To observe the contrast spread in superoposterior transforaminal epidural steroid injection (SP TFESI) and investigate the correlation between spread patterns and efficacy.
Thirty-one patients with lumbosacral radiculopathy underwent single-level TFESI under fluoroscopy. The final needle tip position was targeted toward the SP quadrant of the intervertebral foramen. To observe the spread, 1 mL of contrast material was injected, followed by a steroid injection. The contrast spread was graded anteroposteriorly and vertically in the epidural space. The effect of SP TFESI was evaluated by proportional pain score reduction.
Levels injected were L4-5 (n=20) and L5-S1 (n=11). Seventeen cases were lateral, and 14 were central herniated disc (HD). Baseline mean visual analog scale score was 6.23. Contrast dispersed dorsally in all the cases, and 45.2% cases showed a concurrent ventral spread. The proportion of the pain reduction after 2 weeks showed no difference between the two groups. In vertical spreading analysis, mean cephalic/caudal grades were 1.40/1.55 at L4-5 level and 1.73/1.64 at L5-S1 level. The HD location had no effect on contrast dispersion.
In SP TFESI, ventral contrast spread did not guarantee a better effect; however, the extent of cephalic flow in ventral expansion group correlated with the proportion of pain reduction.
Citations
To evaluate the prevalence of vulnerable blood vessels around cervical nerve roots before cervical nerve root block in the clinical setting.
This retrospective study included 74 patients with cervical radiculopathy who received an ultrasonography-guided nerve block at an outpatient clinic from July 2012 to July 2014. Before actual injection of the steroid was performed, we evaluated the vulnerable blood vessels around each C5, C6, and C7 nerve root of each patient's painful side, with Doppler ultrasound.
Out of 74 cases, the C5 level had 2 blood vessels (2.7%), the C6 level had 4 blood vessels (5.45%), and the C7 level had 6 blood vessels (8.11%) close to each targeted nerve root. Moreover, the C5 level had 2 blood vessels (2.7%), the C6 level 5 blood vessels (6.75%), and the C7 level had 4 blood vessels (5.45%) at the site of an imaginary needle's projected pathway to the targeted nerve root, as revealed by axial transverse ultrasound imaging with color Doppler imaging. In total, the C5 level had 4 blood vessels (5.45%), the C6 level 9 blood vessels (12.16%), and the C7 level 10 had blood vessels (13.51%) either at the targeted nerve root or at the site of the imaginary needle's projected pathway to the targeted nerve root. There was an unneglectable prevalence of vulnerable blood vessels either at the targeted nerve root or at the site of the needle' projected pathway to the nerve root. Also, it shows a higher prevalence of vulnerable blood vessels either at the targeted nerve root or at the site of an imaginary needle's projected pathway to the nerve root as the spinal nerve root level gets lower.
To prevent unexpected critical complications involving vulnerable blood vessel injury during cervical nerve root block, it is recommended to routinely evaluate for the presence of vulnerable blood vessels around each cervical nerve root using Doppler ultrasound imaging before the cervical nerve root block, especially for the lower cervical nerve root level.
Citations
To 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.
A 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.
According 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.
Among 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.
Citations
To compare the long-term effect and safety of an epidural steroid injection in spinal stenosis patients, with or without local anesthetics.
Twenty-nine patients diagnosed with spinal stenosis were included and randomly divided into two groups. Translaminar epidural and selective nerve root spinal injection procedures were performed using steroids mixed with local anesthetics or normal saline. The effects of spinal injection procedures were measured with visual analogue scale (VAS) and functional rate index (FRI). These measurements were performed before injection, at 1 month after injection and at 3 months after injection. The occurrence of side effects was investigated each time.
The VAS and FRI scores were significantly reduced in both the local anesthetics group and normal saline group at 1 and 3 months after the injection. However, there was no significant difference in VAS and FRI score reduction between the two groups each time. Side effects are not noted in both groups.
The spinal injection procedures using steroids mixed either with local anesthetics or normal saline have an effect in reducing pain and improving functional activities. However, there was no significant difference between the two groups in relation to side effects and the long-term effects of pain and function.
Citations
To investigate the efficacy of percutaneous adhesiolysis (PA) compared to fluoroscopy (FL)-guided transforaminal epidural steroid injection (TFESI) in patients with radicular pain caused by lumbar foraminal spinal stenosis (LFSS) by assessing pain relief and functional improvement at 4 and 12 weeks post-procedure.
This retrospective study included 45 patients who underwent PA or FL-guided TFSEI for radicular pain caused by LFSS of at least 3 months' duration. Outcomes were assessed with the Oswestry Disability Index (ODI) and Verbal Numeric Pain Scale (VNS) before the procedure and at 4 and 12 weeks post-procedure. A successful outcome was defined by >50% improvement in the VNS score and >40% improvement in the ODI score.
ODI and VNS scores improved 4 and 12 weeks post-procedure in both groups. Statistically significant differences between groups were observed in ODI and VNS at 12 weeks (p<0.05). The proportion of patients with successful outcomes was significantly different between the two groups only at the 12-week time point.
Our study suggests that PA is effective for pain reduction and functional improvement in patients with chronic radicular pain caused by LFSS. Therefore, PA can be considered for patients with previous ineffective responses to conservative treatment. Although PA seems to be more effective than TFEFI according to the results of our study, in order to fully elucidate the difference in effectiveness, a prospective study with a larger sample size is necessary.
Citations
Epidural steroid injections (ESI) are a common treatment for back pain management. ESI-related complications have increased with the growing number of procedures. We report a case of cervical meningomyelitis followed by multiple lumbar ESI. A 60-year-old male with diabetes mellitus presented to our hospital with severe neck pain. He had a history of multiple lumbar injections from a local pain clinic. After admission, high fever and elevated inflammatory values were detected. L-spine magnetic resonance imaging (MRI) revealed hematoma in the S1 epidural space. Antibiotic treatment began under the diagnosis of a lumbar epidural abscess. Despite the treatment, he started to complain of weakness in both lower extremities. Three days later, the weakness progressed to both upper extremities. C-spine MRI revealed cervical leptomeningeal enhancement in the medulla oblongata and cervical spinal cord. Removal of the epidural abscess was performed, but there was no neurological improvement.
Citations
Infection Risk of Lumbar Epidural Injection in the Operating Theatre Prior to Lumbar Fusion Surgery
We used lumbar magnetic resonance image (MRI) findings to determine possible outcome predictors of a caudal epidural steroid injection (CESI) for radicular pain caused by a herniated lumbar disc (HLD).
Ninety-one patients with radicular pain whose MRI indicated a HLD were enrolled between September 2010 and July 2013. The CESIs were performed using ultrasound (US). A responder was defined as having complete relief or at least a 50% reduction of pain as assessed by the visual analog scale (VAS) and functional status on the Roland Morris Disability Questionnaire (RMDQ); responder (VAS n=61, RMDQ n=51), and non-responder (VAS n=30, RMDQ n=40). MRI findings were analyzed and compared between the two groups with regard to HLD level, HLD type (protrusion or exclusion), HLD zone (central, subarticular, foraminal, and extraforaminal), HLD volume (mild, moderate, or severe), relationship between HLD and nerve root (no contact, contact, displaced, or compressed), disc height loss (none, less than half, or more than half ), and disc degeneration grade (homogeneous disc structure or inhomogeneous disc structure-clear nucleus and height of intervertebral disc).
A centrally located herniated disc was more common in the responder group than that in the non-responder group. Treatment of centrally located herniated discs showed satisfactory results. (VAS p=0.025, RMDQ p=0.040). Other factors, such as HLD level, HLD type, HLD volume, relationship to nerve root, disc height loss, and disc degeneration grade, were not critical.
The HLD zone was significant for pain reduction after CESI. A centrally located herniated disc was a predictor of a good clinical outcome.
Citations
To evaluate the effect of hyaluronidase in patients with failed back surgery syndrome (FBSS) treated with interlaminar lumbar epidural injection (ILEI).
Sixty patients suffering from severe low back pain and sciatica were randomly allocated into three groups. Group T received ILEI with 2 ml triamcinolone 40 mg/ml and 5 ml bupivacaine 0.25%. Group H received ILEI with 1500 IU hyaluronidase and 5 ml bupivacaine 0.25%. Group TH received interlaminar lumbar epidural injection (ILEI) with 1500 IU hyaluronidase, 2 ml triamcinolone 40 mg/ml and 5 ml bupivacaine 0.25%. The effect was evaluated using Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) at pre-injection, 2 weeks, 6 weeks and 12 weeks after ILEI.
After 2 weeks and after 6 weeks, patients in both Group T and Group TH had significant effectiveness more than Group H in decrease of VAS and ODI. After 12 weeks, only patients in Group TH had significant effectiveness in decrease of VAS and ODI (p<0.05). In every period, Group TH had the most effectivess in decrease of VAS and ODI after ILEI.
ILEI for FBSS with triamcinolone and hyaluronidase is considered to have more long term effectiveness to reduce pain and improve function after ILEI than injection with triamcinolone alone or hyaluronidase alone.
Citations
To evaluate the effect of hyaluronidase in lumbar interlaminar epidural injection (LIEI) for low back pain and sciatica.
Sixty-one patients suffering from severe low back pain and sciatica were randomly allocated into three groups. Group T (n=18, mean duration of illness: 2.12±1.16 months) received lumbar interlaminar epidural injection (LIEI) with 2 ml triamcinolone (40 mg/ml) and 5 ml bupivacaine (0.25%). Group H (n=16, mean duration of illness: 2.05±1.12 months) received LIEI with 1,500 IU hyaluronidase and 5 ml bupivacaine (0.25%). Group TH (n=27, mean duration of illness: 2.16±1.65 months) received LIEI with 1,500 IU hyaluronidase, 2 ml triamcinolone (40 mg/ml), and 5 ml bupivacaine (0.25%). The effects were evaluated using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) at preinjection and 2 weeks, 4 weeks, and 8 weeks after LIEI.
Pain improved in all groups after 2 weeks (p<0.05). After 8 weeks, there was no significant difference in VAS improvement among the 3 groups. However, pain improved in 70.4% of Group TH compared with preinjection, in contrast to 44.4% of Group T and 31.3% of Group H. The ODI improved significantly only in Group TH after 8 weeks (p<0.05).
LIEI with triamcinolone and hyaluronidase is more effective for reducing pain after 8 weeks than injection with triamcinolone or hyaluronidase alone.
Citations
Objective: The purpose of this study is to find out what is the effect of epidural corticosteroid injection on bone metabolism.
Method: We have assessed the systemic effects of a single epidural triamcinolone acetonide injection on biochemical indices of bone formation and resorption in patients with lumbosacral radiculopathy. Twenty patients who had lumbosacral radiculopathy and free from exposure to corticosteroid for at least 6 weeks were selected for this study. Patients were classifed as two groups; 1) epidural block with 2% lidocaine 3 ml and 0.9% normal saline 15 ml (4 men, 5 women; mean age 47.2⁑7.6 years) and 2) combination of triamcinolone acetonide 40 mg (5 men, 6 women; mean age 49.6⁑8.2 years). Fasting serum and the second voided urine were collected at 0, 1, 3, 7 and 14 days after the single epidural injection for bone-related biochemical
markers measurements.
Results: 1) Level of serum osteocalcin showed a significant time trend in the epidural corticosteroid injection group. Osteocalcin decreased dramatically from 11.2⁑3.4 ng/ml on day 0 to 5.9⁑2.8 ng/ml on day 1, 6.1⁑1.5 ng/ml on day 3 (p＜0.05). After the initial drop, the level recovered to 9.8⁑3.7 ng/ml by day 7, and returned to preinjection level on day 14, at 10.9⁑4.1. 2) Urinary deoxypyridinoline levels did not show any significant changes.
Conclusion: According to the above results, the epidural injection of corticosteroid may be a better therapeutic mode, with less potential for harmful effects to bone metabolism, in providing effective relief of symptoms to patients with lumbosacral radiculopaties. (J Korean Acad Rehab Med 2002; 26: 203-207)
Objective: To evaluate the efficacy of epidural injection for spinal stenosis with symptoms of low back pain, pseudoclaudication, or radiating pain.
Method: Thirteen patients with spinal stenosis which were confirmed by the computed tomography (CT) studies were treated with epidural injections of steroids and local anesthetics for three times with 1 week interval. The efficacy of epidural injection was assessed by visual analogue scale (VAS), pain rating score (PRS), treadmill test, and jump test.
Results: 1) The VAS, PRS, pain free walking distances, and jump heights were checked right before injection, and at 1 week and 3 months after injection. The VAS and PRS were significantly decreased after epidural injection. The pain free walking distances and the jump heights were significantly increased after epidural injecton.
Conclusion: Epidural injections of steroid and local anesthetics are effective in the short term period, but also in the long term period for patients with spinal stenosis.
Objective: To determine the therapeutic effect of transforaminal epidural injections in patients with refractory lumbar radicular pain.
Method: Thirty-five patients with lumbar radicular pain who did not receive any other interventional procedures were studied. Transforaminal epidurograms and epidural steroid injections via eighty-nine intervertebral foramens were performed under C-arm fluoroscopic visualization. After confirmation of proper needle placement, 20∼40 mg of triamcinolone and 1 cc of 2% lidocaine hydrochloride were injected into each safe triangle of the intervertebral foramen. Patients were evaluated for visual analogue scale (VAS) and straight leg raising (SLR) test at pre-injection, 1 week post-injection and 3 months post-injection. Changes over time were assessed statistically using ANOVA.
Results: The averages of VAS reduced significantly (p＜0.05) from 5.6⁑1.8 at pre-injection, to 3.5⁑1.7 at 1 week pos-tinjection, to 2.1⁑2.0 at 3 months post-injection, respectively. The averages of SLR augmented significantly (p＜0.05) from 51.6o⁑16.7o at pre-injection, to 66.6o⁑16.0o at 1 week post-injection, to 77.2o⁑15.1o at 3 months post-injection, respectively. Twenty-six out of thirty-five patients (74.3%) had a successful long-term outcome, reporting at least an over 50% reduction between pre-injection and 3 months post-injection in VAS.
Conclusion: Transforaminal epidural injection is an effective treatment for patients with lumbar radicular pain when evaluated after 1 week and 3 months post-injection.
Objective: This study is designed to compare the therapeutic effect of continuous epidural injection with catheter and intermittent epidural injection without catheter in the patients with low back pain.
Method: One hundred and nine patients with low back pain were randomly divided into two groups. First group (49 patients) were treated with two or three times of intermittent epidural injections with steroid mixed with local anesthetics. Second group (60 patients) were treated with continuous steroid mixed with local anesthetics injection through epidural catheter. The effect of the epidural injections was assessed by visual analog scale (VAS) at pre-injection and post- injection.
Results: Pre- and post-injection VAS scores of the first group were 6.5⁑1.2 and 3.5⁑1.5, respectively. Pre- and post-injection VAS scores of the second group were 6.2⁑1.6 and 2.3⁑1.1, respectively. VAS score changes between pre-and post-injection were significant (p＜0.01) in both groups. VAS score changes between two groups were greater (p＜0.01) in the second group. The more severe the disc herniation (protrusion and extrusion) in MRI finding, the more marked VAS score changes in the second group. When morbidity period was less than 1 year, the VAS score changes in the second group were greater (p＜0.05).
Conclusion: The therapeutic effect of catheter inserted continuous epidural injection is better than that of intermittent epidural injection in patients with low back pain.
Objective: To evaluate the efficacy of epidural injections of steroid and local anesthetics with the modified Dallas pain questionnaire in the low back pain patients.
Method: Before and after epidural injections with triamcinolone and local anesthetics, we examined the patients with modified Dallas pain questionnaire. The efficacy was assessed by paired t test to compare the results of this questionnaire.
Results: Four aspects of the patient's life (daily activity, work and leisure activity, anxiety- depression, and social interest) were significantly improved after epidural injection in low back pain patients. And their improvements were more definite in patients diagnosed with herniatied lumbar disc, relatively acute onset of symptom, and more serious findings in MRI.
Conclusion: Epdiural injections of steroid and local anesthetics are effective for patients with low back pain, espercially for improving life quality of patients such as daily activity and work-leisure activity. It also decreases anxiety and increases social interest in some patients. However, validity of modified Dallas pain questionnaire must be proved in the future.
Objective: This study was designed to evaluate the long term effect of the epidural injections with steroid and local anesthetics in the low back pain patients by assessments of Visual Analog Scale (VAS) scores and several relating factors that influence good results.
Method: Seventy two low back pain patients with or without sciatica were treated with epidural injections of weekly steroid (methylprednisolone acetate) and daily local anesthetics (lidocaine and bupivacaine) for 2 weeks via an epidural catheter. The efficacy of the epidural injections was assessed with Visual Analog Scale (VAS) score at the day of admission (VAS1), discharge (VAS2) and during the long term follow up period (VAS3)(mean：14 months, 8∼24 months).
Results: VAS1, VAS2 and VAS3 were 6.22⁑2.03, 3.36⁑1.49, and 3.39⁑1.45 respectively. VAS2 and VAS3 were significantly different with VAS1 (p＜0.05).
Conclusion: Epidural injections of steroid and local anesthetics are effective not only in the short term period, but also in the long term peroid for patients with low back pain with or without sciatica
Objective: To evaluate the efficacy of epidural injections of hypertonic saline, steroid and local anesthetics in patients with low back pain and sciatica.
Method: Retrospective study of 325 patients with low back pain and sciatica. Group I, 261 patients, were treated with epidural injection of steroid (Depo-medrolⰒ) weekly for 2 weeks and local anesthetics (lidocaine and bupivacaine) daily via epidural catheter. Group II, 64 patients, were treated with epidural injection of hypertonic saline for three successive days and same method of group I via epidural catheter. The efficacy was assessed with Visual Analog Scale (VAS) on the day of pre- and post- (2weeks later) epidural injection.
Results: (1) VAS score changes from pre- to post-epidural injections were from 6.1⁑3.6 to 3.6⁑1.8 (p＜0.05) in Group I and from 6.2⁑1.6 to 2.6⁑1.4 (p＜0.05) in Group II. (2) VAS score decrease of Group II was more than that of Group I (p＜0.05).
Conclusion: Epidural injections of hypertonic saline, steroid and local anesthetics are effective for patients with low back pain and sciatica in the short term, and more effective than that of steroid and local anesthetics, but prospective long-term follow up studies will be necessary in the future.
Objective: The goal of this study was to determine the efficacy of caudal epidural injection in relieving pseudoclaudication of patients with lumbar spinal stenosis.
Method: Fifteen patients with a spinal stenosis which was confirmed by the magnetic resonance imaging(MRI) studies, received a caudal epidural steroid injection of triamcinolone acetate 120 mg, in a solution mixed with 2 ml of 1% lidocaine, and 15 ml of normal saline.
Results: The visual analogue scales checked at 1 hour prior to injection, 1 hour postinjection, and 1 month postinjection were 8.1⁑0.8, 3.7⁑1.7, and 6.4⁑1.9, respectively.
The exercise tolerance on the treadmill with 0o ramp inclination and 1.8 km/h speed was measured at 1 hour prior to injection, 1 hour postinjection, and 1 month postinjection. The time intervals to the first symptom of the pseudoclaudication were 2.3⁑0.8 minutes, 6.5⁑0.7 minutes, and 4.6⁑1.9 minutes, respectively.
Conclusion: In our study, the caudal epidural injection offered a significant short-term relief for the pseudoclaudication. Also it appeared to be a reasonable therapeutic option among patients with lumbar spinal stenosis after 1 month postinjection.
Objective: Several kinds of steroids had been used epidurally for the treatment of low back pain, but there were few available medical reports as to the effects of each steroid. The purposes of this study were to evaluate the effects of epidural steroid injections and to investigate the factors affecting the results.
Method: Forty four backache patients were randomly assigned to one of three groups: Group 1, epidural saline as a control group(n=12); Group 2, epidural triamcinolone and 1% lidocaine(n=13); Group 3, epidural dexamethasone and 1% lidocaine(n=19). The effects of epidural injections were measured by pain self-assessment scale(pain score) and Rubin scale(success rate).
Results: The pain scores of steroid groups after one to seven days after the injections were significantly lower than those of the control group(p＜0.05), but there were no statistical differences(p＞0.05) between two steroid groups. The overall success rate of the steroid groups was 68.8%. Although there were no statistically significant differences between the steroid groups with respect to sex, age and duration, the younger age group seemed to respond better to the treatment.
Conclusion: We founded that epidural steroid injection could be a valuable adjunct to the management of low back pain but its effective duration was relatively short. Physicians should keep in mind that comprehensive treatment including rest, medication, physical therapy, exercise and education ought to be provided for the better clinical results.
The purpose of this study is to evaluate the efficacy of epidural injections with steroids and local anesthetics for the low back pain patients.
Two hundred fifty patients with low back pain and sciatica were selected for the study. The patients were treated with the epidural injection of steroid(Depo-medrolⰒ) weekly for 2 weeks and local anesthetics(lidocaine and bupivacaine) daily via epidural catheter. The efficacy of epidural injections was assessed with the Visual Analog Scale(VAS) on pre- and 2weeks post-epidural injections. The VAS scores of pre- and post-epidural injections were 6.14⁑2.14 and 3.65⁑1.93(p＜0.05) respectively. The VAS scores were not different by the disease subgroups(p＞0.05). By the main symptoms, VAS scores were reduced prominently in patients with the pseudoclaudication symptom after post-epidural injections.
In conclusion, epidural injections of steroid and local anesthetics are effective for patients with a low back pain and sciatica in the short term. Further prospective long-term follow up studies will be necessary in the future.
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