Unilateral Lumbar Radicular Pain Research Articles

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

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

Combined Ultrasound and Fluoroscopy versus Ultrasound versus Fluoroscopy-Guided Caudal Epidural Steroid Injection for the Treatment of Unilateral Lower Lumbar Radicular Pain: A Retrospective Comparative Study.

Background and Objectives: This study aimed to evaluate the mid-term effectiveness and safety of a combined ultrasound (US) and fluoroscopy (FL)-guided approach in comparison to US-guided and FL-guided caudal epidural steroid injections (CESI) for treating unilateral lower lumbar radicular pain. Materials and Methods: A total of 154 patients who underwent CESI between 2018 and 2022 were included. Patients were categorized into three groups based on the guidance method: combined US and FL (n = 51), US-guided (n = 51), and FL-guided (n = 52). The study design was retrospective case-controlled, utilizing patient charts and standardized forms to assess clinical outcomes, adverse events, complications during the procedures. Results: In all groups, Oswestry Disability Index and Verbal Numeric Scale scores improved at 1, 3, and 6 months after the last injection, with no significant differences between groups (p < 0.05). The treatment success rate at all time points was also similar among the groups. Logistic regression analysis showed that injection method, cause, sex, age, number of injections, and pain duration did not independently predict treatment success. Blood was aspirated before injection in 2% (n = 1), 13.5% (n = 7), and 4% (n = 2) of patients in the combined US and FL groups, FL-guided groups, and US-guided groups, respectively. Intravascular contrast spread was detected in one patient in the combined method groups and seven in the FL-guided groups. Conclusions: When comparing pain reduction and functional improvement, there was no significant difference between the three methods. The combined method took less time compared to using FL alone. The combined approach also showed a lower occurrence of intravascular injection compared to using FL alone. Moreover, blood vessels at the injection site can be identified with an ultrasound using the combined method. Given these advantages, it might be advisable to prioritize the combined US- and FL-guided therapy when administering CESI for patients with unilateral lumbar radicular pain.

Transforaminal Epidural Autologous Conditioned Serum Injection in the Treatment of Unilateral Lumbar Radicular Pain: A Randomized, Controlled, Double-Blind Clinical Trial

Background: Low back pain could related to disc herniation and managed by surgery. Also, less invasive options, including epidural corticosteroid injection, are available; however, it is associated with side effects. This study aimed to evaluate the effectiveness of autologous conditioned serum (ACS) in treating unilateral lumbar radicular pain. Materials and Methods: In this randomized, controlled, double-blind clinical trial study, a total of 68 patients received the transforaminal epidural injection, 28 patients received ACS, and 30 patients received 40 mg triamcinolone. Under fluoroscopic guidance in anterior-posterior and lateral views, a single injection of ACS or triamcinolone was done via the transforaminal epidural technique. Pain intensity was assessed with a visual analogue scale (VAS) and Oswestry disability index (ODI) at three weeks, three months, and six months. Results: A significant reduction in pain intensity was observed in patients of two groups. There was no significant difference between the two groups during the three months of the study. At the final evaluation at six months, the ACS group showed superiority over the triamcinolone based on the VAS score (P&lt;0.05) and ODI (P=0.007). Conclusions: ACS therapy is a new effective option in treating lumbar radicular pain due to herniated disc. Since no specific complication has been reported, it can be used as a substitute for corticosteroids in such cases.

Sonoelastography of Multifidus, Piriformis, Quadratus Lumborum, and Gluteus Medius Muscles in Patients with Unilateral Discogenic Lumbar Pain and Healthy Subjects: A Reliability Study.

This study aimed to estimate the within-day and between-day reliabilities of sonoelastography to measure the strain ratios of lumbopelvic muscles, including multifidus (MF), piriformis (P), quadratus lumborum (QL), and gluteus medius (GM), in a resting position by the sonoelastography device in both patients with unilateral discogenic lumbar pain and healthy individuals. Failthe treatment of deep infection of peri-articular fracture fixation. First of all, the participants (n=25) were enrolled in this study, including patients (n=15) and healthy subjects (n=10). In the first session, an examiner estimated the strain ratio of lumbopelvic muscle three times by sonoelastography. The last session was held at a one-week interval. The collected data were analyzed using an intraclass correlation coefficient (ICC) and a standard error of measurement. The ICC calculated for MF, P, QL, and GM measurements indicated good to excellent reliabilities in both healthy and patient groups for within- and between-intra-examiner reliabilities, which were obtained at 0.94-0.91 and 0.86-0.86, 0.87-0.89 and 0.82-0.82, 0.88-0.86 and 0.86-0.86, 0.88-0.84 and 0.84-0.84, respectively. Furthermore, the standard errors of intra-examiner reliability for MF, P, QL, and GM strain ratio measurements in both healthy and subject groups were estimated at the ranges of 0.52-0.51 and 0.64-0.65, 0.60-0.62 and 0.77-0.78, 0.23-0.25 and 0.25-0.25, 0.25-026 and 0.30-0.35, respectively. The results revealed that sonoelastography seemed to be a reliable instrument to measure MF, P, QL, and GM muscle strain ratios in healthy subjects and patients with unilateral lumbar radicular pain. However, further studies are recommended to support the findings of the present study in other patients.

Comparison Between a Single Subpedicular Transforaminal Epidural Steroid Injection and Lateral Recess Steroid Injection in Reducing Paracentral Disc Herniation–Related Chronic Neuropathic Leg Pain: A Retrospective Study

This retrospective study compares the results of 2 different techniques of transforaminal epidural steroid injection (TFESI)-subpedicular (SP-TFESI) and lateral recess epidural steroid injection (LRSI) in relieving chronic lumbar radicular pain. Records of 97 patients who had undergone injection for unilateral lumbar radicular pain and had a paracentral disc were analyzed. Numerical rating scale (NRS) and Oswestry Disability Index (ODI) scores were measured at baseline and at 2, 4, 12, and 24 weeks thereafter. At 24 weeks, the NRS was significantly lower than the baseline in both groups; NRS in the LRSI group was significantly lower than NRS in the SP-TFESI group at 12 and 24 weeks (P= 0.02 each). ODI score was also significantly lower in the LRSI group through the 12-week time point (P= 0.003 at 2 weeks; P= 0.009 at 4 weeks; P= 0.02 at 12 weeks). At the end of 24 weeks, a significantly greater number of patients in the LRSI group achieved minimal clinically important difference for NRS and ODI (P= 0.008 and 0.016, respectively). At the end of 24 weeks, LRSI appears to be a superior technique in relieving unilateral lumbar radicular pain due to a paracentral disc.

Does obesity have an impact on the radiation exposure during lumbosacral transforaminal epidural steroid injections? Retrospective study

Aim: To find out whether obesity or injection level have an impact on the amount of radiation exposure during fluoroscopy-guided lumbosacral transforaminal epidural steroid injections (TFESIs).Material and Methods: Patients aged 19-65 years who underwent lumbosacral transforaminal epidural steroid injection were retrospectively reviewed. Eighty-three patients with a mean age of 42.7±13.2 (19-65) years with signs and symptoms of unilateral lumbar radicular pain due to single level disc herniation were included. Subjects were categorized as normal weighted (18.5≤body mass index (BMI) ≤ 24.9), overweighed (25≤BMI30) and obese (BMI≥30) according to World Health Organization BMI criteria. All patients were given unilateral TFESIs, including39 (47%) L5, and 44 (53%) S1 level. Radiation exposure dose and procedure time was automatically measured by fluoroscope.Results: Radiation dosage increased significantly with increasing BMI (p=0.0001). No statistically significant differences were found when three groups’ procedure durations and NRS scores were compared (>0.05). The radiation dosages and procedure durations between the two different injection levels (L5 and S1) were not found to be statistically significant (>0.05). Conclusion: Obesity is associated with increased radiation exposure independent of procedure duration and the injection level.

Can Epidural Contrast Dispersal Pattern Help to Predict the Outcome of Transforaminal Epidural Steroid Injections in Patients with Lumbar Radicular Pain

To investigate the relationship between epidurographic contrast dispersal patterns and both immediate and short-term clinical effectiveness of lumbar transforaminal epidural steroid injections (TFESIs) in patients with radicular back pain. A digital database of 64 patients who underwent single-level lumbar TFESI for unilateral lumbar radicular pain was scanned. The type of contrast pattern was analyzed by 1 physiatrist and defined as follows: type 1 (tubular appearance), type 2 (nerve root visible as a filling defect), or type 3 (cloud-like appearance). Pain was evaluated with a visual analog scale (VAS) and recorded before injection and 2 days, 2 weeks, and 3 months after injection. The mean age was 45.9 ± 13.5 years (range, 22-80 years), and the mean duration of symptoms was 5.7 ± 4.2 months. Contrast distribution patterns were as follows: type 1 in 33 patients (51.6%), type 2 in 18 patients (28.1%), and type 3 in 13 patients (20.3%). Mean decrease in VAS scores at all time points was statistically significant in 3 types of contrast dispersal patterns (P < 0.05). Differences in improvements of VAS scores obtained at any assessment period and success rates were not statistically significant between groups. However, the ratio of patients who achieved 50% or greater reduction in pain scores was higher in type 1 and type 2 than type 3 at each follow-up point. TFSEIs have a beneficial effect in managing lumbar radicular pain regardless of contrast pattern type. Success rates were higher in type 1 and type 2 than type3.

Ultrasonography-Guided Lumbar Periradicular Injections for Unilateral Radicular Pain.

Objective. The aim of this study was to compare the accuracy and efficacy of sonographically guided lumbar periradicular injections through in-plane or out-of-plane approach techniques for patients with unilateral lower lumbar radicular pain. The feasibility and accuracy of these techniques were studied by means of computed tomography (CT). Methods. A total of 46 patients with chronic unilateral lumbar radicular pain were recruited and randomly assigned to either the in-plane or out-of-plane injection group. A mixture of 3 mL 1% lidocaine and 7 mg betamethasone was injected. The visual analog scale (VAS) was used to assess pain before and after treatment. Results. The pain intensity, as measured by VAS, significantly decreased in both in-plane and out-of-plane injection groups. Conclusions. The sonographically guided periradicular injections are feasible and effective in treating lumbar unilateral radicular pain.

Comparative Study to Assess the Efficacy of Epidural Steroid Injection by Interlaminar and Trans-Foraminal Approach for Low Back Ache with Unilateral Lumbar Radicular Pain

Comparative Study to Assess the Efficacy of Epidural Steroid Injection by Interlaminar and Trans-Foraminal Approach for Low Back Ache with Unilateral Lumbar Radicular Pain

Effect of Relative Injectate Pressures on the Efficacy of Lumbar Transforaminal Epidural Steroid Injection in Patients with Lumbar Foraminal Stenosis

Transforaminal epidural steroid injections (TFESIs) are often used to treat lumbar foraminal stenosis. Injectate pressure (of contrast) was monitored during fluoroscopically guided TFESI to assess the effect on short-term pain reduction. A total of 40 patients underwent single-level lumbar TFESI for unilateral lumbar radicular pain ascribed to foraminal stenosis. Relative injectate pressure of contrast epidurography during TFESI was recorded and compared with pre- and postprocedural pain levels using the Roland 5-point pain scoring method. Pain relief achieved after TFESI revealed no statistically significant correlation with injectate pressure (mean 13.0 cm H2 O). Mean pressures in patients with and without demonstrable pain reduction were 12.9 and 13.2 cm H2 O, respectively. Secondary outcomes were not measured, and no mid- or long-term follow-up was conducted. In this setting, relative injectate pressures had no significant effect on immediate outcomes of TFESI.

A prospective open label pilot study to investigate whether quantitative sensory testing correlates with the effectiveness of diagnostic dorsal root ganglion block in patients with unilateral lumbar radiculopathy

Lumbar radicular pain is defined as neuropathic pain in the area supplied by the affected nerve root, which may be treated by targeting the dorsal root ganglion (DRG). Central sensitization can occur following peripheral nerve injury, via autosensitization of nociceptive receptors and ectopic firing of DRG cells.1 We hypothesize that central nociceptive processing may be modulated by DRG blockade with local anaesthetic and steroid. This study used quantitative sensory testing (QST) to investigate changes in peripheral and central sensitization in patients undergoing therapeutic DRG block for radicular low back pain. Fifteen patients were recruited for the study, after approval of the local research ethics committee, to undergo DRG blockade with local anaesthetic and steroid (inclusion criteria: unilateral lumbar radicular pain with concordant disc herniation confined to the spinal canal on magnetic resonance imaging). This was performed by a single operator with fluoroscopic guidance, using 1ml 0.25% bupivacaine and 20mg methylprednisolone per level. QST measurements were taken one week before and after their procedure; mechanical pressure pain threshold (PPT) was measured using manual pressure algometry, and diffuse noxious inhibitory control (DNIC) was measured by recording changes in PPT in response to experimental arm pain. A visual analogue scale (VAS) was used to measure pain intensity. There was a significant increase in PPT after DRG blockade (painful side p<0.0005 versus non-painful side p<0.004). A diminished DNIC response was seen prior to DRG blockade, increasing after the procedure (p<0.0001); this suggests ‘normalisation’ of pressure pain modulation. Pain intensity scores improved after DRG blockade (7.45 +/- 1.9 versus 2.28 +/- 0.26). This pilot data indicates that DRG blockade with local anaesthetic and steroid may have effects on peripheral and central sensitization. Potential mechanisms include modulation of afferent fibre nociceptive input on central nociceptive processing. (1. Schwartzman RJ, Arch Neurol, 2001.)

Contrast Dispersal Patterns as a Predictor of Clinical Outcome With Transforaminal Epidural Steroid Injection for Lumbar Radiculopathy

To assess the relationship between epidural contrast dispersal patterns from lumbar transforaminal epidural steroid injections (TFESIs) and both immediate- and short-term pain reduction. We also investigated the effect of the grade of nerve root compression on contrast dispersal pattern and pain reduction. Retrospective review of data from a previous prospective study of outcomes after TFESI. Academic spine and musculoskeletal clinic. Thirty-eight subjects who underwent single-level lumbar TFESI for unilateral lumbar radicular pain. A retrospective assessment of a digital database of TFESIs for unilateral lumbar radicular pain. Type of contrast pattern was analyzed by 2 physiatrists as type I (tubular appearance); type II (nerve root visible as a filling defect); or type III (cloudlike appearance). Grade of nerve root compression on magnetic resonance also was analyzed by 2 physiatrists as grade I abutment, grade II displacement, or grade III entrapment. Effect of type of contrast pattern and grade of nerve root compression on change in Numeric Pain Rating Scale (NPRS) at time of injection (T1), 2 weeks after (T2), and 2 months after (T3). Mean decrease in NPRS at all time points was statistically significant with both types I and III contrast dispersal patterns. Groups with grades II and III nerve root compression had statistically significant reductions in NPRS at all time points. In this retrospective review we found that TFESIs can have an immediate beneficial effect on pain regardless of contrast pattern type or grade of nerve root compression. Subjects with higher grades of nerve root compression and a type I or III contrast pattern have significantly greater reductions in pain at 15 minutes, 2 weeks, and 2 months. Our findings are limited by methodological restrictions, and further confirmation with a prospective trial to review other possible associated factors is recommended.