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Effective radiation dose reduction in computed tomography-guided spinal injections: a prospective, comparative study with technical considerations.

Authors Artner J , Lattig F , Reichel H , Cakir B
Journal Orthopedic reviews
Year 2012
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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Despite the good general patient acceptance, high patient comfort, safety and precision in the needle placement, exposure to radiation in computed tomography (CT)-guided spinal interventions remains a serious concern, and is often used to argue against its use. The aim of this study was to determine the technical possibilities of reducing the radiation dose in CT-guided epidural and periradicular injections in lumbar spine. We evaluated the possibilities of reducing radiation dose to the patient and operator during CT-guided injections on the lumbar spine using the following steps: significant reduction of the tube current and energy used for the topogram-acquisition, narrowing the area of interest in spiral CT-mode and reduction of tube current and radiation energy in the final intervention mode. Fifty-three CT-guided spinal injections were performed in the lumbar spine (34 epidural lumbar, 19 lumbar periradicular) using a low-dose protocol in non-obese patients and compared with 1870 CT-guided injections from the year 2010, when a standard dose protocol was used. Technical considerations on radiation dose reduction were provided. An average dose reduction of 85% was achieved using the low-dose protocol in CT-guided epidural and periradicular injections in lumbar spine without showing any effect on safety or precision.

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CT-guided transforaminal epidural injections with local anesthetic, steroid, and tramadol for the treatment of persistent lumbar radicular pain.

Journal Pain physician
Year 2012
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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BACKGROUND: A substantial number of patients with persistent lumbar radicular pain are treated with a multimodal spectrum of conservative therapies without lasting effect. The duration of pain is certainly a risk factor for chronification. There is evidence that guided periradicular infiltrations are a valid option in the treatment of radiculopathies. Usually a combination of local anesthetic and/or corticosteroid is injected. Tramadol is being used for perioperative analgesia and has been shown to provide effective, long-lasting pain relief after epidural administration. OBJECTIVE: The aim of this pilot study was to evaluate the efficacy of serial CT-guided transforaminal nerve root infiltrations with a supplement of tramadol for patients with persistent, radicular pain. STUDY DESIGN: Interventional cohort study. SETTING: Outpatient department for interdisciplinary pain medicine. METHODS: 37 patients who had radicular leg pain for over 9 weeks received up to 3 CT-guided transforaminal nerve root infiltrations at intervals of 2 weeks as long as their level of pain was over 3 on a numerical rating scale from 0 to 10. 50 mg of Tramadol were added to a combination of local anesthetic (Ropivacain, 2 mg) and corticosteroid (Triamcinolon, 40 mg). Evaluations were carried out 24 hours after the Infiltration as well as 2 weeks, 3 and 6 months after the treatment series. The intensity of their radicular pain was measured by a numerical rating scale (NRS). Pain reduction of at least 50% was defined as successful outcome. RESULTS: In total, 65 infiltrations were carried out with pain relief in more than 90% of the patients within 24 hours and an average pain reduction of 64%. Six months post-injection 23 of 34 patients available for follow-up (67.6%) had a successful pain reduction of 84% on average. No adverse effects ascribable to the use of tramadol were noted. LIMITATIONS: Due to the lack of a control group we cannot make any statement if tramadol improves short-term pain reduction. CONCLUSION: Fast and lasting pain relief is the key to optimize rehabilitation for patients with radicular pain. There is a physiological rationale that the opioid receptors at the spinal level could be used to optimize the analgetic effect of guided periradicular injections. In our case series, serial CT-guided selective nerve root infiltrations with the supplement of tramadol were found to be highly effective in the treatment of persistant radiculopathies. Randomized controlled trials will be necessary to clarify the possible benefit of the supplement of an opioid.

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Efficacy of interlaminar vs transforaminal epidural steroid injection for the treatment of chronic unilateral radicular pain: prospective, randomized study.

Authors Rados I , Sakic K , Fingler M , Kapural L
Journal Pain medicine (Malden, Mass.)
Year 2011
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This article is included in 4 Systematic reviews Systematic reviews (4 references) 1 Broad synthesis Broad syntheses (1 reference)

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UNLABELLED: OBJECTIVE, DESIGN AND SETTINGS: The purpose of this randomized, prospective study is to compare the efficacy of two different routes in administering epidural steroid injections interlaminar (IL) vs transforaminal (TF) in patients with unilateral radicular pain. PATIENTS: We randomly enrolled and followed 64 patients with chronic radiculopathy. RESULTS: Significant improvements were maintained throughout 6 months (24 weeks) of follow-up (P<0.001, respectively). The average visual analog scale (VAS) pain scores at 24 weeks improved to 4.0 ± 2.2 cm in the IL group and 3.8 ± 2.1 cm in the TF group (P=0.717). Baseline functional capacity was comparable for the IL and the TF group (52% vs 53%) when assessed using Oswestry (P=0.647). At 6 months, both groups improved, 39% for the IL group and 38% for the TF group, suggesting change from severe to moderate disability scoring range. There were 24 out of the 32 (75%) patients in the IL group at 24 weeks who improved more than 2 cm on the VAS scale and 17 patients (53%) had >50% of the pain relief. In the TF group, there were 27 out of the 32 (84%) patients with >2 cm improvement on VAS pain scale, and 20 of 32 (63%) with >50% improvement at 24 weeks. Functional capacity changes were similar, 16 out of the 32 patients (50%) improved 10 points or more on the Oswestry scale in the IL group and 21 out of the 32 in the TF group (66%). CONCLUSIONS: Using either route of epidural injections to deliver steroids for unilateral chronic radiculopathy secondary to herniated intervertebral disc provided significant improvements in patients function and pain relief. However, we could not find a statistically significant difference between two indicated groups either in functional improvement or in reduction in pain, although half-dose of steroids delivered via TF route provided somewhat better long-term pain relief and functional capacity improvements.

Primary study

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Prognostic usefulness of high sensitivity C-reactive protein for transforaminal epidural steroid injection in patients with radicular pain.

Authors Park CH , Lee SH
Journal Pain medicine (Malden, Mass.)
Year 2011
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This article is included in 2 Systematic reviews Systematic reviews (2 references)

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OBJECTIVE: There are several types of lumbar stenosis, such as central, lateral recess, foraminal. The symptoms of lumbar stenosis are neurogenic claudication, numbness, tingling, etc. The treatment modality is medication, physical therapy, intervention, and surgery. The epidural steroid injection has been used for treatment of low back pain/radiculopathy. However, we could not predict what percent had pain relief after epidural steroid injection. The purpose of this study was to evaluate the usefulness of high sensitivity C-reactive protein (hsCRP) as a marker for predicting the efficacy of lumbar transforaminal epidural steroid injection. DESIGN: A total of 55 patients with lumbar stenosis underwent lumbar transforaminal epidural steroid injection under fluoroscopic guidance. Prior to injection, all patients were examined and their visual analog scale (VAS) score and hsCRP score were recorded. They returned 4 weeks following their initial injection and repeat hsCRP, and VAS sores were obtained. RESULTS: The average pretreatment hsCRP and VAS score for all 55 patients were 3.2±4.3 mg/L and 8.1±1.1, respectively. Forty-two of 55 patients had 1.6 mg/L of hsCRP. After procedure, the VAS decreased from 8.0±1.1 to 2.5±1.1. In contrast, the averages of hsCRP and VAS scores of 13 patients were 9.4±3.7 mg/L and 8.2±0.9, respectively, at baseline, which decreased to 1.2±0.9 mg/L and 2.5±0.8 at 4 weeks later. At posttreatment, the VAS score difference between the two groups was not statistically significant. There was no correlation between hsCRP and VAS score (P=0.426). CONCLUSION: The results suggest that there was no correlation between pretreat hsCRP and posttreat VAS. Therefore, hsCRP may not be useful as predictor of response to TFESI in patients with spinal stenosis.

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Transforaminal epidural clonidine versus corticosteroid for acute lumbosacral radiculopathy due to intervertebral disc herniation.

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Journal Spine
Year 2011
Links Pubmed DOI PubMed Central

This article is included in 1 Systematic review Systematic reviews (1 reference)

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STUDY DESIGN: Randomized, double-blinded trial clinical trial. OBJECTIVE: To compare efficacies of 2 active therapies for chronic low back pain. SUMMARY OF BACKGROUND DATA: Radicular pain may result from intervertebral disk herniation (IDH). Clonidine has demonstrated analgesic and antiinflammatory activity in animal studies of nerve injury. Extensive clinical experience supports neuraxial clonidine's safety. METHODS: Patients with ˜3 months of low back and leg pain due to IDH were randomized to transforaminal epidural (TFE) injection(s) of 2% lidocaine and either clonidine (200 or 400mcg) or triamcinolone (40mg). Patients received 1- 3 injections administered about 2 weeks apart. Patients, investigators and study coordinators were blinded to treatment. Primary outcome was 11-point Pain Intensity Numerical Rating Scale (PI-NRS) at 1 month. Other outcomes included Patient Global Impression of Change (PGIC), and functional measures. RESULTS: Thirty-three patients were screened and randomized. Twenty-six patients enrolled; 11 received clonidine and 15 triamcinolone. Both groups showed significant improvement in pain score at 2 weeks and 1 month compared to baseline (p< 0.05). The corticosteroid group showed additional functional improvement at 1 month relative to clonidine (p=0.022). There was no difference between groups for primary outcome. However, as target enrollment was not reached, we cannot say with confidence that the 2 treatments would be expected to result in similar short-term pain relief. Side-effects were common in both groups, but there were no serious complications. CONCLUSIONS: Radicular pain due to IDH improved rapidly with TFE injection of either clonidine or triamcinolone. Corticosteroid resulted in greater functional improvement, with unclear differences in analgesia. Future studies will determine if clonidine is superior to placebo and of particular use in those at risk for corticosteroid complications.

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Plasma disc decompression compared with fluoroscopy-guided transforaminal epidural steroid injections for symptomatic contained lumbar disc herniation: a prospective, randomized, controlled trial.

Journal Journal of neurosurgery. Spine
Year 2010
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This article is included in 2 Systematic reviews Systematic reviews (2 references)

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<b>Object: </b>Patients with radiculopathy, with or without back pain, often do not respond to conservative care and may be considered for epidural steroid injection therapy or a disc decompression procedure. Plasma disc decompression (PDD) using the Coblation SpineWand device is a percutaneous, minimally invasive interventional procedure. The purpose of this study was to evaluate clinical outcomes with PDD as compared with standard care using fluoroscopy-guided transforaminal epidural steroid injection (TFESI) over the course of 2 years. <b>METHODS: </b>This was a multicenter randomized controlled clinical study. Ninety patients (18-66 years old) who had sciatica (visual analog scale score &gt; or = 50) associated with a single-level lumbar contained disc herniation were enrolled. In all cases, their condition was refractory to initial conservative care and 1 epidural steroid injection had failed. Participants were randomly assigned to receive either PDD (46 patients) or TFESI (44 patients, up to 2 injections). <b>RESULTS: </b>The patients in the PDD Group had significantly greater reduction in leg pain scores and significantly improved Oswestry Disability Index and 36-Item Short Form Health Survey ([SF-36], physical function, bodily pain, social function, and physical components summary) scores than those in the TFESI Group. During the 2-year follow-up, 25 (56%) of the patients in the PDD Group and 11 (28%) of those in the TFESI Group remained free from having a secondary procedure following the study procedure (log-rank p = 0.02). A significantly higher percentage of patients in the PDD Group showed minimum clinically important change in scores for leg and back pain and SF-36 scores that exceeded literature-based minimum clinically important changes. Procedure-related adverse events, including injection site pain, increased leg or back pain, weakness, and lightheadedness, were observed in 5 patients in the PDD Group (7 events) and 7 in the TFESI Group (14 events). <b>CONCLUSIONS: </b>In study patients who had radicular pain associated with a contained lumbar disc herniation, those patients treated with PDD had significantly reduced pain and better quality of life scores than those treated using repeated TFESI. In addition, significantly more PDD patients than TFESI patients avoided having to undergo a secondary procedure during the 2-year study follow-up.

Primary study

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The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain.

Authors Ghahreman A , Ferch R , Bogduk N
Journal Pain medicine (Malden, Mass.)
Year 2010
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This article is included in 6 Systematic reviews Systematic reviews (6 references)

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BACKGROUND: Transforaminal injection of steroids is used to treat lumbar radicular pain. Not known is whether the route of injection or the agent injected is significant. STUDY DESIGN: A prospective, randomized study compared the outcomes of transforaminal injection of steroid and local anesthetic, local anesthetic alone, or normal saline, and intramuscular injection of steroid or normal saline. Patients and outcome evaluators were blinded as to agent administered. METHODS: The primary outcome measure was the proportion of patients who achieved complete relief of pain, or at least 50% relief, at 1 month after treatment. Secondary outcome measures were function, disability, patient-specified functional outcomes, use of other health care, and duration of relief beyond 1 month. RESULTS: A significantly greater proportion of patients treated with transforaminal injection of steroid (54%) achieved relief of pain than did patients treated with transforaminal injection of local anesthetic (7%) or transforaminal injection of saline (19%), intramuscular steroids (21%), or intramuscular saline (13%). Relief of pain was corroborated by significant improvements in function and disability, and reductions in use of other health care. Outcomes were equivalent for patients with acute or chronic radicular pain. Over time, the number of patients who maintained relief diminished. Only some maintained relief beyond 12 months. The proportions of patients doing so were not significantly different statistically between groups. DISCUSSION: Transforaminal injection of steroids is effective only in a proportion of patients. Its superiority over other injections is obscured when group data are compared but emerges when categorical outcomes are calculated. Over time, the proportion of patients with maintained responses diminishes.

Primary study

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Comparison of the Effectiveness of Lumbar Transforaminal Epidural Injection with Particulate and Nonparticulate Corticosteroids in Lumbar Radiating Pain

Authors Park CH , Lee SH , Kim BI
Journal Pain medicine (Malden, Mass.)
Year 2010
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This article is included in 2 Systematic reviews Systematic reviews (2 references)

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Objective. Lumbar transforaminal epidural steroid injections are procedures often utilized in the treatment of low back pain associated with radicular pain. Particulate steroids have been known to play a role in embolism. It is, unknown whether nonparticulate steroids are as effective as particulate steroids. To investigate the effect of an epidural steroid injection on back pain, we conducted a randomized, controlled trial comparing nonparticulate steroid with particulate steroid to treat lumbar disc herniation.Design. One hundred-six patients were randomized to receive lumbar transforaminal epidural steroid injections (N = 53) with either dexamethasone 7.5mg, or with triamcinolone acetate 40mg (N=53). Measurement were taken before treatment and one month after treatment using a visual analog scale, short McGill pain questionnaire, and revised Oswertry Back Disability Index.Results. There was a statistically significant difference in the visual analog score between those treated with dexamethasone and those given triamcinolone. The two groups did not differ significantly on the McGill Pain Questionnaire, or the Oswestry Disability Index before and after treatment.Conclusion. In this study, dexamethasone and triamcinolone treatments were shown to have different effects on low back pain with sciatica, with triamcinolone being more effective than dexamethsone in lumbar radiculopathy. © 2010 Wiley Periodicals, Inc.

Primary study

Unclassified

Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports.

Journal Pain medicine (Malden, Mass.)
Year 2009
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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OBJECTIVE: To present two case reports of a rare but devastating injury after image-guided, lumbar transforaminal injection of steroids, and to explore features in common with previously reported cases. BACKGROUND: Image (fluoroscopic and computed tomography [CT])-guided, lumbar transforaminal injections of corticosteroids have been adopted as a treatment for radicular pain. Complications associated with these procedures are rare, but can be severe. CASE REPORTS: An 83-year-old woman underwent a fluoroscopically guided, left L3-L4, transforaminal injection of betamethasone (Celestone Soluspan). A 79-year-old man underwent a CT-guided, right L3-L4, transforaminal injection of methylprednisolone (DepoMedrol). Both patients developed bilateral lower extremity paralysis, with neurogenic bowel and bladder, immediately after the procedures. Magnetic resonance imaging scans were consistent with spinal cord infarction. There was no evidence of intraspinal mass or hematoma. CONCLUSION: These cases consolidate a pattern emerging in the literature. Distal cord and conus injury can occur following transforaminal injections at lumbar levels, whether injection is on the left or right. This conforms with the probability of radicular-medullary arteries forming an arteria radicularis magna at lumbar levels. All cases used particulate corticosteroids, which promotes embolization in a radicular artery as the likely mechanism of injury. The risk of this complication can be reduced, and potentially eliminated, by the utilization of particulate free steroids, testing for intra-arterial injection with digital subtraction angiography, and a preliminary injection of local anesthetic.

Primary study

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Intra-arterial injection in the rat brain: evaluation of steroids used for transforaminal epidurals.

Journal Spine
Year 2009
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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STUDY DESIGN: Prospective in vivo experimental animal model. OBJECTIVES: To determine the effect of intra-arterial injection of the steroids commonly used for transforaminal epidurals on the central nervous system. And to determine if all of the steroids have the same effect. SUMMARY OF BACKGROUND DATA.: Transforaminal epidural steroid injection is commonly employed to treat radicular pain. This approach is associated with complications, including stroke and death. While the mechanism is unknown, the leading hypothesis is that intravascular injection of particulate steroids leads to microembolization. METHODS: To characterize the nature of steroid induced injury, a rodent model was employed. The internal carotid artery was dissected and its branches ligated. The external carotid artery was ligated, mobilized, cannulated, and injectate administered. Five solutions were tested: Depo-Medrol (N = 11), Depo-Medrol carrier (N = 6), Solu-Medrol (N = 6), Decadron (N = 8), and normal saline (N = 7). Drugs, in volume of 50 microL, were injected into the ICA via the ECA cannula at 25 microL/min. The extent of central nervous system injury was evaluated by analysis of coronal sections of the brain. RESULTS: Cerebral hemorrhage occurred in test subjects with the following frequency: 8 of 11 in the Depo-Medrol group, 7 of 8 in the Solu-Medrol group, and 3 of 6 in the Depo-Medrol carrier group; no lesions were identified in the Decadron or saline groups (P < 0.01). Evan's blue dye leakage was detected in the Depo-Medrol and Solu-Medrol groups, but not the Decadron or saline groups. CONCLUSION: This study presents the first in vivo evaluation of intra-arterial steroid injection. Data demonstrate Depo-Medrol, as well as its nonparticulate carrier, and Solu-Medrol can produce significant injury to the blood-brain barrier when injected intra-arterially. These results demonstrate that injury is produced not only by particulate obstruction of the cerebral microvasculature, but also by toxicity of the carrier or steroid (methylprednisolone).