Article

Cervical transforaminal injection of corticosteroids into a radicular artery: A possible mechanism for spinal cord injury

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Abstract

Spinal cord injury has been recognized as a complication of cervical transforaminal injections, but the mechanism of injury is uncertain. In the course of a transforaminal injection, an observation was made after the initial injection of contrast medium. The contrast medium filled a radicular artery that passed to the spinal cord. The procedure was summarily abandoned, and the patient suffered no ill effects. This case demonstrates that despite using careful and accurate technique, it is possible for material to be injected into a radicular artery. Consequently, inadvertent injection of corticosteroids into a radicular artery may be the mechanism for spinal cord injury following transforaminal injections. This observation warns operators to always perform a test injection of contrast medium, and carefully check for arterial filling using real-time fluoroscopy with digital subtraction.

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... Judging from previous case reports and our own experiences, cervical TFESI requires preventive efforts because spinal cord injury is a complication with potentially serious consequences. Some have suggested the use of computed tomography (CT) guidance to avoid vital vessels [13] and even argue to monitor the flow of contrast agent using digital subtraction angiography. [14] However, spinal cord injury has also been reported to occur during CT-guided C7 TFESI, [13] suggesting that it is not a completely safe method. ...
... Some have suggested the use of computed tomography (CT) guidance to avoid vital vessels [13] and even argue to monitor the flow of contrast agent using digital subtraction angiography. [14] However, spinal cord injury has also been reported to occur during CT-guided C7 TFESI, [13] suggesting that it is not a completely safe method. ...
Article
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Rationale: Cervical transforaminal epidural steroid injection (TFESI), can be an effective tool to improve pain associated with cervical radiculopathy. However, complications related to the procedure have been reported. Patient concerns: A 50-year-old woman who experienced acute cervical myelopathy with quadriparesis after cervical TFESI under fluoroscopic guidance. Diagnoses: The initial post-procedure cervical MRI revealed acute cervical myelopathy INTERVENTIONS:: She received 1000 mg of methylprednisolone was injected intravenously daily for 3 days OUTCOMES:: Improvement in pain, with the only remaining complaints consisting of lingering mild pain in the left hand and occasional hypoesthesia LESSONS:: Cervical TFESI, despite careful fluoroscopic localization, resulted in spinal cord injury. A spinal cord injury may be treated with conservative treatments, such as medication and rehabilitation.
... Before the actual injection of the steroid was performed, we evaluated the vulnerable blood vessels around each C5, C6, and C7 nerve root of the patient's painful side, with Doppler ultrasound imaging. Ultrasound evaluations were performed using a standard ultrasound device (Philips iU22 DS; Philips Medical Systems, Cleveland, OH, USA) and a high-frequency linear transducer (5)(6)(7)(8)(9)(10)(11)(12). With patients being placed in a supine position, their heads were rotated 30 o to 40 o away from the painful side [7]. ...
... In the study by Baker et al. [10], even real-time contrast fluoroscopy was considered to be insufficient, so it is recommended to check arterial filling using real-time fluoroscopy with digital subtraction, for the detection of unintentional intravascular injections. Also, the fluoroscopy Values are presented as number (%). ...
Article
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Objective To evaluate the prevalence of vulnerable blood vessels around cervical nerve roots before cervical nerve root block in the clinical setting. Methods 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. Results 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. Conclusion 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.
... The chemistry of neuraxial steroids has taken center stage in recent years due to devastating complications following epidural injections, specifically transforaminals (194)(195)(196)(197)(223)(224)(225)(226)(227)(228)(229)(230)(231)(232)(233)(234)236,283). Steroid particle embolization of small radicular arteries is believed to be an important causative factor (197,229,283). Tiso et al (194) and Benzon et al (195) extensively evaluated chemical properties and their relationship to interventional pain management. ...
... Similarly, single dose vials of methylprednisolone (DepoMedrol) are available without alcohol. Latham et al (185) reported that when injected deliberately into the subarachnoid space in sheep, betametha- (143,170,194,195,(226)(227)(228)(229)(230)(231)(232)(233). One of the postulated mechanisms of these events is occlusion of the segmental artery accompanying the nerve root by the particulate steroid or embolization of the particulate steroid through the vertebral artery (194,195,231,(234)(235)(236)(237). ...
Article
Interventional pain management, and the interventional techniques which are an integral part of that specialty, are subject to widely varying definitions and practices. How interventional techniques are applied by various specialties is highly variable, even for the most common procedures and conditions. At the same time, many payors, publications, and guidelines are showing increasing interest in the performance and costs of interventional techniques. There is a lack of consensus among interventional pain management specialists with regards to how to diagnose and manage spinal pain and the type and frequency of spinal interventional techniques which should be utilized to treat spinal pain. Therefore, an algorithmic approach is proposed, providing a stepby-step procedure for managing chronic spinal pain patients based upon evidence-based guidelines. The algorithmic approach is developed based on the best available evidence regarding the epidemiology of various identifiable sources of chronic spinal pain. Such an approach to spinal pain includes an appropriate history, examination, and medical decision making in the management of low back pain, neck pain and thoracic pain. This algorithm also provides diagnostic and therapeutic approaches to clinical management utilizing case examples of cervical, lumbar, and thoracic spinal pain. An algorithm for investigating chronic low back pain without disc herniation commences with a clinical question, examination and imaging findings. If there is evidence of radiculitis, spinal stenosis, or other demonstrable causes resulting in radiculitis, one may proceed with diagnostic or therapeutic epidural injections. In the algorithmic approach, facet joints are entertained first in the algorithm because of their commonality as a source of chronic low back pain followed by sacroiliac joint blocks if indicated and provocation discography as the last step. Based on the literature, in the United States, in patients without disc herniation, lumbar facet joints account for 30% of the cases of chronic low back pain, sacroiliac joints account for less than 10% of these cases, and discogenic pain accounts for 25% of the patients. The management algorithm for lumbar spinal pain includes interventions for somatic pain and radicular pain with either facet joint interventions, sacroiliac joint interventions, or intradiscal therapy. For radicular pain, epidural injections, percutaneous adhesiolysis, percutaneous disc decompression, or spinal endoscopic adhesiolysis may be performed. For non-responsive, recalcitrant, neuropathic pain, implantable therapy may be entertained. In managing pain of cervical origin, if there is evidence of radiculitis, spinal stenosis, post-surgery syndrome, or other demonstrable causes resulting in radiculitis, an interventionalist may proceed with therapeutic epidural injections. An algorithmic approach for chronic neck pain without disc herniation or radiculitis commences with clinical question, physical and imaging findings, followed by diagnostic facet joint injections. Cervical provocation discography is rarely performed. Based on the literature available in the United States, cervical facet joints account for 40% to 50% of cases of chronic neck pain without disc herniation, while discogenic pain accounts for approximately 20% of the patients. The management algorithm includes either facet joint interventions or epidural injections with surgical referral for disc-related pain and rarely implantable therapy. In managing thoracic pain, a diagnostic and therapeutic algorithmic approach includes either facet joint interventions or epidural injections. Key words: Algorithmic approach, chronic pain, chronic spinal pain, diagnostic interventional techniques, therapeutic interventional techniques, comprehensive evaluation, documentation, medical decision making.
... Consider the use of non-particulate corticosteroids, as particulate steroids have been associated with neurological complications in cervical nerve root blocks, presumably from intra-arterial embolic phenomena. 71,72 Visceral Hepatic hilar block Nerves from the left part of the coeliac plexus and parasympathetic branches from the vagus nerve supply the anterior hepatic plexus, while the nerves from the right part of the coeliac plexus travel in the posterior hepatic plexus along the portal vein37. Nerves course with the portal triad in the hepatic hilar plate, which is targeted for nerve blockade. ...
Article
Neurological interventions have taken on a significant role in interventional radiology (IR) practice. Indications fall under three main categories: (1) intraprocedural pain management, (2) cancer pain palliation, and (3) chronic non-cancer pain control. Short-term regional anaesthesia can be achieved with local anaesthetics, while longer-term pain control can be attained with radiofrequency neuromodulation (pulsed or otherwise) or thermal/chemical neurolysis. This review article summarises the therapeutic options, applications, and techniques of commonly used peripheral nerve and plexus interventions in IR.
... Complications described as minor include vasovagal episodes, headache, rashes, worsening pain, pain, and new paresthesia. Major complications, although rare, include direct spinal cord trauma, epidural hematoma or abscess, transection of vertebral artery, and injection of the particulate steroid into a radicu-lomedullary artery or vertebral artery resulting in spinal cord or posterior cerebellar embolic infarction (7,8). Subdural injection of local anesthetic and steroid represents a rare but potentially life threatening complication (2). ...
Article
Introduction: Cervical radiculopathy is a common condition affecting many people each year. The efficacy of cervical epidural steroid injection for patients that have not responded to conservative treatment has been demonstrated. Even with confirmatory radiocontrast dispersion indicating correct presence in the epidural space, there still may be rostral spread of steroid and local anesthetic resulting in an unusual presentation of symptoms and potentially life threatening complications. Case presentation: We present the case of a 52-year-old male presenting for a right sided C6-C7 epidural steroid injection. The epidural space was identified and a Tuohy needle was advanced using loss of resistance technique. Isovue contrast was used for needle localization and after confirmation of the presence of the contrast in the epidural space, dexamethasone and lidocaine were injected to the area without any complications. Five minutes after arrival to the PACU, the patient developed a constellation of symptoms including inability to swallow, vertigo, and horizontal nystagmus which required reassurance and vigilant monitoring. Conclusions: Interventional pain physicians must be cognizant that even with confirmatory epidural radiocontrast dispersion, there still may be inadvertent uptake of steroid and local anesthetic rostrally resulting in an unusual presentation of symptoms and potentially life threatening complications. Potential reasons for the rostral spread include inadvertent subdural or intrathecal injection.
... Several iatrogenic cervical spinal cord injuries have been reported previously. 1,[3][4][5][6][7] This adverse event is too rare to accurately calculate a formal incidence, although a rate between 0.1% and 0.3% appears to be a reasonable estimate across all types and indications for cervical spine surgery. It is expected that this rate will depend on the nature and severity of the spinal pathology being addressed. ...
Article
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Study Design Retrospective cohort study of prospectively collected data. Objective To examine the incidence of iatrogenic spinal cord injury following elective cervical spine surgery. Methods A retrospective multicenter case series study involving 21 high-volume surgical centers from the AOSpine North America Clinical Research Network was conducted. Medical records for 17 625 patients who received cervical spine surgery (levels from C2 to C7) between January 1, 2005, and December 31, 2011, were reviewed to identify occurrence of iatrogenic spinal cord injury. Results In total, 3 cases of iatrogenic spinal cord injury following cervical spine surgery were identified. Institutional incidence rates ranged from 0.0% to 0.24%. Of the 3 patients with quadriplegia, one underwent anterior-only surgery with 2-level cervical corpectomy, one underwent anterior surgery with corpectomy in addition to posterior surgery, and one underwent posterior decompression and fusion surgery alone. One patient had complete neurologic recovery, one partially recovered, and one did not recover motor function. Conclusion Iatrogenic spinal cord injury following cervical spine surgery is a rare and devastating adverse event. No standard protocol exists that can guarantee prevention of this complication, and there is a lack of consensus regarding evaluation and treatment when it does occur. Emergent imaging with magnetic resonance imaging or computed tomography myelography to evaluate for compressive etiology or malpositioned instrumentation and avoidance of hypotension should be performed in cases of intraoperative and postoperative spinal cord injury.
... More severe complications, such as subdural hematoma, quadriparesis, brainstem herniation, spinal cord injury, brainstem and cervical spinal cord infarction, vertebral artery (VA) perforation, and even death, occur more often with cervical transforaminal epidural steroid injection (CTFESI) than with cervical interlaminar epidural steroid injection (CILESI) [15][16][17][18][19][20][21][22][23][24][25][26]. Despite these severe complications, CTFESI is a clinically necessary modality for managing neck pain and cervical radiculopathy because it is the target-specific modality requiring the smallest volume to reach the primary site of pathology [4]. ...
Article
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Objective: A cervical epidural steroid injection is one of the most commonly performed interventions to manage chronic neck pain and cervical radiculopathy. Despite its many severe complications, cervical transforaminal epidural steroid injection (CTFESI) is a clinically necessary modality for managing neck pain and cervical radiculopathy. We aimed in this study to find a safer optimal needle entry angle to decrease the chance of an accidental vertebral artery (VA) puncture even with a proper needle entry angle and to visualize the target of the needle tip. Methods: This retrospective study included 312 patients with neck pain or cervical radiculopathy who had undergone magnetic resonance imaging scans for diagnosis and treatment. The first line was drawn from the midpoint of the two articular pillars and passed through the exact midline of the spinous process. The second line was drawn parallel to the ventral lamina line (conventional transforaminal approach line, CTAL). The third line was drawn parallel to the ventral margin at the midpoint of the superior articular process's ventral border (new transforaminal approach line, NTAL). The angle of intersection between the midline and CTAL versus with NTAL were measured from both sides (right and left) at C5-6, C6-7, and C7-T1 levels. Also, the distance of CTAL and NTAL from VA were measured from both sides at each level. We examined whether the CTAL and NTAL would penetrate the ipsilateral VA, internal carotid artery (ICA), and internal jugular vein (IJV). Results: There were significant differences between CTAL and NTAL angles at all levels (P < 0.001). There were significant differences between the distance of CTAL and NTAL from VA at all levels (P < 0.001). There were also significant differences between the observed frequency of CTAL and NTAL that would penetrate the major ipsilateral vessel (VA, ICA, and IJV) on all levels and sides (P < 0.001~0.030). Conclusion: The angle of NTAL (approximately 70°) is safer than the angle of CTAL (approximately 50°) when considering vascular injuries to vessels, such as the VA, ICA, and IJV.
... In 2004, Tiso et al. presented a case report of quadriparesis and brainstem herniation after C5-6 TFESI [37]. In this case report, Tiso et al. raised concern over the potential embolic effect of inadvertent injection of particulate steroids into vulnerable arteries feeding the CNS resulting in embolic infarct [37], echoing concerns initially published by Baker et al. [43]. ...
Article
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Purpose of Review The purpose of this study is to describe the most common complications of cervical transforaminal epidural steroid injection and to differentiate these from rare but serious risks unique to cervical transforaminal epidural steroid injections (CTFESI). Relevant safety mitigation techniques will also be discussed. Recent Findings The largest available cohort of epidural steroid injections was recently published, without a single case of major neurologic damage captured. Summary A large body of evidence suggests that the risk of neurologic infarct following CTFESI is due to the embolic effect of inadvertent arterial injection of particulate steroids. The advent of safety techniques to mitigate this risk, namely restricting use of steroids to the non-particulate steroid dexamethasone, seems to have greatly improved the safety profile of CTFESI.
... 4 Several reports of anterior spinal artery syndrome or brain injury occurring during CTESI, however, have shown the possibility that CTESI may also cause severe complications. 5,6 In general, the needle approach in the posterior aspect of the foramen during CTESI has been popularly used to avoid the penetration of critical vessels such as the vertebral artery. 7 However, there is always an underlying risk of critical complications due to unintentional vessel injury despite following strict guidelines, such as using the fluoroscopy-guided needle approach in the posterior aspect of the foramen to minimize the risk. ...
Article
Objective: The aim of the study was to evaluate the prevalence of vulnerable vessels around the target of cervical transforaminal epidural steroid injection at the C3-C7 cervical nerve root levels in a clinical setting. Design: Retrospective, cross-sectional study was conducted. Participants: Patients complaining of neck or arm pain with no previous surgical history and who had undergone both precontrast and contrast-enhanced neck computed tomography were included retrospectively. Results: In 26 (21.0%) of 124 patients, none of the vulnerable vessels around the target of cervical transforaminal epidural steroid injection around both sides of the C3-C7 nerve roots were observed. Of 248 cervical root levels, the C3 level had 103 vessels (41.5%), the C4 level had 110 vessels (44.4%), the C5 level had 98 vessels (39.5%), the C6 level had 59 vessels (23.8%), and the C7 level had 34 vessels (13.7%) close to each target nerve root. In addition, variations of the vertebral artery at the C4-C7 level were observed in 11 (8.9%) of 124 patients. Conclusions: To prevent unexpected critical complications involving injury to vulnerable vessels during cervical transforaminal epidural steroid injection, it is recommended to routinely evaluate the vulnerable vessels around the cervical nerve root with computed tomography or Doppler ultrasound before cervical transforaminal epidural steroid injection, especially for the upper cervical nerve root level.
... Apart from direct trauma lesions (particularly spinal), epidural hematomas, and septic complications, serious neurological complications have been, in most cases, reported following cervical or lumbar transforaminal infiltrations. For most cases, this can be explained by an accidental arterial catheterization leading to vascular occlusion in the anterior spinal artery or vertebral artery area [9,[13][14][15]. The rare cases of complications at the interlaminar injection site [15][16][17][18] have occurred in patients with previous spine surgery, probably because the epidural scar tissue is highly vascularized (neoangiogenesis) and may be connected to a radiculomedullary artery [19]. ...
... Hence, the complication prevalence rate is unknown, but it is believed to be significantly higher than procedures performed in the lumbosacral area. The likely cause of many such neurologic injuries is compromised perfusion in a radicular or medullary artery 7 . Particulate material in depot preparations of corticosteroids, or injected air, can serve as emboli that can be injected directly into an artery, or that can be alternatively pressurized through a vessel puncture site. ...
Conference Paper
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Neurologic complications have been reported with spinal transforaminal injections. Causes include intraneural injection, plus embolization occlusion of the radicular artery with subsequent spinal cord infarction. 1 Optical coherence tomography (OCT) is a non-invasive imaging modality, which is used to image tissue microstructure with very high resolution (less than 20 microns) in real-time. With a view toward needle tip OCT visualization of the spinal neuroforamen, we conducted animal studies to explore OCT imaging of paraspinal neurovascular structures. With institutional animal care committee approval, we performed ex-vivo and in situ OCT studies in a euthanized dog, pig, and rabbit. Image data was gathered on spinal nerve roots, dura, and brachial plexus. Two systems were used: frequency domain OCT imaging system developed at California Institute of Technology, and time domain Imalux NIRIS system with a 2.7 mm diameter probe. In a euthanized pig, excised dura was punctured with a 17-gauge Tuohy needle. FDOCT dural images of the puncture showed a subsurface cone-shaped defect. In a rabbit in situ study, puncture of the dura with a 26-gauge needle is imaged as a discontinuity. FDOCT imaging of both small artery and large arteries will be presented, along with H&E and OCT images of the brachial plexus.
... There is no significant correlation between pain relief and needle tip position retroneural or subpedicular approach in relation to the neural foramen and success rate is not dependent on the distance between the needle tip and the nerve root. [33][34][35][36][37][38][39] The predisposing factor for intravascular injection are the size, sharpness, positioning of the needle within the foramen, rate of injection, and vascular engorgement. 40 The ability of the ultrasound to show vessels and increase first pass needle success rate reduces this complication. ...
Article
Full-text available
Ultrasound has gained recognition within the field of pain intervention owing to its definite advantage of visually localizing the specified target and additionally owing to perceived advantages of safety, accuracy, and potency. Ultrasound permits satisfactory imaging of the posterior parts of the spine and paraspinal soft tissues. Despite the introduction of newer and less consuming time’s methods with the possibility of intravascular injection, there is still insufficient clinical evidence to prove the safety of the ultrasound as a sole image guide intervention, especially for transforaminal injection. It is essential to considering safety tips and be aware of complications that are typically terribly unpleasant and cause unwanted social and legal consequence. The most important injection warnings are damage to the spinal cord and nerve roots, intravascular injection and vascular damage, loss of consciousness, paraplegia and incontinence. The object of this review article is to discuss the untoward dangerous complication which can happen after ultrasound-guided spine injections and explain how to diagnosis and manage them. Further technical and equipment advancements are needed to improve and reduce the existing limitations associated with the ultrasound�guided spine injection technique until that time the multimodality imaging guidance is safer.
... It has been shown that an interlaminar approach is safer for successful epidural steroid injections (17,(24)(25)(26). Cryomicrotome epidural space studies have revealed that there are no active boundaries for distribution of solutions in epidural space (27,28). ...
Article
Full-text available
Background: Epidural steroid injections are frequently used to treat lumbar radicular pain. However, the spread of a solute in the epidural space needs further elucidation. We aimed at assessing the distribution of green dye in the epidural space after lumbar epidural injection on cadavers. Methods: We performed ultrasound-guided injections of green dye between lumbar vertebrae 4 and 5 in 24 cadavers. The cadavers were randomly divided into group A and B according to the volume of injected dye; 3 ml in group A (n = 13) and 6 ml in group B (n = 11). Accuracy of the needle insertion and patterns and distributions of the spread were compared between the groups. After local dissection, we examined the spread of dye in dorsal and ventral epidural spaces and presented the distribution as whole numbers and quartiles of intervertebral segments. Mann-Whitney U Test was used to compare distribution of dye spread between groups A and B. Wilcoxon Signed-Rank Test was used to compare the spread of dye in cranial and caudal direction within the group. We considered P < 0.05 as significant. Results: Data were obtained from all 24 cadavers. Median levels of dorsal cranial dye distribution in groups A and B were 2 and 4 (P = 0.02), respectively. In the dorsal caudal−2 and 2, respectively (P = 0.04). In the ventral epidural space cranial dye spread medians were−0 and 2 in groups, respectively (P = 0.04). Ventral caudal spread was 0 and 1, respectively (P = 0.03). We found a significant difference between cranial and caudal dye distribution in group B (P < 0.05). In group A the dye spread was bilateral. In group B cranial and caudal dye spread was observed. Conclusions: Ventral dye flow was observed in 50% of injections. Bilateral spread of dye occurred in 63%, and more often in group A. Cranial spread was slightly higher than caudal spread in group A despite a smaller injected volume, and significantly higher in group B following a larger volume.
... 15 This theory of intra-arterial particulate steroid injections causing embolization has also been supported in the literature. [16][17][18][19][20][21] In addition, many investigators believe that insoluble particulates, such as steroids injected during ESIs, increase the risk for poor neurological sequelae. Benzon et al validated this causal risk for ESI and steroid embolus by comparing the histological size of commonly used particulate steroids with and without the solutions they are mixed with prior to injection. ...
Article
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Background Morbidity has been reported as a sequelae of crystalline steroid epidural steroid injections (ESIs), and particulate steroid size, aggregation, and embolization in brain and spinal cord may be the mechanism related to these neurologic effects. Objective The objective of the study was to examine the aggregation properties of triamcinolone acetonide in commonly used local anesthetics with and without human serum. Setting This study was conducted in an academic tertiary care center. Hypothesis Triamcinolone acetonide shows different aggregation characteristics in serum compared to a non-physiologic solution. Design Triamcinolone acetonide was mixed with lidocaine 1% (first group) and bupivacaine 0.5% (second group) in a 1:1 ratio and then mixed with either distilled water (control group) or serum ex vivo. A pathologist blinded to our hypothesis inspected all solutions under light microscopy with 100× and 400× magnifications. Total number of particulate steroid aggregates and the number of particles forming each aggregate (recorded as single,1 double,2 triple,3 quadruple,4 or large [>4} crystals) were counted. Particle size and aggregate size were measured (in μm). The ratios of quadruple to total aggregates, large to total, and quadruple with large to total aggregates were calculated. Steroid-serum solutions and steroid-sterile water were then compared. Results Triamcinolone aggregates showed an increased crystal and aggregate size when compared with other steroids. Within the triamcinolone subgroup, the mixture of lidocaine 1% and serum resulted in the largest crystal aggregates. Limitations Whole blood analysis may have provided a more physiologically accurate model but was not chosen due to poor microscopic analysis. Serum donor variability may also have affected particle characteristics. Conclusion Fewer large triamcinolone aggregates were noted in the presence of serum when compared to the non-serum control groups. However, when compared to previously studied particulate steroids, it had the largest aggregates when added to serum.
... Second, ultrasound does not provide clear visualization of smaller-gauge needles at deep tissue levels, whereas fluoroscopic imaging provides good needle visualization regardless of tissue depth and needle gauge. Third, the use of real-time contrast fluoroscopy and digital subtraction angiography can prevent unintentional intravascular injection(19). ...
Article
Background: Recently, genicular nerve block and radiofrequency ablation were introduced to alleviate knee pain in patients with chronic knee osteoarthritis. Both ultrasound-and fluoroscopy-guided genicular nerve blocks have been used. However, whether one is superior to the other remains unknown. Objectives: The present study compares the efficacy of ultrasound-vs fluoroscopy-guided genicular nerve blocks. Study Design: This research used a prospective randomized comparison design. Setting: The study took place at a single pain clinic within a tertiary medical center in Seoul, Republic of Korea. Methods: From July 2015 to September 2017, a randomized controlled study was performed to analyze the difference in the efficacy of ultrasound-vs fluoroscopy-guided genicular nerve blocks. The Numeric Rating Scale (NRS-11), Western Ontario and McMaster Universities Arthritis Index (WOMAC), Global Perceived Effect Scales (GPES), and complications were evaluated pre-procedure, and 1 and 3 months after genicular nerve block. Results: A total of 80 patients were enrolled and randomly distributed to groups U (ultrasound-guided, n = 40) and F (fluoroscopy-guided, n = 40). Those who were lost to follow-up or had undergone other interventions were excluded, resulting in 31 and 30 patients in groups U and F, respectively. No differences in NRS-11 or WOMAC were observed between the 2 groups at baseline or during the follow-up period. GPES and complication rates were also similar between both groups. Limitations: We were unable to perform double-blind randomization and did not evaluate patients' baseline emotional states. Conclusions: Pain relief, functional improvement, and safety were similar between groups receiving ultrasound-and fluoroscopy-guided genicular nerve blocks. Therefore, either of the 2 imaging devices may be utilized during a genicular nerve block for chronic knee pain relief. However, considering radiation exposure, ultrasound guidance may be superior to fluoroscopic guidance.
... Second, ultrasound does not provide clear visualization of smaller-gauge needles at deep tissue levels, whereas fluoroscopic imaging provides good needle visualization regardless of tissue depth and needle gauge. Third, the use of real-time contrast fluoroscopy and digital subtraction angiography can prevent unintentional intravascular injection(19). ...
Article
Background: Recently, genicular nerve block and radiofrequency ablation were introduced to alleviate knee pain in patients with chronic knee osteoarthritis. Both ultrasound- and fluoroscopy-guided genicular nerve blocks have been used. However, whether one is superior to the other remains unknown. Objectives: The present study compares the efficacy of ultrasound- vs fluoroscopy-guided genicular nerve blocks. Study design: This research used a prospective randomized comparison design. Setting: The study took place at a single pain clinic within a tertiary medical center in Seoul, Republic of Korea. Methods: From July 2015 to September 2017, a randomized controlled study was performed to analyze the difference in the efficacy of ultrasound- vs fluoroscopy-guided genicular nerve blocks. The Numeric Rating Scale (NRS-11), Western Ontario and McMaster Universities Arthritis Index (WOMAC), Global Perceived Effect Scales (GPES), and complications were evaluated pre-procedure, and 1 and 3 months after genicular nerve block. Results: A total of 80 patients were enrolled and randomly distributed to groups U (ultrasound-guided, n = 40) and F (fluoroscopy-guided, n = 40). Those who were lost to follow-up or had undergone other interventions were excluded, resulting in 31 and 30 patients in groups U and F, respectively. No differences in NRS-11 or WOMAC were observed between the 2 groups at baseline or during the follow-up period. GPES and complication rates were also similar between both groups. Limitations: We were unable to perform double-blind randomization and did not evaluate patients' baseline emotional states. Conclusions: Pain relief, functional improvement, and safety were similar between groups receiving ultrasound- and fluoroscopy-guided genicular nerve blocks. Therefore, either of the 2 imaging devices may be utilized during a genicular nerve block for chronic knee pain relief. However, considering radiation exposure, ultrasound guidance may be superior to fluoroscopic guidance.The study protocol was approved by our institutional review board (2015-0369), and written informed consent was obtained from all patients. The trial was registered with the Clinical Research Information Service (KCT 0002846). This work was presented in part as D-H Kim's MS thesis at the University of Ulsan College of Medicine (2018). Key words: Genicular nerve block, ultrasound, fluoroscopy, knee osteoarthritis, Numeric Rating Scale, The Western Ontario and McMaster Universities Osteoarthritis Index.
... Second, ultrasound does not provide clear visualization of smaller-gauge needles at deep tissue levels, whereas fluoroscopic imaging provides good needle visualization regardless of tissue depth and needle gauge. Third, the use of real-time contrast fluoroscopy and digital subtraction angiography can prevent unintentional intravascular injection(19). ...
Article
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Background: Temple headaches are common, yet the anatomic etiology of headaches in this region is often confusing. One possible cause of temple headaches is dysfunction of the auriculotemporal nerve (ATN), a branch of the third division of the trigeminal nerve. However, the site of pain is often anterior to the described path of the ATN, and corresponds more closely to a portion of the path of a small branch of the second division of the trigeminal nerve called the zygomaticotemporal nerve (ZTN). Objectives: We present the anatomic and clinical differences between these 2 nerves and describe treatment approaches. Diagnosis is made by physical examination of the temporal fossa and the temporomandibular joint, and injection of local anesthetic over the tenderest nerve. Results: In general, treatments of headaches that generated from the peripheral nerve attempt to neutralize the pain origin using surgical or interventional pain techniques to reduce nerve irritation and subsequently deactivate stimulated migraine centers. Conclusions: Treatment of temporal nerve entrapment includes medications, nerve injections, dental appliances, cryoneuroablation, chemical neurolysis, neuromodulation, and surgical decompression. Key words: Headache, migraine, trigeminal nerve, Frey's syndrome, zygomaticotemporal nerve, auriculotemporal nerve, temple pain, jaw pain, ear pain, tooth pain.
... needles at deep tissue levels, whereas fluoroscopic imaging provides good needle visualization regardless of tissue depth and needle gauge. Third, the use of real-time contrast fluoroscopy and digital subtraction angiography can prevent unintentional intravascular injection (14). The limitation of this technique is that only the ablation of the three genicular nerves was possible and recent studies had also shown that there are chances of injury to the vessels which accompany these nerves (15). ...
... With this increase in utilization, there has been an increase in the number of anecdotal and case reports of complications. We cannot tell whether the increase is due solely to utilization or whether changes in technique have led to a higher incidence of complications (2)(3)(4)(5). Most of the recent concern has been related to epidural steroid injections, sacral, lumbar, thoracic and cervical. ...
... Inadvertent intravascular injection has been suggested as the most probable mechanism behind serious neurological complications during TFESI [4][5][6]. The incidence of inadvertent intravascular injection during TFESI has been estimated to be 6-26% depending on the level of the injection [7][8][9][10][11][12]. ...
Article
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Background: Inadvertent intravascular injection has been suggested as the most probable mechanism behind serious neurological complications during transforaminal epidural steroid injections. Authors believe a smaller gauge needle may lead to less intravascular uptake and less pain. Theoretically, there is less chance for a smaller gauge needle to encounter a blood vessel during an injection compared to a larger gauge needle. Studies have also shown smaller gauge needle to cause less pain. The aim of the study was to quantify the difference between a 22-gauge needle and 25-gauge needle during lumbosacral transforaminal epidural steroid injection in regards to intravascular uptake and pain perception. Methods: This was a prospective single blind randomized clinical trial performed at outpatient spine practice locations of two academic institutions. One hundred sixty-two consecutive patients undergoing lumbosacral transforaminal epidural injections from February 2018 to June 2019 were recruited and randomized to each arm of the study - 84 patients were randomized to the 22-gauge needle arm and 78 patients to 25-gauge arm. Each transforaminal injection level was considered a separate incidence, hence total number of incidence was 249 (136 in 22-gauge arm and 113 in 25-gauge arm). The primary outcome measure was intravascular uptake during live fluoroscopy and/or blood aspiration. The secondary outcome measure was patient reported pain during the procedure on the numerical rating scale. Results: Fisher exact test was used to detect differences between 2 groups in regards to intravascular uptake and paired t-tests were used to detect differences in pain scores. The incidence of intravascular uptake for a 22-gauge needle was 5.9% (95% confidence interval: 1.9 to 9.8%) and for a 25-gauge needle, 7.1% (95% confidence interval: 2.4 to 11.8%) [p = 0.701]. Average numerical rating scale scores during the initial needle entry for 22-gauge and 25-gauge needle was 3.46 (95% confidence interval: 2.94 to 3.98) and 3.13 (95% confidence interval: 2.57 to 3.69) respectively [p = 0.375]. Conclusions: The study showed no statistically significant difference in intravascular uptake or pain perception between a 22-gauge needle and 25-gauge needle during lumbosacral transforaminal epidural steroid injections. Trial registration: ClinicalTrials.gov NCT04350307. Registered 4/17/2020. (Retrospectively registered).
... Transforaminal epidural steroid injections have become increasingly utilized since Derby et al described them in 1993 (25). Since then, instances of central nervous system dysfunction due to vascular compromise and infarction have been reported and attributed primarily to intravascular injection of particulate steroids leading to embolization of radicular and medullary arteries (1,26). ...
Article
Digital subtraction angiography (DSA) has been touted as a radiologic adjunct to interventional neuraxial procedures where it is imperative to identify vascular compromise during the injection. Transforaminal epidural steroid injections (TFESI) are commonly performed interventions for treating acute and chronic radicular spine pain. We present a case of instantaneous and irreversible paraplegia following lumbar TFESI wherein a local anesthetic test dose, as well as DSA, were used as adjuncts to fluoroscopy. An 80-year-old man with severe lumbar spinal stenosis and chronic L5 radiculopathic pain was evaluated at a university pain management center seeking symptomatic pain relief. Two prior lumbar interlaminar epidural steroid injections (LESI) provided only transient pain relief, and a decision was made to perform right-sided L5-S1 TFESI. A 5-inch, 22-gauge Quincke-type spinal needle with a curved tip was used. Foraminal placement of the needle tip was confirmed with anteroposterior, oblique, and lateral views on fluoroscopy. Aspiration did not reveal any blood or cerebrospinal fluid. Digital subtraction angiography was performed twice to confirm the absence of intravascular contrast medium spread. Subsequently, a 0.5mL of 1% lidocaine test dose was performed without any changes in neurological status. Two minutes later, a mixture of one mL of 1% lidocaine with 80 mg triamcinolone acetonide was injected. Immediately following the completion of the injection, the patient reported extreme bilateral lower extremity pain. He became diaphoretic, followed by marked weakness in his bilateral lower extremities and numbness up to his lower abdomen. The patient was transferred to the emergency department for evaluation. Magnetic resonance imaging (MRI) of the lumbar and thoracic spine was completed 5 hours postinjection. It showed a small high T2 signal focus in the thoracic spinal cord at the T7-T8 level. The patient was admitted to the critical care unit for neurological observation and treatment with intravenous methylprednisolone. Follow-up MRI revealed a hyper-intense T2 and short-tau inversion recovery signal in the central portion of the spinal cord beginning at the level of the T6 superior endplate and extending caudally to the T9-T10 level with accompanying development of mild spinal cord expansion. The patient was diagnosed with paraplegia from acute spinal cord infarction. At discharge to an acute inpatient rehabilitation program, the patient had persistent bilateral lower extremity paralysis, and incontinence of bowel and bladder functions. In the present patient, DSA performed twice and an anesthetic test dose did not prevent a catastrophic spinal cord infarction and resulting paraplegia. DSA use is clearly not foolproof and may not be sufficient to identify potentially life-or-limb threatening consequences of lumbar TFESI. We believe that this report should open further discussion regarding adding the possibility of these catastrophic events in the informed consent process for lumbar TFESIs, as it has for cervical TFESI. Utilizing blunt needles or larger bevel needles in place of sharp, cutting needles may minimize the chances of this event occurring. Considering eliminating use of particulate steroids for TFESI should be evaluated, although the use of nonparticulate agents remains controversial due to the perception that their respective duration of action is less than that of particulate steroids. Key words: Digital subtraction angiography, transforaminal epidural steroid injections, paraplegia, chronic low back pain.
... Thirdly, as we are using contrast fluoroscopy, it can prevent unintentional intravascular injection. 11 However, potential complications result after performing every diagnostic procedure. There are some common side effects such as leg muscle weakness, discomfort at the injection site. ...
... We reported one case in which the dye delineated injection through the paravertebral network of blood vessels (Fig. 8), the needle tip had been repositioned and the procedure was completed successfully without any side effects. The upper thoracic cord may be supplied by only one small radiculomedullary artery, injuring or injecting steroid prior to RF lesioning, as some authors advocated to reduce the incidence of neuritis may lead to spinal cord infarction (38). ...
Article
Background: Pharmacologic treatment is not successful in all cases of postmastectomy pain syndrome (PMPS). Some patients continue suffering pain while taking their medications, and others cannot tolerate the side effects of antineuropathic analgesics. Radiofrequency technology has provided promising results in the management of chronic neuropathic pain. Objectives: Considering that affection of intercostobrachial nerves are the main reason behind PMPS, we aimed to evaluate and compare the analgesic efficacy of pulsed radiofrequency (PRF) when delivered either on thoracic dorsal root ganglion (DRG) of intercostobrachial nerves (thoracic DRG 2, 3, and 4) or their corresponding thoracic paravertebral nerves (PVNs). Study design: Prospective randomized-controlled clinical trial. Settings: Interventional pain unit, tertiary center, university hospital. Methods: Sixty-four patients complaining of PMPS were randomized to either group DRG (n = 32) that received PRF on thoracic DRG, or group PVN (n = 32) that received PRF on thoracic PVN. The outcome variables were that the patients showed > 50% reduction in their visual analog scale (VAS) pain score; the VAS pain score and global perceived effect (GPE) was evaluated during a 6-month follow-up period. Results: The percentage of patients who showed > 50% reduction of their VAS pain score was significantly higher in group DRG compared with group PVN, assessed at 4 and 6 months postprocedure (23/29:79.3% vs. 13/29:44.8%; P = 0.007) and (22/29:75.9% vs. 7/29:24.1%; P < 0.001), respectively, however, the 2 groups did not significantly differ at 1, 2, and 3 months postprocedure (DRG vs. PVN), (21/29: 72.4% vs. 21/29: 72.4%; P = 0.542), (24/29: 82.8% vs. 23/29: 79.9%; P = 0.778), and (24/29: 82.8% vs. 19/29: 65.5%; P = 0.136), respectively. There was a statistically significant reduction of VAS pain score at 4 and 6 months (DRG vs. PVN, mean ± standard deviation, 2.9 ± 2 vs. 3.9 ± 1.5; mean difference (95% confidence interval), 1 (0.06:1.9); P = 0.038; 3 ± 1.94 vs. 5.1 ± 1.5; mean difference (95% confidence interval), 1.9 (1:2.9); P < 0.001, respectively), however, the 2 groups did not significantly differ at 1, 2, and 3 months postprocedure. With regard to the patient's satisfaction (i.e., GPE), assessed at 3 and 6 months postprocedure, there was a significantly higher satisfaction in group DRG compared with group PVN (median [interquartile range (IQR)], 6 (5:7) vs. 3 (2:4);P < 0.001), however, the patient's satisfaction was similar between groups at 3 months postprocedure: median (IQR), 6 (4:7) vs. 6 (5:6); P = 0.327. Limitations: The study follow-up period is limited to 6 months only. Conclusions: PRF of both the thoracic DRG and the thoracic PVN are effective treatments for PMPS; however, PRF of DRG provided a better long-term analgesic effect. Nevertheless, given the inherent risk of performing thoracic foraminal interventions and the technical difficulty of targeting thoracic DRG, we recommend that PRF of DRG should be reserved for cases that failed to gain adequate response to PRF of thoracic PVN in conjunction with medical treatment. Key words: Postmastectomy pain syndrome, radiofrequency, dorsal root ganglion, paravertebral nerve.
... Although the risk of complication after ESI into lumbar region was smaller than the risk after cervical or thoracic ESI, serious complications such as neural infarctions have occurred [17]. Inadvertent intra-arterial (radicular artery) injection of a particulate steroid can create an embolu that can lead to infarction [19][20][21][22][23]. ...
Article
Background: Low back pain (LBP) is caused by disc herniation, spinal stenosis, facet syndrome or etc. This LBP could be either nociceptive or neuropathic pain (NP). In addition, these neuropathic pain is a major contributor to chronic low back pain. It is already known that lumbar epidural steroid injection (ESI) is effective for low back pain, but no study has assessed both nociceptive and neuropathic pain separately. This study investigated whether neuropathic or nociceptive pain was better improved after an epidural steroid injection. Methods: This was a prospective study. Patients were classified according to the pre-procedure painDETECT questionnaire (PD-Q) score. If the PD-Q score was ≤12, it was considered as nociceptive pain, and it the PD-Q was ≥19, it was considered NP. The patients were given a transforaminal (TF) or interlaminar (IL) epidural steroid injection (ESI). The PD-Q was filled out by each patient prior to the ESI (baseline), and again at 4 weeks after the ESI. Outcomes was assessed using a numerical rating scale (NRS) score, short form McGill Pain Questionnaire (MPQ), and revised Oswestry Back Disability Index (ODI) at 1 month later. Results: A total of 114 patients were enrolled and of these, 54 patients with a PD-Q score of ≤12 were classified into the nociceptive pain, and 60 patients with a PD-Q score ≥19 were classified into the neuropathic pain group. At 1 month after treatment, both groups had significantly lower than improved their mean NRS score. Not withstanding these improvements and difference between NRS, the differences in MPQ and ODI after treatment between the groups (nociceptive vs. neuropathic) not significant. After the procedure (TF-ESI or IL-ESI), the patients in group 1 (PD-Q score ≤12, n = 54) had no change in their PD-Q score. Among the patients in group 2 (pre-treatment PD-Q score ≥19, n = 41), 13 patients moved to a PD-Q score
... 11) Multiple mechanisms of steroids such as anti-inflammatory effect, neural membrane stabilization, and blocking C-fiber activity support the usage of steroids for pain control. 4,15,16) Early studies of cervical nerve block used particulate steroids as the injectate. 13,14) Since using particulate steroids were related to a higher and severe complication, 17) and non-particulate steroids showed similar clinical results compared with particulate steroids, [18][19][20] we have routinely used non-particulate steroids (dexamethasone) for CTEB. ...
Chapter
Several textbooks cover the techniques, indications, contraindications, and the mechanism of action of the interventional pain management techniques, but only few textbooks have focused on the complications and on their consequences. Interventional pain management has evolved tremendously since the first described therapeutic nerve block, performed by Tuffer in 1899. The combination of Interventional Pain Physicians with small amount of experience in the field and the recent significant increase in the utilization of interventional diagnostic and therapeutic techniques raises the potential for increased complications.
Chapter
Epidural steroid injections (ESIs) are used to manage radicular pain in patients with spinal degenerative disk disease, spinal stenosis, and disk herniations. Although rare, devastating neurological complications and death have been reported after cervical transforaminal epidural steroid injections (CTESIs). Knowledge of the anatomy of the cervical spine, careful review of the available images, the use of the appropriate technique, disciplined and accurate imaging while performing the procedure, and continuous patient monitoring are mandatory while performing these injections. A low threshold for aborting the procedure should be considered if persistent venous runoff or vertebral artery outline is observed on plain fluoroscopy and digital subtraction angiography (DSA). Procedures should be aborted immediately if evidence of rapid vascular runoff ascending toward the vertebral artery or directed medially toward radicular arteries providing blood supply to the spinal cord is observed. CTESIs should always be performed by physicians who have had specific training, have proven experience with interventional pain management techniques, and are able to manage eventual complications.
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Background: Cervical Facet radiofrequency ablation is indicated for patient with chronic neck pain. It is generally carried out under fluoroscopic guidance. The long term exposure of the surgeon to radiation may cause serious side effects. Ultrasonography-guided facet ablation has recently been attempted. Objective: Our aim is to compare between ultrasonographic and fluoroscopic imaged guided techniques for non-pulsed radiofrequency ablation of the facets of the cervical spine. Patients and Methods: We followed forty patients who had cervical pain due to facet arthropathy. They were diagnosed as having cervical spondylosis and operated from January 2012 to October 2015 in Departments of Neurosurgery and Radiology in Suez Canal University Hospitals. Patients were divided into two groups: Ultrasound group and fluoroscopy group. Results: We studied 123 levels of the cervical facet joint which underwent radiofrequency ablations in forty patients. Sixty three facets were ablated using fluoroscopy, while sixty one facets were ablated under ultrasonographic guidance. The demographic characteristics between the two groups were not stascally different. The mean execuon me per facet joint was 14 minutes for fluoroscopic guidance compared to 10 minutes for ultrasonographic guidance. Clinical outcomes in both groups showed no significant difference. Ultrasonographic guidance showed less execution time and no radiation exposure. Conclusion: The ultrasound-guided facet joint ablation in the cervical spine is accurate, feasible, and bears minimal risk. It results in a significant pain reduction, not different from fluoroscopic-guided ablations. Additionally a reduction of execution time, radiation dose and resources is highly evident.
Chapter
Transforaminal epidural steroid injections (TFESI) and selective nerve root blocks (SNRB) are effective in the treatment of spine-related pain. They are utilized for both diagnostic and therapeutic purposes. The procedure is typically performed as part of a comprehensive approach in managing symptoms of radiculopathy. They are also utilized as a diagnostic procedure when the etiology of pain is unclear. This chapter reviews the utility of transforaminal epidurals and selective nerve root blocks in relation to the pathophysiology, symptoms, and progression of spine-related pain.
Chapter
Ultrasound (US) lends itself readily as an ideal modality to guide most musculoskeletal interventions, due to its ease of access, availability at the bedside, dynamic nature, and lack of radiation dose. The use of US guidance undoubtedly minimizes the risk of procedure-related complications in musculoskeletal intervention. However, there are still multiple potential pitfalls that the musculoskeletal practitioner should be aware of and look to minimize, in order to reduce the risk of complications and complaints. These pitfalls relate to before the patient arrives for the procedure until after they leave, and taking steps to minimize the risk of their occurrence gives the musculoskeletal practitioner the best chance of a successful and litigation-free practice.
Chapter
A 72-year-old female reports pain in the low back during periods of standing or ambulation for the past 2 years. This is associated with numbness and tingling in the posterior thighs after walking for about half a block. The symptoms are relieved with leaning forward or sitting. Physical examination revealed a broadbased gait, negative sensory, motor, reflex testing or provocative maneuvers. 1. What is spinal stenosis? Lumbar spinal stenosis (LSS) is defined as buttock or lower extremity pain which may occur with or without low back pain, associated with diminished space available for neural and vascular elements in the lumbar spine. Neurogenic claudication refers to pain or discomfort that radiates to the lower extremity which occurs with walking or prolonged standing, and is relieved by rest or bending forward. Today, there are more treatment options for spinal stenosis than any other spinal pathology. It is the commonest indication for spine surgery in people over the age of 65 years.[1] About 75% of the cases of spinal stenosis occur in the lumbar spine. In 2007, about 38 000 operations were performed on patients with a primary diagnosis of lumbar spinal stenosis at a cost of $1.7 billion.[2]
Chapter
Selective nerve root block is a commonly performed procedure for targeted injection of anaesthetic agent and steroids for achieving pain relief in the affected neural distribution. It is widely used as a diagnostic tool and therapeutic procedure in non-malignant conditions such as degenerative disc disease. In the palliative setting, spinal nerve root blocks and neurolysis can be employed for neuropathic pain intractable to systemic analgesics, providing improved quality of life in terminally ill patients. Careful patient selection, appropriate choice of therapy, expert technical skills and a multidisciplinary approach are all important requisites to ensure a good outcome for the patient.
Chapter
This chapter summarized the important anatomy and sonoanatomy pertinent to the performance of the ultrasound-guided cervical nerve root injection. The sonoanatomy of C5 to C7, the different patterns of vessels in the vicinity of the nerve root, and the injection technique are also discussed.
Chapter
Chronic neck pain with or without upper extremity pain or headaches is relatively common in the adult population secondary to disc herniation, discogenic pain, spinal stenosis, spondylosis, and post-surgery syndrome. Treatments for chronic neck pain, recalcitrant to conservative management resulting in disability, include surgical management as well as interventional techniques with epidural injections utilizing either an interlaminar approach or transforaminal approach. Even though there have been multiple systematic reviews and randomized clinical trials of efficacy of cervical interlaminar epidural injections, the literature is sparse in reference to cervical transforaminal epidural injections. In addition, cervical transforaminal epidural injections have been associated with an inordinate risk.
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Objective: To investigate the success rate (technical precision) of ultrasound-guided lumbar transforaminal epidural steroid injection, which was validated by conventional fluoroscopic technique. Methods: A total of 20 patients with unilateral single-level lumbar foraminal disc protrusion causing radiculopathy were enrolled. Using transforming route, the needle location was determined by an axial (transvers) view of the ultrasound with fluoroscopic confirmation. We determined the needle placement accuracy of ultrasound- guided lumbar transforaminal injections approach. Results: The accuracy of ultrasound-guided interventions was 90% as confirmed by fluoroscopy. There were 2 failed cases at the L4-L5 level in the US-guided. The success rate in L5-S1 level was 100%, in L4-L5 level was 80% and in L3-L4 level was 100%. No complications were noted. Conclusion: Ultrasound-guided lumbar transforaminal epidural injections are accurate and feasible in clinical setting with an accuracy of 90% and no complications.
Article
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Background Epidural corticosteroid injections are used frequently worldwide in the treatment of radicular pain. Concerns have risen involving rare major neurologic injuries after this treatment. Recommendations to prevent these complications have been published, but local implementation is not always feasible due to local circumstances and necessitating local recommendations based on literature review. Methods A workgroup of 4 stakeholder pain societies in Belgium, The Netherlands and Luxembourg (Benelux) has reviewed the literature involving neurological complications after epidural corticosteroid injections and possible safety measures to prevent these major neurologic injuries. Results Twenty‐six considerations and recommendations were selected by the workgroup. These involve the use of imaging, injection equipment particulate and non‐particulate corticosteroids, epidural approach and maximal volume to be injected. Conclusion Raising awareness about possible neurological complications and adoption of safety measures recommended by the work group aim at reducing the risks of these devastating events. This article is protected by copyright. All rights reserved.
Chapter
The cervical spinal nerve occupies the lower part of the foramen with the periradicular veins in the upper part. The radicular arteries arising from the vertebral, ascending cervical, and deep cervical arteries lie in close approximation to the spinal nerve.
Article
Introduction: The treatment of persistent cervical radicular pain (CRP) by CT-guided epidural steroid injections (CTESI) by a transforaminal anterolateral (TFA) approach is associated with rare but serious complications. Two recently described transforaminal posterolateral (TFP) and transfacet indirect (TFT) approaches may be safer options, but have not been extensively evaluated. We compared the efficacy of three CTESI approaches (TFA, TFP, and TFT) in the treatment of persistent CRP (>6 weeks). Methods: Patients were prospectively assessed for pain using the visual analog scale (VAS) and for functional disability by the Neck Disability Index (NDI) before treatment, then 6 weeks and 6 months after CTESI. Results: A total of 104 patients were included (n = 30 TFA, n = 36 TFP, and n = 38 TFT approaches). Each group was found to have a statistically significant improvement at 6 weeks (median VAS values: 7 (2-9) at D0 and 2 (3-6) at 6 weeks p < 0.01; median NDI values: 38 (24-50) at D0 and 29 (18-42) at 6 weeks (p < 0.01)), and at 6 months (median VAS values: 7 (2-9) at D0 and 4 (2-6) at 6 months (p < 0.01); median NDI values: 38 (24-50) at D0 and 28 (13-40) at 6 months (p < 0.01)). No significant difference was observed in the decrease in VAS and NDI scores among the three approaches at 6 weeks (p = 0.635 and p = 0.54 for VAS and NDI respectively) or 6 months (p = 0.704 and p = 0.315 for VAS and NDI respectively). No major complications were noted. Conclusion: The results of CTESI using the TFP or TFT approach are similar to those for TFA in the treatment of persistent CRP and could be a safer option.
Article
Cervical spondylotic radiculopathy (CSR) is one of the most common degenerative diseases of the spine that is commonly treated with surgery. The primary goal of surgery is to relieve symptoms through decompression or relieving pressure on compressed cervical nerves. Nevertheless, cutaneous pain distribution is not always predictable, making accurate diagnosis challenging and increasing the likelihood of inadequate surgical outcomes. With the widespread application of minimally invasive surgical techniques, the requirement for precise preoperative localization of the affected segments has become critical, especially when treating patients with multi-segmental CSR. Recently, the preoperative use of a selective nerve root block (SNRB) to localize the specific nerve roots involved in CSR has increased. However, few reviews discuss the currently used block approaches, risk factors, and other aspects of concern voiced by surgeons carrying out SNRB. This review summarized the main cervical SNRB approaches currently used clinically and the relevant technical details. Methods that can be used to decrease risk during cervical SNRB procedures, including choice of steroids, vessel avoidance, guidance with radiographs or ultra-sound, contrast agent usage, and other concerns, also are discussed. We concluded that a comprehensive understanding of the current techniques used for cervical SNRB would allow surgeons to perform cervical SNRB more safely.
Article
Objective: Cervical medial branch blocks (CMBBs) are useful in differentiating facetogenic pain from other sources of cervicogenic headaches and neck pain. The purpose of this systematic review and meta-analysis is to determine the efficacy, performance time, pain reduction, and adverse events associated with ultrasound (US) guided CMBB compared with other commonly used guidance methods such as fluoroscopy and computed tomography (CT). Methods: Searches of MEDLINE, EMBASE, Cochrane Library, and Ovid were completed to identify studies addressing CMBBs utilizing ultrasound compared to other imaging techniques. Three reviewers independently screened the titles, abstracts, and full texts, extracting data from eligible studies. Outcomes of interest including success rate, efficacy, performance time and complication profile were analyzed in meta-analysis. All other reported measures and complication profiles were analyzed descriptively. Results: A total of 9 studies were included. Four randomized controlled trials (RCTs) and 5 cohort studies satisfied inclusion criteria. US-guided CMBBs demonstrated similar success rates (OR = 1.05, 95% CI = 0.15 to 7.52, z = 0.05, P = 0.96) and similar pain efficacy (SMD = -0.54, 95% CI = -1.91 to 0.83, z = - 0.77, P = 0.44) compared to traditional guidance techniques. However, US-guided CMBBs demonstrated reduced performance time (SMD = -1.77, 95% CI = -2.65 to -0.89, z = -3.94, P <0.01) and rate of vascular injury/injection (OR = 0.09, 95% CI = 0.01 to 0.75, z = -2.23, P = 0.03) compared to fluoroscopy guided CMBBs. Conclusion: This review and meta-analysis demonstrated that US-guided cervical medial branch blocks are a reliable alternative to fluoroscopy- and CT-guided CMBBs, with similar efficacy but a potentially improved safety and performance time.
Article
Background: Closed malpractice claim studies allow a review of rare but often severe complications, yielding useful insight into improving patient safety and decreasing practitioner liability. Methods: This retrospective observational study of pain medicine malpractice claims utilizes the Controlled Risk Insurance Company Comparative Benchmarking System database, which contains nearly 400,000 malpractice claims drawn from >400 academic and community medical centers. The Controlled Risk Insurance Company Comparative Benchmarking System database was queried for January 1, 2009 through December 31, 2016, for cases with pain medicine as the primary service. Cases involving outpatient interventional pain management were identified. Controlled Risk Insurance Company-coded data fields and the narrative summaries were reviewed by the study authors. Results: A total of 126 closed claims were identified. Forty-one claims resulted in payments to the plaintiffs, with a median payment of $175,000 (range, $2600-$2,950,000). Lumbar interlaminar epidural steroid injections were the most common procedures associated with claims (n = 34), followed by cervical interlaminar epidural steroid injections (n = 31) and trigger point injections (n = 13). The most common alleged injuring events were an improper performance of a procedure (n = 38); alleged nonsterile technique (n = 17); unintentional dural puncture (n = 13); needle misdirected to the spinal cord (n = 11); and needle misdirected to the lung (n = 10). The most common alleged outcomes were worsening pain (n = 26); spinal cord infarct (n = 16); epidural hematoma (n = 9); soft-tissue infection (n = 9); postdural puncture headache (n = 9); and pneumothorax (n = 9). According to the Controlled Risk Insurance Company proprietary contributing factor system, perceived deficits in technical skill were present in 83% of claims. Conclusions: Epidural steroid injections are among the most commonly performed interventional pain procedures and, while a familiar procedure to pain management practitioners, may result in significant neurological injury. Trigger point injections, while generally considered safe, may result in pneumothorax or injury to other deep structures. Ultimately, the efforts to minimize practitioner liability and patient harm, like the claims themselves, will be multifactorial. Best outcomes will likely come from continued robust training in procedural skills, attention paid to published best practice recommendations, documentation that includes an inclusive consent discussion, and thoughtful patient selection. Limitations for this study are that closed claim data do not cover all complications that occur and skew toward more severe complications. In addition, the data from Controlled Risk Insurance Company Comparative Benchmarking System cannot be independently verified.
Article
Background Epidural steroid injections (ESIs) are a frequently used treatment for refractory radicular spinal pain. ESIs, particularly transforaminal epidural steroid injections (TFESI), may provide pain relief and delay the need for surgery. Corticosteroid agent and diluent choices are known to impact the safety of ESIs. In particular, the risk of embolization with particulate corticosteroids has led to recommendations for non-particulate steroid use by the Multisociety Pain Workgroup. Additionally, there is in vitro evidence that ropivacaine can crystalize in the presence of dexamethasone, potentially creating a particulate-like injectate. Despite widespread use and known risk mitigation strategies, current practice trends related to steroid and diluent choices are unknown. Objective Identify the use of particulate versus non-particulate corticosteroids for epidural steroid injections in the cervical and lumbar spine, as well as local anesthetics commonly used as diluents during these procedures. Methods Cross-sectional survey study of 314 physician members of the Spine Interventional Society. Results 41% and 9% of providers reported using particulate corticosteroids during lumbar TFESIs and cervical TFESI, respectively. Four per cent of providers reported the use of ropivacaine in cervical TFESIs. Forty-four per cent of respondents reported using anesthetic in cervical interlaminar ESIs. 21% of providers report using high volumes (> 4.5 mL) during cervical interlaminar ESIs. Conclusion Current trends, as assessed by this survey study, indicate substantial variability in steroid and diluent choice for ESIs. Patterns were identified that may impact patient safety including the continued use of particulate corticosteroids for TFESIs and the use of ropivacaine during TFESIs by a subset of respondents.
Article
Radicular pain must be distinguished from somatic referred pain. Their causes, investigation, and treatment are distinctly different. Radicular pain is caused by irritation of a dorsal root ganglion. Somatic referred pain is caused by convergence. Evidence suggests that conservative therapy of radicular pain is not effective. Surgery is the mainstay of treatment, but transforaminal injection of steroids can allow patients to avoid surgery. Back pain and neck pain cannot be diagnosed clinically or by imaging. Precision diagnosis requires diagnostic blocks of the zygapophysial joints or the sacroiliac joint, or discography. Zygapophysial joint pain can be treated by percutaneous radiofrequency neurotomy. Minimally invasive techniques are emerging for the treatment of discogenic pain.
Article
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A longitudinal cohort study design was used. All patients underwent a systematically and uniformly applied treatment program with increasing intervention as further pain control was needed. All patients were followed up by questionnaire evaluating function and symptoms. The role of surgical versus nonsurgical treatment of patients with cervical disc herniation has not been adequately studied. The majority of published data reflects surgical outcomes, with little available data regarding the outcome of nonoperatively treated patients. Frequently, these patients are treated surgically if they have neurologic loss or radiculopathy that persists after rest or minimal intervention. In the authors' clinic, patients with cervical herniated nucleus pulposus and radiculopathy are treated with an aggressive physical rehabilitation program. All patients treated by the authors during a specified time period with a clearly defined diagnosis of cervical herniated nucleus pulposus were evaluated for outcome. Twenty-six consecutive patients with cervical herniated nucleus pulposus and radiculopathy were evaluated by an investigator other than the treating physician. The follow-up time was more than 1 year in all patients. Data analyzed included symptom level, activity and function level, medication and ongoing medical care, job status, and satisfaction. Inclusion criteria included a focal cervical disc protrusion of less than 4 mm identified on magnetic resonance imaging and a major complaint of extremity pain compatible with cervical radiculopathy. Exclusion criteria included severe central canal stenosis, symptomatic cervical myelopathy, or condition that precluded participation in the rehabilitation program. Management consisted of traction, specific physical therapeutic exercise, oral anti-inflammatory medication, and patient education. The majority of patients presented with neurologic loss. Twenty-four patients were successfully treated without surgery. Twenty patients achieved a good or excellent outcome of these 19 had disc extrusions. Two patients underwent cervical spine surgery. Twenty-one patients returned to the same job. One patient retired. Many cervical disc herniations can be successfully managed with aggressive nonsurgical treatment (24 of 26 in the present study). Progressive neurologic loss did not occur in any patient, and most patients were able to continue with their preinjury activities with little limitation. High patient satisfaction with nonoperative care was achieved on outcome analysis.
Article
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A subgroup analysis of a prospective, randomized controlled trial was performed. To describe the cost effectiveness of periradicular infiltration with steroid in subgroups of patients with sciatica. A recent trial on periradicular infiltration indicated that a methylprednisolone-bupivacaine combination had a short-term effect, as compared with that of saline. This report describes the efficacy and cost effectiveness of steroid in subgroups of patients with sciatic. This study involved 160 patients with unilateral sciatica. Outcome assessments were leg pain (100-mm visual analog scale), disability on the Oswestry Low Back Disability Questionnaire, and the Nottingham Health Profile. Data on medical costs and sick leaves also were gathered. Patients were randomized for periradicular infiltration with either methylprednisolone-bupivacaine or saline. The adjusted between-group treatment differences at each follow-up assessment, the number of patients free of leg pain (responders, cutoff 75%), and efficacy by the area-under-the-curve method were calculated. For the cost-effectiveness estimate, the total costs were divided by the number of responders. The rate of operations in different subgroups was evaluated by Kaplan-Meier analysis. In the case of contained herniations, the steroid injection produced significant treatment effects and short-term efficacy in leg pain and in Nottingham Health Profile emotional reactions. For symptomatic lesions at L3-L4-L5, steroid was superior to saline for leg pain, disability, and straight leg raising in the short term. By 1 year, steroid seemed to have prevented operations for contained herniations, costing $12,666 less per responder in the steroid group (P < 0.01). For extrusions, steroid seemed to increase the operation rate, and the steroid infiltration was more expensive, costing $4445 per responder (P < 0.01). In addition to short-term effectiveness for contained herniations and lesions at L3-L4-L5, steroid treatment also prevented surgery for contained herniations. However, steroid was countereffective for extrusions. The results of the subgroup analyses call for a verification study.
Article
Objective: To investigate the outcomes resulting from the use of fluoroscopically guided therapeutic selective nerve root block (SNRB) in the nonsurgical treatment of atraumatic cervical spondylotic radicular pain. Study Design: Retrospective study with independent clinical review. Participants: Twenty subjects (10 men, 10 women) with mean age 56.6 years. Methods: Each patient met specific physical examination, radiographic, and electrodiagnostic criteria to confirm a level of cervical involvement. Those patients whose root level remained indeterminate were required to demonstrate a positive response to a fluoroscopically guided diagnostic SNRB prior to the initiation of treatment. Therapeutic injections were administered in conjunction with physical therapy. Data collection and analysis were performed by an independent clinical reviewer. Main Outcome Measures: Pain score, work status, medication usage, and patient satisfaction. Results: Twenty patients with an average symptom duration of 5.8 months were included. An average of 2.2 therapeutic injections was administered. Follow-up data collection transpired at an average of 21.2 months following discharge from treatment. A significant reduction (p =.001) in pain score was observed at the time of follow-up. Medication usage was also significantly improved (p =.005) at the time of follow-up. An overall good or excellent result was observed in 60%. Thirty percent of patients required surgery. Younger patients were more Likely (p =.0047) to report the highest patient satisfaction rating following treatment. Conclusions: This study suggests that fluoroscopically guided therapeutic SNRB is a clinically effective intervention in the treatment of atraumatic cervical spondylotic radicular pain.
Article
Cervical traction is one of the most common methods of treating neck and arm pain, but its effects are poorly understood. This study tested the hypothesis, firstly, that mechanical traction is effective in relieving clinical symptoms and, as a secondary part of a study described elsewhere,1 that the mechanism may be a reduction in muscle tension. One hundred patients with neck and arm pain were randomly allocated to one of two treatment groups: (1) weighted cervical traction (6-15lbs) applied according to a technique commonly used by physiotherapists; (2) placebo traction, applied in exactly the same way, but producing a force of not more than 11b on the head. Both groups were given neck-care education. The weighted traction group tended to improve slightly more than the placebo group on measures of pain, sleep disturbance, social dysfunction, ADL and range of movement at the neck. No significant post-treatment differences were found between the two treatment groups except on flexion and right-side flexion.
Article
Depending on the severity of the clinical problem, three categories of treatment--home, outpatient and hospital--were utilized in 82 patients whose conditions met the strict criteria for cervical radiculitis. Details of the clinical picture, laboratory findings, electromyographic examinations, category and results of treatment are detailed. The follow-up results in 59 patients contacted one to two years after the initial treatment are also included. Eighty percent of the patients had good to excellent results when treated with conservative therapy during the initial episode whereas 71% continued to have good to excellent results after one to two years. Seventeen percent of those patients who were followed required a laminectomy.
Article
Cervical radiculopathy can be surgically approached either posteriorly or anteriorly and the anterior approach has been described with or without fusion. The choice of approach and technique must be based upon anatomic, pathophysiologic, and biomechanical principles in addition to the familiarity of the surgeon with the procedures. The authors discuss the use of the posterior approach for lateral soft-disk disease because it minimizes disruption of soft and bony tissues and does not markedly disrupt the biomechanics of the cervical spine. The anterior approach is preferred for radiculopathy involving osteophytic hard-disk disease, and when properly and carefully performed, the addition of an interbody fusion holds significant advantages over diskectomy without fusion.
Article
One hundred and fourteen patients were admitted to our department for evaluation of their cervical spondylogenetic symptoms, including local cervical pain, radiculopathy and myelopathy. This retrospective study gives the results, expressed as improved, unchanged or worse, of anterior surgery, posterior surgery and conservative treatment. Local cervical pain improved in about half of the patients, without any difference between the groups. The effect of surgery on radiculopathy was superior to that of conservative treatment, 71 percent and 74 percent respectively, being improved after anterior and posterior surgery, compared to 19 percent in the conservatively treated group. The majority of patients with myelopathy were treated with posterior surgery and 69 percent had improved. The results were not influenced by the patients age or the duration of symptoms. It is argued that the positive effects of surgery on the radiculopathy are due to a segmental stabilisation rather then to decompression. The immediate post-operative improvement of the myelopathy is undoubtedly caused by the decompression while the long-termed improvement cannot with certainty be attributed to the operation.
Article
Cervical monoradiculopathy occurs most commonly at C5-6 and C6-7. It is due mostly to acute herniation of nuclear material. The syndrome often responds to conservative prescription but when surgery is indicated, the results are good. The neurologic examination is the most specific and sensitive clinical test. Acute radiculopathies due to herniated nucleus are, in our hands, best approached via a posterior muscle-splitting incision. Chronic radiculopathies due to osteophyte formation may be approached either anteriorly or posteriorly. Reflex discogenic pain requiring anterior fusion exist but are less common. These patients must be carefully screened because of the functional factors involved.
Article
Arterial supply of the cervical spinal cord has been discussed with special reference to the radicular arteries. Thirty-one human spinal cords have been studied with postmortem positive pressure injection techniques using coloured, and radio-opaque media. Observations concluded that radicular arteries were main sources of supply to spinal cord except at the highest segments (C1C2C3), where intracranial vertebral branches contribute. Average number of significant radicular arteries is two or three, in two-thirds of the specimens only one was present. These feeding radicular arteries usually enter into the spinal canal through the intervertebral foramina accompanying C4C5C6 nerve roots to join the anterior and posterior spinal arteries. Anterior, and posterior spinal arteries are probably of segmental origin, and there is only a sparse anastomosis between them. The common radicular artery divides into an anterior, and a posterior branch of which one predominates in size. Cervical radicular arteries may originate from subclavian branches other than vertebral, of these ascending cervical branch of thyrocervical trunk is most important. A terminal zone probably exists at highest thoracic segments where craniocervical, and thoracic radicular flows meet. The filling of the anterior spinal trunk in the cervical region depends on the availability of at least one major anterior radicular artery. Interruption of radicular supply may be precipitated by trauma, spondylosis and other lesions resulting into ischaemia, and myelopathy; the risk is greater if there is only one radicular artery which is involved.
Article
This article discusses the relevant anatomy, clinical presentation, diagnosis and surgical treatment for cervical radiculopathy. The etiology of cervical radiculopathy can play a role in the subsequent treatment of this problem. Both anterior and posterior surgical management is discussed.
Article
This prospective study with independent clinical review was set up to monitor the clinical outcome of patients when using serial periradicular/epidural corticosteroid injection techniques in managing cervical radiculopathy. Over a 10 year period, between 1986 and 1995, a consecutive series of 68 secondary referral patients presenting with cervical radiculopathy were entered into the study. There were 57 men (84%) and 11 women (16%) of average age 47 years (range 31-65 years). The average duration of symptoms prior to presentation was 2 months (range 1-12 months). All patients apart from one had neurological signs. Of the 64 patients (94%) who underwent imaging, relevant pathology thought to correlate with the clinical presentation was demonstrated in all but one patient. Serial periradicular/ epidural corticosteroid injections were used to control pain; an average of 2.5 injections was administered per patient (range 1-6). Patients underwent a final clinical examination when their pain had remained satisfactorily under control for an average of 7 months (range 1-23 months). They subsequently were reassessed, by an independent clinician, at an average of 39 months (range 4-112 months) after initial presentation, via a telephone interview. Despite the fact that all 68 patients were potential surgical candidates, they all made a satisfactory recovery without the need for surgical intervention. Forty-eight patients (76%) did not experience any arm pain, and of the 15 patients (24%) who did, this improved from 10 to an average of 2 (range 1-4) on a 10-point pain scale. Thus, patients with cervical radiculopathy make a satisfactory recovery with serial periradicular/epidural corticosteroid injections without the need for surgical intervention.
Article
This prospective, randomized study compares the efficacy of surgical and conservative treatments in patients with long-lasting cervical radicular pain. To compare the effects of surgery, physiotherapy, and a cervical collar. There are no previous controlled outcome studies that have compared surgical treatment with nonsurgical treatment of patients with cervical radicular pain. The study group comprised 81 patients with cervicobrachial pain of at least 3 months' duration, in whom the distribution of the arm pain corresponded to a nerve root that was significantly compressed by spondylotic encroachment with or without an additional bulging disc, as verified by magnetic resonance imaging or computed tomographic myelography. The patients were randomly allocated to surgery (Cloward technique), individually adapted physiotherapy, or a cervical collar. The therapeutic effects were evaluated with respect to pain intensity by the visual analogue scale, function by the Sickness Impact Profile, and mood by Mood Adjective Check List. The measurements were performed before treatment (control 1), shorter after treatment (control 2), and after a further 12 months (control 3). At control 1, the groups were uniform. At control 2, the surgery group reported less pain (visual analogue scale) and, like the physiotherapy group, better function (Sickness Impact Profile) than the collar group. At control 3, there was no difference in visual analogue scale, Sickness Impact Profile, and Mood Adjective Check List measurements among the groups. In the treatment of patients with long-lasting cervical radicular pain, it appears that a cervical collar, physiotherapy, or surgery are equally effective in the long term.
Article
To investigate the outcomes resulting from the use of fluoroscopically guided therapeutic selective nerve root block (SNRB) in the nonsurgical treatment of atraumatic cervical spondylotic radicular pain. Retrospective study with independent clinical review. Twenty subjects (10 men, 10 women) with mean age 56.6 years. Each patient met specific physical examination, radiographic, and electrodiagnostic criteria to confirm a level of cervical involvement. Those patients whose root level remained indeterminate were required to demonstrate a positive response to a fluoroscopically guided diagnostic SNRB prior to the initiation of treatment. Therapeutic injections were administered in conjunction with physical therapy. Data collection and analysis were performed by an independent clinical reviewer. Pain score, work status, medication usage, and patient satisfaction. Twenty patients with an average symptom duration of 5.8 months were included. An average of 2.2 therapeutic injections was administered. Follow-up data collection transpired at an average of 21.2 months following discharge from treatment. A significant reduction (p = .001) in pain score was observed at the time of follow-up. Medication usage was also significantly improved (p = .005) at the time of follow-up. An overall good or excellent result was observed in 60%. Thirty percent of patients required surgery. Younger patients were more likely (p = .0047) to report the highest patient satisfaction rating following treatment. This study suggests that fluoroscopically guided therapeutic SNRB is a clinically effective intervention in the treatment of atraumatic cervical spondylotic radicular pain.
Article
The purpose of the present study was to determine the effectiveness of selective nerve-root injections in obviating the need for an operation in patients with lumbar radicular pain who were otherwise considered to be operative candidates. Although selective nerve-root injections are used widely, we are not aware of any prospective, randomized, controlled, double-blind studies demonstrating their efficacy. Fifty-five patients who were referred to four spine surgeons because of lumbar radicular pain and who had radiographic confirmation of nerve-root compression were prospectively randomized into the study. All of the patients had to have requested operative intervention and had to be considered operative candidates by the treating surgeon. They then were randomized and referred to a radiologist who performed a selective nerve-root injection with either bupivacaine alone or bupivacaine with betamethasone. The treating physicians and the patients were blinded to the medication. The patients were allowed to choose to receive as many as four injections. The treatment was considered to have failed if the patient proceeded to have the operation, which he or she could opt to do at any point in the study. Twenty-nine of the fifty-five patients, all of whom had initially requested operative treatment, decided not to have the operation during the follow-up period (range, thirteen to twenty-eight months) after the nerve-root injections. Of the twenty-seven patients who had received bupivacaine alone, nine elected not to have the operation. Of the twenty-eight patients who had received bupivacaine and betamethasone, twenty decided not to have the operation. The difference in the operative rates between the two groups was highly significant (p < 0.004). Our data demonstrate that selective nerve-root injections of corticosteroids are significantly more effective than those of bupivacaine alone in obviating the need for a decompression for up to thirteen to twenty-eight months following the injections in operative candidates. This finding suggests that patients who have lumbar radicular pain at one or two levels should be considered for treatment with selective nerve-root injections of corticosteroids prior to being considered for operative intervention.
Article
Thirty-two patients underwent periradicular corticosteroid injections with a lateral percutaneous approach under fluoroscopic guidance, to treat 34 foci of chronic cervical radiculopathy unresponsive to medical treatment alone. The mean evolutionary trends for radicular and neck pain relief were significant at 14 days (P <.001) and at 6 months (P <.001). The procedure did not produce any complications.
Article
A 48-year-old man suffered from intractable neck pain irradiating to his right arm. Magnetic resonance imaging (MRI) of the cervical spine was unremarkable. A right-sided diagnostic C6-nerve root blockade was performed. Immediately following this seemingly uneventful procedure he developed a MRI-proven fatal cervical spinal cord infarction. We describe the blood supply of the cervical spinal cord and suggest that this infarction resulted from an impaired perfusion of the major feeding anterior radicular artery of the spinal cord, after local injection of iotrolan, bupivacaine, and triamcinolon-hexacetonide around the C6-nerve root on the right side.
Article
A randomized, double-blind trial was conducted. To test the efficacy of periradicular corticosteroid injection for sciatica. The efficacy of epidural corticosteroids for sciatica is controversial. Periradicular infiltration is a targeted technique, but there are no randomized controlled trials of its efficacy. In this study 160 consecutive, eligible patients with sciatica who had unilateral symptoms of 1 to 6 months duration, and who never underwent surgery were randomized for double-blind injection with methylprednisolone bupivacaine combination or saline. Objective and self-reported outcome parameters and costs were recorded at baseline, at 2 and 4 weeks, at 3 and 6 months, and at 1 year. Recovery was better in the steroid group at 2 weeks for leg pain (P = 0.02), straight leg raising (P = 0.03), lumbar flexion (P = 0.05), and patient satisfaction (P = 0.03). Back pain was significantly lower in the saline group at 3 and 6 months (P = 0.03 and 0.002, respectively), and leg pain at 6 months (13.5, P = 0.02). Sick leaves and medical costs were similar for both treatments, except for cost of therapy visits and drugs at 4 weeks, which were in favor of the steroid injection (P = 0.05 and 0.005, respectively). By 1 year, 18 patients in the steroid group and 15 in the saline group underwent surgery. Improvement during the follow-up period was found in both the methylprednisolone and saline groups. The combination of methylprednisolone and bupivacaine seems to have a short-term effect, but at 3 and 6 months, the steroid group seems to experience a "rebound" phenomenon.
Article
Cervical radiculopathy presents as pain in a dermatomal distribution. Despite conservative nonoperative therapy, a large subset of patients will require surgical intervention. Indications for surgery include recalcitrant radiculopathy despite nonoperative treatment for more than 6 weeks and progressive motor deficit or disabling motor deficit (deltoid palsy, wrist drop) prior to 6 weeks. Anterior and posterior approaches have both yielded successful results in appropriately selected patients. Anterior cervical diskectomy and fusion is the generally preferred treatment for radiculopathy when there is a significant component of axial neck pain, when the disease is centrally located, or when there is any degree of segmental kyphosis. Posterior laminoforaminotomy is an acceptable choice for lateral soft disk herniations with predominant arm pain and for caudal lesions in large, short-necked individuals.
Article
A prospective study randomized by patient choice from the private practice of a single physician affiliated with a major teaching hospital was conducted. To compare transforaminal epidural steroid injections with saline trigger-point injections used in the treatment of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. Epidural steroid injections have been used for more than half a century in the management of lumbosacral radicular pain. At this writing, however, there have been no controlled prospective trials of transforaminal epidural steroid injections in the treatment of lumbar radiculopathy secondary to a herniated nucleus pulposus. Randomized by patient choice, patients received either a transforaminal epidural steroid injection or a saline trigger-point injection. Treatment outcome was measured using a patient satisfaction scale with choice options of 0 (poor), 1 (fair), 2 (good), 3 (very good), and 4 (excellent); a Roland-Morris low back pain questionnaire that showed improvement by an increase in score; a measurement of finger-to-floor distance with the patient in fully tolerated hip flexion; and a visual numeric pain scale ranging from 0 to 10. A successful outcome required a patient satisfaction score of 2 (good) or 3 (very good), improvement on the Roland-Morris score of 5 or more, and pain reduction greater than 50% at least 1 year after treatment. The final analysis included 48 patients with an average follow-up period of 16 months (range, 12-21 months). After an average follow-up period of 1.4 years, the group receiving transforaminal epidural steroid injections had a success rate of 84%, as compared with 48% for the group receiving trigger-point injections (P < 0.005). Fluoroscopically guided transforaminal injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus.
An Atlas of Vascular Anatomy of the Skeleton and Spinal Cord, . London: Martin Duntz, 1996 p. 31–2.. Goldie I, Landquist A. Evaluation of the effects f different forms of physiotherapy in cervical pain
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Crock HV. An Atlas of Vascular Anatomy of the Skeleton and Spinal Cord,. London: Martin Duntz, 1996 p. 31–2.. Goldie I, Landquist A. Evaluation of the effects f different forms of physiotherapy in cervical pain. Scand J Rehabil Med 1970;2–3:117– 121.
Periradicular infiltration for sciatic. A randomized controlled trial.
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Cost effectiveness of periradicular infiltration for sciatica. Subgroup analysis of a randomized controlled trial.
  • Karpinnen