Nerve Root Injections Research Articles

Etiology of long-term failures of lumbar spine surgery.

Patients who do not improve after lumbar surgery may be given the nonspecific label of "failed back surgery syndrome (FBSS)." Since 1981, there has not been a quantitative assessment of the etiologies of FBSS despite major improvements in surgical techniques and diagnostic testing. To define the causes of FBSS seen in a referral-based spine center. Retrospective review of 181 consecutive charts of patients seen at a single spine center because of continued pain after lumbar surgery performed elsewhere. Evaluation was individualized based on history and physical examination and included x-rays, CT scans, MRI, selective nerve root injections, discography, and psychiatric evaluation. There were 101 men and 80 women; mean age was 47 years. There were 118 patients with one prior surgery, 52 with two, 6 with three, and 5 with four. Mean interval from the last prior surgery to the first clinic visit was 33 months. A predominant diagnosis could be established in 170 of 181 (94%) patients, and included foraminal stenosis (29%), painful disc(s) (17%), pseudarthrosis (14%), neuropathic pain (9%), instability (5%), and psychological problems (3%). We were able to establish a predominant diagnosis in 94% of our patients. Foraminal stenosis remains the leading cause of FBSS, but painful discs are also common. Recurrent disc herniation is seen less often than in the past, and there is increased recognition of neuropathic pain. Knowledge of the potential causes of FBSS leads to a more efficient and cost-effective evaluation of these patients.

The Effect of Nerve-Root Injection on Pain Relief in the Management of Osteoporotic Vertebral Fractures

Purpose : The purpose of this study was to evaluate the efficacy of a nerve-root injection for the alleviation of pain in osteoporotic vertebral fracture. Materials and Methods : Eighteen patients with pain from osteoporotic vertebral fracture, without improvement after conservative treatment, were included in this study. The group consisted of sixteen women and two men, and had with a mean age of 71 years. Patients underwent a nerve-root injection with lidocane, bupivacane and depomedrol, and were allowed as many as three injections. The mean follow-up period was 13.5 months. Results : The average pain scores at pre-injection, 1 month and 6 months after the injection and final follow-up were 85, 24.9, 14.1 and 17.4, respectively. According to the criteria used to assess clinical results, there was one excellent, thirteen good and four fair results. A newly developed compression fracture was noted in one patient. No complication was related to the injection. Conclusion : Our data show that nerve-root injections are effective at improving pain. This suggests that patients with pain from osteoporotic vertebral fractures should be considered for treatment with nerve-root injections prior to being considered for percutaneous vertebroplasty or operative intervention.

(217) Selective Nerve Root Injections Can Accurately Predict Level of Nerve Impairment and Outcome for Surgical Decompression: A Retrospective Analysis

(217) Selective Nerve Root Injections Can Accurately Predict Level of Nerve Impairment and Outcome for Surgical Decompression: A Retrospective Analysis

(217) Selective Nerve Root Injections Can Accurately Predict Level of Nerve Impairment and Outcome for Surgical Decompression: A Retrospective Analysis

(217) Selective Nerve Root Injections Can Accurately Predict Level of Nerve Impairment and Outcome for Surgical Decompression: A Retrospective Analysis

Transforaminal Lumbar Epidural Steroid Injections

Low back pain is an important medical, social, and economic problem involving approximately 15% to 39% of the population. Of the numerous therapeutic interventions available for treatment of chronic low back pain, including surgery, epidural administration of corticosteroids is one such intervention commonly used. Several approaches available to access the lumbar epidural space are the caudal, interlaminar, and transforaminal, also known as nerve root or selective epidural injection. The objective of an epidural steroid injection is to deliver corticosteroid close to the site of pathology, presumably onto an inflamed nerve root. This objective can be achieved by the transforaminal route rather than the caudal or interlaminar routes. Reports of the effectiveness of epidural corticosteroids have varied from 18% to 90%. However, reports of the effectiveness of transforaminal epidural steroids have shown it to be superior, with outcome data indicating cost effectiveness as well as safety. This review describes various aspects of transforaminal epidural steroid injections in managing chronic low back pain.

Efficacité des infiltrations péridurales de corticoïdes par voie périradiculaire ou interépineuse dans le traitement des sciatiques discales. Étude pilote prospective, randomisée, et à double insu

Study objectives. Pilot study comparing the short-term efficacy on pain and functional impairment of nerve root sheath versus interspinous glucocorticoid injections in patients admitted to a French rheumatology department for disk-related sciatica or femoral neuralgia. Patients and methods. Thirty patients with refractory nerve root pain (sciatica, n = 29; femoral neuralgia, n = 1) for a mean of four months were randomized to nerve root injection ( n = 17) or interspinous injection ( n = 13) of the same mixture of 0.10 g of lidocaine hydrochloride and 3.75 mg of cortivazol. Both injection methods were performed under analgesia and benzodiazepine sedation to maintain double blinding. Each patient was evaluated daily during the first seven days of bed rest in the hospital, then after discharge on postinjection day 28. Results. Prompt pain relief was obtained in both groups. On day 1, the mean pain scale score (0–100) fell from 70 ± 3.9 to 26 ± 5.6 in the nerve root group and from 63 ± 4 to 23 ± 4.7 in the interspinous group. These results were sustained on D7 and D28. Conclusions. The unusually high level of efficacy of glucocorticoid injection in our study may be ascribable in part to strong placebo and Hawthorne effects and in part to the intrinsic effects of the injections. Whether nerve root injection is superior over interspinous injection remains unproven.

Winning Studies on Nerve Root Injections, phy, and Gene Modification

Winning Studies on Nerve Root Injections, phy, and Gene Modification

Fluoroscopy Is Medically Necessary for the Performance of Epidural Steroids

We read with great interest the article by Fredman et al. (1) titled “Epidural steroids for treating ‘failed back surgery syndrome:’ is fluoroscopy really necessary?” This well designed and well conducted study described the implications appropriately, but it did not draw the conclusion that fluoroscopy is medically necessary to perform epidural steroids in the treatment of “failed back surgery syndrome.” As they correctly point out, despite accurate placement, the depot-steroid solution will spread to reach the level of pathology in only 26% of cases. If one considers this as the average delivery, and with an average success rate of 60% for epidural steroid injection(s), this would translate into a 16% success rate. However, if one believes that the cardinal site of pathology is considered to be in the ventral epidural space, the results look even more disappointing when using a blind epidural injection (2,3). Several approaches available to access the lumbosacral epidural space are caudal, interlaminar (lumbar), and transforaminal (nerve root or selective epidural injections) (2,3). As stated by the authors (1), the interlaminar approach for lumbar epidural has been perceived as advantageous, because the needle is directed more closely to the assumed site of pathology, facilitating the injectate's delivery directly to its target. However, when using a blind interlaminar technique, one may erroneously miss the targeted interspace by one or two levels. The preferential cranial flow of solutions in the epidural space necessitates the needle's position one level below the site of suspected pathology, and the epidural needle placement may significantly deviate toward the nondependent side, thus negating the presumed benefits (4–9). Other potential difficulties encountered with lumbar epidural injections include congenital abnormalities, postsurgical spine as described, and target specific placement of injectate at L5/S1 (10). Hence, transforaminal epidural injections have been considered the most advantageous in reaching the cardinal site of the pathology under direct fluoroscopic visualization with an extremely low dose of steroids. Based on this report (1) and others in the literature (4–9), without the use of fluoroscopy and epidurography, additional risks can be foreseen with epidural steroid injections because of the increased potential for dural puncture, subarachnoid injection, and intravascular injections with associated complications. Performing a procedure that only has the effectiveness of 16% based on the present data (1) is definitely not a cost-effective procedure. However, whether fluoroscopy and epidurography add any risks is an important question. Radiation exposure is minimal in experienced hands, has a low risk of allergic reaction, and is minimized and almost entirely eliminated by using low volume, nonionic contrast media. At least in the United States, the additional cost of the procedure with fluoroscopy should be immaterial in an ambulatory surgery setting at the present time, because surgery centers are paid for the facility based on global charges regardless of whether fluoroscopy was utilized. With new regulations scheduled to be implemented in hospital outpatient departments, the same global structure will be used with no extra cost for using fluoroscopy and epidurography. In fact, there will be tremendous cost savings by insuring that the epidural space has in fact been reached, thereby reducing failures by as much as 50% to 60% by avoiding misinjection. Laxmaiah Manchikanti MD Cyrus E. Bakhit MD Rajgopal R. Pakanati MD Bert Fellows MD

Extraforaminal stenosis in the lumbosacral spine. Efficacy of MR imaging in the coronal plane.

To review experience with MR images of extraforaminal (EF) stenosis in the lumbosacral spine. MR images from 9 patients with 10 EF stenoses were reviewed. The diagnosis was confirmed in 6 patients at surgery, and in 4 on the basis of findings of nerve root injection combined with nerve block. All patients had congenital lumbosacral anomalies with various degrees of fixation between the last formed level and the pelvis. In all cases, affected roots were compressed between the transverse process of the last lumbar segment and the sacral ala. MR using coronal plane imaging demonstrated the root impingement directly in the far lateral zone in all patients. However, sagittal and axial images were unable to define the EF stenoses in all patients. The results of this study show that a transitional vertebra is a cause of EF stenosis and that MR images using coronal plane are useful in the assessment of EF stenosis.

Metrizamide lumbar epidurography with Seldinger Technique through the sacral notch and selective nerve root injection.

Lumbar epidurography serves as an important radiographic procedure in the evaluation of patients with equivocal myelography and confusing or non-diagnostic physical findings. It is particularly valuable in patients with a wide ventral epidural space secondary to previous surgery, arachnoiditis or on a congenital basis. Several techniques and various contrast agents have been employed for the procedure. A pure Seldinger technique with a caudal approach through the sacral hiatus and injection of metrizamide gives excellent visualization of the epidural space and nerve root sleeves. The proper concentration of metrizamide is crucial for optimal results. Lateral, AP, and AP oblique radiographs, occasionally combined with lateral, complex motion tomography, clearly demonstrate the root sleeves and ventral epidural space. CT scanning, with present technology, does not provide the necessary detail for evaluating the epidural space.