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The clinical use of lumbar epidural steroid injections has increased dramatically. Although there are certainly beneficial effects to using epidural steroid injections in a treatment regimen for lumbar radicular pain, there is a lack of well designed, placebo-controlled studies to define conclusively specific indications and techniques for different spinal diagnoses. This article reviews the pathophysiology of lumbar radiculopathy and the use of epidural steroid injections as one treatment option, as well as describes their risks and benefits. Based on current literature, we offer an evidence-based perspective regarding rational use of lumbar epidural steroid injections for certain indications and treatment goals.
To read the full-text of this research, you can request a copy directly from the authors.
... 2,3 The frequency of spontaneous resolution varies according to diagnosis, with symptoms improving without operative intervention in 80% of patients with LDH and up to 45% of patients with LSS. 4 Lumbar disc herniation involves mechanical compression from herniated disc material, whereas LSS encompasses the degenerative narrowing of the central canal, lateral recess or neural foramen. 4 In both cases, inflammation is widely believed to play a causal role in instigating radiculopathy. ...
... 2,3 The frequency of spontaneous resolution varies according to diagnosis, with symptoms improving without operative intervention in 80% of patients with LDH and up to 45% of patients with LSS. 4 Lumbar disc herniation involves mechanical compression from herniated disc material, whereas LSS encompasses the degenerative narrowing of the central canal, lateral recess or neural foramen. 4 In both cases, inflammation is widely believed to play a causal role in instigating radiculopathy. 2,3,5-9 Epidural steroid injections (ESIs) may therefore have a role in the treatment of radicular low back pain, after the failure of conservative management. ...
... 2,3,5-9 Epidural steroid injections (ESIs) may therefore have a role in the treatment of radicular low back pain, after the failure of conservative management. 3,4, There are 3 primary methods for the injection of corticosteroids into the epidural space: caudal, transforaminal and interlaminar ESI. 7,10-12 Caudal ESI involves the injection of medication through the sacral hiatus, transforaminal ESI uses the neural foramen to target a specific nerve root and interlaminar ESI enters the epidural space between the laminae. ...
We sought to document the efficacy of interlaminar epidural steroid injections (ESIs) for the relief of low back pain in a rural population.
We conducted a prospective observational cohort study with brief follow-up telephone interviews at 1, 3 and 6 months after interlaminar ESI.
A total of 47 ESIs were administered to the 24 participants. In an intention-to-treat analysis, pain relief was achieved in 78.7%, 55.3% and 27.7% of participants at 1, 3 and 6 months.
Interlaminar ESIs, without fluoroscopic guidance, were effective for up to 3 months of symptom relief.
...  Postoperative use of ESIs has not been well studied, but ESIs continue to be performed on postoperative patients, perhaps because they are considered a low-risk alternative compared with repeat surgical procedures or chronic opioid analgesics. 16, Nevertheless, lumbar ESIs may be associated with increased risks of complications due to altered spinal anatomy 18 and prolonged disability. ...
... Also, persisting with a lumbar ESI treatment strategy that is associated with only short-term benefits may explain the poor outcomes after three ESIs. 13,24,36,45 Although lumbar fusion surgeries are more costly than nonlumbar fusion surgeries, 37 the cost and duration of the nonfusion surgery claims approach the cost and duration of the fusion claims as postoperative ESI increase more than three (Figs. 4 and 5). As stated previously, the cost of the ESI itself does not account for this increase. ...
... These findings are consistent with the literature that ESIs provide only temporary relief, so they may be best used as part of an initial rehabilitation program. 6,24 There is scant evidence supporting the systematic use of ESI postoperatively, and the perceived low risk of complications does not justify continued use of ESI, because it does not take into consideration the greater risk of prolonged disability (ie, longer claims duration) and increased cost associated with postoperative or prolonged use of ESI. ...
Assess the relationship between performing lumbar epidural steroid injections (ESIs) after lumbar surgery and workers' compensation claim duration and cost.
A multivariate logistic regression was used to determine the association between performing ESI after the first lumbar surgery in 11,394 lost time injury claims filed from 1999 to 2002 followed for 7 years postinjury.
Odds ratio of costs more than $100,000 is 6.49 (95% confidence interval: 4.30 to 9.81) for ever having lumbar ESI after the first lumbar surgery, compared with no spinal procedures, controlling for sex, age, attorney involvement, opioid use, other spinal procedures, and claim duration. Odds ratio of having claim duration longer than 1000 days was 14.73 (95% confidence interval: 7.01 to 30.95).
Lumbar ESI after the first lumbar surgery was associated with high cost and longer claim duration.
... Absolute contraindications to perform epidural injections include known hypersensitivity to the administered agents, systemic infection or local infection at the planned site of injection, local malignancy and bleeding diathesis/anticoagulation therapy. Relative contraindications are related to the systemic effects of steroids on the heart, diabetes, immune system deficiency and glaucoma . ESIs should not be performed in pregnant women, particularly under fluoroscopic control, due to radiation exposure during the procedure, which can be a risk for foetal development . ...
... Relative contraindications are related to the systemic effects of steroids on the heart, diabetes, immune system deficiency and glaucoma . ESIs should not be performed in pregnant women, particularly under fluoroscopic control, due to radiation exposure during the procedure, which can be a risk for foetal development . ...
The aim of this study was to review all the published articles in the English language literature regarding the systemic effects of epidural corticosteroid injections (ESIs) in humans. ESIs are among the procedures that are most commonly used to manage chronic back pain. However, there has been no conclusive review on the systemic effects of this popular procedure. Reports were searched for in MEDLINE and EMBASE using the terms 'epidural' and 'steroids', 'corticosteroids' or 'glucocorticosteroids' up to and including the year 2012. Reports were also located by examining the references in the identified articles. We concluded that even if epidural steroid injection is one of the most widely- -used techniques to treat radicular pain, it must be administered cautiously, with careful monitoring for systemic side effects. At the very least, a standardised protocol is necessary.
... They can be applied by caudal, interlaminar, or transforaminal approach 1 . They are effective treatment options in the short and medium term in selected cases evaluated clinically and radiologically 1,2 . However, there are few studies 3,4 in the literature on ESI's efficacy in treating radicular pain in patients undergoing lumbar spinal surgery. ...
OBJECTIVE: The efficacy of epi-dural steroid injections (ESIs) in the treatment of radicular pain in patients undergoing lumbar spinal surgery is still unclear. The aim of this study was to investigate the factors affecting the success of ESIs in the treatment of ongoing radicular pain in patients undergoing lumbar spinal surgery. PATIENTS AND METHODS: This study was designed as a single-center, retrospective study, and was conducted at a Pain Management Center of a tertiary care center. A total of 260 patients with failed back surgery syndrome who received fluo-roscopy-guided lumbar ESI were included. Treatment success was defined as ≥50% reduction in the numeric rating scale score at the one-month follow-up. The patients were divided into the treatment success and the treatment failure groups. RESULTS: The presence of spinal instrumen-tation was significantly lower in the treatment success group (p= 0.045). Symptom duration and the numeric rating scale score at 1 hour were significantly lower in the treatment success group (p<0.05). The use of triamcinolone acetonide in the treatment success group was found to be significantly higher than in the treatment failure group (p=0.027). CONCLUSIONS: The short duration of symptoms and the absence of instrumentation seem to be prognostic factors that positively affect the success of ESI treatment in operated patients. A ≥50% pain reduction in the first hour after the procedure is a valuable indicator that treatment success can be achieved in the short term. Finally, the steroid type can also affect the treatment results.
... It is performed using a caudal, interlaminar, or transforaminal approach. ESI is an effective treatment option in the short and medium term in selected cases evaluated clinically and radiologically (6). However, there are few studies on the efficacy of ESIs in elderly patients (7,8). ...
Introduction: Epidural steroid injections are a preferred interventional pain treatment for patients with low back pain. Our aim was to investigate the effectiveness of epidural steroid injections treatment in elderly patients and to examine the effect of patients' diagnosis on the treatment success. Materials and Methods: Patients over the age of 65 who underwent epidural injections between January 2020 and January 2022 were retrospectively screened. The patients were divided into three groups according to their diagnosis: disc herniation, spinal stenosis, and failed back surgery syndrome. Numeric rating scale scores of all patients before the procedure, at three weeks, and at three months were noted. Results: A total of 234 patients were included in the study. Of these, 89 had disc herniation, 98 had spinal stenosis, and 47 had a history of failed back surgery. There were no significant differences between the groups in terms of age, gender, symptom duration, pre-procedural pain score, medical treatment, radiation dose, and procedure duration. Although a significant improvement was detected in pain scores at all follow-ups in all groups, these scores were found to be significantly lower in the disc herniation group than the spinal stenosis and failed back surgery groups at the three-week and month follow-ups. Conclusions: Epidural steroid injections has been found to be effective in back pain in elderly. In addition, elderly patients with disc herniation had a better response to treatment than those with spinal stenosis and failed back surgery. Further prospective and long-term follow-up studies are needed to support these results. ABSTRACT 2023; 26(1):20−26
... Epidural steroid injections (ESI) are one of the preferred interventional pain procedures in patients with lower back pain (LBP) who are unresponsive to conservative treatment, and they have been performed with the caudal, interlaminar or transforaminal approaches (6). ESI is an effective treatment option in the short to medium term in selected cases that are clinically and radiologically evaluated (7). As most elective cases were cancelled during the pandemic period (3), ESI treatment may also have affected elderly patients. ...
Introduction: To investigate the effects of the COVID-19 pandemic on epidural steroid injection treatment in elderly patients and to inform our colleagues to take possible precautions concerning treatment strategies. were classified as Group B. Demographic data, baseline pain scores, and waiting times for procedures and medical treatments in both groups were compared. Results: There were 186 and 81 patients in groups A and B, respectively. The mean age was 74 in Group B and 73 in Group A. Lumbar spinal stenosis and disc herniation were the most common diagnoses in both groups. The waiting time for epidural steroid injection was 39.4 days (0-160) in group B and 23.4 days (0-149) in group A. There was no significant difference between the two groups in terms of medical treatment for neuropathic pain. Conclusions: COVID-19 has caused a significant decrease and delay in the number of epidural procedures related to lower back pain in elderly patients. In the future, this decrease may create a burden on the health system. However, more observational and prospective studies are needed to inform our colleagues about the possible effects of COVID-19 on the elderly.
... ESI is one of the most commonly preferred interventional pain management methods in cases when conservative treatment proves insufficient. 4 It really is an effective treatment option in selected cases that are evaluated clinically and radiologically. 5 In this regard, TFESI, a type of ESI, provides a significant advantage in terms of being targeted treatment and delivering injectate to the ventral epidural area where the pathology is located. ...
Spinopelvic parameters (SPP) is closely associated with diseases such as lumbar disc herniation (LDH), disc degeneration and spondylolisthesis. Although there exists many known clinical and radiological factors affecting success of the transforaminal epidural steroid injection (TFESI) treatment, the effect of SPP has not yet been investigated. This study aims to examine the effects of SPP on treatment success in patients who undergo TFESI due to lumbar disc herniation and to investigate correlation among multifidus cross-sectional area (MFCSA).
This was a prospective, observational study. Patients with low back and/or leg pain, unilateral nerve root compression were applied TFESI. Outcome measures were include the numerical rating scale (NRS), Oswestry Disability Index (ODI) and Beck Depression Inventory (BDI). The patients were evaluated at the first hour, third week and third month. The SPP and MFCSA measurements were made on direct radiographs and MRIs.
A total of 58 patients, 24 women and 34 men, with an average age of 42.0 ± 9.5 were included. NRS, ODI and BDI scores improved significantly up to three months follow-up (P<0.001). A moderately positive correlations were found between leg NRS and PT / PI scores immediately after treatment (r: 0.307 and r: 0.334) and a weak positive correlation was found between BDI and PT at 3'rd weeks (r: 0.269). The MFCSA/vertebral sectional area (VSA) and MFCSA/total multifidus cross-sectional area (TMFCSA) of the affected side were found to be significantly low (p <0.001).
Subjects with high PI and PT reported less improvement in leg pain immediately after treatment and patients with high PT had fewer BDI improvements. MFCSA had no correlations with SPPs in patients who underwent TFESI.
... These include lumbar disc herniation, cervicogenic headaches, occipital neuralgia, articular process disorders, medial branch pain of the posterior spinal nerve, herpes zoster and postherpetic neuralgia, reflective sympathetic dystrophy, thoracic outlet syndrome, intercostal neuralgia, post-operative recurrent radicular pain, and radicular pain. Other indications include scenarios requiring immediate alleviation of radicular pain and in patients with a positive neurological examination, but insignificant vital signs  . For more detailed indications for spine-related pain or diseases, please refer to Table 1. ...
Spinal pain (SP) is a common condition that has a major negative impact on a patient's quality of life. Recent developments in ultrasound-guided injections for the treatment of SP are increasingly being used in clinical practice. This clinical expert consensus describes the purpose, significance, implementation methods, indications, contraindications, and techniques of ultrasound-guided injections. This consensus offers a practical reference point for physicians to implement successfully ultrasound-guided injections in the treatment of chronic SP.
... Triamcinolone is a particulate steroid that theoretically might cause complications, such as vascular penetration, dizziness, nausea, an increase of blood sugar or tension, arrythmia, or even paraplegia due to nerve damage. However, it did not happen among them [21,22]. There is no correlation between the amount of drug dose and the intraepidural therapeutic effect of steroids for reducing pain or neurological improvement. ...
(1) Introduction: Epiconus and conus medullary syndromes that consisted of drop foot, pain, numbness, bladder or bowel dysfunction are serious problems might be caused by lumbar disc(s) herniation (LDH) compression. (2) Objective: To evaluate percutaneous discectomy effectivity for decompressing LDH lesions. (3) Case Report: Three patients suffered from drop feet, numbness, and bowel and bladder problems due to LDH compression. Patient #1 is a male (35 years old, basal metabolism index (BMI) = 23.9), point 1 on manual muscle test (MMT), with protrusion on L3 to S1 discs; Patient #2 is a female (62 years old, BMI = 22.4), point 3 on MMT, with protrusion on L2-4 and L5-S1 discs; Patient #3 is a female (43 years old, BMI = 26.6), point 4 on MMT, with extrusion on T12-L1 and L1-2 and L3-4 protruded discs. Six months follow-up showed of stand and walkability improvement with Patient #1 and #2. Patient #3 showed improvement in bowel and bladder problems within 10 weeks, without suffering of postoperative pain syndromes. (4) Discussion: Patient #1 and #2 showed better outcomes than Patient #3 who affected epiconus and cauda equina syndromes. Triamcinolone and lidocaine have analgesic and anti-inflammatory properties for improving intraepidural circulation adjacent to the lesion sites. (5) Conclusion: Drop foot caused by mechanical compression of LDH ought to be treated immediately. Lateral or posterolateral compression has better outcomes associated with anatomical structures. Discectomy through transforaminal approach that is followed by caudal epidural steroid injection (CESI) under fluoroscopic guidance is a safer and minimally invasive treatment with promising outcomes.
... 69,70 In the face of such uncertainty the decision is left up to patients and their physicians and personal preference holds sway. 71,72 Surgical By the mid-1990s nearly 200,000 discectomies were performed annually in the United States alone. 73,74 It is now frequently performed in an outpatient setting and full activity after a short period of rest and healing is sufficient for postoperative recovery. ...
Lumbar disc herniation is a common cause of low back pain and radiculopathy (sciatica). Diagnosis is
initially made based on history and physical examination and ruling out red flags, particularly surgical
emergencies such as Cauda Equina Syndrome. A trial of conservative treatment consisting of physical
rehabilitation and oral medication is usually successful for back dominant pain. When persistent
radiculopathy indicates lumbar discectomy the diagnosis must be confirmed by imaging but, due to
very high rates of asymptomatic disc herniation, imaging cannot replace clinical diagnosis. For disabling
leg dominant pain discectomy results in faster recovery but has a similar long-term outcomes
compared to conservative treatment.
KEYWORDS: lumbar disc herniation, lower back pain, sciatica, radiculopathy
... Knowledge of a patient's anticoagulation status is important, however, because injection at the facet level is contraindicated in the anticoagulated patient. 81 Box 2 Summary of findings from controlled clinical trials in humans (Strength of Recommendation Taxonomy scale) ...
Prolotherapy involves the injection of nonbiologic solutions, typically at soft tissue attachments and within joint spaces, to reduce pain and improve function in painful musculoskeletal conditions. A variety of solutions have been used; dextrose prolotherapy is the most rigorously studied and is the focus of this review. Although the mechanism of action is not clearly known, it is likely to be multifactorial. Data on effectiveness for temporomandibular dysfunction are promising but insufficient for recommendations. Research on the mechanism of action and clinical effects of dextrose prolotherapy are under way.
... The high-quality systematic review by members of the Cochrane Collaboration did not distinguish among interlaminar, caudal, or transforaminal epidural injection techniques for lumbosacral radicular syndrome, and found no clinically important benefits with use of epidural steroids (see Appendix 1 Table 3). 14,57 By contrast, the reviews authored by members of the American Society of Interventional Pain Physicians (ASIPP) included results from both RCTs and observational studies stratified by injection techniques and type of spinal disorders, and concluded that there is good evidence of short-term and long-term pain reduction and improvement in function with epidural steroids (see Appendix 1 Table 3). 11,15,16,58 These reviews categorized results from individual studies as positive, negative, or statistically insignificant, but failed to address the clinical importance of these categories and did not provide rates of clinically significant improvements in pain and disability, number needed to treat, or attributable events for clinical decision making. ...
Most clinical guidelines do not recommend routine use of epidural steroid injections for the management of chronic low back pain. However, many clinicians do not adhere to these guidelines. This comprehensive evidence overview concluded that off-label epidural steroid injections provide small short-term but not long- term leg-pain relief and improvement in function; injection of steroids is no more effective than injection of local anesthetics alone; post-procedural complications are uncommon, but the risk of contamination and serious infections is very high. The evidence does not support routine use of off-label epidural steroid injections in adults with benign radicular lumbosacral pain.
... Numerous clinical studies have demonstrated the therapeutic benefi t of ESIs, including decreased pain and improved function. 4 There is evidence that patients with back pain receiving numerous ESIs are less likely to seek surgery. 5 However, one of the major adverse effects of steroid use is glucocorticoid-induced osteoporosis, which varies according to the preparation, duration, dose, and route of administration. ...
A prospective, observational study.
To evaluate the effect of epidural steroid injection (ESI) on bone mineral density (BMD) in postmenopausal women.
Summary of background data:
ESIs are used to treat the pain associated with radiculopathy. Although it is known that exogenous steroid use can disrupt skeletal architecture, it is less clear whether ESIs result in a decrease of BMD.
Twenty-eight postmenopausal women experiencing radiculopathy elected L4-L5 ESI treatment. We had a 50% dropout rate due to noncompliance with study requirements. BMD of the hip, femoral neck, and spine along with markers of bone turnover, bone specific-alkaline phosphatase and serum C-telopeptide of collagen I (CTX), was evaluated at baseline preinjection and 3 and 6 months postinjection.
There was a significant decline in the hip BMD of 0.018 g/cm (0.028 ± 0.007, P = 0.002) at 6 months compared with baseline. We compared this decline with an age-matched control population that exhibited a decline of 0.003 g/cm(2), significantly less than our study population (P = 0.007). Bone-specific alkaline phosphatase increased significantly by 2.33 U/L from 3 to 6 months (P = 0.012), but the rise of CTX was not significant.
A single ESI in postmenopausal women adversely affects BMD of the hip. This is in conjunction with a rise in bone remodeling activity, as evidenced by an increase in bone-specific alkaline phosphatase and CTX. In addition, when compared with an age-matched control population, our study population exhibited a greater decline in BMD. Our findings show that epidural administration of corticosteroids has a deleterious effect on bone, which should be considered when contemplating treatment options for radiculopathy. The resulting decrease in BMD, while slight, suggests that ESIs should be used with caution in those at a risk for fracture.
... Since epidural steroid injection (ESI) is a rational treatment approach for radicular pain due to herniated nucleus pulposus and lumbar stenosis , its popularity is rising. It is reported to decrease surgical rates and self-reported pain and disability . Corticosteroids contribute to pain treatment with their ability to decrease inflammation by inhibiting production of prostaglandins and excitation of c-fibers, which is mainly responsible for pain generation. ...
To the Editor,
We read Dr. Gitkind's report with great interest . Since epidural steroid injection (ESI) is a rational treatment approach for radicular pain due to herniated nucleus pulposus and lumbar stenosis , its popularity is rising. It is reported to decrease surgical rates and self-reported pain and disability . Corticosteroids contribute to pain treatment with their ability to decrease inflammation by inhibiting production of prostaglandins and excitation of c-fibers, which is mainly responsible for pain generation. However, ESI is not an option free of side effect due to intervention itself and the drugs used . Here, we describe two patients with abnormal uterine …
Nonsurgical interventional spine pain procedures provide an additional treatment option for lower back pain at the traditional bifurcation of conversative vs. operative management.
Transforaminal epidural steroid injections, radiofrequency ablations, intrathecal drug delivery, and spinal cord stimulation were found to be effective and safe techniques when applied to their specific indication.
Thermal annuloplasty and minimally invasive lumbar decompression showed mixed support.
Discography, sacroiliac joint injections, and spinous process spacers lacked sufficient evidence to support efficacy.
Medial branch blocks and facet joint injections were found to be useful diagnostic tools.
Descriptive epidemiologic study.
To analyze trends and patient characteristics for lumbosacral transforaminal and interlaminar/caudal epidural injection utilization over time.
Lumbosacral transforaminal and interlaminar/caudal epidural injections are considered for varying lumbar pathologies. Reported studies, physician practices, insurance authorization, and other factors may influence utilization patterns over time.
Patients undergoing lumbosacral transforaminal and interlaminar/caudal epidural injections between 2010-2019 were identified in the M91Ortho PearlDiver database based on CPT coding. Patient age, sex, Elixhauser Comorbidity Index (ECI), insurance plan (commercial, Medicaid, Medicare), and region of the country where the procedure was performed (Midwest, Northeast, South, West) were assessed and tracked over the years studied based on prevalence per 100,000 covered lives.
Lumbosacral transforaminal and interlaminar/caudal epidural injections were identified for 426,039 and 501,228 patients, respectively. The number of injections performed per year decreased over the years studied: for transforaminal injections from 160.81 to 76.36 per 100,000 patients and for interlaminar/caudal injections from 200.53 to 77.56 per 100,000 patients. The decrease in overall injections was greatest for those with Commercial and Medicare coverage (53.40% and 66.50%, respectively), with a smaller drop amongst those with Medicaid coverage (32.39%).Over the years, the average patient undergoing injection was older and there was a relative shift toward transforaminal injections (P<0.05 for both). In terms of specialty of those performing the injections, they were most performed by Anesthesiology specialists (who performed less transforaminal than interlaminar/caudal injections).
Lumbosacral transforaminal and interlaminar/caudal spinal epidural injections were shown to decrease by 52.37% per 100,000 patients from 2010-2019. Changing demographics of those undergoing such injections and practice patterns are important to consider in the picture of overall spine service utilization. Variations in injection utilization trends by patient insurance raise questions regarding disparities in care.
Epidural injections are one of the most common injections performed by pain physicians. Typical indications include radiculopathy, spinal stenosis, and discogenic pain. There are three approaches: interlaminar, transforaminal, and caudal. Epidural injections are typically safe when proper patient selection and technique are used as outlined below.KeywordsBack painSpine injectionsEpidural steroidsChronic painFluoroscopy
Epidural injection with corticosteroids is a common treatment option for patients with lower back pain and sciatica. Over the past several decades, the technique and indications for epidural injections have changed substantially. A variety of anesthetics as well as a number of glucocorticoids have been used. The caudal approach, which was originally described, has largely been replaced by interlaminar and transforaminal injections that are typically performed with fluoroscopic guidance. Numerous clinical trials evaluated the effectiveness of epidural corticosteroid injections. Even though epidural injections are one of the most commonly performed procedures in managing low back and radicular pain, conflicting recommendations have been provided, despite the extensive literature. Overall, Epidural steroid injections (ESIs) are well tolerated and represent a much less invasive option than surgery. ESIs have been performed for many decades and are generally considered a very safe and moderately effective treatment for back and leg pain. When performed by an experienced physician using fluoroscopic guidance, the risk of experiencing a serious complication is rare. The current data suggests that ESIs are best used for radicular symptoms with the goal of pain management in the acute to subacute setting to help patients be more comfortable as they progress through the generally favorable natural history of spontaneous improvement. The transforaminal route, which has been studied most recently, appears to be the most efficacious approach for monoradicular symptoms secondary to a disc protrusion. Further, placebo-controlled studies are necessary to define more conclusively the role of ESI for the various causes of radicular pain and to define the best technique for each indication.
Diseases of the intervertebral disk may result from several multifactorial pathophysiologic processes. In this chapter, we discuss the normal anatomy of the intervertebral disk along with their anatomic variants and pathologic processes responsible for disk disease and their imaging correlates on conventional radiography, computed tomography, and magnetic resonance imaging.
New studies continue to show the increased risk of morbidity and mortality that is associated with poor or ineffective pain control in postoperative settings. The appropriate technical selection must consider several key factors in addition to the patient’s comorbidities and type of surgery being performed. Furthermore, complications related to neural blockade are rare but not completely avoidable. This chapter reviews various agents and techniques that can be used by physicians utilizing a multimodal analgesic model.
Dextrose prolotherapy (DPT) is a treatment for chronic pain involving the injection of hypertonic dextrose at soft tissue attachments or within joint spaces. The mechanism of action of DPT is likely multifactorial. Controlled animal and human trials have reported proliferation of soft tissue and a potential direct neural effect of dextrose injections. Systematic review of clinical trials show that DPT reduces pain and improves function in the long term for knee osteoarthritis; existing studies also suggest that DPT is efficacious for finger/hand osteoarthritis and Osgood Schlatter disease, and may be efficacious for rotator cuff tendinopathy, lateral epicondylosis, and sacroiliac pain.
Low back pain, or spinal pain, is the second most common chief complaint in the adult population seeking medical care in the ambulatory care setting. Treatment is often initiated due to the high rate of concomitant degenerative pathology seen on magnetic resonance imaging in both symptomatic and asymptomatic adults. However, in the absence of radicular pain localizing to a compressive pathology, and clear evidence of the appropriate spinal pain generator, a more thorough work-up is warranted. The algorithm for localization of the appropriate lumbar level of disease can be complex and still leave the surgeon without a definitive answer. This is in part due to the complex innervation of the spine where in the case of the facets and disc space a mixed innervation from somatic peripheral and autonomic nerve system supply is seen. Additionally, chronic compression of the neural elements and inflammation of neural fibers may result in hyperexcitability of nociceptive neuronal pathways. In this case, neuronal excitability can be spontaneous or with a greatly lowered threshold, and surgical compression may not always provide pain relief. As a result, more patients are diagnosed with failed back surgery syndrome, a loosely defined term in the spinal literature referring to painful symptoms persisting beyond the expected postoperative time course. The authors highlight several pain generators of the spine and highlight potential nonsurgical interventions that should be considered in the spinal surgeon’s armamentarium as a means of addressing this problem in the clinic.
Spinal epidural steroid injections are generally considered a safe, effective treatment for radicular pain in a variety of spinal conditions. Complications secondary to these injections, although rare, can result in devastating neurologic symptoms. Patients with preexisting moderate-to-severe spinal stenosis and recent use of chronic anticoagulation pose a challenging dilemma when making treatment decisions, as a history of both can increase the risk of complications.
The following case study provides a description of a patient with spinal stenosis who discontinued anticoagulation therapy according to the recommended guidelines but who experienced a subsequent acute epidural hematoma and significant neurologic injury.
This case report describes the potential risk factors present in this patient. Presence of spinal stenosis and the interlaminar approach seem to be significant risk factors in this case. Presence of an intrinsic coagulopathy was not determined.
Objective: To review the diagnosis and treatment of osteoporotic vertebral compression fractures. Methods: Literature review. Results: Osteoporotic compression fractures of the spine are a relatively common cause of back pain, especially in elderly individuals. Approximately 700,000 new vertebral compression fractures occur in the United States every year. Pain is the most common presenting symptom and can occur anywhere in the spine, with the lower thoracic and upper lumbar regions being most common. An x-ray is often the simplest test that will confirm the presence of an osteoporotic compression fracture. They are best seen in the lateral view. Initial treatment of an osteoporotic compression fracture focuses on pain control and avoiding disability. For a wedge or stable burst fracture, heat, massage and relative rest are often beneficial. For unstable fractures, surgical intervention is often required. Vertebroplasy and kyphoplasty are 2 minimally invasive procedures that can be employed for osteoporotic compression fractures. In addition to treatment of the osteoporotic compression fracture, the clinician must look at treating the underlying osteoporosis. Physical medicine and rehabilitation intervention is an emerging therapy for osteoporosis management. Conclusion: For patients who have osteoporotic vertebral compression fractures, identification of the fracture and assessment of the type of fracture are essential to proper treatment. Very few osteoporotic vertebral compression fractures will require surgery. Treatment of the underlying osteoporosis is also essential for successful long-term patient functioning. Copyright 2011 by Turner White Communications Inc. All rights reserved.
Invasive analgesic therapies provide an alternative to medical management of chronic pain. With the increasing incidence of chronic pain not only in the United States but worldwide, more therapies have evolved to address the growing need for pain relief options. These therapies include spinal injections, nerve blocks, radiofrequency ablation, neurostimulation, and intrathecal drug delivery.
Treating sciatic pain caused by intervertebral disk herniation remains challenging. Not only does the symptomatology put a strain on patients, it is also of enormous socioeconomic impact. Next to conservative measures that include physical therapy and adequate pain medication, surgery—absolutely indicated in cases of cauda syndrome and severe motor deficit—seems to be the treatment of choice. In some cases though surgery seems to have identical long-term results compared with conservative management. Yet, neither conservative measures nor surgery always provide sufficient results. Moreover, there are a number of patients who do on the one hand not respond to conservative therapy, but do on the other hand not have the indication for surgery. As a result alternative, minimally invasive, image-guided therapies, such as periradicular therapy, have been introduced in recent years. Periradicular therapy is indicated in patients with radicular pain symptoms or radiculopathy, which may be caused by foraminal or spinal canal stenosis, tumors, or spondylolisthesis, and has become popular in the treatment of lumbar radicular complaints due to disk herniation. This review article focusses on different aspects of CT-guided periradicular injections and emphasizes a selection of practical considerations of important interventions at different spinal regions.
Athletes represent a specific subgroup of highly motivated patients with a unique set of social and psychological incentives. Demands placed on the lumbosacral system are high, and athletes may be particularly prone to the pathology discussed above. For this reason, it is crucial to consider the athlete as a functional whole operating in concert with intrinsic and extrinsic factors and to consider the lumbosacral system within the context of the complete kinetic chain. Spinal interventions should never be considered in isolation but rather as part of a comprehensive rehabilitation program targeting psychosocial as well as biomechanical opportunities. When interventional procedures are warranted, they should be performed according to existing guidelines regarding indication, patient selection, and technique where possible and with systems in place to maximize patient safety and to consistently monitor for response. Each of the interventions discussed above should be performed with fluoroscopic guidance, given the lack of accuracy without fluoroscopy, and generally be reserved for athletes not responding to conservative care. When returning an athlete to play after ESI, we recommend careful serial evaluation as well as involvement of appropriate family members, athletic trainers, and coaches in the decision-making process. Athletes should not return to play with any significant objective neurologic deficits. In appropriate athletes, return to play should occur with graduated and comprehensive rehabilitation as discussed above. Because evidence concerning the interventions discussed in this article is often lacking, clinical judgment is paramount regarding their allocation. The interventions explored above likely do provide viable treatment adjuncts in the carefully selected athlete but are not without risk. Athlete safety and global well being should guide any decision to pursue interventional treatment options.
The objective of this article was to present a systematic review of the safety issues encountered in interventional pain management. Patient safety is an important consideration in the practice of interventional pain management. Although there is a paucity of scientific articles addressing this topic, the authors have reviewed the literature and present a review of the topic, as well as strategies to minimize the risk to patients undergoing interventional spine procedures.
Epidural steroid injection (ESI) is the most commonly performed intervention in pain clinics across the United States. This article provides an evidence-based review of ESI, including data on efficacy, patient selection, comparison of types, and complications. The data strongly suggest that ESI can provide short-term relief for radicular symptoms but are less compelling for long-term effects or relief of back pain. Although it has been asserted that transforaminal ESIs are more efficacious than interlaminar injections, the evidence supporting this is limited.
There has been recent concern regarding the safety of cervical epidural steroid injections. The decision to proceed with treatment requires balancing the risk and benefits. This article is an in depth review of the efficacy, complications, and technique of both interlaminar and transforaminal cervical epidural steroid injections in the management of cervical radiculitis.
Lumbar interlaminar and transforaminal epidural injections are used in the treatment of lumbar radicular pain and other lumbar spinal pain syndromes. Complications from these procedures arise from needle placement and the administration of medication. Potential risks include infection, hematoma, intravascular injection of medication, direct nerve trauma, subdural injection of medication, air embolism, disc entry, urinary retention, radiation exposure, and hypersensitivity reactions. The objective of this article is to review the complications of lumbar interlaminar and transforaminal epidural injections and discuss the potential pitfalls related to these procedures. We performed a comprehensive literature review through a Medline search for relevant case reports, clinical trials, and review articles. Complications from lumbar epidural injections are extremely rare. Most if not all complications can be avoided by careful technique with accurate needle placement, sterile precautions, and a thorough understanding of the relevant anatomy and contrast patterns on fluoroscopic imaging.
Degenerative lumbar stenosis is a common source of pain and disability in the elderly. It presents clinically with a variety of symptoms, though neurogenic claudication is the hallmark. There is a multifactorial pathogenesis to lumbar stenosis and its symptoms, and thus, there are multiple management approaches available. Epidural steroid injections (ESIs) are a popular choice in management, however, the literature is vague in definitive support of their use, and providers that utilize injections can use variable techniques to access the spinal canal in order to deposit the steroid at the appropriate site. This article will review degenerative lumbar stenosis in general and focus on the use of ESIs to better define their role in this management process. In addition, the evidence to discern the optimal injection route will be presented.
In this paper, we report new progress in developing the instrument and software platform of a combined X-ray mammography/diffuse optical breast imaging system. Particularly, we focus on system validation using a series of balloon phantom experiments and the optical image analysis of 49 healthy patients. Using the finite-element method for forward modeling and a regularized Gauss-Newton method for parameter reconstruction, we recovered the inclusions inside the phantom and the hemoglobin images of the human breasts. An enhanced coupling coefficient estimation scheme was also incorporated to improve the accuracy and robustness of the reconstructions. The recovered average total hemoglobin concentration (HbT) and oxygen saturation (SO2) from 68 breast measurements are 16.2 microm and 71%, respectively, where the HbT presents a linear trend with breast density. The low HbT value compared to literature is likely due to the associated mammographic compression. From the spatially co-registered optical/X-ray images, we can identify the chest-wall muscle, fatty tissue, and fibroglandular regions with an average HbT of 20.1+/-6.1 microm for fibroglandular tissue, 15.4+/-5.0 microm for adipose, and 22.2+/-7.3 microm for muscle tissue. The differences between fibroglandular tissue and the corresponding adipose tissue are significant (p < 0.0001). At the same time, we recognize that the optical images are influenced, to a certain extent, by mammographical compression. The optical images from a subset of patients show composite features from both tissue structure and pressure distribution. We present mechanical simulations which further confirm this hypothesis.
Epidural steroid injection is a low-risk alternative to surgical intervention in the treatment of lumbar disc herniation. The objective of this study was to determine the efficacy of epidural steroid injection in the treatment of patients with a large, symptomatic lumbar herniated nucleus pulposus who are surgical candidates.
One hundred and sixty-nine patients with a large herniation of the lumbar nucleus pulposus (a herniation of >25% of the cross-sectional area of the spinal canal) were followed over a three-year period. One hundred patients who had no improvement after a minimum of six weeks of noninvasive treatment were enrolled in a prospective, non-blinded study and were randomly assigned to receive either epidural steroid injection or discectomy. Evaluation was performed with the use of outcomes scales and neurological examination.
Patients who had undergone discectomy had the most rapid decrease in symptoms, with 92% to 98% of the patients reporting that the treatment had been successful over the various follow-up periods. Only 42% to 56% of the fifty patients who had undergone the epidural steroid injection reported that the treatment had been effective. Those who did not obtain relief from the injection had a subsequent discectomy, and their outcomes did not appear to have been adversely affected by the delay in surgery resulting from the trial of epidural steroid injection.
Epidural steroid injection was not as effective as discectomy with regard to reducing symptoms and disability associated with a large herniation of the lumbar disc. However, epidural steroid injection did have a role: it was found to be effective for up to three years by nearly one-half of the patients who had not had improvement with six or more weeks of noninvasive care.
We have assessed whether an epidural steroid injection is effective in the treatment of symptoms due to compression of a nerve root in the lumbar spine by carrying out a prospective, randomised, controlled trial in which patients received either an epidural steroid injection or an intramuscular injection of local anaesthetic and steroid. We assessed a total of 93 patients according to the Oxford pain chart and the Oswestry disability index and followed up for a minimum of two years. All the patients had been categorised as potential candidates for surgery.
There was a significant reduction in pain early on in those having an epidural steroid injection but no difference in the long term between the two groups. The rate of subsequent operation in the groups was similar.
To determine the effectiveness and predictors of response to lumbar epidural corticosteroid injections (ESI) in patients with sciatica. We performed a 12-month, multicentre, double-blind, randomized, placebo-controlled, parallel-group trial in four secondary pain-care clinics in the Wessex Region.
Two hundred and twenty-eight patients with a clinical diagnosis of unilateral sciatica of 1-18 months' duration were randomized to either three lumbar ESIs of triamcinolone acetonide or interligamentous saline injections at intervals of 3 weeks. The main outcome measure was the Oswestry low back pain disability questionnaire (ODQ).
At 3 weeks, the ESI group demonstrated a transient benefit over the placebo group (patients achieving a 75% improvement in ODQ, 12.5 vs 3.7%; number needed to treat, 11.4). No benefit was demonstrated from 6 to 52 weeks. ESIs did not improve physical function, hasten return to work or reduce the need for surgery. There was no benefit of repeated ESIs over single injection. No clinical predictors of response were found. At the end of the study the majority of patients still had significant pain and disability regardless of intervention.
In this pragmatic study, ESIs offered transient benefit in symptoms at 3 weeks in patients with sciatica, but no sustained benefits in terms of pain, function or need for surgery. Sciatica is a chronic condition requiring a multidisciplinary approach. To fully investigate the value of ESIs, they need to be evaluated as part of a multidisciplinary approach.
To evaluate the pattern and flow of epidural contrast in fluoroscopically guided lumbar interlaminar steroid injections.
A prospective case series of 25 (twenty-five) consecutive patients receiving 25 (twenty-five) injections. Patients had either lumbar spinal stenosis (LSS) or herniated nucleus pulposus (HNP). All patients received their injection using a loss of resistance technique. Once the epidural space was felt localized 0.5 mL of Isovue contrast was injected to confirm accurate needle placement. If in the epidural space, another 4.5 mL was injected for a total of 5 mL contrast media. Both AP and lateral radiographs were obtained and reviewed by a physician trained in fluoroscopic injections for review of the contrast pattern. Patterns recorded were Unilateral, Bilateral, Ventral or Dorsal. The dorsal flow was also characterized as being cephalad or caudad and the number of lumbar intervertebral levels of flow were recorded as well.
Dorsal contrast flow occurred in all 25 injections. Thirty-six percent (9 out of 25) resulted in ventral spread of contrast. Eighty-four percent (21 out of 25) of the injections had flow of contrast unilaterally and 16% (4 out of 25) was bilateral. The mean number of levels of flow of contrast cephalad from the injection site was 1.28 and caudally 0.88. There was a significant difference in more cephalad than caudal contrast flow (P = 0.004)
Thirty six percent of the injections observed in the study revealed ventral contrast flow. Bilateral contrast flow occurred in 16% of the injections. Caudad contrast flow is less than cephalad. The observed contrast flows need to be studied clinically to determine if this can affect clinical outcome.
This study sought to determine the efficacy of fluoroscopic caudal epidural steroid injections as a conservative treatment in patients with presumably chronic lumbar discogenic pain.
Epidural steroid injections have been used in the treatment of lumbar radicular pain with success. However, despite their widespread use, there are few, if any, reports of the efficacy of Epidural steroid injections in patients with predominantly axial lumbar pain. Prior studies have been limited by the use of non-fluoroscopically guided injections and failing to apply a specific injection approach (i.e. transforaminal, interlaminar, or caudal) to a specific patient population.
Ninety-seven patients with chronic axial low back pain and Magnetic Resonance Imaging evidence of disc pathology without stenosis were selected from chart review. All patients received at least one fluoroscopically guided caudal epidural injection with 12 mg of betamethasone and 8 cc of 0.5% lidocaine. Collected follow-up information included Roland-Morris Disability, Visual Numeric Pain Scale, and patient satisfaction scores.
Only nineteen patients (23%) were determined to have a successful long- term (> 1 year) outcome and 65 (77%) were deemed failures. Average follow-up was 28.6 +/- 15.6 months. Successes were found to differ significantly from failures in pre-injection pain scores and patient satisfaction. Overall patient satisfaction was 45%.
At greater than two year follow-up, the efficacy of fluoroscopically guided caudal epidural steroid injections in patients with chronic lumbar discogenic pain is poor. Patient satisfaction exceeds the reported rate of efficacy. Patients responding to injection have significantly lower pre-injection pain scores.
To retrospectively evaluate flow patterns of interlaminar lumbar epidural steroid injections and compare these patterns to needle tip position.
This study was approved by the institutional review board and complied with HIPAA guidelines. The requirement for informed consent was waived. Fluoroscopic images from 701 consecutive lumbar epidural steroid injections in 485 patients were reviewed. Vertebral level, needle placement, and injectate flow patterns were determined from procedural images. History of previous spinal operations was determined from procedural records. A subset of patients with three or more injections at the same site was also examined. Patterns in the data were evaluated with chi(2) tests and t tests.
Images from 406 lumbar epidural steroid injections, one per patient (214 women, 192 men; mean age, 59.8 years), were used for final analysis. Midline injections were less likely to result in unilateral flow than a more lateral approach (P>.001). Flow within only the posterior epidural space was associated with unilateral flow (P=.001). Patients with previous spinal operations were more likely to have cephalad or caudad flow of less than one vertebral level than patients without a history of spinal operations (P<.001). Flow varied considerably within a series of injections in a single patient.
Epidural injectate flow is highly variable, both among patients and between injections in a single patient. Fluoroscopic monitoring and administration of contrast material mixed with medication, allowing visualization of the full extent of medication flow, are essential to ensure adequate coverage of the target area.
The purpose of this study was to assess the natural history of sciatica due to lumbosacral nerve root compromise and to evaluate the pathomorphologic changes that accompany the natural resolution of the disease. One hundred sixty-five consecutive patients, 114 males and 51 females, with an average age of 41 years (range, 17-72) and an average duration of symptoms of 4.2 months (range, 1-72) presenting with sciatica thought to be due to lumbosacral nerve root compromise were admitted to the study. The cornerstone of treatment was the serial epidural administration of steroid and local anesthetic by the caudal route on an outpatient basis. Lumbar epidural injection or periradicular infiltration at the appropriate level, confirmed under image intensifier, was the next step before considering surgical decompression. An average of three injections (range, 0-8) was received by each patient. Patients underwent clinical examination and computed tomography. Twenty-three patients (14%) underwent surgical decompression. The remainder were clinically assessed at 1 year after presentation, and 111 were rescanned at the appropriate levels. All conservatively managed patients made a satisfactory clinical recovery: average reduction of pain on the visual analog scale was 94% (range, 45-100), and 64 (76%) of the 84 disc herniations and 7 (26%) of the 27 disc bulges showed partial or complete resolution (chi-square = 20.27 P = 0.0001). Thus a high proportion of patients with discogenic sciatica make a satisfactory recovery with aggressive conservative management, and this recovery is accompanied by resolution of disc herniations in a significant number. Only a small proportion of patients needed surgical decompression.
The lumbosacral cerebrospinal fluid volume is a major determinant of the intrathecal spread of local anesthetics. Ultrasound imaging of the lumbar spine allows measurement of dural sac dimensions, which may potentially be used as a surrogate of cerebrospinal fluid volume. The purpose of this study was to investigate the correlation between lumbar dural sac diameter, dural sac length (DSL), and dural sac volume (DSV), measured by ultrasound, and the intrathecal spread of isobaric bupivacaine during combined spinal-epidural (CSE) analgesia for labor.
We examined 41 women with singleton pregnancies requesting neuraxial analgesia for labor. Using a 5-2-MHz curved-array ultrasound probe in the paramedian sagittal plane, we measured the dural sac width at each lumbar interspace and the DSL from L1-2 to L5-S1 interspace and calculated the dural sac volume (DSV). Following CSE block with 0.25% isobaric bupivacaine 1.75 mg and fentanyl 15 μg, peak sensory levels (PSLs) were recorded using ice, cotton, and pinprick. Statistical correlation coefficients between dural sac dimensions and PSLs were assessed by Spearman rank correlation. In addition, multiple linear regression models were used to select important predictors of PSLs.
There was a moderate correlation between DSL and PSL to ice (ρ = -0.62; P < 0.0005) and to pinprick (ρ = -0.52; P = 0.017). Similarly, there was a moderate correlation between DSV and PSL to ice (ρ = -0.56; P = 0.004) and to pinprick (ρ = -0.61; P < 0.0008). Neither the DSL nor DSV correlated with PSL to cotton. Multiple linear regression analysis revealed that DSL, weight, and body mass index contributed to PSLs.
The length of the lumbar spine determined by ultrasound, rather than the lumbar spine volume, combined with the weight or body mass index of the subject, is of particular value in predicting the intrathecal spread of isobaric bupivacaine during CSE analgesia for labor.
To critically review the best available studies evaluating the efficacy of lumbosacral transforaminal epidural steroid injections (TFESIs) in the treatment of radicular pain.
MEDLINE, EMBASE, and the Cochrane database were searched for the period between 1950 and May 2008. Search terms included epidural steroid injection (ESI), transforaminal ESI, foraminal ESI, selective nerve root block, nerve root injection (NRI), selective NRI, periradicular infiltration, and periradicular injection. Randomized controlled trials (RCTs), published in English, which evaluated the efficacy of fluoroscopically guided TFESIs were reviewed.
Studies were analyzed with a quality checklist modeled after the 2001 CONSORT Statement: Revised Recommendations for Improving the Quality of Reports of Parallel-Group Randomized Trials. Nine studies were found to include a majority of these items.
Data included study design, inclusion criteria, symptom duration, randomization protocol, blinding protocol, intervention, control, outcomes, follow-up, dropout, statistical analysis, and conclusions.
Each article was assigned a level of evidence: I (high-quality RCT) or II (RCT with <80% follow-up, no blinding or improper randomization). Studies were divided according to control, and overall evidence was graded as A (good), B (fair), C (conflicting/poor quality), or I (insufficient).
There is fair evidence supporting TFESIs as superior to placebo for treating radicular symptoms. There is good evidence that TFESIs should be used as a surgery-sparing intervention, and that TFESIs are superior to interlaminar ESIs (ILESIs) and caudal ESIs for radicular pain. In patients with subacute or chronic radicular symptoms, there is good evidence that a single TFESI has similar efficacy as a single transforaminal injection of bupivacaine or saline. Future studies should address the ideal number of injections. While more placebo-controlled trials are needed to conclusively define the role of TFESIs, current studies support their use in the treatment of lumbosacral radicular pain.
To determine the effects of lumbosacral transforaminal and caudal epidural betamethasone injections on blood glucose levels in diabetic subjects. The hypothesis is that epidural steroid injections result in transient elevation of blood glucose levels in diabetic subjects.
This is a prospective, observational cohort. Twelve diabetic subjects (6 non-insulin-dependent and 6 insulin-dependent) receiving lumbosacral or caudal epidural betamethasone injections for neurogenic claudication or radicular pain were studied. Spinal level and approach were decided based on symptoms, pathology, and magnetic resonance imaging findings. Subjects recorded their finger stick blood glucose levels twice daily for 3 days before the injection, the day of the injection, and 3 days after the injection.
A tertiary, university-based, spine center.
Inclusion criteria included diabetic subjects (age 18 years) with the ability and willingness to monitor and report their blood glucose. Exclusion criteria included epidural steroid injections (ESIs) within the previous 2 months or peripheral corticosteroid injections within the previous 2 weeks. Nineteen subjects initially enrolled, and 12 successfully completed the study.
After informed consent was obtained, subjects underwent fluoroscopically guided lumbosacral transforaminal ESIs (TFESIs) or caudal ESIs, using contrast to confirm targeted needle placement and to rule out vascular uptake.
Subjects recorded morning and evening blood glucose (mg/dL) via glucometer.
There was a 106 mg/dL average elevation in blood glucose level on the evening of the injection day. The blood glucose elevation remained statistically significant for 3 days after the injection (P < .002). Blood glucose remained elevated through postinjection day 2, though these elevations were not statistically significant.
Lumbosacral transforaminal and caudal epidural betamethasone injections are associated with statistically significant elevations in blood glucose levels in diabetic subjects. This effect peaked on the day of the injection and lasted approximately 2 days.
Prospective, double-blind, randomized, case-control study.
To evaluate the efficacy of caudal epidural injections (CEI) containing steroid versus nonsteroid preparations when treating patients suffering from low back pain (LBP) and sciatica.
Literature seems to be deprived of well-designed randomized, controlled studies that evaluate the effectiveness of CEI in the treatment of chronic LBP; hence the value of CEI remains still the subject of controversy.
Patients suffering from severe chronic LBP and sciatica were randomly allocated into 2 groups. Steroid-group's patients (n = 93) underwent CEI containing 12 mL of xylocaine 2% and 1 mL of betamethasone dipropionate and betamethasone phosphate (2 + 5) mg/dL. Water for Injection (WFI)-group's patients (n = 90) underwent CEI containing 12 mL of xylocaine 2% and 8 mL of WFI. Both groups were statistically comparable as far as their demographic data and the cause and duration of symptoms were concerned. Patients answered the Oswestry Disability Index questionnaire and underwent physical examination, before and at 1 week, 1 month, 6 months, and 1 year following the CEI.
Symptoms improved in 132 patients (72.1%) following CEI. The mean Oswestry Disability Index questionnaire score of steroid-group's patients was statistically significant lower than that of the WFI-group at all postinjection re-evaluations. Patients receiving steroid CEI experienced faster relief during the first postinjection week. The Straight Leg Rising test improved in both groups following CEI; this improvement was faster among steroid-group's patients. Fifty-one patients (27.8%), noticed no improvement 1 week post-CEI and underwent a second CEI (with the same preparation) 7 to 14 days later. Nineteen of them reported improvement; 32 (steroid-group:13, WFI-group:19) did not respond well and underwent operative decompression (n = 15) or spinal fusion (n = 17).
CEI containing local anesthetic and steroids or WFI seems to be effective when treating patients with LBP and sciatica. CEI containing steroid preparations demonstrated better and faster efficacy.
Randomized single-blind controlled trial.
We aimed to compare the effects of epidural steroid injections and physical therapy program on pain and function in patients with lumbar spinal stenosis (LSS).
LSS is one of the most common degenerative spinal disorders among elderly population. Initial treatment of this disabling painful condition is usually conservative including analgesics, nonsteroidal anti-inflammatory drugs, exercise, physical therapy, or epidural steroid injections. Owing to lack of sufficient data concerning the effectiveness of conservative treatment in LSS, we aimed to compare the effectiveness of epidural steroid injections and physical therapy program in a randomized controlled manner.
A total of 29 patients diagnosed as LSS were randomized into 3 groups. Group 1 (n = 10) received an inpatient physical therapy program for 2 weeks, group 2 (n = 10) received epidural steroid injections, and group 3 (n = 9) served as the controls. All study patients additionally received diclofenac and a home-based exercise program. The patients were evaluated at baseline, 2 weeks, 1 month, 3 months, and 6 months after treatment by finger floor distance, treadmill walk test, sit-to-stand test, weight carrying test, Roland Morris Disability Index, and Nottingham Health Profile.
Both epidural steroid and physical therapy groups have demonstrated significant improvement in pain and functional parameters and no significant difference was noted between the 2 treatment groups. Significant improvements were also noted in the control group. Pain and functional assessment scores (RMDI, NHP physical activity subscore) were significantly more improved in group 2 compared with controls at the second week.
Epidural steroid injections and physical therapy both seem to be effective in LSS patients up to 6 months of follow-up.
To report a rare case of complicated paraplegia caused by a spontaneous epidural hematoma following an epidural steroid injection in a patient with unrecognized chronic idiopathic thrombocytopenic purpura (ITP) and to review relevant literature and discuss etiology, pathogenesis, and clinical features.
A spinal epidural hematoma is a rare but potentially catastrophic complication, which could develop in patients without any risk factors. Some patients with chronic ITP are asymptomatic. To our knowledge there has been no previous report of such a complication.
This is a retrospective review of a case seen at our institution.
The authors present a case of a 67-year-old woman who received an epidural steroid injection following complaints of lower back pain and bilateral buttock and leg pain. One day later, the patient had right leg numbness and weakness extending to her right knee; she was taken for emergency surgery. An emergency magnetic resonance imaging revealed an epidural hematoma with high-signal intensity on T2 imaging in the lumbar spinal cord and spinal cord compression with subdural hematoma. One week later, she was progressively developing lower extremity paraplegia with an L1 motor level and no sensory or sphincter activity. She was taken from the emergency room at our institution to the operating room for emergency decompression. After an uneventful course for 1 year, the patient presented with progressive bilateral lower extremity paralysis.
Epidural steroid therapy is a commonly used conservative therapy; however, complications could develop in patients without any risk factors. Clinicians who plan an epidural steroid injection must perform a rigorous evaluation through a detailed physical examination, simple laboratory tests, and history taking to prevent various risks associated with spinal cord compression.
To systematically assess benefits and harms of nonsurgical interventional therapies for low back and radicular pain.
Although use of certain interventional therapies is common or increasing, there is also uncertainty or controversy about their efficacy.
Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of local injections, botulinum toxin injection, prolotherapy, epidural steroid injection, facet joint injection, therapeutic medial branch block, sacroiliac joint injection, intradiscal steroid injection, chemonucleolysis, radiofrequency denervation, intradiscal electrothermal therapy, percutaneous intradiscal radiofrequency thermocoagulation, Coblation nucleoplasty, and spinal cord stimulation. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and by Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force.
For sciatica or prolapsed lumbar disc with radiculopathy, we found good evidence that chemonucleolysis is moderately superior to placebo injection but inferior to surgery, and fair evidence that epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. We found fair evidence that spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. We found good or fair evidence that prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. Insufficient evidence exists to reliably evaluate other interventional therapies.
Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.
Little attention has been afforded to the potential adverse sequelae of withholding anticoagulation therapy in a patient after neuraxial interventions.
Presenting a case of thromboembolic stroke in a patient after holding warfarin for a lumbar epidural steroid injection, previously unreported in published literature. The discussion that follows reviews the guidelines available to reduce the risk of thromboembolic events in anticoagulated patients in the periprocedural period.
An 81-year-old female with radicular pain secondary to spinal stenosis had been seen on 5 previous occasions for lumbar epidural steroid injections. Prior to each procedure warfarin was held for 5-7 days with demonstrable reversal of anticoagulation to within the safe limits set for neuraxial techniques by the American Society of Regional Anesthesia and Pain Medicine. On the morning following the sixth injection the patient was admitted to the hospital for new onset slurred speech and left-sided hemiparesis. A computed tomography scan established an acute, localized infarct in the distribution of the right middle cerebral artery. Her symptoms were non-reversible and permanent.
Thromboembolism is a potentially devastating complication associated with atrial fibrillation. Twenty percent of thromboembolic events in patients with atrial fibrillation are fatal, and greater than 50% result in permanent disability. While thromboembolic events following a brief period of normalization of coagulation for interventions appear rare, so is the incidence of epidural hematomas. Considering the high mortality and permanent rate of disability with thromboembolic events associated with atrial fibrillation, perhaps it is time to balance our focus on the complications of withholding anticoagulation with those of bleeding.
A systematic review of randomized controlled trials (RCTs).
To determine if injection therapy is more effective than placebo or other treatments for patients with subacute or chronic low back pain.
The effectiveness of injection therapy for low back pain is still debatable. Heterogeneity of target tissue, pharmacological agent, and dosage, generally found in RCTs, point to the need for clinically valid comparisons in a literature synthesis.
We updated the search of the earlier systematic review and searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE databases up to March 2007 for relevant trials reported in English, French, German, Dutch, and Nordic languages. We also screened references from trials identified. RCTs on the effects of injection therapy involving epidural, facet, or local sites for subacute or chronic low back pain were included. Studies that compared the effects of intradiscal injections, prolotherapy, or ozone therapy with other treatments were excluded unless injection therapy with another pharmaceutical agent (no placebo treatment) was part of one of the treatment arms. Studies about injections in sacroiliac joints and studies evaluating the effects of epidural steroids for radicular pain were also excluded.
Eighteen trials (1179 participants) were included in this review. The injection sites varied from epidural sites and facet joints (i.e. intra-articular injections, peri-articular injections and nerve blocks) to local sites (i.e. tender-and trigger points). The drugs that were studied consisted of corticosteroids, local anesthetics, and a variety of other drugs. The methodologic quality of the trials was limited with 10 of 18 trials rated as having a high methodologic quality. Statistical pooling was not possible because of clinical heterogeneity in the trials. Overall, the results indicated that there is no strong evidence for or against the use of any type of injection therapy.
There is insufficient evidence to support the use of injection therapy in subacute and chronic low-back pain. However, it cannot be ruled out that specific subgroups of patients may respond to a specific type of injection therapy.
To document the per patient rate of vasovagal reactions and other complications of cervical vs. lumbar translaminar epidural steroid injections.
Anecdotal observations at our institution suggested that vasovagal reactions are much more common during cervical epidural steroid injections than lumbar injections, and more frequent than previously reported.
Records of 249 patients undergoing their first cervical epidural steroid injection were reviewed for vasovagal reactions and other adverse events. For comparison, a first lumbar epidural steroid injection performed by the same staff physician was matched to each cervical procedure and reviewed for complications.
The incidence of vasovagal reaction was 7 points more common (P < 0.001, 95% confidence interval 0.04-0.12) in the cervical group (8%) than in the lumbar group (1%). This correlates to an additional vasovagal reaction for every 14 patients who were treated with cervical injection in comparison with those treated with lumbar injection.
The risk of vasovagal reaction is significantly higher for cervical translaminar epidural steroid injections than for lumbar injections. The risk of vasovagal reaction remained higher for cervical injection even when adjusting for differences between the two populations. The higher rate of cervical vasovagal reactions may result from a combination of anxiety, the prone position with neck flexed, head drapes, and stimulus from a neck procedure.
Increased vigilance for patients undergoing translaminar cervical epidural steroid injections may be warranted. Clinicians may choose to consider these results when counseling patients regarding risk and the need for conscious sedation during the procedure.
The purpose of this study was to assess the natural history of sciatica due to lumbosacral nerve root compromise and to evaluate the pathomorphologic changes that accompany the natural resolution of the disease. One hundred sixty-five consecutive patients, 114 males and 51 females, with an average age of 41 years (range, 17-72) and an average duration of symptoms of 4.2 months (range, 1-72) presenting with sciatica thought to be due to lumbosacral nerve root compromise were admitted to the study. The cornerstone of treatment was the serial epidural administration of steroid and local anesthetic by the caudal route on an outpatient basis. Lumbar epidural injection or periradicular infiltration at the appropriate level, confirmed under image intensifier, was the next step before considering surgical decompression. An average of three injections (range, 0-8) was received by each patient. Patients underwent clinical examination and computed tomography. Twenty-three patients (14%) underwent surgical decompression. The remainder were clinically assessed at 1 year after presentation, and 111 were rescanned at the appropriate levels. All conservatively managed patients made a satisfactory clinical recovery: average reduction of pain on the visual analog scale was 94% (range, 45-100), and 64 (76%) of the 84 disc herniations and 7 (26%) of the 27 disc bulges showed partial or complete resolution (chi-square = 20.27, P = 0.0001). Thus a high proportion of patients with discogenic sciatica make a satisfactory recovery with aggressive conservative management, and this recovery is accompanied by resolution of disc herniations in a significant number. Only a small proportion of patients needed surgical decompression.
The purpose of this study was to evaluate the natural history of morphologic changes within the lumbar spine in patients who sustained lumbar disc extrusions. All patients in this study were treated nonoperatively for radicular pain and neurologic loss. The following questions were addressed: 1) Does perithecal or perineural fibrosis result when extrusions are not removed surgically, and 2) Do disc extrusions spontaneously resolve, and, if so, how rapidly? The study population consisted of 11 patients with extrusions and radiculopathy. All patients were successfully treated nonoperatively. All had a primary complaint of leg pain and all had positive straight leg raising reproducing their leg pain at less than or equal to 60 degrees. Additionally, 87% had muscle weakness on a neurologic basis in a root level distribution corresponding to the site of disc pathology. Computed tomographic (CT) examinations were obtained on all patients at the inception of treatment. These studies were compared with follow-up MRI studies. The initial CT scans were evaluated for the following criteria: disc size and position, thecal sac effacement, nerve root enlargement or displacement, and evidence of central or intervertebral canal stenosis. In addition to the pathomorphology evaluated on the CT scans, follow-up MRI studies also evaluated disc hydration at the herniated and contiguous levels, and the presence of perithecal or perineural fibrosis. The following grading system was used to evaluate change in fragment size on the follow-up studies: Grade 1-0 to 50% decrease in size; Grade 2-50 to 75% decrease in size; Grade 3-75 to 100% decrease in size.(ABSTRACT TRUNCATED AT 250 WORDS)
LOW back pain is usually a self-limiting symptom, but it costs at least $16 billion each year1 , 2 and disables 5.4 million Americans.3 The fact that a benign physical condition has such an important socioeconomic effect can probably be explained by complex psychological, societal, and legal factors. This article emphasizes that simple treatment is sufficient for most patients with low back pain and sciatica. Timely surgical intervention for the minority of patients with sciatica and neurologic claudication who do not respond to conservative care, and aggressive rehabilitation for those disabled by chronic low back pain, will favorably influence the outcome in . . .
To determine the therapeutic value and long-term effects of fluoroscopic transforaminal epidural steroid injections in patients with refractory radicular leg pain.
Although numerous studies have evaluated the efficacy of traditional transsacral (caudal) or translaminar (lumbar) administration of epidural steroids, to our knowledge no studies have assessed specifically the therapeutic value of fluoroscopic transforaminal epidural steroids.
A prospective case series that investigated the outcome of patients with lumbar herniated nucleus pulposus and radiculopathy who received fluoroscopic transforaminal epidural steroid injections.
Patients who met our inclusion criteria received fluoroscopically guided, contrast-enhanced transforaminal epidural administration of anesthetic and steroid directly at the level and side of their documented pathology. Patients were evaluated by an independent observer and received sequential questionnaires before and after injection, documenting pain level, activity level, and patient satisfaction.
Sixty-nine patients met our inclusion criteria and were followed for an average period of 80 weeks (range, 28 to 144 weeks); 75.4% of patients had a successful long-term outcome, reporting at least a >50% reduction between preinjection and postinjection pain scores, as well as an ability to return to or near their previous levels of functioning after only 1.8 injections per patient (range, 1 to 4 injections). Of our patients, 78.3% were satisfied with their final outcomes.
Fluoroscopic transforminal epidural steroids are an effective nonsurgical treatment option for patients with lumbar herniated nucleus pulposus and radiculopathy in whom more conservative treatments are not effective and should be considered before surgical intervention.
Epidural corticosteroid injections provide lasting relief for selected patients with pain associated with lumbosacral radiculopathy and do not appear to be associated with substantial risk of neurologic dysfunction.
Combined prospective human cohort and prospective controlled animal model.
To determine whether free glutamate is available in herniated disc material in concentrations sufficient to diffuse to glutamate receptors and affect the activity of neurons in the dorsal root ganglion that may transmit pain information.
The severity of lumbar radicular pain cannot be fully explained by physical pressure on nerve roots or ganglions. In experimental models, inflammatory processes are relatively modest under conditions of disc herniation. The hypothesis for the current study was that the proteoglycan link and core proteins, which contain high fractions of acidic amino acids, may be a source of glutamate when enzymatically degraded in an environment without glutamate reuptake systems. Glutamate would be free to diffuse to the dorsal root ganglion to affect glutamate receptors.
Disc material was harvested during surgery from herniated and nonherniated portions in patients undergoing elective lumbar disc surgery and subjected to immunohistochemistry and high-performance liquid chromatography for assessment of the presence of extracellular disc matrix glutamate. Miniosmotic pumps with differing concentrations of radiolabeled glutamate based on human data were implanted in the rat epidural space for 72 hours and dorsal root ganglion (DRG) in the region were harvested.
Densitometry of disc matrix demonstrated immunohistochemical evidence for significant extracellular glutamate (P < 0.002). High performance liquid chromatography showed significant concentrations of glutamate in disc material and significantly more in herniated than in nonherniated disc material (P < 0.05). Significant radiolabeling of the dorsal root ganglion after epidural glutamate infusion was found at concentrations two orders of magnitude below measured disc glutamate levels. Autoradiography demonstrated radiolabeling of adjacent DRG.
Glutamate originating from degenerated disc proteoglycan may diffuse to the dorsal root ganglion and effect glutamate receptors. Consideration may be given to treating disc radiculopathy with epidural glutamate receptor antagonists.
Pilot study comparing the short-term efficacy on pain and functional impairment of nerve root sheath versus interspinous glucocorticoid injections in patients admitted to a French rheumatology department for disk-related sciatica or femoral neuralgia.
Thirty patients with refractory nerve root pain (sciatica, n = 29; femoral neuralgia, n = 1) for a mean of four months were randomized to nerve root injection (n = 17) or interspinous injection (n = 13) of the same mixture of 0.10 g of lidocaine hydrochloride and 3.75 mg of cortivazol. Both injection methods were performed under analgesia and benzodiazepine sedation to maintain double blinding. Each patient was evaluated daily during the first seven days of bed rest in the hospital, then after discharge on postinjection day 28.
Prompt pain relief was obtained in both groups. On day 1, the mean pain scale score (0-100) fell from 70 +/- 3.9 to 26 +/- 5.6 in the nerve root group and from 63 +/- 4 to 23 +/- 4.7 in the interspinous group. These results were sustained on D7 and D28.
The unusually high level of efficacy of glucocorticoid injection in our study may be ascribable in part to strong placebo and Hawthorne effects and in part to the intrinsic effects of the injections. Whether nerve root injection is superior over interspinous injection remains unproven.
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.
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.
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.
To identify the short- and long-term therapeutic benefit of fluoroscopically guided lumbar transforaminal epidural steroid injections in patients with radicular leg pain from degenerative lumbar stenosis.
This prospective cohort study performed at a multidisciplinary spine center. There were a total of 34 patients who met our inclusion criteria for the treatment of unilateral radicular pain from degenerative lumbar spinal stenosis who underwent fluoroscopically guided lumbar transforaminal epidural injections. Patients with radiculopathy, who did not respond to physical therapy, antiinflammatories, or analgesics, caused by degenerative lumbar stenosis and confirmed by magnetic resonance imagining received fluoroscopically guided lumbar transforaminal epidural steroid injections at the presumed symptomatic nerve root. The injectant consisted of 12 mg of betamethasone acetate and 2 ml of 1% preservative-free lidocaine HCL. Patients were evaluated by an independent observer and received questionnaires before the initial injection, at 2 mo, and at 12 mo after the injections. Questionnaires included a visual analog scale, Roland 5-point pain scale, standing/walking tolerance, and patient satisfaction scale.
A total of 34 patients met our inclusion criteria and were followed for 1 yr. Seventy-five percent of patients had successful long-term outcome, reporting at least a >50% reduction between preinjection and postinjection pain scores, with an average of 1.9 injections per patient. Sixty-four percent of patients had improved walking tolerance, and 57% had improved standing tolerance at 12 mo.
Fluoroscopically guided transforaminal epidural steroid injections may help reduce unilateral radicular pain and improve standing and walking tolerance in patients with degenerative lumbar spinal stenosis.
STUDY DESIGN A prospective, observational, human, study was conducted. OBJECTIVES To evaluate the incidence of vascular penetration during fluoroscopically guided, contrast-enhanced transforaminal cervical epidural steroid injections, and to determine whether the observation of blood in the needle hub can be used to predict a vascular injection. SUMMARY OF BACKGROUND DATA Incorrectly placed intravascular cervical spinal injections result in medication flow systemically and not to the desired target. A recently published study demonstrates a high incidence of intravascular injections in transforaminal lumbosacral epidural injections. No studies so far have evaluated the incidence of vascular injections in transforaminal cervical epidural steroid injections, nor have they calculated the ability of observed blood in the needle hub to predict a vascular injection in the cervical spine.METHODS The incidence of fluoroscopically confirmed intravascular uptake of contrast was prospectively observed in 337 patients treated with cervical transforaminal epidural steroid injections. The ability of observed blood in the needle hub to predict intravascular injection was also investigated. For each subject, the injection level was chosen on the basis of the clinical scenario including history, physical examination, and review of imaging studies. Some patients had multilevel injections. Using fluoroscopic guidance, the authors placed a 25-gauge needle into the epidural space using a transforaminal approach according to accepted standard technique. Needle tip location was confirmed with biplanar imaging. The presence or absence of blood in the needle hub spontaneously ("flash") and after attempted aspiration by pulling back on the syringe's plunger was documented. Contrast then was injected under real-time fluoroscopy to determine whether the location of the needle tip was intravascular. The results were recorded in a prospective manner indicating the presence or absence of blood in the needle hub and whether a vascular pattern was noted with contrast injection, and these were correlated. Relevant epidemiologic data also were recorded. RESULTS The study included 504 transforaminal epidural steroid injections. The overall rate of fluoroscopically confirmed intravascular contrast injections was 19.4%. Use of observed blood in the needle hub to predict intravascular injections was 97% specific, but only 45.9% sensitive. There was no significant difference in intravascular rates related to age or gender. CONCLUSIONS As compared with a previous study of lumbosacral epidural steroid injections, there is an overall higher incidence of intravascular injections with cervical transforaminal epidural steroid injections. Use of observed blood in the needle hub to predict an intravascular injection is not sensitive, and therefore the absence of blood in the needle hub despite aspiration is not reliable. The reported sensitivity and specificity rates are similar to lumbar data. Fluoroscopically guided procedures without contrast confirmation instill medications intravascularly, and therefore not in the desired epidural location. This study confirms that there is a need not only for fluoroscopic guidance, but also for contrast instillation in cervical transforaminal epidural steroid injections.
A prospective, randomised, double-blind study was carried out to compare the respective efficacies of transforaminal and interspinous epidural corticosteroid injections in discal radiculalgia. Thirty-one patients (18 females, 13 males) with discal radicular pain of less than 3 months' duration were consecutively randomised to receive either radio-guided transforaminal or blindly performed interspinous epidural corticosteroid injections. Post-treatment outcome was evaluated clinically at 6 and 30 days, and then at 6 months, but only by mailed questionnaire. At day 6, the between-group difference was significantly in favour of the transforaminal group with respect to Schober's index, finger-to-floor distance, daily activities, and work and leisure activities on the Dallas pain scale. At day 30, pain relief was significantly better in the transforaminal group. At month 6, answers to the mailed questionnaire still showed significantly better results for transforaminal injection concerning pain, daily activities, work and leisure activities and anxiety and depression, with a decline in the Roland-Morris score. In recent discal radiculalgia, the efficacy of radio-guided transforaminal epidural corticosteroid injections was higher than that obtained with blindly-performed interspinous injections.
Epidural steroid injection (ESI) is one of the most common nonsurgical interventions prescribed for back and leg pain symptoms. Although the use of ESI is widespread, proof of efficacy among the broad population of low back pain patients is lacking and use is predicated to a great extent on the cost and morbidity of the perceived "next step" in many patient's care-surgery.
To review the relative indications and clinical features that predict success with ESI therapy, and to provide a physiological rationale to guide clinical decision-making.
Review of literature and clinical experience.
Clinical studies have alternately supported and refuted the efficacy of ESI in the treatment of patients with back and leg pain. Steroid medications do benefit some patients with radicular pain, but the benefit is often limited in duration, making efficacy difficult to prove over time. Steroids appear to speed the rate of recovery and return to function, however, allowing patients to reduce medication levels and increase activity while awaiting the natural improvement expected in most spinal disorders. Fluoroscopic verification of needle placement, with contrast injection, greatly improves steroid delivery while reducing risks. Although it is assumed that the benefit of steroids is related to their effect on inflammation, that remains unproven, and it is possible that benefit is gained through an unrecognized action.
Randomized, controlled trials are needed to conclusively identify those patients most likely to benefit from ESI, and when and for how long. Until then, epidural steroids provide a reasonable alternative to surgical intervention in selected patients with back and/or leg pain, whose symptoms are functionally limiting. When appropriate goals are established and proper patients are selected, sufficient short-term benefit has been documented to warrant continued use of this tool.
A randomized, double-blind controlled trial.
To determine the treatment effect of corticosteroids in periradicular infiltration for chronic radicular pain. We also examined prognostic factors in relation to the outcome of the procedure.
Various studies have examined the therapeutic value of periradicular infiltration using treatment agents consisting of local anesthetic and corticosteroids for radicular pain, secondary to lumbar disc herniation and spinal stenosis. There is currently no randomized trial to determine the efficacy of a single injection of corticosteroids for chronic radicular pain.
Eligible patients with radicular pain who had unilateral symptoms who failed conservative management were randomized for a single injection with bupivacaine and methylprednisolone or bupivacaine only. Outcome measures included the Oswestry Disability Index, visual analogue score for back pain and leg pain, claudication walking distance, and the patient's subjective level of satisfaction of the outcome.
We recruited 43 patients in the bupivacaine and methylprednisolone group and 43 patients in the bupivacaine only group. The follow-up rate is 100%. Five patients had early termination of the trial for discectomy and further root block. There is no statistically significant difference in the outcome measures between the groups at 3 months (change of the Oswestry Disability Index [P = 0.68], change in visual analogue score [back pain, P = 0.68; leg pain, P = 0.94], change in walking distance [P = 0.7]). Duration of symptoms has a statistically significant negative association with the change in Oswestry Disability Index (P = 0.03).
Clinical improvement occurred in both groups of patients. Corticosteroids did not provide additional benefit.
To critically review the best available trials of the utility of transforaminal epidural steroid injections (TFESIs) or selective nerve root blocks (SNRBs) to treat lumbosacral radiculopathy.
MEDLINE (PubMed, Ovid, MDConsult), EMBASE, and the Cochrane database. Databases were searched from inception through 2003.
A database search was conducted by using the following key words: prospective , transforaminal and foraminal epidural steroid injections , selective nerve root block and injection , and periradicular and nerve root injection . We included English-language, prospective, randomized studies of patients with lower-limb radicular symptoms treated with fluoroscopically guided nerve root or transforaminal epidural injections.
Data were compiled for each of the following categories: inclusion criteria, randomization protocol, total number of subjects enrolled initially and at final analysis, statistical analysis utilized, documentation of technique, outcome measures, follow-up intervals and results (positive or negative), and reported complications. These data were abstracted by 1 reviewer and reviewed by a second. Study quality was assessed with the system developed by the Agency for Health Care and Policy Research.
We selected 6 articles for review. Our analysis identified a single article as the highest quality study addressing the appropriate use of TFESIs or therapeutic SNRBs. Coupled with the evidence provided by 4 other articles (1 article was excluded because its patients were not truly randomized), our review of the evidence for TFESIs found level III (moderate) evidence in support of these minimally invasive and safe procedures in treating painful radicular symptoms. However, conclusive evidence (level I) is lacking.
The evidence for TFESIs reveals level III (moderate) evidence in support of these minimally invasive and safe procedures in treating painful lumbar radicular symptoms. Current studies support use of TFESIs as a safe and minimally invasive adjunct treatment for lumbar radicular symptoms. However, more prospective, randomized, placebo-controlled studies using sham procedures are needed to provide conclusive evidence for the efficacy of TFESIs in treating lumbar radicular symptoms.
In a previous prospective, randomized, controlled, double-blinded study on the effect of nerve root blocks on the need for operative treatment of lumbar radicular pain, we found that injections of corticosteroids were more effective than bupivacaine for up to thirteen to twenty-eight months. We performed a minimum five-year followup of those patients who had avoided surgery.
All of the patients were considered to be operative candidates by the treating surgeon, and all had initially requested operative intervention. They had then been randomized to be treated with a selective nerve-root block with either bupivacaine or bupivacaine and betamethasone. Both the treating physician and the patient were blinded to the type of medication. Of fifty-five randomized patients, twenty-nine avoided an operation in the original study. Twenty-one of those twenty-nine patients were reevaluated with a follow-up questionnaire at a minimum of five years after the initial block.
Seventeen of the twenty-one patients still had not had operative intervention. There was no difference between the group treated with bupivacaine alone and the group treated with bupivacaine and betamethasone with regard to the avoidance of surgery for five years. At the five-year follow-up evaluation, all of the patients who had avoided operative treatment had significant decreases in neurological symptoms and back pain compared with the baseline values.
The majority of patients with lumbar radicular pain who avoid an operation for at least one year after receiving a nerve root injection with bupivacaine alone or in combination with betamethasone will continue to avoid operative intervention for a minimum of five years.
Based on the available evidence, the Therapeutics and Technology Assessment subcommittee concluded that 1) epidural steroid injections may result in some improvement in radicular lumbosacral pain when assessed between 2 and 6 weeks following the injection, compared to control treatments (Level C, Class I-III evidence). The average magnitude of effect is small and generalizability of the observation is limited by the small number of studies, highly selected patient populations, few techniques and doses, and variable comparison treatments; 2) in general, epidural steroid injection for radicular lumbosacral pain does not impact average impairment of function, need for surgery, or provide long-term pain relief beyond 3 months. Their routine use for these indications is not recommended (Level B, Class I-III evidence); 3) there is insufficient evidence to make any recommendation for the use of epidural steroid injections to treat radicular cervical pain (Level U).
To determine a critical canal dimension in patients with spinal stenosis that predicts response to epidural steroid injections (ESI).
Lumbar spinal stenosis patients with a computed tomography scan before ESI were identified through ICD-9/CPT codes. Using a digital caliper, canal dimensions on axial cuts of each lumbar intervertebral level were recorded: the transverse canal diameter in line with the facets including the soft tissues, TC; the transverse osseous canal diameter, OS; and the mid-sagittal anteroposterior diameter, MS. Minimum and maximum measurements were determined. Patients who improved after ESI and those that required a decompression after ESI were differentiated.
Eighty-four patients were included in the study. Fifty required surgical decompression after ESI and 34 patients improved after ESI. There were no statistically significant differences in the demographics between the 2 groups. Mean minimum dimensions in the surgical group were 9.47 mm (TC), 16.53 mm (OS), and 12.40 mm (MS); and 9.75 mm (TC), 16.65 mm (OS), and 12.39 mm (MS) in the nonsurgical group. Mean ratio between the maximum and minimum dimensions in the surgical group was 1.76 (TC), 1.35 (OS), and 1.57 (MS); and 1.86 (TC), 1.47 (OS), and 1.63 (MS) in the nonsurgical group. There was no statistically significant difference in the minimum measurement in any dimension between the surgical and the nonsurgical group. There was also no statistically significant difference in the ratio between the minimum and maximum measurement in any dimension between the surgical and the nonsurgical group.
Spinal canal dimension is not predictive of success or failure of ESI in patients with spinal stenosis.
Lumbar epidural steroid injection can be accomplished by one of three methods: caudal (C), interlaminar (IL), or transforaminal (TF). In this study we sought to determine the efficacy of these techniques for the management of radicular pain associated with lumbar disk herniations.
Ninety patients aged 18-60 years with L5-S1 disk herniations and radicular pain were randomly assigned to one of these groups to have epidural steroid injection therapy every 2 wk for a maximum of three injections. Pain relief, disability, and activity levels were assessed.
Pain relief was significantly more effective with TF injections. At 24 wk from the initiation of this study, pain relief was as follows: C: complete pain relief: 1/30, partial pain relief: 16/30, and no relief: 13/30; IL: complete pain relief: 3/30, partial pain relief: 15/30, and no relief: 12/30; and TF: complete pain relief: 9/30, partial pain relief: 16/30, and no relief: 5/30.
The TF route of epidural steroid placement is more effective than the C or IL routes. We attribute this observation to a higher incidence of steroid placement in the ventral epidural space when the TF method is used.
To prospectively evaluate the short- and midterm effectiveness of transforaminal epidural steroid injection (TFESI) for lumbosacral radiculopathy with respect to injection level.
Institutional review board approval and written informed consent were obtained. From March 2005 to February 2006, 239 consecutive patients (106 male, 133 female; mean age, 49.8 years; range, 13-82 years) who were scheduled to undergo lumbar TFESI were enrolled. The patients were randomly assigned to either the ganglionic (TFESI at the location of the exiting nerve root) or preganglionic group (TFESI at the supraadjacent intervertebral disk level). Follow-up was conducted within 1 month (short term) and more than 6 months (midterm) after injections. Short- and midterm outcomes were measured by using a visual analog scale and a four-grade scale. Univariate analysis (by using the Fisher exact and chi(2) tests) and multiple logistic regression analysis were performed to evaluate the relationship between possible outcome predictors (ganglionic or preganglionic injection levels, cause of radiculopathy, duration of symptoms, age group, and sex) and the therapeutic effect.
Univariate analysis showed that the preganglionic group had a better treatment effect (99 of 112, 88.4%) than did the ganglionic group (90 of 127, 70.9%) at short-term follow-up (P = .001). Multiple logistic regression analysis showed that the only significant outcome predictor at short-term follow-up was injection level (odds ratio = 2.232, P = .037). No significant difference was identified regarding TFESI approach or cause of radiculopathy at midterm follow-up.
TFESI for lumbosacral radiculopathy with a preganglionic approach is more effective than TFESI with a ganglionic approach at short-term follow-up.
Lumbar midline interlaminar and transforaminal (TF) epidural steroid injections are treatments for low back pain with radiculopathy secondary to degenerative disk disease. Since pain generators are located anteriorly in the epidural space, ventral epidural spread is the logical target for placement of antiinflammatory medications. In this randomized, prospective, observational study, we compared contrast flow patterns in the epidural space using the parasagittal interlaminar (PIL) and transforaminal approaches with continual fluoroscopic guidance.
Sixty adult patients with low back pain and unilateral radiculopathy from herniated or degenerated discs were enrolled. Subjects were randomly assigned to one of two groups: TF or PIL (30 in each). All procedures were performed using continual fluoroscopic guidance and 5 mL of contrast. Contrast spread was rated (primary outcome measure) by the interventionalist. Spread was scored 0-2, with 0 = no anterior spread; 1 = anterior spread, same level as needle insertion; and 2 = anterior spread at > or = 1 segmental level. The secondary outcome measure was analgesia at 2 wk, 1, 3, and 6 mo.
One hundred percent (29 of 29) patients in the PIL group and 75% (21 of 28) patients in the TF group demonstrated anterior epidural spread. The mean spread grade was 1.93 (95% confidence interval [CI], 1.83-2.0) in the PIL group and 1.46 (95% CI, 1.17-1.46) in the TF group (P = 0.003). Mean fluoroscopy time was 28.96 s (95% CI, 23.9-34.1 s) in the PIL group and 46.25 s (95% CI, 36.27-56.23 s) in the TF group (P = 0.003). Visual analog scale scores were equivalent between groups.
The PIL approach is superior to the TF approach for placing contrast into the anterior epidural space with reduction in fluoroscopy times and an improved spread grade. With increasing attention to neurological injury associated with TF, the PIL approach may be more suitable for routine use.
To determine the current evidence to support guidelines for frequency and timing of epidural steroid injections (ESIs), to help determine what sort of response should occur to repeat an injection, and to outline specific research needs in these areas.
A PubMed, Medline (EBSCO), and Cochrane library search (January 1971-December 2005), as well as additional references found from the initial search.
There were no studies that specifically addressed the objectives outlined. Eleven randomized controlled trials, 1 prospective controlled trial, and 2 prospective cohort studies were identified that included a protocol involving repeat epidural injections for radicular pain secondary to herniated nucleus pulposus or spinal stenosis. One qualitative survey was also identified. Five review articles were also included that discussed this topic.
Data were extracted from clinical trials if they included the following: (1) protocols in clinical trials on ESIs that included repeat injections and the response required to trigger these injections, (2) any evidence given for establishing these protocols, and (3) similar studies that included only 1 injection. Specific mention of repeat ESIs and partial response that was mentioned in review articles was also included.
There is limited evidence to suggest guidelines for frequency and timing of ESIs or to help to define what constitutes the appropriate partial response to trigger a repeat injection. No study has specifically evaluated these objectives. Methodologically limited research suggests that repeat injections may improve outcomes, but the evidence is insufficient to make any conclusions.
There does not appear to be any evidence to support the current common practice of a series of injections. Recommendations for further research are made, including a possible study design.
To describe and answer questions concerning the spread of contrast in patients receiving correctly placed lumbar epidural steroid injections (ESIs) under fluoroscopy.
Prospective observational study.
An outpatient surgery center.
Consecutive patients (N=114) receiving ESIs under fluoroscopy who met inclusion criteria.
Spread of contrast in relation to variables, including unilateral versus bilateral, anterior versus posterior, and spread more than 1 level caudally versus less than 1 level. Variables were examined in relation to needle tip placement, level of injection, and male versus female patients. All data were collected with fluoroscopy images in lateral and anteroposterior views after injection of 5 mL of fluid.
Spread was greater than 1 segment caudally more than 75% of the time under all variables. Anterior versus posterior epidural spread on the lateral view was approximately even over all cases and anterior spread was found more often when the needle was within the width of the distal spinous process tip. Needle placement medial or lateral to the spinous process width also significantly affected whether the spread was unilateral versus bilateral. If the needle tip was lateral to the width of the spinous process, spread was unilateral 75% of the time, versus 45% of the time if the needle tip was medial.
Contrast spread is affected by needle placement, with other variables kept equal, in the performance of an interlaminar lumbar ESI. These data support the performance of interlaminar lumbar ESIs with fluoroscopic guidance and provide some parameters with which to guide the injectionist.
The purpose of this study was to document particulate size in commonly used corticosteroid preparations. Inadvertent injection of particulate corticosteroids into a vertebral or foraminal artery can cause brain and spinal cord embolic infarcts and the size of the particles could be directly related to the chance that a clinically significant infarct would occur. One might assume that corticosteroids with particles significantly smaller than red blood cells might be safer.
The following four types of corticosteroid preparations were used in various solutions and evaluated under light microscopy: dexamethasone sodium phosphate injection, triamcinolone acetonide injectable suspension, betamethasone sodium phosphate and betamethasone acetate injectable suspension, and methylprednisolone acetate injectable suspension.
Dexamethasone sodium phosphate particle size was approximately 10 times smaller than red blood cells and the particles did not appear to aggregate; even mixed with 1% lidocaine HCl solution and with contrast dye, the size of the particles were unchanged. Triamcinolone acetonide and betamethasone sodium phosphate showed variable sizes; some particles were larger than red blood cells, and aggregation of particles was evident. Methylprednisolone acetate showed uniformity in size and the majority were smaller than red blood cells which were not aggregated, but the particles were densely packed.
Compared with the particulate steroid solutions, dexamethasone sodium phosphate had particles that were significantly smaller than red blood cells, had the least tendency to aggregation, and had the lowest density. These characteristics should significantly reduce the risk of embolic infarcts or prevent them from occurring after intra-arterial injection. Until shown otherwise in clinical studies, interventionalists might consider using dexamethasone or another corticosteroid preparation with similar high solubility and negligible particle size when performing epidural injections.
Prospective validity study.
To determine how accurately intermittent fluoroscopy detects inadvertent intravascular injection during transforaminal epidurals.
Serious morbidity caused by transforaminal epidural injections is frequently related to inadvertent vascular injection of corticosteroids. Several methods have been proposed to reduce the risk of vascular injection, but none have demonstrated efficacy. Because of the fleeting appearance of vascular contrast patterns, live fluoroscopy is recommended during contrast injection. Despite this, many practitioners continue to use intermittent fluoroscopy.
During 50 epidural injections dynamic contrast flow was observed under live fluoroscopy, and the "dynamic true" image was determined. Two intermittent fluoroscopy images were saved from each injection, the first just before completing the contrast injection ("static C" image), and another 1 second after the contrast injection ceased ("static PC" image). Five physicians with experience performing these injections independently interpreted the 100 randomly ordered static images. Accuracy of intermittent fluoroscopy was determined by comparing the interpretation of the 100 static images with the dynamic true patterns observed under live fluoroscopy.
Overall, interpretation of the static images missed 57% of the vascular injections. Timing of the static images influenced accuracy with the static C images missing 50% of vascular injections, and the static PC images missing 68% of vascular injections (P = 0.075). Accuracy was significantly worse when vascular injections occurred simultaneous to the expected epidural injection (P = 0.041), and in lumbar images (P = 0.012).
Based on these findings, we recommend use of live fluoroscopy to observe dynamic contrast flow during transforaminal epidural steroid injections.