To compare the treatment effects of epidural neuroplasty (NP) and transforaminal epidural steroid injection (TFESI) for the radiating pain caused by herniated lumbar disc.
Thirty-two patients diagnosed with herniated lumbar disc through magnetic resonance imaging or computed tomography were included in this study. Fourteen patients received an epidural NP and eighteen patients had a TFESI. The visual analogue scale (VAS) and functional rating index (FRI) were measured before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment.
In the epidural NP group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.00±1.52, 4.29±1.20, 2.64±0.93, 1.43±0.51 and those of FRI were 23.57±3.84, 16.50±3.48, 11.43±2.44, 7.00±2.15. In the TFESI group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.22±2.05, 4.28±1.67, 2.56±1.04, 1.33±0.49 and those of FRI were 22.00±6.64, 16.22±5.07, 11.56±4.18, 8.06±1.89. During the follow-up period, the values of VAS and FRI within each group were significantly reduced (p<0.05) after the treatment. But there were no significant differences between the two groups statistically.
Epidural NP and TFESI are equally effective treatments for the reduction of radiating pain and for improvement of function in patients with a herniated lumbar disc. We recommend that TFESI should be primarily applied to patients who need interventional spine treatment, because it is easier and more cost-effective than epidural NP.
Citations
To compare a newly developed minimally-invasive method for percutaneous transforaminal epidural injection (INJ group) with the existing method for lumbar epidural catheterization (CATH group).
Through anatomical review of experimental rats, the cephalic one fourth of the neural foramen was selected as the target point for drug delivery. After the rats had undergone lumbar epidural catheterization, lidocaine, and 1% methylene blue were injected through the unilateral or bilateral L5/6 neural foramen in the INJ group, and through an epidural catheter in the CATH group. Measurement of body weight and the mechanical allodynia test before and after injection of lidocaine, and fine dissection after injection were performed.
Results of the mechanical allodynia test of 1.0% lidocaine 50 µl injection in the CATH group were statistically similar to those of 0.5% lidocaine 100 µl injection in the INJ group. The results of 2.0% lidocaine 50 µl injection in the CATH group were statistically similar to those of 1.0% lidocaine 100 µl injection in the INJ group. After dissection, only one distal partial spinal nerve was stained by methylene blue 50 µl through the transforaminal pathway. However, the dorsal root ganglion, nerve root, and adjacent hemi-partial spinal cord were stained by methylene blue 100 µl through the transforaminal pathway.
The percutaneous transforaminal epidural injection is practical, easy, and safe, and, in particular, does not cause significant pain compared to the existing lumbar epidural catheterization. We expect this method to be effective in an animal study showing that drug delivery to the spinal epidural space is necessary.
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To observe the contrast spreading patterns in the retrodiscal (RD) approach for transforaminal epidural steroid injections and their effect on pain reduction.
Patients with L5 radiculopathy who were scheduled to receive lumbar TF-EPB were consecutively included. We randomly divided them into the L4-5 RD and L5-S1 RD groups and administered 1 cc of contrast dye into epidural space. We observed the shape and the location of contrast dye on the anterior-posterior and lateral views. We injected 1 cc of 0.5% lidocaine mixed with 20 mg of triamcinolone, and checked the pain intensity before and two weeks after the procedure by using visual analogue scale (VAS).
In the L4-5 RD group (n=30), contrast spread over the L4 nerve root in 27 cases and the L4 and L5 nerve roots in 3 cases. In the L5-S1 RD group (n=33), contrast spread over the L5 nerve root in 20 cases, the S1 nerve root in 3 cases, and the L5 and the S1 nerve roots in 10 cases. The contrast spreading patterns could be divided into 4 patterns: the proximal root in 40 cases, the distal root in 19 cases, the anterior epidural space in 3 cases and an undefined pattern in 1 case.
In RD lumbar TF-EPB, the contrast dye mostly went into the cephalic root and about 60% spread over the proximal nerve root. There was less pain reduction when the contrast dye spread over the distal nerve root.
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Effect of Needle Tip Position on Contrast Media Dispersion Pattern in Transforaminal Epidural Injection Using Kambin’s Triangle Approach
To compare the short-term effect and advantage of transforaminal epidural steroid injection (TFESI) performed using the Kambin's triangle and subpedicular approaches.
Forty-two patients with radicular pain from lumbar spinal stenosis were enrolled. Subjects were randomly assigned to one of two groups. All procedures were performed using C-arm KMC 950. The frequency of complications during the procedure and the effect of TFESI at 2 and 4 weeks after the procedure between the two groups were compared. Short-term outcomes were measured using a visual numeric scale (VNS) and a five-grade scale. Multiple logistic regression analyses were performed to evaluate the relationship between possible outcome predictors (Kambin's triangle or subpedicular approach, age, duration of symptoms and sex) and the therapeutic effect.
VNS was improved 2 weeks after the injection and continued to improve until 4 weeks in both groups. There were no statistical differences in changes of VNS, effectiveness and contrast spread pattern between these two groups. No correlation was found between the other variables tested and therapeutic effect. Spinal nerve pricking occurred in five cases of the subpedicular and in none of the cases of the Kambin's triangle approach (p<0.05).
The Kambin's triangle approach is as efficacious as the subpedicular approach for short-term effect and offers considerable advantages (i.e., less spinal nerve pricking during procedure). The Kambin's triangle approach maybe an alternative method for transforaminal epidural steroid injection in cases where needle tip positioning in the anterior epidural space is difficult.
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The objectives of this study were to clarify the short-term effects of transforaminal epidural steroid injection (TFESI) for degenerative lumbar scoliosis combined with spinal stenosis (DLSS), and to extrapolate factors relating to the prognosis of treatment.
Thirty-six patients with lumbar radicular pain from DLSS were enrolled. Subjects were randomly assigned to one of two groups (steroid or lidocaine group). We compared the effect of pain suppression at 2, 4 and 12 weeks after the procedure between the two groups. Radiographic analysis included measurement of the Cobb's angle, the upper endplate obliquities of L3 and L4, and maximal lateral olisthy between two adjacent lumbar vertebrae. Sagittal plane measurement included lumbar lordosis, and thoracolumbar kyphosis. Statistical analysis of both radiographic and clinical parameters along with treatment outcome was performed to determine any significant correlations between the two.
There were no significant differences in the demographic data, initial visual analogue scale (VAS) or Oswestry disability index (ODI) between the steroid group (n=17) and the lidocaine group (n=19). Two, 4, and 12 weeks after injection VAS, ODI showed a significantly greater improvement in the steroid group compared to the lidocaine group (p<0.05). The radiographic and clinical parameters were not significantly correlated with treatment outcome.
Our findings suggest that fluoroscopic transforaminal epidural steroid injections appear to be an effective non-surgical treatment option for patients with degenerative lumbar scoliosis combined with spinal stenosis (DLSS) and radicular pain.
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To compare the technical strengths and weaknesses between retrodiscal (RD) and conventional subpedicular (SP) approaches of transforaminal epidural block (TF-EPB).
Sixty-one patients with L5 radiculopathy who planned to undergo TF-EPB were consecutively enrolled as study subjects. Subjects were randomly assigned to one of two groups. For the RD approach, the positioning of the patient and the C-arm were similar to that for lumbar discography. We compared the pattern of dye spreads, the frequency of complications during the procedures, and the effect of the pain block 2 weeks after the procedure between the two groups.
For the RD group (n=24), the contrast dye diffused around the L5 and S1 nerve roots in 16 cases (67%), but it diffused around only the L5 root in 27 cases (73%) in the SP group (n=37) (p<0.05). Two weeks after the procedure, the visual analogue scale (VAS) decreased by the same amount in both groups (RD group: 3.1±1.6, SP group: 3.2±2.6). Symptoms of nerve root irritation occurred in 1 case of the RD group and in 10 cases of the SD group (p<0.05).
The RD approach was as efficient as the SP approach for temporary diagnostic relief and offered considerable advantages, such as lower nerve root irritation possible lower risk of vascular injection. Thus, it could be a useful technique when a herniated disc segment is stuck or when the foraminal stenosis is severe.
Citations
Effect of Needle Tip Position on Contrast Media Dispersion Pattern in Transforaminal Epidural Injection Using Kambin’s Triangle Approach
To compare the short-term effects and advantages of transforaminal epidural steroid injection (TFESI) performed using the conventional (CL) and posterolateral (PL) approaches.
Fifty patients with lumbar radicular pain from lumbar spinal stenosis and herniated lumbar disc were enrolled. Subjects were randomly assigned to one of two groups (CL or PL group). All procedures were performed using a C-arm (KMC 950, KOMED, Kwangju, Kyunggi, Korea). We compared the frequency of complications during the procedure and the effects of the pain block between the two groups at 2, 4, and 12 weeks after the procedure.
There were no significant differences in the demographic data, initial VNS (Visual numeric scale), or ODI (Oswestry disability index) between the CL group (n=26) and the PL group (n=24). There was no statistically significant difference in the outcome measures (VNS and ODI) between the groups at 2, 4, or 12 weeks. Symptoms of nerve root irritation occurred in 1 case of the CL group and in 7 cases of the PL group (p<0.05). Pricking of spinal nerve during the procedure and transient weakness after the procedure occurred in 6 cases and 3 cases, respectively in the CL group, but did not occur in the PL group.
Our findings suggest that the posterolateral approach represents an alternative TFESI method in cases with difficult needle tip positioning in the anterior epidural space, and could lower the risk of target nerve root irritation and nerve penetration.
Citations
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: The goal of this study was to compare the therapeutic and the functional value between translaminar approach and transforaminal approach of epidural steroid injection in patient with refractory radicular pain.
Method: Among 31 patients with unilateral herniated nucleus pulposus (HNP) which was confirmed by physical examination and magnetic resonance imaging (MRI), 17 patients received a transforaminal approach and 14 patients received a translaminar approach. All patients were evaluated by independent observer and were checked by visual analogue scale (VAS), functional score before and 1 day, 2 weeks and 4 weeks after injection.
Results: The VAS of transforaminal approach was significantly lower than that of translaminar approach after 2 weeks and after 4 weeks (p＜0.05), although there were no statistical difference before and 1 day after injection. The functional score of transforaminal approach was significantly higher than that of translaminar approach after 4 weeks (p＜0.05), although there were no statistical difference before and 1 day, 2 weeks after injection. The translaminar approach needs more frequent injection (p＜0.05).
Conclusion: This study suggests that both translaminar approach and transforaminal approach could be valuable to the initial management of refractory radicular pain, but the duration of therapeutic effects was relatively short in translaminar approach. Transforaminal approach will be the promising treatment of refractory radicular pain, because it has better therapeutic efficacy, safety and longer duration of therapeutic effects than translaminar approach.
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