Transforaminal Steroid Injections Research Articles

24. Cervical spine steroid injections for delay of surgery for cervical spondylotic myelopathy

BACKGROUND CONTEXT Cervical spine steroid injections are increasingly being used for diagnosis and treatment of degenerative pathology. For cervical spondylotic myelopathy traditionally treated with surgery, there has been little investigation of the possible therapeutic or preventive effects of targeted injections. As injections may be targeted to the epidural space, the transforaminal region, or the zygapophyseal joints, differing injection modalities may also have variable therapeutic effects. PURPOSE To determine the potential for cervical spine steroid injections to delay surgical treatment for cervical spondylotic myelopathy. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 39,590 patients with a new diagnosis of cervical spondylotic myelopathy, without previous cervical spine surgery. OUTCOME MEASURES Timing of surgical treatment (cervical decompression, fusion, or arthroplasty, from anterior or posterior approaches). METHODS Administration of cervical epidural, transforaminal, or zygapophyseal steroid injections was determined based on Current Procedural Terminology (CPT) codes. Timing of surgical treatment (cervical decompression, fusion, or arthroplasty, from anterior or posterior approaches) was also determined based on CPT codes. Multivariate logistic regression was used to determine the association of steroid injection administration with surgical treatment at various time points after initial diagnosis (1, 3, 6 months, and 1, 2, 5 years). RESULTS A total of 39,590 patients with a new diagnosis of cervical spondylotic myelopathy were identified. A total of 6,405 patients (16.2%) underwent cervical epidural steroid injections, 1,426 (3.6%) underwent transforaminal steroid injections, and 647 (1.6%) underwent zygapophyseal injections. Mean time from initial diagnosis to surgery was 180.2 days (standard deviation=345.9 days). In multivariate analysis epidural injections were associated with decreased odds of surgery within 1 month of diagnosis (odds ratio [OR]=0.69, P CONCLUSIONS Epidural steroid injections do not prevent surgical treatment of cervical spondylotic myelopathy in the long run. There may be some short-term symptomatic benefits that lead to delayed surgical treatment, although the clinical benefits have yet to be demonstrated. No significant benefit is seen with transforaminal or zygapophyseal injections for treatment of cervical myelopathy. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

A Randomized Comparative Trial of Targeted Steroid Injection via Epidural Catheter vs Standard Transforaminal Epidural Injection for the Treatment of Unilateral Cervical Radicular Pain: Six-Month Results.

Compare the effectiveness of catheter-directed cervical interlaminar epidural steroid injection (C-CIESI) with triamcinolone to cervical transforaminal steroid injection (CTFESI) with dexamethasone for the treatment of refractory unilateral radicular pain. Prospective, randomized, comparative trial. Primary outcome: proportion of participants with ≥50% numeric rating scale pain score reduction from baseline "dominant pain" (the greater of arm vs neck) at one month postinjection. Secondary outcomes: ≥30% Neck Disability Index (NDI-5) reduction and Patient Global Impression of Change (PGIC) response indicating "much improved" or "very much improved." One hundred twenty participants (55.6% females, 52.3 ± 12.5 years of age, BMI 28.2 ± 6.5 kg/m2), were enrolled. The proportions of participants who experienced ≥50% pain reduction at one, three, and six months were 68.5% (95% CI = 54.9-79.5%), 59.3% (95% CI = 45.7-71.6%), and 60.8% (95% CI = 46.7-73.2%), respectively, in the C-CIESI group compared with 49.1% (95% CI = 36.4-62.0%), 46.4% (95% CI = 33.8-59.6%), and 51.9% (95% CI = 38.4-65.2%), respectively, in the CTFESI group. The between-group difference at one month was significant (P = 0.038). The proportions of participants who experienced a ≥30% NDI-5 score improvement were 64.0% (95% CI = 49.8-76.1%) and 54.9% (95% CI = 41.1-68.0%) in the C-CIESI and CTFESI groups (P = 0.352). Participants reported similar PGIC improvement in both groups: At six months, 53.2% (95% CI 38.9-67.1%) and 54.5% (95% CI = 39.7-68.7%) of the C-CIESI and CTFESI groups reported being "much improved" or "very much improved," respectively (P = 0.897). Both C-CIESI with triamcinolone and CTFESI with dexamethasone are effective in reducing pain and disability associated with refractory unilateral cervical radiculopathy in a substantial proportion of participants for at least six months.

CT fluoroscopy-guided transforaminal and intra-articular facet steroid injections for the treatment of cervical radiculopathy: injectate distribution patterns and association with clinical outcome.

To investigate injectate dispersal patterns and their association with therapeutic efficacy during a transforaminal (TFSI) or an intra-articular facet steroid injection (IFSI) to treat cervical radiculopathy. This retrospective study examined the post-intervention cervical spine CT of 56 patients randomized to receive one CT fluoroscopy-guided IFSI (29 patients; 10 (34.5%) males; mean age 45.0years; SD 8.8years; range 26-61years) or TFSI (27 patients; 13 (48.2%) males; mean age 51.1years; SD 11.2years; range 29-72years) (December 2010 to August 2013). The presence of contrast within the intra-articular facet, juxta-articular facet, retrodural, epidural, and foraminal and extraforaminal spaces during IFSI, and within the extraforaminal, foraminal, and epidural spaces during TFSI was assessed. Descriptive data are presented as frequencies. The association between injectate dispersal patterns and therapeutic efficacy, 4-week post-intervention, was assessed with ANCOVA models. During IFSI, the injectate predominantly spread to the retrodural (62%; 18/29) or juxta-articular (21%; 6/29) space. During TFSI, the injectate predominantly spread to the extraforaminal/foraminal spaces (41%; 11/27) or to the extraforaminal/foraminal/epidural spaces (33%; 9/27). Injectate presence in the juxta-articular (p = .007) or extraforaminal (p < .001) space was a predictor of therapeutic efficacy but not in the foraminal (p = .54), epidural (p = .89), or retrodural (p = .75) space. TFSI and IFSI led to preferential extraforaminal and retrodural injectate spread, respectively. Targeting the extraforaminal or juxta-articular facet space improved the clinical efficacy of steroid injections when treating cervical radiculopathy. • During intra-articular facet injection, the injectate spreads from the facet joint to the retrodural space and rarely reaches the epidural and/or foraminal spaces. • Epidural spread of the injectate during an anterolateral transforaminal steroid injection is the least effective for pain relief in patients with cervical radiculopathy. • Injection techniques targeting the extraforaminal or juxta-articular facet space are safer than transforaminal injections and effectively relieve pain in patients with cervical radiculopathy.

Three-Dimensional Imaging Angiography (3DIA) vs Fluoroscopy To Reveal Intravascular Injection During Lumbar Transforaminal Steroid Injection: A Retrospective Study

Demonstrate of accidental intravascular injection during lumbar transforaminal anterior epidural steroid injection (TAESI) performed with three-dimensional imaging angiography (3DIA) and fluoroscopy.We assessed 20 (9 males and 11 females) patients (with a total of 40 levels) whose images were received with simultaneously 3DIA and fluoroscopy-guided TAESI between January 2016 and September 2016 as retrospective. Injections were carried out in the lumbar fourth intervertebral space bilaterally and performed in the same way all of the cases.The mean age and body mass index of the patients were 47.9±2.72 years and 26.95±1.21, respectively. There were 10 patients with disc herniation, seven patients with spinal stenosis, and three patients with failed back surgery syndrome. In 3D imaging, vascular escape was detected in the 7 levels (17.5%) which were thought to be no escape in the fluoroscopy imaging.In chronic lumbar radiculopathy patients, intravascular escapes may occur during the fluoroscopic TAESI procedure. To avoid intravascular injections during TAESI procedure, it may be appropriate to use different imaging methods that can give more detailed results such as 3D angiography.

151. Efficacy of transforaminal steroid injections to prevent surgical treatment for patients with cervical radiculopathy

BACKGROUND CONTEXT The use of epidural spinal injections (ESIs) is a nonoperative method to treat patients dealing with cervical radiculopathy. The efficacy of ESI as a treatment for cervical radiculopathy varies significantly in literature and the possibility of prognostic indicators is controversial. PURPOSE The objective of this study was to determine the efficacy of transforaminal steroid injections in the prevention of surgical treatment for patients with cervical radiculopathy. We also evaluated clinical and demographic factors that may correlate with the success rate of ESI. STUDY DESIGN/SETTING Retrospective study from a single academic center. PATIENT SAMPLE One hundred consecutive patients who received cervical transforaminal epidural steroid injections between February 2009 and March 2014. OUTCOME MEASURES Using clinical and demographic data, we will determine the efficacy of ESIs in the prevention of surgical treatment for patients with cervical radiculopathy. METHODS Clinical and demographic data were collected. Patients were categorized into surgical and nonsurgical treatment groups. Demographic data (gender, BMI, number of injections, number of levels affected, symptom duration, comorbidities) were analyzed in relation to the clinical outcome (surgery or no surgery). The analysis included Chi-square tests for categorical variables and ANOVA tests for continuous variables. RESULTS Study sample, n=100; mean age was 51.5 years (range: 32-82 years), and gender: males=50 and females= 50. The average follow-up was 3.7 years (range: 0-9 years). The average length of time between injection appointments was 3.64 months (range: 0.5-17 months). The average duration of injection treatment for those with multiple appointments was 5.53 months (range: 0.5-34 months). Sixty-three patients (63%) did not require surgery and thirty-seven patients (37%) required surgery following ESIs. The average age was no different between the groups, surgery group (52 years) and nonsurgical group (50 years), p=0.34. The surgery rate was lower in patients with one level of radiculopathy (29%) compared to patients with multilevel radiculopathy (46%), p=0.06. The surgery rate was 57% with patients suffering from acute pain and 34% with patients suffering chronic pain, p=0.08. The average time period between the initial injection and surgery in the surgery group was 5.2 months (1-29 months). No difference was noticed for gender, BMI, comorbidities and the average number of injections between the surgical group and nonsurgical group. CONCLUSIONS The surgery rate was lower in single-level radiculopathy patients who received transforaminal epidural steroid injections. There was a trend toward a higher rate of surgical treatment in patients who had multilevel radiculopathy and were suffering from acute pain. The small study sample and retrospective nature of the study were limitations. FDA DEVICE/DRUG STATUS Epidural spinal injection (Approved for this indication).

The Effectiveness of Lumbar Transforaminal Injection of Steroid for the Treatment of Radicular Pain: A Comprehensive Review of the Published Data

To determine the effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain. Comprehensive systematic review. The primary outcome of interest was the proportion of individuals with reduction of pain by ≥50%. Additional outcomes of interest were a more-than-two-point reduction in pain score, patient satisfaction, functional improvement, decreased use of pain medication, and avoidance of spinal surgery. For patients with disc herniations, using the criterion of ≥50% reduction in pain, success rates across included studies (range) were 63% (58-68%) at one month, 74% (68-80%) at three months, 64% (59-69%) at six months, and 64% (57-71%) at one year. For patients with lumbar spinal stenosis, success rates across included studies (range) were 49% (43-55%) at one month, 48% (35-61%) at three months, 43% (33-53%) at six months, and 59% (45-73%) at one year, but there was a lack of corroboration from appropriately controlled studies. There is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. There is a lack of high-quality evidence demonstrating their effectiveness for the treatment of radicular pain due to spinal stenosis, though small studies suggest a possible benefit. Lumbar transforaminal injection of nonparticulate steroids is as effective as injections with particulate steroids.

Epidural chloroma and spinal cord compression

Epidural chloroma and spinal cord compression

Rare Case of Ischaemic Stroke Following Cervical Transforaminal Injection.

We report a case of brainstem infarction following a C5–C6 cervical transforaminal injection, a rare and serious neurological complication of this procedure. Cervical transforaminal steroid injection is a common therapy for patients with persistent cervical radiculopathy not relieved by conservative treatment, and is effective in 65–70% of cases. Unfortunately, this procedure may lead to serious complications such as neurological damage. These complications are rare but potentially fatal, as reported in our case. Complications could be due to three mechanisms: the technique itself, the cervical vascular anatomy and the properties of the product (corticoids). The neurological complications can be diagnosed through brain MRI. This case report focuses on the importance of a risk/benefit evaluation when performing this medical procedure.LEARNING POINTSPhysicians should be better informed about severe complications following cervical transforaminal epidural steroid injections and their strict indications.Severe adverse events are rare but they can be disastrous.Non-particulate corticosteroid should be used.

Comparative Study between Treatment of Lumbar Disc Herniation with Intra Discal Ozone and Transforaminal Steroid Injection versus Steroid Injection only

Background: Oxygen-ozone therapy is a minimally invasive treatment for lumbar disc herniation that exploits the biochemical properties of a gas mixture of oxygen and ozone. Objective: The purpose of our study was to prospectively evaluate the clinical effectiveness of oxygenozone therapy and compared the therapeutic outcome of injection of oxygen-ozone combined steroid with injection of steroid alone at different follow-up period. Patients and Methods: One hundred patients were included for this study from al-Agouza Physical Medicine, Rheumatology and Rehabilitation center. From March 2014 to April 2016, we treated 100 patients (42 men, 58 women; age range, 23–65 years) with lumbar disk herniation (L3-4, 23 patients; L4-5, 61 patients; L5-S1, 75 patients) and radicular pain. The mean duration of radicular pain at the time of treatment was 8 weeks. Result: Satisfactory clinical outcomes were obtained in both groups after two weeks, three months and at 6 months. Treatment was successful in patients in group I and patients in group II. The difference between group I and group II was insignificant. Conclusion: O2–O3 seems to play a role in pain relief, and we suggest the administration of the O2– O3 mixture combined with transforaminal steroid injection as a first-choice treatment before recourse to surgery or when surgery is not possible.

Comparative Study between Treatment of Lumbar Disc Herniation with Intra Discal Ozone and Transforaminal Steroid Injection versus Steroid Injection only

Comparative Study between Treatment of Lumbar Disc Herniation with Intra Discal Ozone and Transforaminal Steroid Injection versus Steroid Injection only

Long-term comparative study between transforaminal and interlaminar epidural injection of steroids in lumbar radiculopathy due to single-level disc herniation

Background: Epidural steroid injection is commonly used in treating radicular pain secondary to lumbar disc prolapse, which is a common clinical condition. Two main techniques were suggested to deliver the steroids: interlaminar and transforaminal injections. Methods: From June 2013 to March 2016 we performed a prospective study on 40 patients between the ages of 19 and 55 yr. All the patients had low back pain and lower limb radiculopathy secondary to a single-level lumbar disc prolapse. The pupose of this study was to compare interlaminar and tranforaminal injection techniques regarding the short-term and long-term improvement of back pain, leg pain, and functional outcomes. On admission the patients were evaluated using a visual analogue scale (VAS) for back and leg pain, and the Oswestry Disability Index (ODI) for functional capacity. They were followed for a period of 47 to 49 wk (mean 48 wk), and clinical and functional outcomes were assessed using the same tools for evaluation. Results: We found that VAS and ODI improved in both the transforaminal and interlaminar groups both short and long term, but the only statistically significant improvement was in VAS for leg pain and the ODI in the transforaminal group. Conclusions: Epidural steroid injection is generally a safe procedure, but the transforaminal approach gives better results than the interlaminar approach in relieving radicular pain and improving functional outcome.

Study on the functional outcome of fluoroscopically guided transforaminal epidural steroid injections in patients suffering from lumbar disc herniation

&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Intervertebral disc herniation of the lumbar region is one of the common causes of acute low back ache and lower extremity pain. While multiple treatment modalities exist, the efficacy of the usage of a transforaminal steroid injection as a tool to either alleviate pain or delay surgery needs to be further evaluated. The aim of this study is to determine the functional outcome of patients suffering from lumbar disc herniation treated with fluroscopically-guided transforaminal epidural steroid injections.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This is a prospective case study in which total of 43 patients were included in the study dating between August 2014 and July 2015. These patients were evaluated and identified with lumbar disc herniation, confirmed with a magnetic resonance imaging prior to the procedure. A pre-injection VAS score was taken. These patients were administered TFESI under fluoroscopic guidance using 2ml of 40mg of Methylprednisolone with 1 ml of 2% xylocaine. They were then evaluated during follow up at 2 weeks, 6 weeks, 12 weeks, and 6 months. Their pain outcome was evaluated using the VAS (visual analog scale) scores and functional outcome was evaluated using Oswestry disability index (ODI).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; All patients showed significant improvement in the VAS score during their regular follow up when compared to their pre injection levels. Patient satisfaction was the high at 2 weeks post operatively slightly declining over time. 3 patients underwent surgery during the follow up period. The ODI scores also showed significant improvements when compared to the pre injection scores at all follow up periods&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;TFESI provides significant short-term pain relief in patients suffering from a single level lumbar herniated disc and is a viable, effective short-term analgesic tool to address pain and may retard an early surgical intervention.&lt;/p&gt;

3:27 PMAbstract No. 419 - Efficacy of transforaminal steroid injections (TFESI) in adolescents with lumbosacral radiculopathy

3:27 PMAbstract No. 419 - Efficacy of transforaminal steroid injections (TFESI) in adolescents with lumbosacral radiculopathy

The Prognostic Value of Enhanced-MRI and Fluoroscopic Factors for Predicting the Effects of Transforaminal Steroid Injections on Lumbosacral Radiating Pain.

ObjectiveTo investigate the predictive value of enhanced-magnetic resonance imaging (MRI) and fluoroscopic factors regarding the effects of transforaminal epidural steroid injections (TFESIs) in low back pain (LBP) patients with lumbosacral radiating pain.MethodsA total of 51 patients who had LBP with radiating pain were recruited between January 2011 and December 2012. The patient data were classified into the two groups ‘favorable group’ and ‘non-favorable group’ after 2 weeks of follow-up results. The favorable group was defined as those with a 50%, or more, reduction of pain severity according to the visual analogue scale (VAS) for back or leg pain. The clinical and radiological data were collected for univariate and multivariate analyses to determine the predictors of the effectiveness of TFESIs between the two groups.ResultsAccording to the back or the leg favorable-VAS group, the univariate analysis revealed that the corticosteroid approach for the enhanced nerve root, the proportion of the proximal flow, and the contrast dispersion of epidurography are respectively statistically significant relative to the other factors. Lastly, the multiple logistic regression analysis showed a significant association between the corticosteroid approach and the enhanced nerve root in the favorable VAS group.ConclusionAmong the variables, MRI showed that the corticosteroid approach for the enhanced target root is the most important prognostic factor in the predicting of the clinical parameters of the favorable TFESIs group.

Comparative Effectivenesses of Pulsed Radiofrequency and Transforaminal Steroid Injection for Radicular Pain due to Disc Herniation: a Prospective Randomized Trial.

Transforaminal Epidural steroid injections (TFESI) have been widely adopted to alleviate and control radicular pain in accord with current guidelines. However, sometimes repeated steroid injections have adverse effects, and thus, this prospective randomized trial was undertaken to compare the effectivenesses of pulsed radiofrequency (PRF) administered to a targeted dorsal root ganglion (DRG) and TFESI for the treatment of radicular pain due to disc herniation. Subjects were recruited when first proved unsuccessful (defined as a score of > 4 on a visual analogue scale (VAS; 0-10 mm) and of > 30% according to the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI)). Forty-four patients that met the inclusion criteria were enrolled. The 38 subjects were randomly assigned to receive either PRF (PRF group; n = 19) or additional TFESI (TFESI group; n = 19) and were then followed for 2, 4, 8, and 12 weeks. To evaluate pain intensity were assessed by VAS. ODI and NDI were applied to evaluate functional disability. Mean VAS scores for cervical and lumbar radicular pain were significantly lower 12 weeks after treatment in both study groups. NDI and ODI scores also declined after treatment. However, no statistically significant difference was observed between the PRF and TFESI groups in terms of VAS, ODI, or NDI scores at any time during follow-up. PRF administered to a DRG might be as effective as TFESI in terms of attenuating radicular pain caused by disc herniation, and its use would avoid the adverse effects of steroid.

Effect of High-Volume Injectate in Lumbar Transforaminal Epidural Steroid Injections: A Randomized, Active Control Trial

Background: There have been many studies proving the effectiveness of lumbar transforaminal epidural steroid injections (TFESIs) for the treatment of radicular pain. Dexamethasone has been suggested as an alternative to particulate steroids. However, no controlled trials have investigated the effect of different injected volumes for a same dose of dexamethasone. Objective: To compare the effects of a high-volume injectate with those of a low-volume injectate using the same dose of dexamethasone for 2 groups in lumbar TFESI. Study Design: A prospective, randomized, active control trial. Setting: The outpatient clinic of a single academic medical center. Methods: A total of 66 patients were randomized to receive lumbar transforaminal epidural dexamethasone injections with either a low-volume injectate (3mL, N = 30) or a high-volume injectate (8mL, N = 32). The primary outcome measures for this study were the incidence of the patients achieving meaningful pain relief and a reduction on the Visual Analogue Scale (VAS, range 0 – 100) at 4 weeks after the procedure. The definition of “meaningful pain relief” was ≥ 50% from baseline. The secondary outcomes included the Roland-Morris Disability Questionnaire (RMDQ, range 0 – 24) score and adverse effects. The outcomes were assessed 4 weeks after the procedure. Results: Four weeks after the procedure, in the DL8 group, the incidence of achieving meaningful pain relief was higher compared with DL3 group (19, 59.4% vs. 9, 30%, P = 0.024). Both groups demonstrated a significant improvement in their VAS and RMDQ scores (P &lt; 0.05). The VAS of the high-volume injectate group (DL8) was significantly lower than that of the low-volume injectate group (DL3) (33.3 ± 25 vs. 46.3 ± 25, P = 0.036). There was no significant difference in the RMDQ score between the 2 groups. Limitations: We enrolled a small number of patients and did not assess the long-term outcomes. Conclusions: Injectate at a volume of 8 mL was more effective than injectate at a volume of 3 mL for radicular pain in a lumbar transforaminal steroid injection, although both of the injectates contained the same dose of dexamethasone. Key words: Dexamethasone, disc herniation, epidural injection, lumbar, radiculopathy

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.

Sciatic perineural edema treated by Botulinum toxin injection on piriformis muscle

An 80-year-old woman presented with right leg and buttock pain since a few months' duration. Paresthesias on the right leg were associated with a prolonged seated position. The right leg visual analog scale score was 6/10. The right side straight leg raise test (Lasègue test) was painless. Magnetic resonance imaging revealed mild bilateral L3–L4 and L4–L5 foraminal stenosis (Fig. 1). Transforaminal steroid injections over right L3–L4 and L4–L5 were performed but the leg and buttock pain did not improve at all. A pelvic magnetic resonance imaging revealed perineural edema of the right sciatic nerve at the level below the right piriformis muscle (Figs. 2 and 3), compatible with piriformis muscle syndrome [ [1] Michel F. Decavel P. Toussirot E. Tatu L. Aleton E. Monnier G. et al. The piriformis muscle syndrome: an exploration of anatomical context, pathophysiological hypotheses and diagnostic criteria. Ann Phys Rehabil Med. 2013; 56: 300-311 Crossref PubMed Scopus (36) Google Scholar ]. Under computed tomography-guidance, 100 IU Botulinum toxin was injected into the right piriformis muscle belly under local anesthesia (Fig. 4, Left and Middle) [ [2] Al-Al-Shaikh M. Michel F. Parratte B. Kastler B. Vidal C. Aubry S. An MRI evaluation of changes in piriformis muscle morphology induced by botulinum toxin injections in the treatment of piriformis syndrome. Diagn Interv Imaging. 2015; 96: 37-43 Crossref PubMed Scopus (33) Google Scholar ]. A repeat Botulinum toxin injection was given 3 months later to boost the muscle atrophy effect. Follow-up pelvic computed tomography demonstrated right piriformis muscle atrophy (Fig. 4, Right). After the second injection, the right leg visual analog scale score improved to 1/10. Fig. 2Sacral T1-weighted coronal magnetic resonance imaging shows right sciatic perineural edema (arrow) when comparing with the left side. View Large Image Figure Viewer Download Hi-res image Fig. 3Serial sacral T1-weighted axial magnetic resonance imaging shows right sciatic perineural edema (arrow) just below the piriformis muscle (asterisk). View Large Image Figure Viewer Download Hi-res image Fig. 4(Left) Before the computed tomography (CT)-guided Botulinum toxin injection, axial imaging shows symmetrical piriformis muscle thickness. (Middle) CT-guided Botulinum toxin was injected over the piriformis muscle belly under local anesthesia. (Right) Follow-up CT imaging revealed right piriformis muscle atrophy (arrow). View Large Image Figure Viewer Download Hi-res image

Cervical foraminal steroid injections under CT guidance: retrospective study of in situ contrast aspects in a serial of 248 cases.

To describe all the CT findings after in situ contrast injection just before steroid injection and to recognize the abnormal aspects associated with intravascular contamination. We retrospectively evaluated 248 cervical transforaminal steroid injections done at the university hospital in Dijon, France, in 2008-2012, to treat cervicobrachial neuralgia inadequately improved by optimal medical treatment for at least 3weeks. Features describing the opacification patterns were recorded. Five main nonvascular opacification patterns were identified: clumps of contrast agent outside the foramen (16%), a crab claw pattern surrounding the ganglion (13%), a "French" circumflex accent pattern (15%), reflux along the needle (7%), and facet joint capsule opacification (22%). Concerning the situations requiring a change in needle position, intravenous injection occurred in 26% of the patients, with a crab claw pattern in half the cases and a clump pattern in half the cases. Intraarteriolar injection was noted in two patients. CT after in situ contrast injection ensures proper needle positioning outside the blood vessels before steroid injection. Penetration of the needle tip into a vein is very common, whereas arteriolar puncture is extremely rare.

Response to Transforaminal Injection of Steroids and Correlation to MRI Findings in Patients with Cervical Radicular Pain or Radiculopathy due to Disc Herniation or Spondylosis

To determine the effectiveness of cervical transforaminal injection of steroids (CTFIS) and to explore possible determinants of response in patients with cervical disc herniation. Retrospective practice audit covering a time period of 6 months. Single spine center in which the patients underwent CTFIS, surgery, and subsequent treatment. Magnetic resonance images were reviewed independently by a radiologist and two neurosurgeons. Consecutive patients with cervical radicular pain and a magnetic resonance imaging demonstrating nerve root affection received CTFIS. Evaluation in terms of pain reduction and in relation to the level and side of the affected nerve root, the duration of pain, neck or radicular pain, and the presence of sensory or motor deficits. The radiological features assessed were the location, grading, and cause of the impingement. Forty-eight patients were included. Only 35.4% of patients achieved at least 50% reduction in pain 1 month after treatment. The initial pain on the numeric rating scale was reduced from 6.8 to 1.8. None of the clinical or radiological features was associated with a successful outcome. 22.9% of the included patients had to undergo an operation. The duration of these patients' symptoms was significantly shorter (P = 0.01) than in patients without operation. Only a minority of patients with disc herniation or spondylosis and a proven nerve root compression benefits from CTFIS. The potential advantage for the patient must be compared with the risk of the procedure. Even with the combination of clinical and radiological findings, the prediction of a favorable outcome of CTFIS was not possible.