Transforaminal Epidural Injections Research Articles

Comparable Overall Risk of Neurologic Adverse Events Following Cervicothoracic Interlaminar and Transforaminal Epidural Injections: An Analysis of 1.29 Million Patients.

Retrospective cohort study. To characterize the incidence and odds of neurologic adverse events following interlaminar (IL) and transforaminal (TF) cervicothoracic epidural spinal injections (CESI). CESI may be considered in the management of various cervical pathology. Adverse events, although rare, can be devastating and have been reported following both IL and TF injections. The literature is mixed with regard to the risk-profile of these two types of CESI, but is largely limited to case reports, single centered studies, and literature reviews, which may incompletely characterize the relative risk of these injections at a national level. All adult patients undergoing IL and TF-CESI were identified from a large, national, multi-insurance database. The incidence of any post-injection neurologic complication was reported per 1,000 patients. The odds of specific neurologic adverse events occurring within 48-hours following TF-CESI, relative to IL-CESI, were compared by multivariable logistic regression controlling for age, sex, and Elixhauser comorbidity index (ECI). A total of 1,073,215 IL-CESI patients and 220,597 TF-CESI patients were identified. The overall incidence of any neurologic complication following IL and TF-CESI occurred at a rate of 4.15 and 4.56 per 1,000 patients, respectively (P=0.889). TF-CESI was associated with higher odds ratio (OR) of nerve root injury (OR 1.69, P<0.001), but lower odds of epidural hematoma (OR 0.60, P=0.040), relative to IL-CESI. Conversely, no other neurologic adverse events were statistically different between approaches (P>0.05 for all). Following IL and TF-CESI, adverse events are relatively rare but not absent. Although the odds of the majority of individual neurologic adverse events were found to be similar, both approaches were independently associated with specific complications. Providers should therefore recognize that, at the national level, one CESI approach may not be universally associated with a lower risk of complications.

Comparison of Clinical Effects and Physical Examination of Transforaminal and Caudal Steroid Injection With Targeted Catheter in Lumbar Radiculopathy: A Single-Blind Randomized Clinical Trial.

Transforaminal and caudal epidural injections are two methods of steroid injection in lumbar radiculopathy. Using a targeted catheter with the possibility of accessing the involved spinal roots and steroid administration selectively next to them during the caudal procedure may achieve the benefits of both transforaminal and caudal procedures. The aim of this study was to investigate the clinical effects and physical examinations of transforaminal steroid injection compared to caudal through a targeted catheter in lumbar radiculopathy. Fifty patients with lumbar radiculopathy candidates for epidural steroid injection were divided into transforaminal (T) and caudal (C) groups. Steroid injection under fluoroscopic guidance was performed in group T with the transforaminal method and in group C with the caudal method using a targeted catheter for each involved spinal nerve root. Pain intensity visual analog scale (VAS), Oswestry Disability Index (ODI), daily analgesic consumption, and physical examinations on four follow-ups (before injection, second week, first and third month) were evaluated. Pain score (VAS) and functional disability index (ODI) were similar in both groups, and there was no significant difference between the two groups (p>0.05). The positive Lasègue test was significantly higher in the caudal group than in the transforaminal group only in the third month (p<0.05). Other physical examinations in both groups did not have significant differences in all the follow-ups. Moreover, there was no difference in the amount of analgesic consumption in the two groups. No complications were observed in both groups. This study showed that transforaminal and caudal steroid injection (with a targeted catheter) in patients with lumbar radiculopathy had similar effects in controlling pain and improving functional disability of patients in the short term. Cases of recurrence of positive Lasègue test in physical examinations in the long term (third month) in the caudal group may indicate the preference of the transforaminal approach. Iranian Registry of Clinical Trials (IRCT) number: IRCT20111102007984N31.

Efficacy and Outcomes of Selective Nerve Root Blocks in Diagnosis: A Systematic Review

Background: Selective nerve root blocks or transforaminal epidural injections are commonly utilized for both diagnosing and treating various spinal disorders, such as radiculopathy or nerve compression. However, there is currently no clear consensus on their role as a diagnostic tool. The effectiveness of these injections in accurately diagnosing the underlying cause of spinal pain remains uncertain, as studies show mixed results regarding their diagnostic reliability. While these injections can provide temporary pain relief and may help identify the specific nerve root involved, their long-term diagnostic value is still a topic of debate. A systematic review of clinical studies was conducted to evaluate the accuracy of selective nerve root injections for diagnosing spinal pain. Methodological quality was assessed using the PRISMA guidelines. Studies were categorized based on the strength of evidence into five levels: problem identification, literature searching, data review and evaluation, data synthesis and analysis or data presentation. Studies were categorized based on the strength of evidence into five levels: conclusive, strong, moderate, limited, or indeterminate. The review included an extensive literature search across multiple databases such as PubMed, Google Scholar and EMBASE. There is limited evidence regarding the effectiveness of selective nerve root injections as a diagnostic tool for spinal pain. Although the research is insufficient to provide stronger support, the existing literature suggests that selective nerve root injections can be useful in diagnosing uncertain cases of radicular pain. Moderate evidence supports their use in preoperative evaluations, particularly when imaging studies are negative or inconclusive. While the positive predictive value of these injections is low, they are valuable for their negative predictive value, meaning they are more effective in ruling out conditions than in confirming them.

Transforaminal Epidural Injection with Local Anesthesia and Steroid for Single-level Radiculopathy and Pain Score: A Prospective Study in the Tertiary Center of Western Nepal

Introduction: Radiculopathy resulting from prolapse of intervertebral disc commonly at L4-L5 and L5-S1, the prominent cause of low back pain affecting daily activities and has a significant socioeconomic burden. Hence, this needs to be addressed with a prominent solution, of which, the transforaminal epidural steroid injection has been one of the promising solutions these days. Aims: To assess the short term and long-term pain relief after transforaminal epidural steroid injection. Methods: 58 patients with radiculopathy at the single level of the lumbar or lumbosacral region were included for transforaminal epidural steroid injection with local anesthesia. Visual analog score, pain score was recorded before, in 15 minutes and four weeks after the steroid injection under C-arm guidance. Statistical analysis was done on the basis of Wilcoxon Signed Ranks Test, Spearman’s correlation test. A p-value &lt; 0.05 was considered to be statistically. Results: The change in Visual Analog Score from the time of presentation in relation to short and long term was significant, viz; VAS0 VAS15m p&lt;0.5 and VAS0/VAS4wks was p&lt;0.5. There was a positive correlation between immediate pain relief and long-term pain reduction however it was not significant (r=0.28, p=0.10) Conclusion: This study suggested the improvement of symptoms with transforaminal epidural steroid injection with local anesthesia and showed a positive correlation between immediate and long-term relief of pain, however it may not be significant.

Prediction of transforaminal epidural injection success in sciatica (POTEISS): a protocol for the development of a multivariable prediction model for outcome after transforaminal epidural steroid injection in patients with lumbar radicular pain due to disc herniation or stenosis

BackgroundTransforaminal epidural injections (TEI) can alleviate symptoms and help to maintain physical functioning and quality of life in patients with lumbar radicular pain. We aim to develop a prediction model for patient outcome after TEI in patients suffering from unilateral lumbar radicular pain due to lumbar disc herniation (LDH) or single-level spinal stenosis (LSS). The secondary aim is to estimate short-term patient outcome differences between LDH and LSS patients, the association between psychological variables and patient outcome, the rate of additional injections, surgery and complications, and to explore the short-term cost-effectiveness of TEI.MethodsThis study is designed as a multi-centre, observational, prospective cohort study in two large regional hospitals in the Netherlands. Patients diagnosed with unilateral lumbar radicular pain secondary to LDH or LSS and congruent with MRI findings, who are referred for TEI along usual care pathways, are eligible for study participation. A total of 388 patients with LDH or LSS will be included. A pre-defined set of demographic, clinical and radiological variables will be used as the predictors in the model. The primary outcome measure is the Numerical Rating Scale (NRS) for leg pain. Secondary outcome measures include back pain, physical functioning, perceived recovery, pain coping strategies, anxiety and depression and use of analgesics and physical therapy. Patients will be evaluated at baseline, 2 weeks and 6 weeks after treatment. NRS leg pain and Likert perceived recovery data will be used as the dependent variables in a generalized linear mixed model for prediction of TEI outcome, with internal validation of performance (explained variation) by bootstrap resampling. Cost-effectiveness for a period of 6 weeks prior to and after treatment will be performed with decision-analytic modelling.DiscussionPatients with severe lumbar radicular pain often request additional treatment when conservative care is insufficient. TEI can offer relief of symptoms. Currently, it is not possible to predict responsiveness to this treatment for individual patients. This study is designed to explore predictors that can differentiate between patients that will and will not have a positive outcome after TEI. This information may support treatment strategies for this patient group.Trial registrationThis study is registered at ClinicalTrials.gov database under registry number NCT04540068 on September 1, 2020.

35. Comparable risk of adverse events following cervicothoracic interlaminar and transforaminal epidural injections: an analysis of 1.29 million patients

35. Comparable risk of adverse events following cervicothoracic interlaminar and transforaminal epidural injections: an analysis of 1.29 million patients

Conservative combination therapy of sciatica due to lumbar disc herniation with mechanical physiotherapy (McKenzie), gabapentin, and transforaminal epidural injections

Treatment of sciatica due to lumbar disc herniation can be surgical or conservative. Conservative management has been described to be effective in 90% of patients; however, in most studies no consistent treatment concept was used. In the present study, we evaluated the effect of acombined nonsurgical management (McKenzie physiotherapy, gabapentin, and periradicular injections) in 40patients during a10-day inpatient treatment. In addition to the neuro-orthopedic examination, pain severity at rest and after walking were assessed. The Oswestry pain disability scale, the pain severity scale, and the painDETECT scale were examined to assess neuropathic pain components. The duration of incapacity for work and the requirement of alater surgery were recorded. Examinations were performed on the day of admission, on days3, 6, 10, and84, 3months after discharge. During conservative treatment, acontinuous reduction of pain and an improvement of the straight leg raise test as well as finger-to-floor distance could be documented. As the three treatment options were introduced with atime delay, it could be demonstrated that all significantly contributed to the improvement. All treatments were tolerated without side-effects and persistent improvement after 12weeks. On admission, 32% of patients revealed aneuropathic pain component which decreased to 7% at the follow-up. A total of 28patients showed impaired muscle strength on admission, which decreased to 7patients on follow-up. Electromyography revealed pathological results in 70% of patients examined. Asignificant improvement of quality of life (Oswestry Disability Index [ODI]) could be observed and the patients returned to work after 5.8weeks. Only 3/40patients required surgical management due to persistent pain. The combined nonsurgical operative treatment program is effective and well tolerated.

A novel simplified sonographic approach with fluoroscopy-controlled L5 transforaminal epidural injections in patients with high iliac crest: a retrospective study

BackgroundTo explore a novel ultrasound (US) modality for lumbar transforaminal epidural injections (TFEIs) in patients with low back pain (LBP) and L5 radicular pain combined with high iliac crest (HIC).MethodsOne-hundred and forty-one patients were retrospectively stratified into two groups based on the treatment they received: novel group, receiving US-guided and fluoroscopy (FL)-controlled TFEIs using a sagittal oblique approach between the superior articular process of L5 and S1, and control group, receiving US-guided TFEIs with conventional transverse approach combined with FL confirmation. Accuracy of contrast dispersing into lumbar epidural space was set as the primary endpoint. Radiation dosages, procedure time, numeric rating scale (NRS) scores, Modified Oswestry Disability Questionnaire (MODQ) scores, adverse events, and rescue analgesic requirement were also recorded. The generalized liner mixed model (GLMMs) was employed to compare the repeatedly measured variables between groups, taking individual confounding factors as covariance.ResultsThe accuracy of TFEIs was 92.8% and 65.2% in novel and control group, with a significant difference of 26.7% (95% CI: 15.4%, 39.8%) between two modalities (p < 0.001). Significant pain relief was observed in novel group as opposed to control group after one injection. Procedure time in novel group (8.4 ± 1.6 min) was shorter than control group (15.8 ± 3.5 min) (p < 0.001) with less radiation dosage (3047 ± 5670 vs. 8808 ± 1039 μGy/m2, p < 0.001). Significantly, lower incidence of L5 paresthesia occurred in novel group. Statistical differences of NRS scores between the novel and control group were reached at 1 week after procedure (1 (IQR: − 1–3) vs. 3 (IQR: − 1–7), p = 0.006), while not reached at both 1- (1 (IQR: 0–2) vs. 1 (IQR: − 1–3), p = 0.086) or 3-month follow-up (0 (IQR: − 1–1) vs. 1 (IQR: 0–2), p = 0.094). Both groups showed similar functional improvement (F = 0.103, p = 0.749) during follow-up.ConclusionsThe novel sonographic technique provided superior accuracy needle placement and better pain-relieving effect through one injection as compared to the routine transverse approach. Consequently, in situations where the HIC imposed limitations for TFEIs performance on L5, the novel technique should be recommended to consider increasing accurate puncture, minimizing radiation exposure, consuming procedure time, and reducing the risk of neuraxial injury.

(037) VESTIBULODYNIA SECONDARY TO LUMBOSACRAL ANNULAR TEAR-INDUCED SACRAL RADICULOPATHY

Abstract Introduction Vestibulodynia is a prevalent problem in individuals with vulvas, with as many as 30% reporting complaints consistent with entry dyspareunia. Distinctive vestibulodynia pathophysiologies may include psychosocial factors, pelvic floor muscle dysfunction, dermatologic disorders, inflammatory disorders, hormonal deficiencies, neuroproliferative pathology, and pudendal neuropathy. Sacral radiculopathy is considered an inflammatory irritation of S2-S3 nerve roots in the cauda equina by various pathologies such as lumbosacral annular tear. S2-S3 nerve roots are formed by the convergence of the pelvic, pudendal, and sciatic nerves and genito-pelvic clinical symptoms may result from inflammatory involvement of the sensory fields of these nerves. Vestibulodynia may occur from sacral radiculopathy since the somatic and visceral afferent innervation of the vestibule occurs via the pudendal and pelvic nerves, respectively; however, to the best of our knowledge, there has not been a case series of such patients previously reported. Objective To perform a chart review of patients with vestibulodynia secondary to lumbosacral annular tear-induced sacral radiculopathy. Methods Vestibulodynia patients who presented to our sexual medicine clinic were evaluated by detailed history, vulvoscopy, vestibular anesthesia testing, neurogenital testing and lumbosacral MRI. When these tests warranted it, a transforaminal epidural spinal injection with 1 ml lidocaine 1% was performed to substantiate the diagnosis. If appropriate, spine surgery was performed. Improvement was assessed using the Patient Global Impression of Improvement (PGI-I). Results Four patients, 3 cis-gender women and 1 trans-man, mean age 33 years (range 25-42), were diagnosed with vestibulodynia secondary to lumbosacral annular tear-induced sacral radiculopathy. Concomitant sacral radiculopathy symptoms included: clitoral hypersensitivity (50%), bladder urgency/frequency (75%), umbilical hypersensitivity (75%), vaginal dysesthesia (25%), vulvar itching (50%), low back pain (100%), and sciatica (75%). Vulvoscopy was performed to exclude other forms of vestibulodynia. All patients had: a) positive cotton-tipped swab testing throughout the entire vestibule; b) negative vestibular anesthesia testing; c) abnormal neurogenital testing; d) lumbosacral MRI that revealed surgically treatable lumbosacral annular tear (L5-S1, L4-L5); e) transforaminal epidural spinal injection resulting in clinically significant symptom reduction. Lumbar endoscopic spine surgery resulted in improvement in 75% reporting PGI-I 1-3 (very much better - somewhat better). Conclusions We report the first series of patients with vestibulodynia resulting from lumbosacral annular tear-induced sacral radiculopathy. Clinicians should be aware that bothersome vestibulodynia in patients with vulvas can occur from cauda equina pathology (Region 3) outside the genitals (Region 1) and/or pelvis/perineum (Region 2). Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Elliquence.

Functional Outcomes of Fluoroscopy-Guided Intra-articular Steroids in Lumbar Facet Arthropathy: A Retrospective Comparative Study of Dexamethasone Versus Triamcinolone Acetonide.

Introduction Mechanical low back pain frequently originates from the lumbar facet joint (LFJ). Axial low back discomfort can result from osteoarthritis in the LFJ. Depending on the severity of LFJ degeneration, the effect of intra-articular (IA) LFJ corticosteroid injection may vary. For LFJ discomfort, IA block with steroids and local anaesthetics has also been utilised, with varying degrees of success. The main objective of this study was to assess the efficacy of IA steroid injections dexamethasone vs. triamcinolone acetonide for the treatment of LFJ syndrome and to compare functional outcome in terms of Visual Analog Scale(VAS) score, Modified Oswestry Disability Index(MODI) score, and short-form McGill Pain Questionnaire between the two groups. Methodology Dexamethasone 8 mg or triamcinolone acetonide 40 mg was given intra-articularly to27 patients comprising group A and 33 patients comprising group B, respectively (total 60 patients). Before intervention and at one, three, and six months, observation was conducted using the VAS score, short-form McGill pain questionnaire, and MODI score. Results There was a significant difference between both the groups after the procedure with pain alleviation and functional improvement, more in the group that received triamcinolone acetonide. A significant difference was observed in all three parameters that assessed pain with differences more pronounced at six months. Conclusion Pain reduction and clinical outcomes were better among the group that received triamcinolone acetonide. Injection of a steroid alone is associated with its own side effects. When a lumbar transforaminal epidural injection is used to treat radiculopathy in the lumbar area, particulate medication (triamcinolone) is more effective than non-particulate medication (dexamethasone) with no known drug-related complications.

Safety of cervical transforaminal epidural steroid injections

BackgroundIn 2014 the FDA issued a drug safety warning that steroids in the epidural space may result in rare but serious neurological adverse events. The FDA identified 131 cases of neurological adverse events and most complications were related to cervical transforaminal epidural injections (TFESIs). These complications occurred before the standard use of non-particulate steroids. Many still consider cervical TFSEIs to be unsafe. ObjectivesThe objective of this study was to evaluate the safety of cervical TFESIs with non-particulate steroids. MethodsA review was done of all cervical TFESIs from 2004 to 2021 at an academic institution when non-particulate steroids became more commonly used by reviewing CPT code 64479 linked to the performing physician. All treating physicians and department directors were queried about catastrophic complications (stroke, spinal cord injury, death or other). A secondary analysis was done on 200 consecutive cervical TFESIs looking at immediate and delayed side-effects documented by the nurse in recovery, day-after phone calls and clinic follow-up notes. ResultsFrom 2004 to 2021 the CPT code 64479 was used 6967 times, with 6241 cervical TFESIs and 726 thoracic TFESIs. No catastrophic complications occurred. In the subset analysis of 200 consecutive cervical TFESIs, 7 patients (3.5 %, 95 % CI 1.0–6.0) had a transient increase in pain, 18 (9 %, 95 % CI 5.0–13.0) had no change in pain and 171 (85.5 %, 95 % CI 80.6–90.4) had a decrease in pain. The average pain score among all participants dropped 3.7 (95 % 3.0–4.4) points. A 2-point drop was seen in 75.5 % (95 % CI 69.5–81.5) and a 3-point drop was seen in 62.5 % (95 % CI 59.1–65.9). Five of the seven patients with transient increased pain had an increase of ≥ 3 points on numerical rating scale. There was one of each of the following reported: insomnia, glucose >500, transient thumb numbness with pain, and hypertension. Two cases of headaches were reported. ConclusionThis study supports the safety of cervical TFESIs with non-particulate steroids as recommended by consensus opinions from medical societies.

Differences between the healthcare systems of Quebec and France for the treatment of pain due to spinal disorders.

In Quebec, Canada, the public healthcare system offers free medical services. However, patients with spinal pain often encounter long waiting times for specialist appointments and limited physiotherapy coverage. In contrast, private clinics provide expedited care but are relatively scarce and entail out-of-pocket expenses. Once a patient with pain caused by a spinal disorder meets a pain medicine specialist, spinal intervention is quickly performed when indicated, and patients are provided lifestyle advice. Transforaminal epidural steroid injections are frequently administered to patients with radicular pain, and steroid injections are administered on a facet joint to control low back or neck pain. Additionally, medial branch blocks are performed prior to thermocoagulation. France's universal healthcare system ensures accessibility at controlled costs. It emphasizes physical activity and provides free physical therapy services. However, certain interventions, such as transforaminal and interlaminar epidural injections, are not routinely used in France owing to limited therapeutic efficacy and safety concerns. This underutilization may be a potential cause of chronic pain for many patients. By examining the differences, strengths, and weaknesses of these two systems, valuable insights can be gained for the enhancement of global spinal pain management strategies, ultimately leading to improved patient outcomes and satisfaction.

Cost-effectiveness of Transforaminal epidural steroid injections for patients with ACUTE sciatica: a randomized controlled trial

BackgroundTransforaminal epidural injections with steroids (TESI) are increasingly being used in patients sciatica. The STAR (steroids against radiculopathy)-trial aimed to evaluate the (cost-) effectiveness of TESI in patients with acute sciatica (< 8 weeks). This article contains the economic evaluation of the STAR-trial.MethodsParticipants were randomized to one of three study arms: Usual Care (UC), that is oral pain medication with or without physiotherapy, n = 45); intervention group 1: UC and transforaminal epidural steroid injection (TESI) 1 ml of 0.5% Levobupivacaine and 1 ml of 40 mg/ml Methylprednisolone and intervention group 2: UC and transforaminal epidural injection (TEI) with 1 ml of 0,5% Levobupivacaine and 1 ml of 0.9% NaCl (n = 50). The primary effect measure was health-related quality of life. Secondary outcomes were pain, functioning, and recovery. Costs were measured from a societal perspective, meaning that all costs were included, irrespective of who paid or benefited. Missing data were imputed using multiple imputation, and bootstrapping was used to estimate statistical uncertainty.ResultsNone of the between-group differences in effects were statistically significant for any of the outcomes (QALY, back pain, leg pain, functioning, and global perceived effect) at the 26-weeks follow-up. The adjusted mean difference in total societal costs was €1718 (95% confidence interval [CI]: − 3020 to 6052) for comparison 1 (intervention group 1 versus usual care), €1640 (95%CI: − 3354 to 6106) for comparison 2 (intervention group 1 versus intervention group 2), and €770 (95%CI: − 3758 to 5702) for comparison 3 (intervention group 2 versus usual care). Except for the intervention costs, none of the aggregate and disaggregate cost differences were statistically significant. The maximum probability of all interventions being cost-effective compared to the control was low (< 0.7) for all effect measures.ConclusionThese results suggest that adding TESI (or TEI) to usual care is not cost-effective compared to usual care in patients with acute sciatica (< 8 weeks) from a societal perspective in a Dutch healthcare setting.Trial registrationDutch National trial register: NTR4457 (March, 6th, 2014).

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

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

Transforaminal Epidural Block and Erector Spinae Plane Block to Manage Acute Zoster-Associated Pain: A Retrospective Case-Control Study.

Background and Objectives: Achieving adequate pain reduction in the acute phase of herpes zoster is essential for preventing postherpetic neuralgia (PHN). For this purpose, appropriate antiviral medications, oral analgesic medications, and various nerve block methods could be applied. Erector spinae plane block (ESPB) is a simple, novel ultrasound-guided block technique, and its use has increased because the procedure is convenient and relatively safe. Although several cases have reported the zoster-associated pain (ZAP) control effect of ESPB, the efficacy of ESPB has not been compared with that of other types of nerve blocks for managing ZAP. This study aimed to compare the efficacy of ESPB with that of other types of nerve blocks for managing ZAP. Study Design: Retrospective case-control study. Materials and Methods: Medical records of 53 patients with acute thoracic herpes zoster were reviewed. We divided the participants into two groups: patients who received transforaminal epidural injection (TFEI) (n = 32) and those who received ESPB (n = 21). The efficacy of the procedure was assessed by a numerical rating scale (NRS) and by recording patient medication doses before the procedure and at 1 week, 1 month, 2 months, and 3 months after the procedure. Results: The time required for pain intensity to decrease to NRS ≤ 2 was not significantly different between the groups. The rate of medication discontinuation also was not different between the groups. There was no significant difference between the two groups in the proportion of clinically significant PHN (NRS ≥ 3) at any time point. Limitations: The relatively small sample size from a single center and the retrospective nature of the study served as limitations. Conclusions: The clinical effects of ESPB and TFEI were similar in patients with acute thoracic herpes zoster. ESPB could be considered an interventional option for ZAP management.

Author's Reply to the Letter of Van Boxem, Van Gaag, Van Zundert, and Kallewaard, Entitled 'Response to Ter Meulen et al. Effect of Transforaminal Epidural Corticosteroid Injections in Acute Sciatica'.

Author's Reply to the Letter of Van Boxem, Van Gaag, Van Zundert, and Kallewaard, Entitled 'Response to Ter Meulen et al. Effect of Transforaminal Epidural Corticosteroid Injections in Acute Sciatica'.

Comparing the Efficacy of Transforaminal and Caudal Epidural Injections of Calcitonin in Treating Degenerative Spinal Canal Stenosis: A Double-Blind Randomized Clinical Trial.

Lumbar spinal stenosis (LSS) is the most common indication for lumbar surgery in elderly patients. Epidural injections of calcitonin are effective in managing LSS. This study aimed to compare the efficacy of transforaminal and caudal injections of calcitonin in patients with LSS. In this double-blind randomized clinical trial, LSS patients were divided into two equal groups (N = 20). The first group received 50 IU (international units) of calcitonin via caudal epidural injection (CEI), and the second group received 50 IU of calcitonin via transforaminal epidural injection (TEI). The Visual Analogue Scale (VAS) and Oswestry Low Back Pain Disability Questionnaire (ODI) were used to assess the patient's pain and ability to stand, respectively. Visual Analogue Scale and ODI scores were recorded and analyzed. The results showed that caudal and TEIs of calcitonin significantly improved pain and ability to stand during follow-up compared to before intervention (P < 0.05). Additionally, CEI of calcitonin after 6 months significantly reduced pain in LSS patients compared to TEI of calcitonin (P < 0.05). However, no significant difference was observed between the two epidural injection techniques in improving the patient's ability to stand (P > 0.05). The results of the study indicate that epidural injection of calcitonin in long-term follow-up (6 months) had a significant effect on improving pain intensity and mobility in patients with LSS, and its effect on pain in the TEI method was significantly greater than that in the CEI method.

(148) “Zebras” in Sexual Medicine from Cauda Equina Pathology

Abstract Introduction Unrelenting, bothersome sexual medicine problems in individuals with a vulva or penis sometimes do not respond to conventional therapies, frustrating both patient and provider. These distressing problems can be categorized as a genito-pelvic dysesthesia (GPD), including genito-pelvic (penile, scrotal, clitoral, vulvar, vestibular, vaginal, bladder, rectal) pain, persistent genital arousal disorder (PGAD), sleep related prolonged erections (SRPE) and hard-flaccid syndrome (HFS), currently considered as “zebras” in sexual medicine. We recently published a study on 20 patients with PGAD/GPD who underwent a multi-disciplinary management algorithm, were determined to have lumbosacral annular tear induced sacral radiculopathy, and with one year follow-up post-spine surgery, 80% revealed improvement in symptoms. Objective To apply our (spine-sexual medicine) multi-disciplinary management algorithm to sexual medicine “zebras”. Methods Patients who presented between July 1, 2021, and June 30, 2023, to our sexual medicine clinic were included in the study cohort. The management algorithm was as follows: biopsychosocial history, multiple validated instruments, physical examination, neurogenital testing, regional anesthesia testing, lumbosacral MRI, and when appropriate, a caudal epidural or transforaminal epidural spinal injection. Those with clinically significant symptom reduction from the spinal injection were offered appropriate spine surgery. Patient Global Impression of Improvement (PGI-I) was assessed post-operatively (1 = very much better, 2 = much better, 3 = better, 4 = no change, 5 = worse, 6 = much worse and 7 = very much worse. Results Our study cohort consisted of 24 patients, 14 with a vulva and 10 with a penis, mean age 42 years (range 25-69) who presented to our clinic over a period of two years. The patients' GPD complaints included genital pain (13), PGAD (6), SRPE (2), HFS (1), bladder pain (1) and rectal pain (1). All patients had results of neurogenital and regional anesthesia tests consistent with sacral radiculopathy, then underwent a diagnostic focal lidocaine spinal injection. Each had a positive response to either a transforaminal epidural spinal injection and underwent lumbar endoscopic spine surgery (n = 21) or a caudal epidural and underwent Tarlov cyst surgery (n = 3). PGI-I scores after surgery indicative of improvement (PGI-I = 1, 2, 3) at one week was 10/22 (45%), at 6 weeks was 9/17 (53%) at 3 months was 9/16 (56%) and at 6 months was 5/6 (83%). Conclusions Patients presenting with sexual medicine complaints not successfully managed by routine treatment strategies often experienced delay in diagnosis and excessive healthcare-seeking behavior resulting in significant distress. In our experience, GPD can result from triggers in the cauda equina, far from the location of the presenting genito-pelvic symptom(s). Our cohort of sexual medicine “zebras” who underwent our multi-disciplinary management algorithm were diagnosed with sacral radiculopathy. These patients opted for spine surgery and reported improvement of symptoms that continued to get better over time. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Eliquence.

Transforaminal Epidural Injection for Far Lateral Lumbar Disc Herniations: An Alternative to Surgery or Just a Delay?

Far lateral lumbar disc herniations (FLLDH) are known for causing severe and persistent radicular pain due to direct nerve root and dorsal root ganglion compression. This study evaluates the effectiveness of transforaminal epidural steroid injection (TFSI) in patients with FLLDH, assessing its role as a potential alternative to surgery. The study retrospectively analyzed 42 patients with radicular pain caused by FLDH, confirmed via lumbar magnetic resonance imaging, who had not benefited from conservative treatment. All patients underwent TFSI, and their pre-treatment Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores were compared with scores at one, two, and three months post-procedure. The study group comprised 19 males (45.23%) and 23 females (54.77%), with a mean age of 51.9 ± 11.63 years (range 29-76 years). The most common herniation levels were L4-L5 (22 patients), followed by L5-S1 (15 patients) and L3-L4 (five patients). The mean VAS score decreased significantly from 8.58 ± 0.63 to 2.89 ± 1.87 over three months (p = 0.001). Similarly, the mean ODI score significantly reduced from 61.29 ± 6.72 to 16.88 ± 11.25 (p = 0.001). However, eight of the 42 patients (19.04%) underwent surgery within three months due to lack of benefit from TFSI. Our study sheds light on the significant potential of TFSI as a treatment option for FLLDH. The marked improvement in pain and functional capacity, as evidenced by the substantial decrease in VAS and ODI scores, suggests that TFSI can be an effective non-surgical intervention for a majority of patients suffering from FLLDH. However, a notable proportion of patients may still require surgery, indicating that TFSI might not be a definitive alternative but can be an effective interim treatment in managing FLLDH.

Intercepting Intracept: A Case Report of Idiopathic Arachnoiditis

Introduction: Determining the exact diagnoses for low back is challenging due to the myriad of causative factors. Consequently, rare diagnoses like arachnoiditis are often overlooked, causing patients with this condition to be ineffectively treated. Arachnoiditis involves inflammation of the arachnoid membrane enveloping the spinal cord, can is caused by diverse etiological factors, including infections, trauma, spinal cord contamination, tumors, and genetic predispositions. Case: In this case report, the author describe a 43-year-old female with a past medical history of anxiety and depression who presented with chronic back pain. The patient had previously undergone trials of various neuropathic and nociceptive modulating medications as well as transforaminal and caudal epidural corticosteroid injections, yielding minimal relief. On the evaluation, the patient’s lumbar spine MRI revealed findings suggestive arachnoiditis, a diagnosis that had also been missed on a previous MRI a year prior. Given this, the patient was advised to not undergo the Intercept procedure which had been previously recommended by another provider. Discussion: Given its resemblance to other neurologic conditions, the diagnosis of arachnoiditis involves a comprehensive approach with history, physical examination, and imaging modalities such as MRI or CT myelography serving as critical components. In this case, the patient did not have any history of infection or trauma, making the diagnosis more elusive, and requiring the team to pay more heed to the imaging finding. Although her imaging served supportive evidence or arachnoiditis, it is important to recognize its correlation with clinical findings and the severity of symptoms is not always consistent. Management of arachnoiditis requires a multi-faceted approach with steroids, neuropathic modulating medications, muscle relaxants, cognitive behavioral therapy, and physical therapy. Conclusion: This case report underscores the diagnostic challenges and clinical intricacies associated with spinal arachnoiditis. The presented patient's atypical symptoms and protracted diagnostic journey highlight the importance of ongoing vigilance and comprehensive evaluation in chronic pain management. Further research should investigate effective treatment modalities for this chronic and debilitating condition that is overlooked, given its similarity to other diagnoses and rare prevalence.