicular Pain Pathway was introduced with two objectives. Patients would be seen sooner by suitably trained health care professionals to avoid long waiting times for assessment with a spinal surgeon, and if a set of criteria were met, they would receive a selective nerve root injection to manage their pain. Patients were seen by specially trained orthopaedic physiotherapists following routine general practitioner (GP) referral. A radiologically guided nerve root injection was carried out if patients had radicular pain between 6 and 52 weeks duration and a magnetic resonance imaging (MRI) scan demonstrating an intervertebral disc prolapse correlating with their radicular symptoms. Patient-recorded outcome measures were taken before and after nerve root injection. Seventy five patients entered the pathway. Mean patient age was 49.9 years and 27 patients (36.0%) were male. Mean time from referral to assessment was 15.5 weeks. Mean visual analogue score (VAS) for leg pain was 7.4 out of 10 before nerve root injection and 4.8 out of 10 following nerve root injection (p < 0.001). Mean Oswestry Low Back Pain Disability Questionnaire score before nerve root injection was 58.4% and 49.7% following nerve root injection (p = 0.024). Mean Euroqol EQ-5D-5L Health Index was 0.2 before nerve root injection and 0.4 afterwards (p < 0.001). This study suggests that this pathway may help to reduce waiting times for patients with lumbar radiculopathy secondary to intervertebral disc prolapse. The resulting enhanced care may be associated with a reduction in leg and back pain and an improvement in quality of life.

Therapeutic role of Trans - foraminal nerve root block in management of lumbar radiculopathy

Treatment of Acute Lumbar Radicular pain has many controversies. While pure mechanical compression was considered previously as a source of sciatica, there is increasing evidence that chemical irritation of the nerve root plays an essential and perhaps even more important role. Trans foraminal selective nerve root block is an approved method for management of radicular pain. The aim of our study was to conduct a prospective study, 1. To assess the adequacy of relief provided by trans-foraminal Nerve Root Block for Lumbar Radicular pain. 2. To determine the effectiveness of selective (trans-foraminal) nerve root injection in diagnosis and treatment of patients with Lumbar radiculopathy. 28 patients with radicular pain involving single nerve root were selected. Trans-foraminal selective nerveroot block was done as per standard technique. Results were analyzed using VAS Score & RMDQ Score. Analyzing results showed that 89.3% patients had improvement. RMDQ score were reduced by 61% by end of 6 months. 18 patients (85.7%) who are on more than 6 months of follow up are able to do their daily activities without difficulty. We conclude by our study that, the trans-foraminal nerve root block combined with careful history, physical examination and quality radiolographic studies, is an important tool in the diagnosis and treatment of patients with predominant Lumbar radicular symptoms.

Safety of CT-guided cervical nerve root corticosteroid injections.

Computed tomography-guided cervical nerve root corticosteroid injections are a commonly performed procedure for cervical radiculopathy. There have been major complications such as spinal cord infarction and posterior circulation stroke reported mostly with X-ray fluoroscopic-guided methods, however, there is relatively little data on the safety of newer CT-guided methods. The purpose of this study was to identify any major complications and evaluate the rate of minor complications from CT-guided cervical nerve root corticosteroid injections performed in a tertiary public hospital. Four hundred and three CT-guided cervical nerve root injection procedures were identified over a period from July 2015 to January 2018 using the radiology information system (RIS) and data collected about the technique and any immediate complications. Patient follow-up and delayed complications were then reviewed, either via outpatient clinic records or telephone consultation. Two hundred and eighty-six procedures were performed by radiology registrars or fellows, and 117 by radiologists, most commonly via an anterolateral approach and injecting 4mg (in 1mL) of dexamethasone. Follow-up data were obtained for all 403 procedures and identified 16 minor complications, but no major neurovascular complications. The overall recorded rate of minor complications with CT-guided nerve root injection was 4.0% with no major neurovascular complications, suggesting that CT-guided transforaminal cervical corticosteroid injection is a safe procedure.

The effectiveness of ultrasound-guided cervical transforaminal epidural steroid injections in cervical radiculopathy: a prospective pilot study.

BackgroundCervical transforaminal epidural steroid injection (CTFESI) is used to provide pain relief and restore function in patients with cervical radiculopathy. Traditionally, it is performed under the guidance of fluoroscopy or computed tomography. Here, we introduce a novel technique – ultrasound-guided CTFESI – with which operators can easily distinguish the close soft tissue (nerve, vessels) around the cervical foramina to avoid intravascular injection during the procedure.ObjectiveTo present the immediate and long-term effectiveness of ultrasound-guided CTFESI in patients with cervical radiculopathy in an academic pain-management center with prospective clinic experiments.MethodsFifteen patients with cervical radiculopathy who were resistant to conservative therapies and ultrasound-guided selective cervical spinal nerve-root injections, were treated with ultrasound-guided CTFESI. During the injection procedures, the needle tips were reconfirmed by real-time fluoroscopy. Pain numeric rating-scale and neck-disability-index scores were assessed from onset to six months after the procedures.ResultsDuring the procedures, based on real-time fluoroscopic confirmation, the injection solution outlined the spinal nerve root and spread into the epidural space in most cases (14 of 15). All patients reported pain relief within 10 minutes after the injection. The majority of patients (eleven of 15) experienced pain relief and neck-disability index-score improvement throughout the 6-month study period. No patient experienced any complication.ConclusionWe suggest that ultrasound-guided CTFESI is an effective, safe, and simple procedure free of radiation or magnetization and provides sustained pain relief in patients with cervical radiculopathy who have failed previous conservation therapies.

Nerve root injection cancellations because of incomplete anticoagulation management.

Computed tomography-guided steroid injection is a well-recognized, conservative treatment of localized spinal pain as a result of facet arthropathy and radiculopathy secondary to nerve root compression. An extremely rare complication is the development of an epidural haematoma with potential to cause permanent neurological damage, so anticoagulation at the time of procedure is contraindicated. Routinely injections are performed as an outpatient requiring the referring physician to implement a peri-procedural anticoagulation plan. Anecdotal experience suggested that cancellations were occurring as patients remained on anticoagulation at the time of their appointment. The authors therefore assessed the existing service against expected standards to identify the causes of cancellations and find ways to improve the service. This audit aimed to identify the incidence of cancelled computed tomography-guided nerve root injections secondary to incorrect peri-procedural anticoagulation management, develop an intervention to help reduce the incidence of cancellations and then re-audit to assess the effect of the intervention. The audit standard was that 100% of outpatients attending for computed tomography-guided nerve root and facet injections should have an appropriate anticoagulation plan implemented. Baseline data collection took place prospectively between 1 September and 30 November 2016. The study population was elective computed tomography-guided spinal nerve root and facet injections scheduled on the radiology information system at the authors' trust. Descriptive analysis was completed. The intervention involved a revised electronic request form being implemented with new compulsory fields concerning antiplatelets and anticoagulants. Re-audit post-intervention involved prospective data collection between 1 September and 30 November 2017 using the same methods. Baseline audit found that of three out of 55 (5%) patients had cancellations. On re-audit, there were 0 cancellations out of 93 patients. The new request form prevented 5% of patients referred for computed tomography-guided nerve root injection being cancelled because of incorrect anticoagulation management. Extrapolated over the year the potential savings through preventing lost activity are £3445.56.

A review of 571 radiographs on Tuffier's inter-cristal line and its' application in lumbar spinal surgery.

Tuffier's line (TL) is an anatomical landmark used to identify the L4/5 interspace by palpating inter-cristal level in lumbar spinal surgery. The routine use of pre-operative pre-incision radiographs for level check by spinal surgeons is variable due to reliance on this palpation. The anatomical violation of neighbouring normal levels in microscope assisted lumbar surgery is unknown. The aim of this study was to evaluate the effects of patient-related demographic factors and radiographic parameters on TL in a cohort of patients undergoing lumbar spinal procedures. We retrospectively analysed 195 patients (571 radiographs) from a spinal database undergoing lumbar spinal procedures included nerve root injections, decompressions, micro-discectomies and instrumented fusions under a single surgeon. Radiographs were analysed with regard to age, gender, radiographic views (AP & lateral) and weight-bearing (wb) & non-weight bearing (non-wb). The mean age was 59.8 years (range, 24-88 years). The most common level of TL was L4 vertebra (40% <60; 44% >60 years). The most common level in females was L5, while in males L4 vertebra. In 186 radiographs, 68% displayed a difference of at least one vertebral level on AP versus lateral planes. In 11 patients, there was at least 1 level vertebral difference between weight bearing & non-weight bearing radiographs. TL can be affected by age, gender, radiographic views and weight bearing status variably. We recommend employing pre-incision radiographs in all microscope assisted lumbar spinal procedures to eliminate the clinical variations in inter-cristal line and thereby avoiding anatomical violation of neighbouring normal levels in microscope-assisted lumbar surgery. We highlight such variations in inter-cristal line should be given enough consideration in order to avoid a wrong level surgery. Palpatory method for level check without performing pre-incision lateral X-ray should be discouraged.

Lumbar Selective Nerve Root Block: Comparative Study Using Two Pharmacological Formulae.

Study Design:Retrospective cohort study.Objectives:The objective of the present study was to compare the effectiveness of 2 different pharmacological formulae in selective nerve root injections.Methods:We studied a series of 298 patients who received a selective nerve root injection and made a comparative study dividing them into 2 groups according to the drugs used. In group A, we used betamethasone 6 mg and lidocaine, while in group B, triamcinolone 60 mg and bupivacaine were used for the procedure. We evaluated the patients for a period of at least 8 months, assuming the need for surgical therapy as the failure of the procedure.Results:Both groups had 149 patients with similar etiological characteristics. Forty-seven patients (16%) required surgery to relieve pain with a similar distribution between groups (24 from group A and 23 from group B). Time between nerve root injection and surgery was 86.79 (14-360) days on average in group A and 75.76 (2-180) days in group B with no statistical difference (P = .67). Only one complication was documented, an anaphylactic shock in a patient in group B.Conclusions:Based on these results, we found no difference in the type of steroid or local anesthetic used for selective nerve root injections.

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

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

P90 - A Randomized Control Trial Evaluating the Effectiveness of Selective Nerve Root Injections in Patients with Lumbar Disc Herniation

P90 - A Randomized Control Trial Evaluating the Effectiveness of Selective Nerve Root Injections in Patients with Lumbar Disc Herniation