Transforaminal Route Research Articles

Effectiveness of epidural steroid injection in the management of lumbar prolapsed intervertebral disc using interlaminar and transforaminal route

Introduction: In the conservative management of lumbar intervertebral prolapsed disc, the epidural steroid injection is one of the important modality. There is a controversy with respect to decrease the pain and how much improvement in the function of daily activities.Aim: The purpose of this study was to assess the efficacy of steroids via transforaminal and interlaminar epidural route and to compare their results. Materials and Methods: A prospective study of 64 patients with prolapsed lumbar intervertebral disc diagnosed in MRI were included and treated with epidural steroid methyl prednisolone via interlaminar and transforaminal routes 32 each by using computer generated randomization by using our hospital software ie., R L Jalappa Hospital, Tamaka, Kolar, Karnataka, India between April 2018 to May 2019. Pre injection and post injection Japanese Orthopaedic Association (JOA) Score was calculated and effectiveness of the medication was calculated for each route. The data was compared by ANOVA and LSD method to prove the significance. Average follow-up was six months.Results: At six months after epidural steroid injection, both interlamiar and transforaminal routes were found to be effective in improving the JOA Score (Interlaminar in 87.5% and transforaminal in 96.875%). Transforaminal route was significantly more effective than interlaminar route (p=0.03) at 6 months after injection. Conclusion: For patients having lower back pain with or without radiculitis diagnosed in MRI with prolapsed lumbar intervertebral disc can be managed conservatively by using epidural steroid injection and is satisfactory in our study. Both interlaminar and transforaminal routes are effective. By transforaminal route we obtained best result.

Management of Infected Transforaminal Lumbar Interbody Fusion Cage in Posterior Degenerative Lumbar Spine Surgery

The postoperative infection rates for transforaminal lumbar interbody fusion (TLIF) have ranged from <2% to 4%. However, no consensus has been reached on the treatment strategies. TLIF cage preservation or revision surgery for lumbar spine reconstruction are 2 possible treatments. We aimed to determine the most effective method for organ/space infection control. The data from 4923 patients who had undergone TLIF with cage and posterior pedicle-screw instrumentation for spondylolysis or degenerative spondylolisthesis from January 2008 to December 2015 were retrospectively analyzed. Of the 4923 patients, 32 (0.65%) had developed organ/space infection of the interbody cage and were divided into 2 groups: those whose interbody cage was removed for revision (group 1) and those who interbody cage was retained (group 2). We compared the initial management of both groups in terms of age, sex, elapsed time to diagnosis, changes in spinal lordotic angle, visual analog scale score, fusion status, and Kirkaldy-Willis functional outcomes. The 32 patients with organ/space infection had a mean age of 66.3 years and a follow-up period of 23.8 months. Significant differences were observed in the mean elapsed time to diagnosis (P= 0.004), lordotic angle correction at the disease level (P= 0.03), and Kirkaldy-Wallis functional outcomes (P= 0.01). Of the 17 patients undergoing debridement for implant retention, 9 (52.9%) exhibited poor results. The most important factor contributing to TLIF cage retention failure was epidural fibrosis of the previous transforaminal route and biofilm adhesion on interbody devices affecting infection clearance. Thus, we would recommend a combined anterior and posterior approach or the transforaminal route for radical debridement with cage removal and fusion to achieve better clinical outcomes.

Inyección epidural de betametasona en el síndrome radicular lumbosacro: evaluación de su eficacia por abordajes interlaminar y transforaminal

espanolRESUMEN Introduccion: La betametasona es un esteroide utilizado en las inyecciones epidurales, de reciente incorporacion en Uruguay. Objetivos: Evaluar la eficacia de la inyeccion epidural de betametasona administrada por los abordajes interlaminar parasagital y transforaminal en pacientes con dolor radicular lumbosacro unilateral cronico, utilizando el Inventario Abreviado de Dolor. Material y metodo: Estudio prospectivo aleatorizado que compara la administracion de betametasona por ambos accesos, interlaminar parasagital y transforaminal. El IAD se aplico previamente y al mes de las inyecciones epidurales. La intensidad del dolor se midio por la Escala Visual Numerica (EVN) obtenida de la pregunta 6 del IAD y el Indice de Intensidad. Tambien se midio la interferencia funcional producida por el dolor mediante el Indice de Interferencia. Se establecio como respuesta satisfactoria un descenso de 2 puntos en la EVN basal al mes de los procedimientos, definiendo a estos pacientes como respondedores. Se utilizo la prueba t de Student y de Chi cuadrado para el analisis estadistico, tomando un valor de p EnglishABSTRACT Introduction: Betamethasone is a frequently used steroid for epidural injection, recently incorporated in the Uruguayan pharmaceutical market. Aims: The aim of this study is to evaluate the efficacy of parasagittal interlaminar and transforaminal epidural betamethasone in unilateral lumbosacral radicular syndrome, utilizing the Brief Pain Inventory (BPI). Material and method: Is a prospective study comparing parasagittal interlaminar and transforaminal epidural betamethasone. Patients with chronic unilateral lumbosacral radicular pain were included. The BPI was administered before and one month after epidural injections. Pain intensity was measured by the Visual Numeric Scale (VNS, question 6 of the BPI) and the Intensity Score. Interference of pain in daily activities was measured by the Interference Score. Satisfactory responses to injections were considered with a 2 points reduction in VNS. The statistical evaluation was performed by paired an unpaired T test to continuous data and Chi Square to evaluate proportions. A p value less than 0.05 was considered statistically significant. Results: Fifty four patients were treated with epidural betamethasone. In 29 the parasagittal interlaminar route was utilized while 25 were treated by the transforaminal route. A 20 % reduction in baseline VNS was observed with the interlaminar route and 36 % reduction with transforaminal approach. Intensity and Interference Scores were also reduced. This reductions were statistically significant when comparing to baseline data (paired t test) but differences between groups were not significant (unpaired t test). However the number of positive responses as defined above was greater in the transforaminal group, 64 % versus 38 % in the interlaminar group, statistically significant difference using the Chi Square analysis (p=0.01). In patients with positive responses, interlaminar and transforaminal betamethasone produce clinical and statistically significant reductions in pain intensity and interference, without difference between groups. Conclusion: Epidural betamethasone produced a reduction in pain intensity and interference utilizing the BPI, by the two routes utilized to access the epidural space. Although no statistically differences were observed in this reductions between groups, the frequency of positive responses were higher when the drug is administered by the transforaminal route. Epidural interlaminar parasagittal betamethasone injection is a reasonable alternative to the transforaminal route, without the neurologic complications described utilizing this technique.

Endoscopic Approach Technique for Recurrent Lumbar Prolapsed Disc

Introduction: Recurrent disc after lumbar discectomy is not uncommon, with most of the patients requiring a new surgery. A greater bone decompression and scar tissue dissection become necessary with the new procedure, resulting in a higher chance of postoperative complications. Recently, many surgeons have begun to treat recurrent disc with endoscopic approaches, in order to reach the prolapsed disc avoiding tissue dissection. We present our up-to-dated experience on the treatment of recurrent disc by endoscopic technique. Material and methods: We prospectively collected 30 patients treated for recurrent lumbar disc prolapse, from May 2016 to December 2017, with an endoscopic procedure. We collected data on age, sex, location, diagnosis, leg pain by VAS, and degree of disability via the Oswestry Disability Index (ODI), and if any adverse events occurred. All patients underwent an ODI (Oswestry Disability Index) and a VAS (Visual Analogue Scale) questionnaire before the operation and after 3, 6 and 15 months [3-6] at the follow-up visit. No patients were lost at follow-up. Patients characteristics: Age at presentation ranged between 23 and 78 years with a male to female ratio of 1.5 to 1. The level treated more was L4-L5. In all cases, we performed transforaminal route access, except for two, where an interlaminar approach was necessary because of the disc fragment location. Twenty-six cases had been operated previously by microsurgical access and the remaining by an endoscopic technique. In one case the disc had recurred for a second time, requiring open revision surgery. Results: Median operative time was 52 minutes (range 44 to 79 minutes). After a median follow up of 15 months (range 15-24 months) 93% of patients were pain-free. Pain by VAS ranged from a mean value of 6.3 at admission to 1.9 at 15 months of follow-up. ODI scores went from a mean preoperative value of 59.8% to 14.6% at the same follow-up. Four patients experienced transient paresthesia along the dermatomeric distribution of the involved nerve, while 3 had an intraoperative dural tear. One patient had to undergo new revision surgery for a disc recurrence. No late adverse events occurred. Conclusions: Endoscopic discectomy might be a valuable procedure for recurrent lumbar disk prolapse treatment. Our results showed good outcomes with only a few transient complications and less postoperative pain. Also, iatrogenic mechanical instability might be avoided with this technique.

Wednesday, September 26, 2018 1:00 PM – 2:00 PM Interventional Pain Management: 31. Epidural perineural injection of autologous conditioned serum is better than methylprednisolone in unilateral cervical radiculopathy at longer duration: a prospective randomized comparative study

BACKGROUND CONTEXT Cytokine molecules like IL-1 and prostaglandins are considered sensitizers of nerve root at chemical level in the pathogenesis of pain in cervical radiculopathy. Autologous conditioned xerum which contains interleukin-1 receptor antagonist (IL-1Ra) in high concentration may be a promising, new treatment option for patients with unilateral cervical radicular compression. It can be given by translaminar or transforaminal routes to the affected roots but the rationale for using a transforaminal route of injection rather than an inter-laminar route is that the injectate is delivered directly onto the target nerve root. PURPOSE To compare the efficacy of epidural perineural injection of autologous conditioned serum (ACS) with methylprednisolone (MPS) in treating unilateral cervical radiculopathy and to evaluate the treatment safety of ACS. STUDY DESIGN/SETTING A prospective randomized comparative study. PATIENT SAMPLE Two groups, ACS group (50 patients), MPS group (50 patients). Randomized with computer generated charts. OUTCOME MEASURES VAS scores for pain at 3 weeks (first follow up, 3 months (second follow-up), 6 months (third follow-up). METHODS Male or female patient aged between 30 years and 60 years with complaints of neck pain (moderate to severe as determined by VAS) and unilateral upper limb radiculopathy with radiological criteria: abnormal disc degeneration correlating with clinical findings were included and randomly divided into two groups. ACS group received autologous conditioned serum and the other group received methylprednisolone (MPS group) by transforaminal route under fluoroscopic guidance. ACS preparation -ACS was prepared by withdrawing 50 ml of blood from the patient under aseptic precautions and transferred to a centrifuge tube containing medical grade glass beads for incubation at 37°C, with 5% CO2 for 24 hours. After incubation, ACS was retrieved by centrifugation and stored at –20°C. RESULTS The ACS group had a decrease in pain by 50.70% (VAS score) at first follow-up (3 weeks), by 66.19% at second follow-up (3 months) and by 73.24% at third follow-up (6 months) compared to baseline. Group MPS had a decrease in pain by 68.12% at first follow-up, by 63.04% at second follow-up and by 58.45% at third follow-up compared to baseline. The difference between the two groups was statistically significant at first follow-up (p=.000) in favor of MPS group, but at third follow-up it was significant (P=.027) in favor of ACS. CONCLUSIONS Steroids (MPS) are effective in pain control in cervical radiculopathy for short duration but ACS improves disability and general health in long duration and is safe. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Gross Total Resection of Chordoid Glioma of the Third Ventricle via Anterior Interhemispheric Transcallosal Transforaminal Approach at Two Stages

Suprasellar tumors in particular tumors located in the retrochiasmatic area and anterior third ventricle are challenging cases in terms of optimal surgical exposure. Several approaches have been described including transsylvian, translamina terminalis, endoscopic endonasal, and anterior interhemispheric. Each approach has advantages and disadvantages. In this video, we present a case of retrochiasmatic anterior third ventricular tumor that was operated via anterior interhemispheric transcallosal transforaminal approach. The patient is a 42-year-old female who presented with sudden onset of severe headache and depressed level of consciousness. Computed tomography (CT) scan of the head showed a hemorrhage in the third ventricle and suprasellar cisterns. CT angiogram and magnetic resonance imaging (MRI) confirmed diagnosis of hemorrhagic mass lesion in the third ventricle. Upon further questioning of her family, we found out that she was having excessive urination and short-term memory problems for last 2 weeks. First, ventriculostomy was placed for obstructive hydrocephalus. She then underwent surgical resection via anterior interhemispheric transcallosal transforaminal approach. Foramen of Monro was enlarged by performing transchoroidal dissection. Using transforaminal route, tumor was resected. Due to the narrow surgical corridor and high vascularity of the tumor, decision was made to come back at a second stage. Using same surgical approach, in the second stage, gross total resection was performed. Postoperative MRI confirmed gross total resection. Histopathology was chordoid glioma of the third ventricle. She made excellent recovery with persistent diabetes insipidus. Currently, she is completing radiation therapy. In this video, we demonstrate techniques and pitfalls of anterior interhemispheric transcallosal approach to anterior third ventricular tumor. The link to the video can be found at: https://youtu.be/CI5c6Zup8sY .

Fluoroscopically Guided Epidural Injections of the Cervical and Lumbar Spine.

Advances in imaging and the development of injection techniques have enabled spinal intervention to become an important tool in managing chronic spinal pain. Epidural steroid injection (ESI) is one of the most widely used spinal interventions; it directly delivers drugs into the epidural space to relieve pain originating from degenerative spine disorders-central canal stenoses and neural foraminal stenoses-or disk herniations. Knowledge of the normal anatomy of the epidural space is essential to perform an effective and safe ESI and to recognize possible complications. Although computed tomographic (CT) or combined CT-fluoroscopic guidance has been increasingly used in ESI, conventional fluoroscopic guidance is generally performed. In ESI, drugs are delivered into the epidural space by interlaminar or transforaminal routes in the cervical spine or by interlaminar, transforaminal, or caudal routes in the lumbar spine. Epidurography is usually performed before drug delivery to verify the proper position of the needle in the epidural space. A small amount of contrast agent is injected with fluoroscopic guidance. Familiarity with the findings on a typical "true" epidurogram (demonstrating correct needle placement in the epidural space) permits proper performance of ESI. Findings on "false" epidurograms (demonstrating incorrect needle placement) include muscular staining and evidence of intravascular injection, inadvertent facet joint injection, dural puncture, subdural injection, and intraneural or intradiscal injection. ©RSNA, 2016 An earlier incorrect version of this article appeared online. This article was corrected on December 22, 2016.

P26 The effectiveness of transforaminal versus caudal routes for epidural steroid injections in managing lumbosacral radicular pain: a systematic review and meta-analysis

P26 The effectiveness of transforaminal versus caudal routes for epidural steroid injections in managing lumbosacral radicular pain: a systematic review and meta-analysis

Comparative Anatomical Study on Operability in Surgical Approaches to the Anterior Part of the Third Ventricle

Surgery of the third ventricle still represents a challenge in modern neurosurgery. To optimize the surgical planning, some aspects, related to ventricular anatomy, have to be taken into consideration. An operability score could represent a preoperative tool to evaluate these variables to choose a tailored surgical approach. We compared the transcallosal transforaminal approach and the combined interhemispheric subcommissural translamina terminalis approach (CISTA) to the anterior part of the third ventricle, applying the operability score. Compared with the transcallosal transforaminal approach, the CISTA provides a statistically significant improvement in terms of depth of surgical field, surgical angle of attack, and maneuverability arc considering as 4 approach-related critical structures: the optic chiasm (P value: <0.0001, <0.0001, <0.0001, respectively), the anterior commissure (P value: <0.0001, <0.0001, <0.0001 respectively), the tuber cinereum (P value: <0.0001, 0.0224, 0.0173), and the interthalamic adhesion (P value: 0.2917, <0.0001, <0.0001 respectively). Tumors originating from the anterosuperior part of the third ventricle can be easily approached through a transcallosal transforaminal route, whereas lesions arising from the anteroinferior portion of the third ventricle might be safely and effectively approached through the CISTA.

Percutaneous Endoscopic Lumbar Discectomy for L5-S1 Disc Herniation: Consideration of the Relation between the Iliac Crest and L5-S1 Disc

Percutaneous transforaminal techniques for the treatment of lumbar disc herniation have markedly evolved. Percutaneous endoscopic lumbar discectomy (PELD) for L5-S1 disc herniation is regarded as challenging due to the unique anatomy of the iliac crest, large facet joint, and inclinatory disc space. Among these, the iliac crest is considered a major obstacle. There are no studies regarding the height of the iliac crest and their appropriate procedures in PELD. This study discusses PELD for L5-S1 disc herniation and the appropriate approach according to the height of iliac crest. Retrospective evaluation. 100 consecutive patients underwent PELD via the transforaminal route for L5-S1 disc herniation by a single surgeon. The study was divided into 2 groups: the foraminoplasty group requiring foraminal widening to access the herniated disc and the non-foraminoplasty group treated by conventional posterolateral access. Radiological parameters such as iliac height, the relative position of the iliac crest to the landmarks of the L5-S1 level, iliosacral angle and foraminal height, and disc location were considered. Clinical outcomes were assessed by the Visual Analogue Scale (VAS, 0 - 10) for back and leg pain, the Oswestry Disability Index (ODI, 0 - 100%), and the modified MacNab criteria. The overall VAS scores for back and leg pain decreased from 6.0 to 2.3 and from 7.5 to 1.7. The mean ODI (%) improved from 54.0 to 11.6. Using modified MacNab criteria, a good outcome was 92%. Foraminoplasty was required in 19 patients. Iliac crest height was significantly higher in the foraminoplasty group than the non-foraminoplasty group (37.7 mm vs 30.1 mm, P < 0.001). In the foraminoplasty group, the iliac crest is above the mid L5 pedicle on lateral radiography in all cases. There were no significant differences in foraminal height, foraminal width, iliosacral angle, or disc height between the 2 groups. In addition, there were no differences in clinical outcome between the 2 groups. This study is a retrospective analysis and simplifies the complexity of the L5-S1 level and iliac bone using two-dimensional radiography. In high iliac crest cases where the iliac crest is above the mid L5 pedicle in lateral radiography, foraminoplasty may be considered for transforaminal access of L5-S1 disc herniation. Conventional transforaminal access can be utilized with ease in low iliac crest cases where the iliac crest is below the mid-L5 pedicle.

Efficacy of Epidural Steroid Injection in Management of Lumbar Prolapsed Intervertebral Disc: A Comparison of Caudal, Transforaminal and Interlaminar Routes.

Epidural steroid is an important modality in the conservative management of prolapsed lumbar disc and is being used for over 50 years. However, controversy still persists regarding their effectiveness in reducing the pain and improving the function with literature both supporting and opposing them are available. To study the efficacy of epidural steroid injection in the management of pain due to prolapsed lumbar intervertebral disc and to compare the effectiveness between caudal, transforaminal and interlaminar routes of injection. A total of 152 patients with back pain with or without radiculopathy with a lumbar disc prolapse confirmed on MRI, were included in the study and their pre injection Japanese Orthopaedic Association (JOA) Score was calculated. By simple randomization method (picking a card), patients were enrolled into one of the three groups and then injected methyl prednisone in the epidural space by one of the techniques of injection i.e. caudal, transforaminal and interlaminar. Twelve patients didn't turn up for the treatment and hence were excluded from the study. Remaining 140 patients were treated and were included for the analysis of the results. Eighty two patients received injection by caudal route, 40 by transforaminal route and 18 by interlaminar route. Post injection JOA Score was calculated at six month and one year and effectiveness of the medication was calculated for each route. The data was compared by LSD and ANOVA method to prove the significance. Average follow-up was one year. At one year after injecting the steroid, all three routes were found to be effective in improving the JOA Score (Caudal route in 74.3%, transforaminal in 90% and interlaminar in 77.7%). Transforaminal route was significantly more effective than caudal (p=0.00) and interlaminar route (p=0.03) at both 6 months and one year after injection. No significant difference was seen between the caudal and interlaminar route (p=0.36). The management of low back pain and radicular pain due to a prolapsed lumbar intervertebral disc by injecting methyl prednisone in epidural space is satisfactory in the current study. All three injection techniques are effective with the best result obtained by transforaminal route.

Effectiveness of Parasagittal Interlaminar Epidural Local Anesthetic with or without Steroid in Chronic Lumbosacral Pain: A Randomized, Double-Blind Clinical Trial

Background: Epidural injections (EI) are the most commonly performed minimally invasive intervention to manage chronic low back pain (CLBP) with lumbosacral radicular pain (LRP). Local anesthetic (LA) and/ or steroids are frequently used injectates for EI and are reported with variable effectiveness. The majority of earlier studies have used either caudal, transforaminal (TF), or undefined interlaminar approaches for EI. The parasaggital interlaminar (PIL) approach route is reported to have good ventral epidural spread and comparable effectiveness to the TF route. However, there is a lack of head-to-head comparative effectiveness research of LA with or without steroid for managing CLBP with LRP using a PIL approach. Objective: To compare the effectiveness of EI of LA alone and LA with steroid using a PIL approach for managing CLBP with LRP. Study Design: Randomized, double blind, active control one year follow-up study. Setting: Interventional pain management clinic in a tertiary care center in India. Methods: Sixty-nine patients were randomized to receive fluoroscopic guided EI of either 8 mL of 0.5% lidocaine (group L, n = 34) or 6 mL of 0.5% lidocaine mixed with 80 mg (2 mL) of methylprednisolone acetate (group LS, n = 35). Patients were evaluated for pain intensity using 0 – 10 numerical rating scale (NRS) and functional disability using Modified Oswestry Disability Questionnaire (MODQ) at baseline; and 2 weeks, one, 2, 3, 6, 9, and 12 months after injection. Patients with inefficacy with the initial injection or response deterioration received an additional injection of the same injectate and dose. Patients were evaluated for achieving effective pain relief (EPR, i.e., ≥ 50% from baseline), overall NRS and MODQ, number of injections, and presence of ventral and perineural spread over one year follow-up. Primary outcome was proportion of patients achieving EPR at 3 months. Results: A significantly higher proportion of patients achieved EPR at 3 months in group LS [30 (86%, 90% CI 73% – 93%)] as compared to group L [17 (50%, 90% CI 36% – 64%)] (P = 0.02). Similar results were obtained at 6, 9, and 12 months, respectively. The probability of achieving EPR was significantly higher in group LS at various time-points during the one year follow-up as compared to group L (P = 0.01) A significant reduction in NRS and improvement in MODQ were observed at all time-points post-intervention compared to baseline (P &lt; 0.001) in both groups. NRS and MODQ scores were significantly lower in group LS as compared to group L at all time intervals post baseline. On average patients in group L received 2.0 (0.85) and group LS received 1.7 (0.71) injections annually (P = 0.07). Ventral epidural spread was comparable in both groups (97%). No major complications were encountered in either group; however, intravascular spread of contrast was noted during 2 injections (one in each group) requiring relocation. Limitations: A single center study, lack of documentation of adjuvant therapies like individual analgesic medication, and lack of placebo group. Conclusions: Using a PIL approach and the addition of steroid to LA for EI may provide superior effectiveness in terms of extent and duration of pain relief for managing CLBP with unilateral LRP, even though, local anesthetic alone also was effective. Trial registration: CTRI/2014/04/004572 Key words: Epidural injection, epidural steroid, chronic low back pain, chronic lumbosacral pain, parasagittal interlaminar

Outcome of single level disc prolapse treated with transforaminal steroid versus epidural steroid versus caudal steroids

To determine the efficacy of fluoroscopic guided transforaminal steroid versus interlaminar epidural steroid versus caudal steroid. A total of 90 patients were studied who had complains of low back pain with radiculopathy and MRI evidence of disc prolapse. Out of this group, patients were randomly assigned to three groups each having 30 patients. First group received transforaminal steroid injection, second group received caudal steroid injection, and third group received epidural steroid. All patients were followed up for 12 months, and the results were compared using change in Visual Analogue Scale score and Oswestry Disability Index (OSD). The change in pain scores was statistically different at 1- and 6-month interval such that a higher change was observed by transforaminal route as compared to the other two. There was no difference in change of scores between interlaminar and caudal routes. For OSD, a greater change was seen in transforminal at all times as compared to the other two. There was no difference in change of scores between interlaminar and caudal routes at any time of assessment. In current study, transforaminal steroid injection group has better symptomatic improvement for both short and long term as compared to interlaminar and caudal steroid injection group.

Transforaminal Retrieval of Intradiscal Retained Broken Surgical Knife Blade

Case report. To report a middle-aged female in whom a knife blade was broken and lodged in the disc space during lumbar discectomy. Transforaminal route as an alternative corridor for its removal is proposed. Lumbar discectomy is being done in increasing frequency worldwide. One risk associated with this procedure is breaking of the surgical knife during discectomy. Most of the broken blades can be removed during the initial surgery. However, in a few cases, surgeon's attempts might be unsuccessful, resulting in retained foreign body in the disc space. Literature regarding this issue is scarce, and there are no unique guidelines to address this complication. A 69-year-old female in whom a surgical knife blade was inadvertently broken and retained in the disc space during lumbar discectomy. The broken blade could not be removed during the first surgery. In the second surgery, it was retrieved through the initial midline incision but via transforaminal route. The patient was discharged a day after blade removal and is doing well now. Retrieval of a broken knife blade unintentionally buried in the intervertebral disc space can be a challenge and even impossible to achieve, despite hours of attempts. In the second surgery, the retained blade in the disc space is traditionally removed via the anterior approach. The transforaminal corridor might be a simple alternative route that does not carry inherent difficulties and risks associated with the anterior corridor. Eventually, removal of a broken blade via this route does not require the collaboration of an access surgeon.

Access routes and reported decision criteria for lumbar epidural drug injections: a systematic literature review

To review lumbar epidural drug injection routes in relation to current practice and the reported criteria used for selecting a given approach. This was a HIPPA-compliant study. Employing a systematic search strategy, the MEDLINE and EMBASE databank as well as the Cochrane Library were searched for studies on epidural drug injections. The following data were noted: access route, level of injection, use of image guidance, and types and doses of injected drugs. Justifications for the use of a particular route were also noted. Data were presented using descriptive statistics. A total of 1,211 scientific studies were identified, of which 91 were finally included (7.5%). The interlaminar access route was used in 44 of 91 studies (48.4%), the transforaminal in 37 of 91 studies (40.7%), and the caudal pathway in 26 of 91 studies (28.6%). The caudal pathway was favored in the older studies whereas the transforaminal route was favored in recent studies. Decision criteria related to correct needle placement, concentration of injected drug at lesion site, technical complexity, costs, and potential complications. Injection was usually performed on the level of the lesion using local anesthetics (71 of 91 studies, 78.0%), steroids (all studies) and image guidance (71 of 91 studies, 78%). The most commonly used access routes for epidural drug injection are the interlaminar and transforaminal pathways at the level of the pathology. Transforaminal routes are being performed with increasing frequency in recent years.

Lateral Parasagittal Versus Midline Interlaminar Lumbar Epidural Steroid Injection for Management of Low Back Pain with Lumbosacral Radicular Pain

Epidural steroid injections are commonly used for management of low back pain with lumbosacral radicular pain and can be administered by either interlaminar or transforaminal routes. The transforaminal route is reported to be more effective than the interlaminar route due to higher delivery of drug at the ventral epidural space. However, the transforaminal route has been associated with serious complications including spinal cord injury and permanent paralysis. Hence, there is a search for a technically better route with fewer complications for drug delivery into the ventral epidural space. Recently, a parasagittal interlaminar (PIL) approach of epidural contrast injection was reported to have 100% ventral epidural spread. However, the therapeutic efficacy of this route has never been investigated. We compared the therapeutic efficacy of the PIL approach and midline interlaminar (MIL) approach. We hypothesized that the PIL approach may produce a better clinical outcome because of better ventral epidural spread of the drug compared with MIL approach. Thirty-seven patients were randomized to receive injection of 80 mg methylprednisolone either by the PIL (PIL group, n = 19) or MIL (MIL group, n = 18) approach under fluoroscopic guidance. Patients were evaluated for effective pain relief (≥50% from baseline) by visual analog scale and improvement in disability by the modified Oswestry Disability Questionnaire at intervals of 15 days, 1, 2, 3, and 6 months. Patients having <50% pain relief from baseline received additional epidural injection of the same drug, dosage, and route, a maximum of 3 injections at least 15 days apart. The primary outcome of our study was the incidence of effective pain relief at 6 months. The incidence of patients having effective pain relief was higher with the PIL approach (13/19 [68.4%]) vs MIL (3/18 [16.7%]) at the end of 6 months. A significantly higher relative success of effective pain relief was noted in the PIL group (relative risk, 4.10; 95% confidence interval, 1.40-12.05; P = 0.001) at the end of the 6-month follow up with the requirement of fewer total injections (29 vs 41 in MIL, P = 0.043). Visual analog scale and modified Oswestry Disability Questionnaire scores were significantly lower in the PIL group compared with the MIL group at all time intervals after the procedure. Ventral epidural spread of contrast was significantly higher in the PIL 89.7% vs 31.7% in the MIL group. The administration of epidural steroid injection was without any complications with an exact 95% Clopper-Pearson confidence interval of 0.0% to 17.6% in the PIL group and 0.0% to 18.5% in the MIL group. Epidural steroid injection administered with the PIL approach was significantly more effective for pain relief and improvement in disability than the MIL approach for 6 months in the management of low back pain with lumbosacral radicular pain.

Fluoroscopy-guided Periradicular Injections in Spine

Summary: Periradicular injection is a modality that is extensively used for diagnosing and treating nerve root pain both in the cervical and lumbar spinal regions. It offers a viable alternative to surgical management of radicular pain because of disorders of the intervertebral disks or degenerative spinal conditions. These injections usually comprise steroids and local anaesthetics. There is evidence suggesting that periradicular injections of local anaesthetic without steroids may be equally effective treatment for a select group of patients with chronic function-limiting axial or extremity pain secondary to spinal stenosis. These injections can be administered by transforaminal, interlaminar, or caudal routes with the aid of fluoroscopy or computed tomography guidance. Despite good clinical outcomes, the underlying mechanism of action of periradicular steroid and local anesthetic injections is still not fully understood. We hereby describe the technique of transforaminal periradicular injections at the lumbar, lumbosacral, cervical, and thoracic levels. The article gives an overview of essential requirements for the procedure, concepts, technical tips, and potential complications.

Redo Surgery for Lumbar Postdiscectomy Discitis by Transforaminal Approach with or without Graft and Posterior Instrumentation

Introduction Aggressive anterior debridement and fusion with autogenous bone graft followed with posterior instrumentation are the accepted mode for management of postoperative lumbar discitis failing to respond to conservative measures. This can be done in one stage same day or two stage operation. Here, we will describe our experience in single stage posterior transforaminal approach for debridement, interbody bone graft insertion, and posterior instrumentation with safe and less hospital stay and good long-term outcomes. This method has been described neither for pyogenic discitis nor for postdiscectomy discitis before. Materials and Methods The current study include 23 cases with postlumbar discectomy discitis not responding to antibiotic therapy and immobilization. The patients were divided into two groups. Group I includes nine patients with subacute discitis resistant to conservative measures. End plate destruction was minimal in the patients of this group. Therefore, only simple transforaminal debridement, irrigation with normal saline mixed with gentamycin and putting a small gentamycin pad in the space, was used in five patients with L4-L5, two with L3-L4, and two with L5-S1 postoperative discitis. Group II includes 12 chronic patients who had pain secondary to continuation of infection, despite of several weeks to months of antibiotic therapy or even one to two redo surgeries. Discitis in majority of these cases were accompanied with marked vertebral destruction resulting in deformity in three. In all of the patients of this group, transforaminal debridement and curettage was done. The pedicle screws were placed either in involved or in noninvolved vertebras before debridement and the space was distracted between the screws for ease of debridement. Subsequently, an appropriately shaped autogenous bone graft was inserted and fitted in the intervertebral disk space through transforaminal route. Later, the bony construct was secured by compression of the posteriorly placed hardware considering ideal lumbar lordosis, which was already brought by positioning of the operating table. Results In the first group, transforaminal debridement plus 2- to 3-week antibiotic therapy result in remarkable clinical paraclinical improvement. In both patients with L5-S1, discitis debridement results in massive venous bleeding at the final attempts of debridement necessitating package of the floor of the intervertebral disk space with Surgicel. Both of these subjects despite of ultimate disappearance of low back and radicular pain, showed occlusion of the left internal iliac vein necessitating anticoagulant treatment. Despite of anticoagulant therapy, both developed clinical manifestation of deep vein thrombosis with good recovery. In all patients of the second group, pain decreased dramatically within a few days after operation and laboratory markers lowered within a week or two and finally became normal within 6 weeks after surgery. All patients of the second group returned to their previous activities. Conclusion We believe that in the patients with postoperative spondylodiskitis, debridement through transforaminal approach is a simple and safe method in subacute cases. However, we strongly advise not to use this method in L5-S1 discitis. Reconstruction of the vertebral column with autogenous bone graft can be done through the same corridor in chronic subjects with vertebral destruction with or without deformity. Adding screw rod even in involved vertebras will secure the graft, but do not carry an additional risk. I confirm having declared any potential conflict of interest for all authors listed on this abstract Yes Disclosure of Interest None declared

Redo Surgery for Lumbar Postdiscectomy Discitis by Transforaminal Approach with or without Graft and Posterior Instrumentation

IntroductionAggressive anterior debridement and fusion with autogenous bone graft followed with posterior instrumentation are the accepted mode for management of postoperative lumbar discitis failing to respond to conservative measures. This can be done in one stage same day or two stage operation. Here, we will describe our experience in single stage posterior transforaminal approach for debridement, interbody bone graft insertion, and posterior instrumentation with safe and less hospital stay and good long-term outcomes.This method has been described neither for pyogenic discitis nor for postdiscectomy discitis before. Materials and MethodsThe current study include 23 cases with postlumbar discectomy discitis not responding to antibiotic therapy and immobilization. The patients were divided into two groups.Group I includes nine patients with subacute discitis resistant to conservative measures. End plate destruction was minimal in the patients of this group. Therefore, only simple transforaminal debridement, irrigation with normal saline mixed with gentamycin and putting a small gentamycin pad in the space, was used in five patients with L4-L5, two with L3-L4, and two with L5-S1 postoperative discitis.Group II includes 12 chronic patients who had pain secondary to continuation of infection, despite of several weeks to months of antibiotic therapy or even one to two redo surgeries. Discitis in majority of these cases were accompanied with marked vertebral destruction resulting in deformity in three. In all of the patients of this group, transforaminal debridement and curettage was done. The pedicle screws were placed either in involved or in noninvolved vertebras before debridement and the space was distracted between the screws for ease of debridement. Subsequently, an appropriately shaped autogenous bone graft was inserted and fitted in the intervertebral disk space through transforaminal route. Later, the bony construct was secured by compression of the posteriorly placed hardware considering ideal lumbar lordosis, which was already brought by positioning of the operating table. ResultsIn the first group, transforaminal debridement plus 2- to 3-week antibiotic therapy result in remarkable clinical paraclinical improvement. In both patients with L5-S1, discitis debridement results in massive venous bleeding at the final attempts of debridement necessitating package of the floor of the intervertebral disk space with Surgicel. Both of these subjects despite of ultimate disappearance of low back and radicular pain, showed occlusion of the left internal iliac vein necessitating anticoagulant treatment. Despite of anticoagulant therapy, both developed clinical manifestation of deep vein thrombosis with good recovery.In all patients of the second group, pain decreased dramatically within a few days after operation and laboratory markers lowered within a week or two and finally became normal within 6 weeks after surgery. All patients of the second group returned to their previous activities. ConclusionWe believe that in the patients with postoperative spondylodiskitis, debridement through transforaminal approach is a simple and safe method in subacute cases. However, we strongly advise not to use this method in L5-S1 discitis. Reconstruction of the vertebral column with autogenous bone graft can be done through the same corridor in chronic subjects with vertebral destruction with or without deformity. Adding screw rod even in involved vertebras will secure the graft, but do not carry an additional risk.I confirm having declared any potential conflict of interest for all authors listed on this abstractYesDisclosure of InterestNone declared

Efficacy of Interlaminar vs Transforaminal Epidural Steroid Injection for the Treatment of Chronic Unilateral Radicular Pain: Prospective, Randomized Study

OBJECTIVE, DESIGN AND SETTINGS: The purpose of this randomized, prospective study is to compare the efficacy of two different routes in administering epidural steroid injections interlaminar (IL) vs transforaminal (TF) in patients with unilateral radicular pain. We randomly enrolled and followed 64 patients with chronic radiculopathy. Significant improvements were maintained throughout 6 months (24 weeks) of follow-up (P<0.001, respectively). The average visual analog scale (VAS) pain scores at 24 weeks improved to 4.0 ± 2.2 cm in the IL group and 3.8 ± 2.1 cm in the TF group (P=0.717). Baseline functional capacity was comparable for the IL and the TF group (52% vs 53%) when assessed using Oswestry (P=0.647). At 6 months, both groups improved, 39% for the IL group and 38% for the TF group, suggesting change from severe to moderate disability scoring range. There were 24 out of the 32 (75%) patients in the IL group at 24 weeks who improved more than 2 cm on the VAS scale and 17 patients (53%) had >50% of the pain relief. In the TF group, there were 27 out of the 32 (84%) patients with >2 cm improvement on VAS pain scale, and 20 of 32 (63%) with >50% improvement at 24 weeks. Functional capacity changes were similar, 16 out of the 32 patients (50%) improved 10 points or more on the Oswestry scale in the IL group and 21 out of the 32 in the TF group (66%). Using either route of epidural injections to deliver steroids for unilateral chronic radiculopathy secondary to herniated intervertebral disc provided significant improvements in patients function and pain relief. However, we could not find a statistically significant difference between two indicated groups either in functional improvement or in reduction in pain, although half-dose of steroids delivered via TF route provided somewhat better long-term pain relief and functional capacity improvements.