Transforaminal Steroid Injections Research Articles

The Efficacy of Transforaminal Injection of Steroids for the Treatment of Lumbar Radicular Pain

Transforaminal injection of steroids is used to treat lumbar radicular pain. Not known is whether the route of injection or the agent injected is significant. A prospective, randomized study compared the outcomes of transforaminal injection of steroid and local anesthetic, local anesthetic alone, or normal saline, and intramuscular injection of steroid or normal saline. Patients and outcome evaluators were blinded as to agent administered. The primary outcome measure was the proportion of patients who achieved complete relief of pain, or at least 50% relief, at 1 month after treatment. Secondary outcome measures were function, disability, patient-specified functional outcomes, use of other health care, and duration of relief beyond 1 month. A significantly greater proportion of patients treated with transforaminal injection of steroid (54%) achieved relief of pain than did patients treated with transforaminal injection of local anesthetic (7%) or transforaminal injection of saline (19%), intramuscular steroids (21%), or intramuscular saline (13%). Relief of pain was corroborated by significant improvements in function and disability, and reductions in use of other health care. Outcomes were equivalent for patients with acute or chronic radicular pain. Over time, the number of patients who maintained relief diminished. Only some maintained relief beyond 12 months. The proportions of patients doing so were not significantly different statistically between groups. Transforaminal injection of steroids is effective only in a proportion of patients. Its superiority over other injections is obscured when group data are compared but emerges when categorical outcomes are calculated. Over time, the proportion of patients with maintained responses diminishes.

Complications of Cervical Transforaminal Epidural Steroid Injections

Although cervical transforaminal epidural steroid injections are used in the treatment of radicular pain, there are a number of major and minor complications reported in the medical literature. These complications are limited to retrospective studies, retrospective survey studies, case reports, and data obtained from studies evaluating the benefit of cervical transforaminal steroid injections. Thus, the data are limited in value with regard to identifying evidence-based recommendations for future research. We aim to review and critically evaluate literature focusing on the incidence and clinical presentations of major complications associated with cervical transforaminal steroid injections. The goal of this review is to identify pertinent journal information that aids in the improvement in clinical care and guides future research by increasing the awareness of the potential major complications associated with this procedure and their presentations.

Reducing the Risk of Spinal Cord Infarction during Transforaminal Steroid Injections

We read with great interest the recent report by Lyders and Morris[1][1] of their case of spinal cord infarction following lumbar transforaminal epidural steroid injection. We would like to highlight the fact that not all corticosteroid preparations are associated with the same risk of embolization

Paraplegia Following Image-Guided Transforaminal Lumbar Spine Epidural Steroid Injection: Two Case Reports

To present two case reports of a rare but devastating injury after image-guided, lumbar transforaminal injection of steroids, and to explore features in common with previously reported cases. Image (fluoroscopic and computed tomography [CT])-guided, lumbar transforaminal injections of corticosteroids have been adopted as a treatment for radicular pain. Complications associated with these procedures are rare, but can be severe. An 83-year-old woman underwent a fluoroscopically guided, left L3-L4, transforaminal injection of betamethasone (Celestone Soluspan). A 79-year-old man underwent a CT-guided, right L3-L4, transforaminal injection of methylprednisolone (DepoMedrol). Both patients developed bilateral lower extremity paralysis, with neurogenic bowel and bladder, immediately after the procedures. Magnetic resonance imaging scans were consistent with spinal cord infarction. There was no evidence of intraspinal mass or hematoma. These cases consolidate a pattern emerging in the literature. Distal cord and conus injury can occur following transforaminal injections at lumbar levels, whether injection is on the left or right. This conforms with the probability of radicular-medullary arteries forming an arteria radicularis magna at lumbar levels. All cases used particulate corticosteroids, which promotes embolization in a radicular artery as the likely mechanism of injury. The risk of this complication can be reduced, and potentially eliminated, by the utilization of particulate free steroids, testing for intra-arterial injection with digital subtraction angiography, and a preliminary injection of local anesthetic.

Retrograde Filling of a Thoracic Spinal Artery During Transforaminal Injection

Transforaminal injection of steroids has been associated with infrequent but devastating neurological complications and death. Direct injection of particulate steroids into the vertebral artery or medullary arteries is the leading theory in the majority of these complications. Practice guidelines have been published to minimize the likelihood of directly encountering vulnerable arterial structures. However, retrograde flow into a vertebral or medullary artery has not been considered in the literature. This case demonstrates retrograde flow into a common arterial trunk with subsequent antegrade flow of intravenous contrast into a thoracic spinal artery during thoracic transforaminal injection. Antegrade flow of particulate steroids through direct cannulation of a vertebral or medullary artery has been advocated as one explanation for complications involving brain or spinal cord infarction. The possibility of retrograde flow into a common arterial trunk with subsequent antegrade flow into vulnerable arteries should also be considered as a possible mechanism by which embolic spinal cord or brain injury may occur. Retrograde flow into medullary or vertebral arteries without direct cannulation can occur, and provides an alternative mechanism of potential injury to the spinal cord or brain during transforaminal injections.

Evaluation of the efficacy of CT-guided epidural and transforaminal steroid injections in patients with diskogenic radiculopathy

To evaluate the efficacy of CT-guided epidural and transforaminal steroid injections in patients with diskogenic radiculopathy.

134. Transforaminal Steroid Injections Delay Motor Recovery in Patients with Acute Sciatica Secondary to Herniated Nucleus Pulposus

134. Transforaminal Steroid Injections Delay Motor Recovery in Patients with Acute Sciatica Secondary to Herniated Nucleus Pulposus

Évaluation de l’efficacité des infiltrations canalaires et foraminales de corticoïdes guidées par TDM dans le traitement des radiculalgies par conflit disco radiculaire

To evaluate the efficacy of CT-guided epidural and transforaminal steroid injections in patients with diskogenic radiculopathy. Seventy patients underwent CT guided injections after failure of medical management. Only patients with minimal degenerative changes and diskogenic monoradicular symptoms were treated. Only two patients with fibrosis were included. 78.6% of patients experienced persistent symptomatic improvement. No difference was noted between lumbar segments and there was no more failures with epidural injections compared to transforaminal injections. Cervical disk herniations responded better than lumbar disk herniations. Good results were obtained in younger patients (M=46.25 years), symptomatic for 3-4 months or less, and with clear radicular symptoms and clinical neurological deficits (hypoesthesia, absent DTR) without motor deficit. No patient with severe spinal stenosis (S-) was included and the disk herniations were small (b1, b2, c1, c2 or d1, d2). Only a single injection was needed. Cortivazol provided superior results compared to dexamethasone. CT-guided injections should be included in the therapeutic armamentarium after standard medical management, with cure as the goal.

Multislice CT Fluoroscopy-assisted Cervical Transforaminal Injection of Steroids

A prospective study of 19 consecutive patients who underwent multislice computed tomography (CT)-guided cervical transforaminal steroid injection. To evaluate the feasibility and the outcome of cervical transforaminal steroid injection guided by multislice CT fluoroscopy. Cervical transforaminal steroid injection has been accepted as an effective therapeutic modality for radiculopathy that results from a cervical herniated disc or stenosis. However, there has been debate on the safety of the transforaminal approach technique, with C-arm fluoroscopy guidance, compared with the posterior interlaminar approach. We present an advanced approach technique for cervical transforaminal steroid injection guided by multislice CT fluoroscopy and the clinical outcomes. Nineteen consecutive patients presenting with radiating pain to the shoulder or arm had CT or magnetic resonance image scan findings compatible with cervical herniated disc or foraminal stenosis and were recruited to participate in this study. They underwent cervical transforaminal steroid injection using multislice CT fluoroscopy guidance up to 3 times with a minimal interval of 2 weeks. The participants were evaluated for the safety and efficacy of this technique for a follow-up period of 16 weeks. No serious complications were found during and after the procedures. Eleven patients received a second steroid injection but none required a third injection over the 16-week follow-up period. The mean visual analog scale score improved significantly at 2, 4, 8, and 16 weeks (P < 0.001). The multislice CT fluoroscopy-guided approach is feasible and a safe and effective approach for cervical transforaminal steroid injection. With the advantages of safety for the patient and precise placement of the needle for injection, this technique might be an additional option and may eventually replace the conventional C-arm fluoroscopy-guided cervical transforaminal steroid injection technique.

PR_129: Hiccups—An Unusual Complication After Lumbar Epidural Steroid Injection: A Case Report

Setting: Tertiary care hospital. Patients: 2 cases of persistent hiccups after lumbar epidural steroid injections. Case Descriptions: A 46-year-old man complained of low back pain (LBP) with radiation into both lower extremities, and numbness in his feet, with decreased sensation in L5 distribution. He had central disk herniation at L4-5 on magnetic resonance imaging (MRI). He had bilateral L5 transforaminal steroid injections with preservative-free bupivacaine and betamethasone. He developed hiccups on the evening of the day of injection, which persisted for 5 days and resolved spontaneously.

Transforaminal steroid injections for the treatment of cervical radiculopathy: a prospective and randomised study

Steroid injections are often employed as an alternative treatment for radicular pain in patients with degenerative spinal disorders. Prospective randomised studies of the lumbar spine reveal contradictory results and non-randomised and most often retrospective studies of the cervical spine indicate pain reduction from steroid injections. No prospective randomised study on transforaminal steroid injections for the treatment of radicular pain in the cervical spine focusing on short-term results has been performed. Forty consecutive patients were employed for the study. The inclusion criteria were one-sided cervical radiculopathy with radicular distribution of arm pain distal to the elbow and corresponding significant degenerative pathology of the cervical spine at one or two levels on the same side as the radicular pain and visualised by MRI. A transforaminal technique was used for all injections. A positive response to a diagnostic selective nerve root block at one or two nerve roots was mandatory for all patients. The patients were randomised for treatment with steroids/local anaesthetics or saline/local anaesthetic. Only the neuroradiologist performing the blocks was aware of the content of the injection; all other persons involved in the study were blinded. Follow up was made 3 weeks after the randomised treatment by a clinical investigation and with a questionnaire focusing on the subjective effects from the injections. At follow up, there were no differences in treatment results in the two patient groups. Statistical analysis of the results confirmed the lack of difference in treatment effect. Further studies have to be performed before excluding steroids in such treatment and for evaluating the influence of local anaesthetics on radiculopathy in transforaminal injections.

Cervical Transforaminal Injection and the Radicular Artery: Variation in Anatomical Location Within the Cervical Intervertebral Foramina

Recent articles have detailed the adverse events associated with transforaminal steroid injections into the radicular arteries. Guidelines on strict transforaminal epidural techniques have been described to limit complications. There remains limited information regarding the cervical level of entry, location within the intervertebral foramina, and prevalence of the radicular arteries within the population. With the aid of premortem angiography and postmortem latex-injected vasculature, a single detailed cadaveric dissection was performed to elucidate the specific anatomic location of the radicular arteries within the intervertebral foramina and the anastomoses of the arteries to the anterior spinal artery. Five radicular arteries (C5, C6, two at C7, C8) were traced entering the foramina either anteriorly or posteriorly to supply the anterior and posterior spinal arteries. Radicular arteries received blood supply from either the deep cervical (C8) or vertebral arteries. The C8 radicular artery entered the lateral aspect of the foramen and penetrated the dural sleeve within the inferior portion of the foramen, directly inferior to the exiting spinal nerve, to supply the anterior spinal artery. This artery was of a large enough caliber to be entered by a 22-gauge needle. A larger population is necessary to characterize the range of anatomic variations in arterial supply within the foramina. Available studies support the current technique of fluoroscopic needle insertion. Yet, there is wide anatomic variation in the origin and location of these vessels, and even with strict adherence to technique, it is feasible that a properly placed needle could penetrate a radicular artery.

CT Guided Cervical Transforaminal Steroid Injection: 2 Months Follow-up

경추 부위의 디스크 탈출증이나 협착증으로 인한 신경근 병증(radiculopathy)의 보존적 치료에 있어서 C-arm 영상증강 장치 유도하 경추부위 경추간공 경막 외 스테로이드주입술 (cervical transforaminal steroid injection)은 환자의 증상완화 및 치료에 도움을 줄 수 있는 유용한 수기로 현재까지 많은 환자에 있어서 시행되어 왔고 그 효과는 여러 논문에서 보 고되었다. 이러한 C-arm 영상증강장치 유도하 경추간공 경막외 스테로이드주입술의 안전성 또한 인정받고 있으나, 최근에 이 시술에 의한 사지마비 및 사망과 같은 치명적인 합병증이 보고되고 있으며, 3,4) 이에 대한 안전성 논란도 일 부에서 제기하고 있다. 경추 부위는 좁은 부위에 여러 중요 한 혈관 및 구조물들이 존재하여 수기미숙 혹은 시술 중 의도되지 않은 혈관내 침범 등으로 심각한 합병증을 일으 킬 수 있는 소지가 요추부위보다 많다. 이에 저자들은 경추부위 디스크 탈출증과 추간공 협착증 으로 인한 어깨 및 팔 부위의 신경근병증 환자에 있어서 보다 안전하고 정확한 시술을 위하여 MDCT (Multi Detector Computed Tomography) 유도하 경추간공 경막외 스테로이드 주입술을 시행하였으며, 기술적인 방법과 함께 이에 의한 CT 유도하 경추부위 경추간공 경막외 스테로이드주입술: 2개월 경과관찰 김포공항 우리들병원 마취통증의학과, *신경외과, 방사선과

Disk Entry: A Complication of Transforaminal Epidural Injection—A Case Report

Finn KP, Case JL. Disk entry: a complication of transforaminal epidural injection—a case report. Correctly identifying the etiology of low back pain can be challenging. The importance of making an expedient, accurate diagnosis of lumbar radicular pain cannot be overemphasized, as proper treatment is based on the outcome. The application of fluoroscopically guided, contrast enhancement during spinal injections is commonly performed, but is not without complications. Intradiskal placement of contrast dye during lumbar transforaminal epidural injection is important to identify, as serious potential complications, such as diskitis, may occur. Additionally, postprocedure assessment may not be accurate if contrast placement is not correctly identified. This case report reviews the literature on complications of transforaminal steroid injection and presents the first documentation of intradiskal placement of contrast dye in the United States. A 72-year-old man presenting with a right L4 radiculopathy underwent a fluoroscopically guided, contrast-enhanced lumbar transforaminal epidural steroid injection and experienced intradiskal placement of contrast as a complication of this procedure. Although the patient was treated prophylactically and achieved good results, the need for fluoroscopy and contrast enhancement during performance of spinal injections is reemphasized.

Transforaminal steroid injections in the treatment of cervical radiculopathy. A prospective outcome study

The aim of this study was to assess if transforaminal steroid injections applied to cohort of patients waiting for cervical disc surgery, reduce the pain of cervical radiculopathy and hence reduce the need for surgical intervention. Cervical radiculopathy due to cervical disc herniation or spondylosis is a common indication for cervical disc surgery. Surgery is however not always successful, and is not done without risk of complications. Transforaminal injection of steroids has gained popularity due to the rationale that inflammation of the spinal nerve roots causes radicular pain, and therefore steroids placed locally should relieve symptoms. During a 12-month period, 21 secondary referral patients with unilateral cervical radiculopathy entered the study. Cervical disc herniation or spondylosis affecting the corresponding nerve root was demonstrated by appropriate investigation (MRI or myelography). The patients then received 2 transforaminal steroid injections, at 2 weeks interval, while waiting for operative treatment. The pain intensity (VAS), Odom's criteria and operative indications were registered at 6 weeks and 4 months. After receiving injection treatment 5 of the 21 patients decided to cancel the operation due to clinical improvement. A statistically significant reduction (0.02) in radicular pain score was simultaneously measured. This corresponds well with the reduction in operative requirements since radicular pain is the main indication for operative treatment. The responders experienced a long-lasting effect. Those responding positively however improved neck pain to the same extent as radicular pain, and patients with cervical spondylosis responded as positively as those with disc herniation. This prospective cohort study indicates a reduction in the need for operative treatment due to injection treatment. The clinical effect is measurable, and a statistically significant improvement of the radicular pain is registered. Routine transforaminal injection treatment prior to surgery seems rewarding, but the complication risk must be taken into consideration.

CT Guided Cervical Transforaminal Steroid Injection for the Elderly Patient with Enlarged Internal Jugular Vein and Vertebral Artery: A case report

Seventy nine-year old female patient visited our department presenting radicular pain on her neck, left shoulder and arm. She had a history of hypertension and underwent coronary angiography and angioplasty 4 years ago. Cervical MRI showed central disc herniation with osteophyte and left foraminal stenosis at C5-6 level and bulging disc with osteophyte and foraminal stenosis (left ＞ right) at C6-7. First plan was transforaminal steroid injection under C-arm fluoroscopy at C5-6 level. Unexpectedly, we could find enlarged internal jugular vein and vertebral artery on MRI scan, which is due to cardiovascular disease. These important vascular structures were expected to be injured by needle during the procedure if done under C-arm fluoroscopy. We decided to give transforaminal steroid injection under CT fluoroscopy to avoid injury to the large vessels and inadvertent complication. The procedure was successfully done using CT fluoroscopy (Brilliance , , USA) without any complication associated with vascular injury or intravascular injection.

Infiltration foraminale L5-S1 radioguidée dans le traitement de la lombosciatique S1

Objective To assess the efficacy of fluoroscopy guided L5-S1 transforaminal steroid injections for the treatment of S1 radiculopathy secondary to intervertebral disk disorder. Method 41 patients were included : prospective study (20 patients) and retrospective study (21 patients). All patients suffered from S1 radiculopathy secondary to nerve root compression by intervertebral disk material, as demonstrated by lumbar spine CT. The patients underwent 2 fluoroscopy guided L5-S1 transforaminal injections of steroid (Hydrocotancyl ® 125 mg), at 8 days interval. Results 60 % of patients showed significant improvement of their painful radiculopathy at day 8 (n:41), 60-67 % at day 30 (n:41) and 67 % at day 90 (n:18). Conclusion Fluoroscopy guided L5-S1 transforaminal injection showed good efficacy in the treatment of S1 radiculopathy.

Cervical transforaminal injection of steroids.

Cervical transforaminal injection of steroids.

Transforaminal selective nerve root steroid injection in the radicular pain

Transforaminal selective nerve root steroid injection in the radicular pain

Transforaminal selective nerve root steroid injection in the radicular pain

Transforaminal selective nerve root steroid injection in the radicular pain