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Coker C, Park J, Jacobson RD. Neurologic Approach to Radiculopathy, Back Pain, and Neck Pain. Prim Care 2024; 51:345-358. [PMID: 38692779 DOI: 10.1016/j.pop.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Back pain and neck pain are common in clinical practice, but significant challenges and pitfalls exist in their diagnosis, treatment, and management. From the neurologic standpoint, cervical radiculopathy and lumbosacral radiculopathy are characterized by neck pain or back pain accompanied by sensory and motor symptoms in an arm or leg. The basic neurologic examination is vital, but testing like electromyography and MRI is often needed especially in cases that fail conservative management. Oral medications, injection-based therapies, physical therapy, and surgical evaluation all have a place in the comprehensive neurologic management of back and neck pain and associated radiculopathy.
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Affiliation(s)
- Canaan Coker
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison Street, Suite 1118, Chicago, IL 60612, USA
| | - Jade Park
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison Street, Suite 1118, Chicago, IL 60612, USA
| | - Ryan D Jacobson
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison Street, Suite 1118, Chicago, IL 60612, USA.
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Guillemin PC, Salomir R, Lauper N, Lorton O, Maturana E, Stöckli A, Poletti PA, Dominguez DE, Boudabbous S, Scheffler M. Clinical outcomes of 3T magnetic resonance imaging-guided lumbar and sacral foraminal injections. Neuroradiology 2023; 65:1793-1802. [PMID: 37848741 PMCID: PMC10654205 DOI: 10.1007/s00234-023-03234-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/03/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE This article evaluates the feasibility, safety, and efficacy of MRI-guided lumbar or sacral nerve root infiltration for chronic back pain. We compared the outcomes of our MRI-guided infiltrations with data from CT-guided infiltrations reported in the literature and explored the potential advantages of MRI guidance. METHOD Forty-eight MRI-guided nerve root infiltrations were performed using a 3 T MRI machine. The optimal needle path was determined using breathhold T2-weighted sequences, and the needle was advanced under interleaved guidance based on breathhold PD-weighted images. Pain levels were assessed using a numeric rating scale (NRS) before the procedure and up to 5 months after, during follow-up. Procedure success was evaluated by comparing patients' pain levels before and after the infiltration. RESULTS The MRI-guided infiltrations yielded pain reduction 1 week after the infiltration in 92% of cases, with an average NRS substantial change of 3.9 points. Pain reduction persisted after 5 months for 51% of procedures. No procedure-related complications occurred. The use of a 22G needle and reconstructed subtraction images from T2 FatSat sequences improved the workflow. CONCLUSION Our study showed that MRI-guided nerve root infiltration is a feasible, safe, and effective treatment option for chronic back pain. Precise positioning of the needle tip and accurate distribution of the injected solution contributed to the effectiveness of MRI-guided infiltration, which appeared to be as accurate as CT-guided procedures. Further research is needed to explore the potential benefits of metal artifact reduction sequences to optimize chronic back pain management.
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Affiliation(s)
| | - Rares Salomir
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Radiology, Geneva University Hospitals, Geneva, Switzerland
| | - Nicolas Lauper
- Division of Orthopedic Surgery and Traumatology, Geneva University Hospitals, Geneva, Switzerland
| | - Orane Lorton
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Enrique Maturana
- Division of Radiology, Geneva University Hospitals, Thônex, Switzerland
| | - Alex Stöckli
- Division of Radiology, Geneva University Hospitals, Thônex, Switzerland
| | | | - Dennis E Dominguez
- Division of Orthopedic Surgery and Traumatology, Geneva University Hospitals, Geneva, Switzerland
| | - Sana Boudabbous
- Division of Radiology, Geneva University Hospitals, Geneva, Switzerland
| | - Max Scheffler
- Division of Radiology, Geneva University Hospitals, Thônex, Switzerland
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Budrovac D, Radoš I, Hnatešen D, Haršanji-Drenjančević I, Tot OK, Katić F, Lukić I, Škiljić S, Nešković N, Dimitrijević I. Effectiveness of Epidural Steroid Injection Depending on Discoradicular Contact: A Prospective Randomized Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3672. [PMID: 36834367 PMCID: PMC9962306 DOI: 10.3390/ijerph20043672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 06/18/2023]
Abstract
Lumbar radicular pain is a major public health and economic problem. It is among the most common reasons for professional disability. The most common cause of lumbar radicular pain is intervertebral disc herniation, which results from degenerative disc changes. The dominant pain mechanisms are direct pressure of the hernia on the nerve root and the local inflammatory process triggered by intervertebral disc herniation. Treatment of lumbar radicular pain includes conservative, minimally invasive, and surgical treatment. The number of minimally invasive procedures is constantly increasing, and among these methods is epidural administration of steroids and local anesthetic through a transforaminal approach (ESI TF). The aim of this research was to examine the effectiveness of ESI TF as measured by a visual analog scale (VAS) and the Oswestry Disability Index (ODI), depending on whether there is contact between the herniated intervertebral disc and the nerve root. In both groups of participants, there was a significant reduction in pain intensity, but there was no significant difference between the groups. In the group with disc herniation and nerve root contact, the only significant reduction was in pain intensity (p < 0.001). There were no significant differences in measurements in other domains of the ODI. In the group without disc herniation and nerve contact, there was a significant difference in all domains except weight lifting. In the group without contact, there was significant improvement after 1 month (p = 0.001) and 3 months (p < 0.001) according to the ODI, while there was no significant improvement in the group with contact. In addition, there were no significant differences in the distribution of participants based on the ODI and whether disc herniation and nerve contact was present. The results suggest that transforaminal epidural administration of steroids is a clinically effective method for treating lumbar radicular pain caused by intervertebral disc herniation in people with and without nerve root contact, without significant differences.
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Affiliation(s)
- Dino Budrovac
- Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Department of Anaesthesiology, Reanimatology and Intensive Care, University Hospital Centre Osijek, 31000 Osijek, Croatia
| | - Ivan Radoš
- Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Department of Anaesthesiology, Reanimatology and Intensive Care, University Hospital Centre Osijek, 31000 Osijek, Croatia
| | - Dijana Hnatešen
- Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Department of Anaesthesiology, Reanimatology and Intensive Care, University Hospital Centre Osijek, 31000 Osijek, Croatia
- Nursing Institute “Professor Radivoje Radić”, Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
| | - Ivana Haršanji-Drenjančević
- Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Department of Anaesthesiology, Reanimatology and Intensive Care, University Hospital Centre Osijek, 31000 Osijek, Croatia
| | - Ozana Katarina Tot
- Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Department of Anaesthesiology, Reanimatology and Intensive Care, University Hospital Centre Osijek, 31000 Osijek, Croatia
| | - Franjo Katić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital Centre Osijek, 31000 Osijek, Croatia
| | - Iva Lukić
- Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Clinical Institute for Laboratory Diagnostics, University Hospital Centre Osijek, 31000 Osijek, Croatia
| | - Sonja Škiljić
- Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Department of Anaesthesiology, Reanimatology and Intensive Care, University Hospital Centre Osijek, 31000 Osijek, Croatia
| | - Nenad Nešković
- Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Department of Anaesthesiology, Reanimatology and Intensive Care, University Hospital Centre Osijek, 31000 Osijek, Croatia
| | - Iva Dimitrijević
- Department of Anaesthesiology, Reanimatology and Intensive Care, University Hospital Centre Osijek, 31000 Osijek, Croatia
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Diagnosis and Treatment of Transforaminal Epidural Steroid Injection in Lumbar Spinal Stenosis. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 54:327-332. [PMID: 33312031 PMCID: PMC7729724 DOI: 10.14744/semb.2020.89983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 04/28/2020] [Indexed: 11/25/2022]
Abstract
Objectives: Transforaminal epidural steroid injection reduces the low back-leg pain and enables daily activities of the patients. In this study, we aim to evaluate the treatment of transforaminal epidural steroid injection for lumbar spinal stenosis, which was mainly performed for lumbar disc herniation and share our diagnostic experience for lumbar spinal stenosis which is treated surgically. Methods: In our study, 37 patients were included who were treated by transforaminal epidural steroid injection for Grade B lumbar spinal stenosis in our clinic between June-2014 and June-2018. We evaluated the patients at the second weeks, third/sixth months and one year after the treatment by Oswestry-Disability-Index and Visual-Analogue-Scale and followed up for surgical treatment after one year. Results: The mean low back and leg pain Visual Analogue Scale was 5.1±0.3 before the transforaminal epidural steroid injection procedure, and it was 2.7±0.1 after two weeks. It was 2.8±0.2, 3.1±0.1 at three and six months after procedure, respectively. The improvement of low back-leg pain mean Visual-Analogue-Scale is statistically significant at two weeks, three and six months after transforaminal epidural steroid injection procedure, respectively. The mean Oswestry-Disability-Index was 29.6±0.4 before the transforaminal epidural steroid injection procedure, and it was 14.1±0.3 after two weeks. It was 15.3±0.5, 24.4±0.2 at three and six months after procedure, respectively. The improvement of Oswestry-Disability-Index is statistically significant at two weeks, three-six months. Conclusion: The transforaminal epidural steroid injection is safe procedure for non-surgical treatment of lumbar spinal stenosis and this procedure may be preferred support to the indication of the surgical treatment of level of lumbar spinal stenosis.
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Smith CC, McCormick ZL, Mattie R, MacVicar J, Duszynski B, Stojanovic MP. The Effectiveness of Lumbar Transforaminal Injection of Steroid for the Treatment of Radicular Pain: A Comprehensive Review of the Published Data. PAIN MEDICINE 2019; 21:472-487. [DOI: 10.1093/pm/pnz160] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Abstract
Objective
To determine the effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain.
Design
Comprehensive systematic review.
Outcome Measures
The primary outcome of interest was the proportion of individuals with reduction of pain by ≥50%. Additional outcomes of interest were a more-than-two-point reduction in pain score, patient satisfaction, functional improvement, decreased use of pain medication, and avoidance of spinal surgery.
Results
For patients with disc herniations, using the criterion of ≥50% reduction in pain, success rates across included studies (range) were 63% (58–68%) at one month, 74% (68–80%) at three months, 64% (59–69%) at six months, and 64% (57–71%) at one year. For patients with lumbar spinal stenosis, success rates across included studies (range) were 49% (43–55%) at one month, 48% (35–61%) at three months, 43% (33–53%) at six months, and 59% (45–73%) at one year, but there was a lack of corroboration from appropriately controlled studies.
Conclusions
There is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. There is a lack of high-quality evidence demonstrating their effectiveness for the treatment of radicular pain due to spinal stenosis, though small studies suggest a possible benefit. Lumbar transforaminal injection of nonparticulate steroids is as effective as injections with particulate steroids.
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Affiliation(s)
- Clark C Smith
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ryan Mattie
- Providence Cedars-Sinai Tarzana Hospital, Providence Specialty Medical Group, Comprehensive Spine & Interventional Pain Management, Tarzana, California
| | | | | | - Milan P Stojanovic
- Anesthesiology, Critical Care and Pain Medicine Service, VA Boston Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
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Fabris G, Tommasini G, Petralia B, Lavaroni A, De Nardi F, De Luca G, Biasizzo E, Iaiza F. L'ossigeno-ozono terapia intra-foraminale. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/19714009010140s114] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Scopo di questo lavoro è valutare l'efficacia dell'ossigeno-ozono terapia intra-foraminale nel trattamento del dolore lombare. Dal Gennaio 1997 al Dicembre 1999, sono stati trattati 407 pazienti con infiltrazione intra-foraminale. Le patologie di più frequente riscontro sono rappresentate dall'ernia del disco, eventualmente aggravata da artrosi delle faccette articolari o da stenosi del canale vertebrale, e dalla fibrosi post-chirurgica; dal punto di vista clinico i pazienti presentavano lombalgia pura o irradiazione radicolare del dolore arto inferiore. L'analisi del risultato è stata effettuata con controllo telefonico e/o clinico, a tre o quattro settimane dal trattamento e con il questionario di McGill sec. R. Melzack per la valutazione del dolore. I risultati migliori (superiori all'80%) sono stati ottenuti nei pazienti affetti da lombalgia, da ernie di piccole dimensioni e da fibrosi post-chirurgica. I dati ottenuti ci consentono di considerare l'ossigeno-ozono terapia intra-foraminale come un'arma potente per sconfiggere il dolore lombare, in modo relativamente semplice, efficace e sicuro.
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Affiliation(s)
| | | | | | | | - F. De Nardi
- U.O. Neurochirurgia, Azienda Ospedaliera S. Maria della Misericordia; Udine
| | - G. De Luca
- U.O. Fisiatria Sud, Ospedale Medicina Fisica e Riabilitazione; Udine
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Kennedy DJ, Levin J, Rosenquist R, Singh V, Smith C, Stojanovic MP, Vorobeychik Y. Epidural Steroid Injections are Safe and Effective: Multisociety Letter in Support of the Safety and Effectiveness of Epidural Steroid Injections. PAIN MEDICINE 2015; 16:833-8. [PMID: 25586082 DOI: 10.1111/pme.12667] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND In April 2014, the Food and Drug Administration (FDA) issued a Drug Safety Communication requesting that corticosteroid labeling include warnings that injection of corticosteroids into the epidural space of the spine may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death. RESULTS The International Spine Intervention Society spearheaded a collaboration of more than a dozen other medical societies in submitting the letter below to the FDA on November 7, 2014. We are publishing the letter to ensure that the readership of Pain Medicine is aware of the multisociety support for the safety and effectiveness of these procedures. A special note of thanks to all of the societies who signed on in support of the message.
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Affiliation(s)
- David J Kennedy
- Department of Orthopaedics, Stanford University Redwood City, CA
| | - Joshua Levin
- Department of Orthopaedics and Neurosurgery, Stanford University, Palo Alto, CA
| | | | - Virtaj Singh
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Clark Smith
- Department of Rehabilitation and Regenerative Medicine, Columbia University, New York, NY
| | - Milan P Stojanovic
- Department of Anesthesiology, Critical Care and Pain Medicine Service, VA Boston Healthcare System, Boston, MA
| | - Yakov Vorobeychik
- Departments of Anesthesiology and Neurology, Penn State Hershey Medical Center, Hershey, Pennsylvania
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Access routes and reported decision criteria for lumbar epidural drug injections: a systematic literature review. Skeletal Radiol 2013; 42:1683-92. [PMID: 23995263 DOI: 10.1007/s00256-013-1713-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 08/07/2013] [Accepted: 08/08/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To review lumbar epidural drug injection routes in relation to current practice and the reported criteria used for selecting a given approach. MATERIAL AND METHODS This was a HIPPA-compliant study. Employing a systematic search strategy, the MEDLINE and EMBASE databank as well as the Cochrane Library were searched for studies on epidural drug injections. The following data were noted: access route, level of injection, use of image guidance, and types and doses of injected drugs. Justifications for the use of a particular route were also noted. Data were presented using descriptive statistics. RESULTS A total of 1,211 scientific studies were identified, of which 91 were finally included (7.5%). The interlaminar access route was used in 44 of 91 studies (48.4%), the transforaminal in 37 of 91 studies (40.7%), and the caudal pathway in 26 of 91 studies (28.6%). The caudal pathway was favored in the older studies whereas the transforaminal route was favored in recent studies. Decision criteria related to correct needle placement, concentration of injected drug at lesion site, technical complexity, costs, and potential complications. Injection was usually performed on the level of the lesion using local anesthetics (71 of 91 studies, 78.0%), steroids (all studies) and image guidance (71 of 91 studies, 78%). CONCLUSIONS The most commonly used access routes for epidural drug injection are the interlaminar and transforaminal pathways at the level of the pathology. Transforaminal routes are being performed with increasing frequency in recent years.
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Streitparth F, De Bucourt M, Hartwig T, Leidenberger T, Rump J, Walter T, Maurer M, Renz D, Stelter L, Wiener E, Hamm B, Teichgräber U. Real-Time MR-Guided Lumbosacral Periradicular Injection Therapy Using an Open 1.0-T MRI System. Invest Radiol 2013; 48:471-6. [DOI: 10.1097/rli.0b013e31828362be] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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MacVicar J, King W, Landers MH, Bogduk N. The Effectiveness of Lumbar Transforaminal Injection of Steroids: A Comprehensive Review with Systematic Analysis of the Published Data. PAIN MEDICINE 2013; 14:14-28. [DOI: 10.1111/j.1526-4637.2012.01508.x] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Choi SJ, Song JS, Kim C, Shin MJ, Ryu DS, Ahn JH, Jung SM, Park MS. The use of magnetic resonance imaging to predict the clinical outcome of non-surgical treatment for lumbar intervertebral disc herniation. Korean J Radiol 2007; 8:156-63. [PMID: 17420633 PMCID: PMC2626775 DOI: 10.3348/kjr.2007.8.2.156] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We wanted to investigate the relationship between the magnetic resonance (MR) findings and the clinical outcome after treatment with non-surgical transforaminal epidural steroid injections (ESI) for lumbar herniated intervertebral disc (HIVD) patients. MATERIALS AND METHODS Transforaminal ESI were performed in 91 patients (50 males and 41 females, age range: 13-78 yrs) because of lumbosacral HIVD from March 2001 to August 2002. Sixty eight patients whose MRIs and clinical follow-ups were available were included in this study. The medical charts were retrospectively reviewed and the patients were divided into two groups; the successful (responders, n = 41) and unsatisfactory (non-responders, n = 27) outcome groups. A successful outcome required a patient satisfaction score greater than two and a pain reduction score greater than 50%. The MR findings were retrospectively analyzed and compared between the two groups with regard to the type (protrusion, extrusion or sequestration), hydration (the T2 signal intensity), location (central, right/left central, subarticular, foraminal or extraforaminal), and size (volume) of the HIVD, the grade of nerve root compression (grade 1 abutment, 2 displacement and 3 entrapment), and an association with spinal stenosis. RESULTS There was no significant difference between the responders and non-responders in terms of the type, hydration and size of the HIVD, or an association with spinal stenosis (p > 0.05). However, the location of the HIVD and the grade of nerve root compression were different between the two groups (p < 0.05). CONCLUSION MRI could play an important role in predicting the clinical outcome of non-surgical transforaminal ESI treatment for patients with lumbar HIVD.
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Affiliation(s)
- Soo-Jung Choi
- Department of Radiology, GangNeung Asan Hospital, University of Ulsan College of Medicine, GangNeung 210-711, Korea
| | - Jae Seok Song
- Department of Preventive Medicine, University of Kwandong College of Medicine, GangNeung 210-701, Korea
| | - Chunghwan Kim
- Department of Orthopedic Surgery, GangNeung Asan Hospital, University of Ulsan College of Medicine, GangNeung 210-711, Korea
| | - Myung Jin Shin
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
| | - Dae Sik Ryu
- Department of Radiology, GangNeung Asan Hospital, University of Ulsan College of Medicine, GangNeung 210-711, Korea
| | - Jae Hong Ahn
- Department of Radiology, GangNeung Asan Hospital, University of Ulsan College of Medicine, GangNeung 210-711, Korea
| | - Seung Moon Jung
- Department of Radiology, GangNeung Asan Hospital, University of Ulsan College of Medicine, GangNeung 210-711, Korea
| | - Man Soo Park
- Department of Radiology, GangNeung Asan Hospital, University of Ulsan College of Medicine, GangNeung 210-711, Korea
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Ammirati M, Perino F. Symptomatic air trapped in the spine after lumbar epidural corticosteroid injection. Case report. J Neurosurg Spine 2006; 5:359-61. [PMID: 17048774 DOI: 10.3171/spi.2006.5.4.359] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report the first case involving trapped epidural air in the spine that mimicked a mass lesion and caused neurological symptoms after epidural corticosteroid injection in the lumbar region. New neurological symptoms developed immediately after injection, and magnetic resonance (MR) imaging demonstrated trapped air displacing the dural sac. After the patient underwent conservative treatment, the new symptoms resolved, and follow-up MR imaging and computed tomography demonstrated resorption of the epidural air in the lumbar region. To limit this problem, the clinician should decrease the amount of air injected in the epidural space or substitute nitrous oxide for air when injecting steroid agents epidurally.
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Affiliation(s)
- Mario Ammirati
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio 43210, USA.
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von Rothenburg T, Drescher R, Koester O, Schmid G. Magnetic resonance imaging of the lumbar spine after epidural and nerve root injection therapy: evaluation of soft tissue changes. Clin Imaging 2006; 30:331-4. [PMID: 16919554 DOI: 10.1016/j.clinimag.2006.03.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2005] [Revised: 03/01/2006] [Accepted: 03/17/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Magnetic resonance imaging (MRI) was performed to evaluate soft tissue changes after nerve root and epidural injections in lumbar spine in patients with radiculopathy. MATERIALS/METHODS Patients underwent a multiple-shot injection protocol to nerve root/epidural space. The MRI protocol included T1-weighted, T2-weighted, STIR, and contrast-enhanced, fat-saturated T1-weighted sequences before and after treatment. RESULTS In all treated patients, a diffuse wedge-shaped edema in paravertebral tissues with a slight contrast enhancement was seen. Two small hematomas in the paravertebral muscle were noted. No changes in the epidural space, the abscess, or a lipodystrophy in epidural/nerve root space occurred. CONCLUSION Normal tissue changes after injection therapy of lumbar radiculopathy include wedge-shaped tissue edema at the injection level. In a minority of patients, small hematomas may occur.
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Affiliation(s)
- Thomas von Rothenburg
- Department of Radiology and Nuclear Medicine, St. Josef Hospital, University Hospital, Gudrunstrasse 56 44712 Bochum, Germany
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Veihelmann A, Devens C, Trouillier H, Birkenmaier C, Gerdesmeyer L, Refior HJ. Epidural neuroplasty versus physiotherapy to relieve pain in patients with sciatica: a prospective randomized blinded clinical trial. J Orthop Sci 2006; 11:365-9. [PMID: 16897200 DOI: 10.1007/s00776-006-1032-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2005] [Accepted: 03/22/2006] [Indexed: 01/19/2023]
Abstract
BACKGROUND Epidural neuroplasty seems to be one of the promising minimally invasive techniques for adhesiolysis in patients with chronic sciatica with or without low back pain. However, because no data exist from randomized studies the aim was to investigate whether this procedure is superior to conservative treatment with physiotherapy. METHODS A total of 99 patients with chronic low back pain were enrolled in this study and randomly assigned into either a group with physiotherapy (n = 52) or a second group undergoing epidural neuroplasty (n = 47). Patients were assessed before and 3, 6, and 12 months after treatment by a blinded investigator. RESULTS After 3 months, the visual analog scale (VAS) score for back and leg pain was significantly reduced in the epidural neuroplasty group, and the need for pain medication was reduced in both groups. Furthermore, the VAS for back and leg pain as well as the Oswestry disability score were significantly reduced until 12 months after the procedure in contrast to the group that received conservative treatment. CONCLUSIONS Epidural neuroplasty results in significant alleviation of pain and functional disability in patients with chronic low back pain and sciatica based on disc protrusion/prolapse or failed back surgery on a short-term basis as well as at 12 months of follow-up.
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Affiliation(s)
- Andreas Veihelmann
- Department of Orthopaedics, Ludwig Maximilians University of Munich, Munich, Germany
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Gerdesmeyer L, Gollwitzer H, Diehl P, Wagner K. Evidence-Based Medicine and Clinical Trials in Pain Practice and Orthopedics. Pain Pract 2005; 5:289-97. [PMID: 17177761 DOI: 10.1111/j.1533-2500.2005.00031.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Medical practices should be based on scientific findings pursuant to the rules of evidence-based medicine. Quality standards for interventional pain therapy and orthopedic clinical studies have been lacking. As a result, the efficacy of many forms of therapy is insufficiently documented, making the level of evidence low. This article identifies common deficiencies in the conduct of clinical trials, as well as limitations in conducting randomized controlled studies. Recommendations for improvement are provided. The discussion provides the clinically active physician with interpretation aids for the evaluation of meta-analyses, supports personal evidence-based decisions, and reviews the most important principles for planning and conducting of experimental clinical studies. Current examples in the literature verify the implementation of these principles and present current findings in accordance with evidence-based medicine (EBM) criteria. In spite of an increasing emergence of EBM-based studies, we conclude that the number of well-designed, high quality, controlled studies conducted in accordance with the guidelines of Good Clinical Practice examining interventional pain therapy and orthopedic clinical studies remains unacceptably low.
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Affiliation(s)
- Ludger Gerdesmeyer
- Technical University Munich, Department of Orthopedic Surgery and Sportstraumatology, Munich, Germany.
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Gerdesmeyer L, Lampe R, Veihelmann A, Burgkart R, Göbel M, Gollwitzer H, Wagner K. [Chronic radiculopathy. Use of minimally invasive percutaneous epidural neurolysis according to Racz]. Schmerz 2005; 19:285-95. [PMID: 15549419 DOI: 10.1007/s00482-004-0371-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Treatment of chronic low back pain exhibiting radicular symptoms poses a clinical problem that has not yet been solved. The technique of percutaneous minimally invasive neurolysis described by Racz is being performed increasingly to treat chronic radiculopathy. A total of 61 patients with corresponding symptomatology after screening for inclusion and exclusion criteria in the region of the lumbar spinal nerve were treated with the Racz catheter technique. Distinct clinical improvement was observed at the 3- and 6-month follow-ups after percutaneous minimally invasive epidural neurolysis. Subjective pain perception, quantified by the McNab score, clearly improved after 3 as well as 6 months. With the exception of partial catheter shearing in two cases and one occurrence of infection, no relevant side effects were noted. The Racz catheter technique for treatment of chronic radiculopathy following disk surgery is suitable with minimal side effects.
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Affiliation(s)
- L Gerdesmeyer
- Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München.
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Cornefjord M, Olmarker K, Otani K, Rydevik B. Effects of diclofenac and ketoprofen on nerve conduction velocity in experimental nerve root compression. Spine (Phila Pa 1976) 2001; 26:2193-7. [PMID: 11598507 DOI: 10.1097/00007632-200110150-00007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN The effects of diclofenac and ketoprofen on nerve conduction velocity in experimental nerve root compression were evaluated in a setup using an established pig model. OBJECTIVE To assess the effects of two potent nonsteroidal antiinflammatory drugs, diclofenac and ketoprofen, in experimental nerve root compression. SUMMARY OF BACKGROUND DATA Compression of spinal nerve roots is recognized to be of major etiologic importance for several common spinal pain syndromes. Secondary inflammatory changes, induced by microvascular permeability changes and leakage of inflammatory mediators into the endoneural tissue, have been proposed as important for the induction of spinal nerve root injury by chronic compression. METHODS This study involved 21 pigs. An ameroid constrictor was used to induce compression. Seven pigs were treated with daily intramuscular injections of diclofenac 3 mg/kg for 7 days. Seven other pigs were treated with daily intramuscular injections of ketoprofen 4 mg/kg. For a control, seven pigs did not receive any drug treatment. After 7 days, the pigs were reanesthetized, and the nerve conduction velocity in the compressed nerve root segments was determined. RESULTS The nerve conduction velocity was significantly higher (P < 0.05, Student's t test) in the pigs treated with diclofenac (50 +/- 16 m/second) than in the untreated pigs (32 +/- 15 m/second). The nerve conduction velocity also was significantly higher (P < 0.05) in the pigs treated with ketoprofen (59 +/- 16 m/second) than in the untreated pigs. There were no significant differences in nerve conduction velocity between pigs treated with ketoprofen and those treated with diclofenac. CONCLUSIONS The findings indicate that intramuscular administration of diclofenac or ketoprofen, both potent antiinflammatory drugs, may reduce nerve root dysfunction induced by compression of spinal nerve roots in an experimental pig model.
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Affiliation(s)
- M Cornefjord
- Department of Orthopaedics, Göteborg University, Gothenburg, Sweden.
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Ojala R, Vahala E, Karppinen J, Klemola R, Blanco-Sequeiros R, Vaara T, Tervonen O. Nerve root infiltration of the first sacral root with MRI guidance. J Magn Reson Imaging 2000; 12:556-61. [PMID: 11042636 DOI: 10.1002/1522-2586(200010)12:4<556::aid-jmri6>3.0.co;2-c] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The purpose of this clinical trial was to describe the methodology and evaluate the accuracy of optical tracking-based magnetic resonance (MR)-guided infiltration of the first sacral (S1) root. Thirty-five infiltrations were performed on 34 patients with a 0. 23-T open C-arm magnet installed in a fully equipped operation room with large-screen (36 inches) display and optical navigator utilizing infrared passive tracking. T1 and T2 fast spin-echo (FSE) images were used for localizing the target and fast field echo for monitoring the procedure. Saline as contrast agent in single-shot (SS)FSE images gave sufficient contrast-to-noise ratio. Twenty-four patients had unoperated L5/S1 disc herniation, and 10 had S1 root irritation after failed back surgery. Needle placement was successful in 97% of the cases, and no complications occurred. Outcome was evaluated 1-6 months (mean 2.2 months) after the procedure and was comparable to that of other studies using fluoroscopy or computed tomography guidance. MR-guided placement of the needle is an accurate technique for first sacral root infiltration.
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Affiliation(s)
- R Ojala
- Department of Radiology, University Hospital of Oulu, 90220 Oulu, Finland.
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