Periradicular Therapy Research Articles

Predicting the Outcome of Periradicular Therapy is Based on Strict Inclusion/Exclusion Critera and Co-Medication.

Predicting the Outcome of Periradicular Therapy is Based on Strict Inclusion/Exclusion Critera and Co-Medication.

Clinical Effectiveness of Single Lumbar Periradicular Infiltration in Patients with Sciatica.

Periradicular therapy (PRT) is a minimally invasive radiological procedurein patients with chronic lumbar pain.The aim of the study is to identify clinical and radiological predictive factors for treatment success after a single PRT treatment in patients with sciatica.The study includes a prospective follow-up of 166 patients treated with PRT. The pain intensity is determined according to the VAS scale and the degree of improvement is presented as excellent (over 75%), good (50-70%), moderate (25-49%), and weak (less than 25%). The follow up of the treated patients was done at 2 weeks, 3 and 6 months. In patients with pain duration up to 3 months, the improvement was excellent in n=32 (58.18%) after 2 weeks, after 3 months n=41 (74.55%) and after 6 months n=41 (74.55%). This stands in contrast to patients with pain over 1 year. The percentage of improvement after 6 months, post-intervention, was highest in patients without nerve root compression (86.25±19.2),and the highest improvement after 6 months was in patients with localization of pain at the L4-L5 level (69.69±29.7), the greatest improvement after six months was in patients with extraforaminal hernia (62.82±34.3), and the lowest in patients with central stenosis (40.21±30.7).Our study results suggest that the shorter a pain duration, low-grade root compression, injection level and type of herniation area predictor the more favourable response patients have to transforaminal epidural steroid injection in patients with sciatica.

Periradicular corticosteroid infiltration for radicular pain - comparison of Diprophos and Depomedrone and ozone effects.

To determine the treatment effect of corticosteroids in periradicular therapy (PRT) for radicular pain and to compare different types of corticosteroids and ozone. We also examined the effect in different indication groups for periradicular therapy for each type of treatment agent. Various studies have examined the therapeutic value of periradicular infiltration using treatment agents consisting of local anesthetic and corticosteroids or ozone application for radicular pain. This is the first study to compare different types of corticosteroids and ozone. Eligible patients with radicular pain who failed conservative management were divided into five indication groups and prospectively followed to assess the PRT effect of corticosteroids or ozone application. PRT was performed under computer tomography (CT) monitoring. A set of three PRT applications in three weeks was applied and the outcome was evaluated using a visual analogue score for back and leg pain. The in-group and between-group treatment effect was tested using the Wilcoxon signed-rank test and the Kruskal-Wallis H-test with Dunn's post-hoc tests, respectively. The dependency between treatment effectiveness and indication for each group was tested using the Kruskal-Wallis H-test and Dunn's post-hoc tests. We prospectively followed 150 patients, randomized into three groups of 50 patients each. The follow-up rate was 100%. All three treatment agents showed a statistically significant treatment effect (P<0.001). The statistically significant effect was higher in betamethasone (Diprophos) versus methylprednisolone (Depomedrone) (P=0.019) and Diprophos versus ozone (P<0.001). Diprophos also showed the highest decrease of VAS after therapy versus VAS prior to therapy (median decrease = 4) compared to Depomedrone and ozone (median decrease = 3 and 2, respectively). The statistically significant outcome was better with the indication of spondylolisthesis and disc herniation (P=0.019) indication for the Diprophos group and between spinal stenosis and spondylolisthesis (P=0.022) and spondylolisthesis and disc herniation (P=0.016) for the ozone group. Clinical improvement occurred in all three groups but Diprophos showed the statistically best treatment effect compared to Depomedrone and ozone. Disc herniation resulting in radicular pain had a statistically significant better effect in comparison with spondylolisthesis in the Diprophos and ozone groups, but the ozone group showed heterogeneity depending on treatment effect and indication.

The role of periradicular infiltration in dorsal root ganglion stimulation for chronic neuropathic pain

BackgroundTargeting the correct spinal level is essential in dorsal root ganglion (DRG) stimulation. Anatomical selection of the DRG alone is not ideal since the pain area is not necessarily confined to the borders of the dermatomes. This study aims to establish the role of periradicular infiltration therapy (PRT) in the preoperative assessment of the correct level for DRG stimulation performed under general anesthesia.MethodWe report a prospective study of 20 patients selected for DRG stimulation and submitted to a PRT for identification of the spinal level. Lead implantation for the stimulation trial occurred under general anesthesia: 19 patients experienced positive results and underwent implantation of the pulse generator. All patients suffered from chronic neuropathic pain unresponsive to best medical treatment. PRT levels were compared with the levels targeted with DRG leads. Patients were followed for up to 12 months; pain intensity and coverage of the painful area were assessed.ResultsIn 12 patients, the trial leads were placed on the same level as previously tested positive by PRT. In 6 patients, leads were placed in the PRT target and additionally in adjacent spinal levels. In one case, the selected target for the trial diverged from the PRT target because of intense fibrosis in the chosen level. Coverage of the target area of at least 50% was achieved by two-thirds of the patients. For the six subjects with additional implanted leads as a consequence of the PRT results, 80% achieved a coverage of at least 50%. A total of 47.4% of the patients achieved sustained significant pain relief in the last follow-up. None of the patients needed a repeated surgery for implantation of additional leads.ConclusionsPRT is a helpful tool to confirm the stimulation targets. A PRT preceding the stimulation trial is an additional opportunity to optimize the coverage of the target area with stimulation-induced paresthesia for patients operated under general anesthesia.

The physician as a success determining factor in CT-guided pain therapy

BackgroundBack pain is a common problem and a burden for the patient. MR-morphologically proven pain-causing changes of the spine is often successfully treated utilizing CT-guided pain therapy. The CT-guided execution enables a controlled and reproducible therapy. Nevertheless, treatment results can differ even with the same patient; the physician is a possible influencing factor of the outcome. Accordingly, the present study analyzes the different behaviors and forms of communication of the treating physicians during the course of the intervention as factors influencing the outcome of treatment.Methods67 patients suffering from specific back pain were included in this study. 5 treating physicians (2 female, 3 male) of different age (29–63 years), and experience and a total of 244 CT-guided treatments were included in this study. In every case a psychologist observed the treatment based on a standardized observation protocol. Observed were both the verbal and non-verbal interactions as well as the reaction of patient and physician. The success of the therapy was measured in the course of the treatment using the visual analogue pain scale. The technical comparability of the performed CT-guided periradicular therapy was ensured by the distribution of the drug mixture.ResultsThe outcome is significantly better if the patient considers the treating physician to be competent (correlation coefficient: 0.24, p < 0.006) and feels understood (correlation coefficient: 0.29, p < 0.001). In addition, the outcome is better when the physician believes that the treatment brings a positive reduction of pain, underlining his belief with positive statements of affirmation before the intervention thus creating a positive atmosphere [correlation coefficient: 0.24 (p < 0.009)]. In contrast, the outcome is worse if the patient complains about pain during the intervention [average pain reduction M = 0.9 (pain group) vs. M = 2.0 (no-pain group)].ConclusionOur study shows that with comparable implementation of CT-guided periradicular therapy, the outcome of the patient with specific back pain can be significantly improved by certain behavioral patterns of the performing physician and this without side effects and without significant additional time expenditure. Our findings indicate that there is a non-negligible psychological factor linking confidence in therapy to actual therapy success.Trial Registration: The study was designed as an observational study, therefore a trial registration was not necessary.

IMPORTANCE OF PAIN DURATION PRIOR PAIN RELIEF TREATMENT WITH CT-GUIDED PERIRADICULAR THERAPY IN PATIENTS WITH CHRONIC LUMBAR PAIN

CT-guided periradicular therapy (PRT) is a minimally invasive interventional technique for treatment of chronic lumbar pain. Aim: To investigate importance of pain duration before PRT treatment in patients with chronic lumbar pain and radiculopathy, with clinical effectiveness assessment. A prospective follow-up CT guided PRT study was done in 166 patients divided into 4 groups according duration of pain before intervention (&lt;3 months, 4-6months, 7-12months, &gt;1year). Degree of pain intensity was determined according to VAS scale. Improvement degree was excellent, good, moderate, or weak.Good clinical response was defined when improvement is greater or equal to 50% on VAS scale, and functional improvement was equal to 40% in the reduction of the ODI index. Follow-up was done at 2nd weeks, 3 and 6 months. Good response was observed in 51.8% of the cases after 2 weeks, 54.2% after 3 months and 59% after 6 months. ODI index parameters was greater or equal to 40% in 22.2% after 2 weeks, 13.8% after 3 months, and 8.4% after 6 months.After 6 months in patients with pain duration up to 3 months, the improvement was excellent in 41(74.5%), moderate in 3(5.4%), good in 6(10.9%) and weak in 4(7.2%) patients in contrast to patients with pain over one year who showed excellent improvement in only 2(5.7%) patients, moderate in 11(31.4%), good in 6(17.1%) and weak in 16 (45.7%) patients. PRT is clinically effective with better clinical outcomein patients with shorter duration of symptoms. Keywords: chronic lumbar pain, radiculopathy, CT guided, interventional, steroids

Vertebral disk morphology of the lumbar spine: a retrospective analysis of collagen-sensitive mapping using dual-energy computed tomography

ObjectivesTo investigate the diagnostic accuracy of collagen-sensitive maps derived from dual-energy computed tomography (DECT) for the detection of lumbar disk pathologies in a feasibility setting.Materials and methodsWe retrospectively reviewed magnetic resonance imaging (MRI), computed tomography (CT), and DECT datasets acquired in patients who underwent periradicular therapy of the lumbar spine from June to December 2019. Three readers scored DECT collagen maps, conventional CT, and MRI for presence, type, and extent of disk pathology. Contingency table analyses were performed to determine diagnostic accuracy using MRI as standard of reference. Interrater agreement within and between imaging modalities was evaluated by computing intraclass correlation coefficients (ICCs) and Cohen’s kappa. Correlation between sum scores of anteroposterior disk displacement was determined by calculation of a paired t test.ResultsIn 21 disks in 13 patients, DECT had a sensitivity of 0.87 (0.60–0.98) and specificity of 1.00 (0.54–1.00) for the detection of disk pathology. Intermodality agreement for anteroposterior disk displacement was excellent for DECT (ICC 0.963 [0.909–0.985]) and superior to CT (ICC 0.876 [0.691–0.95]). For anteroposterior disk displacement, DECT also showed greater within-modality interrater agreement (ICC 0.820 [0.666–0.916]) compared with CT (ICC 0.624 [0.39–0.808]).ConclusionOur data suggest that collagen-sensitive imaging has an added benefit, allowing more accurate evaluation of the extent of disk displacement with higher interrater reliability. Thus, DECT could provide useful diagnostic information in patients undergoing CT for other indications or with contraindications to MRI.

Training of CT-guided Periradicular Therapy in a Realistic Simulation Environment – Evaluation and Recommendations for a Training Curriculum

To evaluate the training of computed tomography (CT)-guided periradicular therapy in a realistic simulation environment and to derive recommendations for a training curriculum. A novel simulation environment including the use of a 3D printed, patient-mimicking phantom was used to train medical students to perform CT-guided periradicular therapy of the lumbar spine. Seventeen participants underwent three training sessions (day 0, day 7, and after day 28) with six procedures per session. Procedure duration and the number of fluoroscopy image acquisitions were recorded. Participants' performance was assessed by an independent investigator using a six-point checklist scale (0 = lowest, 6 = highest). In addition, participants self-evaluated their skills and the simulation training in questionnaires. Procedure durations and image acquisitions decreased after one training session (p < 0.001) without further improvement thereafter (p > 0.6). They also decreased within training sessions and were lowest after five procedures in all sessions. Performance scores improved after the first session to nearly perfect scores in the second session (mean 5.7; 95%CI: 5.5-6.0; p < 0.001) and decreased again in the third session (mean 4.9; 95%CI: 4.6-5.3; p = 0.008). Participants were satisfied with their training progress and felt adequately prepared to perform CT-guided periradicular therapies on patients after the training. Simulation-based training of CT-guided periradicular therapy in a realistic environment is effective and should ideally be performed with one training session consisting of five procedures shortly before treating the first patient.

CT-guided Interventional Therapy of Back Pain – Predictors of Success in Treatment

The aim of the presented study was to investigate if distribution of the drug-contrast medium mixture in CT-guided periradicular therapy can predict intervention success. Over a 15-month period, 97 patients admitted to our institution by a pain physician for CT guided periradicular therapy were treated. In 420 CT guided interventions, we measured the relative distribution of the drug mixture in relationship to the neuroforamen. The distribution was correlated to the patient's pain score over time. In addition, dependence of success in treatment with regards to the treating physician was evaluated. Ninety percent of the patients experienced a decrease of pain score under therapy, only 10 % showed no change. On average there was an improvement in pain score from 7.4 (2-10) before therapy to 3.7 (0-9) at the end of therapy. We observed a weak correlation of -0.22 (p < 0.028) between distribution of drug mixture to the neuroforamen and reduction of pain score. The therapy outcome displayed a dependency regarding the treating physician (p < 0.0084). CT guided periradicular therapy offers good pain reduction in most of the patients. Drug distribution near the affected nerve and treating physician are factors for clinical success. · CT-guided periradicular therapy shows a good or very good improvement in the symptoms in 90 % of the treated patients.. · In addition to technical performance, the treating radiologist is an important parameter determining success.. · The success of CT-guided treatment is only moderately correlated with an absolute distribution of the drug mixture.. · Stueckle CA, Talarczyk S, Hackert B et al. CT-guided Interventional Therapy of Back Pain - Predictors of Success in Treatment. Fortschr Röntgenstr 2021; 193: 42 - 48.

Ultra-low-dose periradicular infiltration of the lumbar spine: spot scanning and its potential for further dose reduction by replacing helical planning CT.

Computed tomography (CT)-guided periradicular infiltration has become an accepted procedure for treating radiculopathy-associated low back pain. The purpose of this study is to compare spot scanning and segmental helical planning CT in terms of dose reduction. Eighty-five patients underwent CT-guided single-site lumbar periradicular therapy. Prior imaging was not available for planning. Sixty-three patients were examined with a new dedicated spot scanning technique (group I), and twenty-two patients underwent conventional segmental planning CT examinations with helical image acquisition serving as controls (group II). Examinations were reviewed retrospectively for dose-length product (DLP) and number of acquisitions required for intervention. Pain reduction accomplished with the intervention was recorded for quality assurance. Median DLP was 0.80mGycm for spot scanning versus 6.50mGycm for segmental planning CT. Thus, the contribution of the planning scan to the total interventional dose decreased from 73 to 25%. As a result, the total interventional dose was reduced significantly from a median DLP of 8.90mGycm to 3.20mGycm (-64%). Acquisitions required during the intervention had a median DLP of 2.40mGycm for group I and 2.35mGycm for group II, showing no significant difference. Median pain reduction in both groups was two points on the numeric rating scale. Dedicated spot scanning for planning reduced the total median effective dose of the intervention by more than 64% without increasing the number of images required during the interventional procedure. Significant pain reduction was achieved with both approaches. Spot scanning is recommended for dose reduction.

Periradicular infiltration of the lumbar spine: testing the robustness of an interventional ultra-low-dose protocol at different body mass index levels.

Background Computed tomography (CT)-guided periradicular infiltration remains a frequent interventional procedure for treatment of low back pain. Purpose To present an interventional ultra-low-dose protocol for CT-guided periradicular infiltration therapy and assess its application at different body mass index (BMI) levels. Material and Methods Over a period of 14 months, 79 patients underwent 183 CT-guided interventions for single-site lumbar periradicular therapy using an ultra-low-dose protocol with a basic setup of 100 kV and 5 mAs. Procedures were performed via intermittent fluoroscopy. A retrospective review was performed to analyze the parameters tube current and tube voltage, dose-length product, and BMI. Results The interventional ultra-low-dose protocol allowed safe treatment of 91.1% of the patients without a need for adapting the protocol. In seven patients with a higher BMI (range, 31-38 kg/m2; mean, 34 kg/m2), the tube current had to be increased to retain sufficient image quality. Only patients with a BMI of 30 and higher showed a significant correlation between BMI and dose-length product ( P value = 0.02), resulting in a slightly increased dose ( P value = 0.002). Conclusion The protocol presented for the interventional part of CT-guided periradicular infiltration allows to safely treat patients with a median calculated effective dose of 0.045 mSv (converted from a dose-length-product of 2.26 mGy*cm). Patients with a BMI of 30 and higher required a higher calculated effective dose with just one patient slightly exceeding 0.1 mSv.

Prospective Evaluation of the Radiologist's Hand Dose in CT-Guided Interventions

Assessment of radiologist's hand dose in CT-guided interventions and determination of influencing factors. The following CT-guided interventions were included: Core biopsy, drainage, periradicular therapy, and celiac plexus neurolysis. The hand dose was measured with an immediately readable dosimeter, the EDD-30 (Unfors, Sweden). The default parameters for CT fluoroscopy were 120 kV, 90 mA and a 4 mm slice thickness. All interventions were performed on a 16-slice CT unit (Aquilion 16 Toshiba, Japan). The tumor size, degree of difficulty (1 - 3), level of experience and device parameters (mAs, dose-length product, scan time) were documented. 138 CT-guided interventions (biopsy n = 99, drainage n = 23, pain therapy n = 16) at different locations (lung n = 41, retroperitoneum n = 53, liver n = 25, spine n = 19) were included. The lesion size was 4 - 240 mm (median: 23 mm). The fluoroscopy time per intervention was 4.6 - 140.2 s (median: 24.2 s). The measured hand dose ranged from 0.001 - 3.02 mSv (median: 0.22 mSv). The median hand dose for lung puncture (n = 41) was slightly higher (median: 0.32 mSv, p = 0.01) compared to that for the liver, retroperitoneum and other. Besides physical influencing factors, the degree of difficulty (p = 0.001) and summed puncture depth (p = 0.004) correlated significantly with the hand dose. The median hand dose for different CT-guided interventions was 0.22 mSv. Therefore, the annual hand dose limit would normally only be reached with about 2000 interventions.

Computed Tomography-guided Periradicular Injections on Cervical and Lumbar Spine

Treating sciatic pain caused by intervertebral disk herniation remains challenging. Not only does the symptomatology put a strain on patients, it is also of enormous socioeconomic impact. Next to conservative measures that include physical therapy and adequate pain medication, surgery—absolutely indicated in cases of cauda syndrome and severe motor deficit—seems to be the treatment of choice. In some cases though surgery seems to have identical long-term results compared with conservative management. Yet, neither conservative measures nor surgery always provide sufficient results. Moreover, there are a number of patients who do on the one hand not respond to conservative therapy, but do on the other hand not have the indication for surgery. As a result alternative, minimally invasive, image-guided therapies, such as periradicular therapy, have been introduced in recent years. Periradicular therapy is indicated in patients with radicular pain symptoms or radiculopathy, which may be caused by foraminal or spinal canal stenosis, tumors, or spondylolisthesis, and has become popular in the treatment of lumbar radicular complaints due to disk herniation. This review article focusses on different aspects of CT-guided periradicular injections and emphasizes a selection of practical considerations of important interventions at different spinal regions.

Minimally invasive treatment of spinal diseases

SummaryTreatments of spinal diseases can be performed safely under CT and MRI guidance. Both techniques allow full transparency of all structures in the body. In combination with micro endoscopy small endoscopes with a diameter less than 1 mm can be used to visualize the operative field in the foramen intervertebrale or in the spinal canal. Small arteries and vessels under 0.01 mm can be seen and protected. Facet joint treatment, periradicular therapy are less invasive methods with a wide indication for spinal diseases. In cases with free fragments we have developed a new technique for percutaneous seques-trectomy. The combination of CT scanning, fluoroscopy MRI and micro endoscopy for guidance of nucleotomes, lasers and micro instruments offers a safe and effective treatment of small free fragments and scar tissue in the spinal canal and the foramen.