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Joo HJ, Choi S, Kim BH, Kim MS, Shim GY, Chung SJ, Chon J, Yoo MC, Soh Y. Therapeutic Efficacy of Ultrasound-Guided Selective Nerve Block on Chronic Cervical Radiculopathy. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1002. [PMID: 38929619 PMCID: PMC11205526 DOI: 10.3390/medicina60061002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/09/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024]
Abstract
Background and Objectives: Cervical radiculopathy (CR) manifests as pain and sensorimotor disturbances in the upper extremities, often resulting from nerve root compression due to intervertebral disc herniation, degenerative changes, or trauma. While conservative treatments are initially preferred, persistent or severe cases may require surgical intervention. Ultrasound-guided selective nerve root block (SNRB) has emerged as a promising intervention for alleviating symptoms and potentially obviating the need for surgery. This study evaluates the therapeutic efficacy of ultrasound-guided SNRB in managing chronic CR, aiming to determine its potential in symptom relief and delaying or avoiding surgical procedures. Materials and Methods: A retrospective analysis was conducted on 720 outpatients treated for CR between October 2019 and March 2022. After excluding patients with traumatic CR, previous surgeries, malignancies, progressive neurological symptoms requiring immediate surgery, or inadequate conservative treatment, 92 patients who had experienced cervical radicular pain for more than three months and had failed to improve after more than six weeks of conservative treatment with VAS scores ≥ 5 were included. The patients underwent single or multiple ultrasound-guided SNRB procedures, involving the injection of dexamethasone and lidocaine under real-time ultrasound guidance. Symptom severity was assessed at the baseline, and at 4, 8, and 12 weeks post-procedure using the Visual Analog Scale (VAS). The data collected included age, sex, presence of neck and/or radicular pain, physical examination findings, recurrence of symptoms, improvement in symptoms, and whether surgical intervention was ultimately required. Statistical analyses were performed to identify the factors associated with symptom improvement or recurrence. Results: Significant symptom improvement was observed in 69 (75.0%) participants post-SNRB, with 55 (79.7%) showing improvement at 4 weeks, 11 (15.9%) at 8 weeks, and 3 (4.4%) at 12 weeks. Symptom recurrence, defined by an increase in VAS score accompanied by a pain flare lasting at least 24 h after a pain-free interval of at least one month, was noted in 48 (52.2%) patients. The presence of combined neck and radicular pain was a significant predictor of recurrence (p = 0.008). No significant associations were found between symptom relief and factors such as age, gender, initial pain severity, or MRI findings. Conclusions: Ultrasound-guided SNRB effectively manages chronic CR, providing substantial symptom relief and potentially reducing the need for surgical intervention. This technique offers a promising conservative treatment option, especially given its real-time visualization advantages and minimal radiation exposure.
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Affiliation(s)
- Hyo Jin Joo
- Department of Physical Medicine & Rehabilitation, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea; (H.J.J.); (S.C.); (G.Y.S.); (J.C.)
| | - Seongmin Choi
- Department of Physical Medicine & Rehabilitation, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea; (H.J.J.); (S.C.); (G.Y.S.); (J.C.)
- Department of Physical Medicine & Rehabilitation, Kyung Hee University Medical Center, Seoul 02447, Republic of Korea
| | - Byoung Hoon Kim
- Department of Physical Medicine & Rehabilitation, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea; (H.J.J.); (S.C.); (G.Y.S.); (J.C.)
| | - Min-Su Kim
- Department of Physical Medicine & Rehabilitation, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea; (H.J.J.); (S.C.); (G.Y.S.); (J.C.)
| | - Ga Yang Shim
- Department of Physical Medicine & Rehabilitation, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea; (H.J.J.); (S.C.); (G.Y.S.); (J.C.)
- Department of Physical Medicine & Rehabilitation, Kyung Hee University Medical Center, Seoul 02447, Republic of Korea
| | - Sung Joon Chung
- Department of Physical Medicine & Rehabilitation, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea; (H.J.J.); (S.C.); (G.Y.S.); (J.C.)
| | - Jinmann Chon
- Department of Physical Medicine & Rehabilitation, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea; (H.J.J.); (S.C.); (G.Y.S.); (J.C.)
- Department of Physical Medicine & Rehabilitation, Kyung Hee University Medical Center, Seoul 02447, Republic of Korea
| | - Myung Chul Yoo
- Department of Physical Medicine & Rehabilitation, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea; (H.J.J.); (S.C.); (G.Y.S.); (J.C.)
- Department of Physical Medicine & Rehabilitation, Kyung Hee University Medical Center, Seoul 02447, Republic of Korea
| | - Yunsoo Soh
- Department of Physical Medicine & Rehabilitation, College of Medicine, Kyung Hee University, Seoul 02447, Republic of Korea; (H.J.J.); (S.C.); (G.Y.S.); (J.C.)
- Department of Physical Medicine & Rehabilitation, Kyung Hee University Medical Center, Seoul 02447, Republic of Korea
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Muhammad F, Hameed S, Haynes G, Mohammadi E, Khan AF, Shakir H, Smith ZA. Degenerative cervical myelopathy: establishing severity thresholds for neuromotor dysfunction in the aging spine using the NIH Toolbox Assessment Scale. GeroScience 2024; 46:2197-2206. [PMID: 37880488 PMCID: PMC10828326 DOI: 10.1007/s11357-023-00983-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/12/2023] [Indexed: 10/27/2023] Open
Abstract
Degenerative cervical myelopathy (DCM) is a leading cause of age-related non-traumatic spinal cord disorders resulting from chronic degeneration of the cervical spine. While traditional clinical assessments rely on patient-reported measures, this study used the NIH Toolbox Motor Battery (NIHTBm) as an objective, quantitative measure to determine DCM severity. The objective is to define NIHTBm cutoff values that can accurately classify the severity of DCM neuromotor dysfunction. A case-controlled pilot study of patients with DCM and age-matched controls. The focus was an in-depth quantitative motor assessment using the NIHTBm to understand the severity of neuromotor deficits due to degenerative spine disease. Motor assessments, dexterity, grip strength, balance, and gait speed were measured in 45 DCM patients and 37 age-matched healthy subjects (HC). Receiver operating curve (ROC) analysis determined cutoff values for mild and moderate-to-severe myelopathy which were validated by comparing motor assessment scores with disability scores. The ROC curves identified thresholds for mild dexterity impairment (T-score range 38.4 - 33.5, AUC 0.77), moderate-to-severe dexterity impairment (< 33.5, AUC 0.70), mild grip strength impairment (47.4 - 32.0, AUC 0.80), moderate-to-severe grip strength impairment (< 32.0, AUC 0.75), mild balance impairment (36.4 - 33.0, AUC 0.61), and moderate-to-severe balance impairment (< 33.0, AUC 0.78). Mild gait speed impairment was defined as 0.78-0.6 m/sec (AUC 0.65), while moderate-to-severe gait speed impairment was < 0.6 m/sec (AUC 0.65). The NIHTB motor score cutoff points correlated negatively with the DCM neck disability index (NDI) and showed balance and dexterity measures as independent indicators of DCM dysfunction. The use of NIHTB allows for precise delineation of DCM severity by establishing cutoff values corresponding to mild and moderate-to-severe myelopathy. The use of NIHTB in DCM allows enhanced clinical precision, enabling clinicians to better pinpoint specific motor deficits in DCM and other neurological disorders with motor deficits, including stroke and traumatic brain injury (TBI). Furthermore, the utility of objective assessment, NIHTB, allows us to gain a better understanding of the heterogeneity of DCM, which will enhance treatment strategies. This study serves as a foundation for future research to facilitate the discovery of innovative treatment strategies for DCM and other neurological conditions.
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Affiliation(s)
- Fauziyya Muhammad
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - Sanaa Hameed
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Grace Haynes
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK, USA
| | - Esmaeil Mohammadi
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ali F Khan
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Hakeem Shakir
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Zachary A Smith
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Hanley M, Eustace SK, Ryan DT, McLoughlin S, Hynes JP, Kavanagh EC, Eustace SJ. Are brake response times altered post CT-guided cervical spine nerve root injections? Br J Radiol 2024; 97:834-837. [PMID: 38337059 PMCID: PMC11027323 DOI: 10.1093/bjr/tqae034] [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: 11/16/2023] [Revised: 01/24/2024] [Accepted: 02/05/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVES To assess if brake response times are altered pre and post CT-guided cervical spine nerve root injections. METHODS Brake response times were assessed before and after CT-guided cervical spine nerve root injections in a cohort of patients. The average of 3 brake response times was recorded before and 30 min after injection. Statistical analysis was performed using GraphPad. A paired Student t-test was used to compare the times before and after the injections. RESULTS Forty patients were included in this study. The mean age was 55 years. There were 17 male and 23 female patients. There was no significant difference in the mean pre and post CT-guided cervical spine nerve root injection brake response times; 0.94 s (range 0.4-1.2 s) and 0.93 s (range 0.5-1.25 s), respectively (P = .77). CONCLUSIONS Brake response time did not significantly differ pre and 30 min post CT-guided cervical spine nerve root injections. ADVANCES IN KNOWLEDGE To the authors' best knowledge, there are no current studies assessing brake response times post CT-guided cervical spine nerve root injections. While driving safety cannot be proven by a single metric, it is a useful study in demonstrating that this is not inhibited in a cohort of patients.
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Affiliation(s)
- Marion Hanley
- Radiology Department, National Orthopaedic Hospital Cappagh, Dublin, D11 EV29, Ireland
| | - Sarah K Eustace
- Radiology Department, National Orthopaedic Hospital Cappagh, Dublin, D11 EV29, Ireland
| | - David T Ryan
- Radiology Department, National Orthopaedic Hospital Cappagh, Dublin, D11 EV29, Ireland
| | - Stephen McLoughlin
- Radiology Department, National Orthopaedic Hospital Cappagh, Dublin, D11 EV29, Ireland
| | - John P Hynes
- Radiology Department, National Orthopaedic Hospital Cappagh, Dublin, D11 EV29, Ireland
| | - Eoin C Kavanagh
- Radiology Department, National Orthopaedic Hospital Cappagh, Dublin, D11 EV29, Ireland
| | - Stephen J Eustace
- Radiology Department, National Orthopaedic Hospital Cappagh, Dublin, D11 EV29, Ireland
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Chalermkitpanit P, Pannangpetch P, Kositworakitkun Y, Singhatanadgige W, Yingsakmongkol W, Pasuhirunnikorn P, Tanasansomboon T. Ultrasound-guided pulsed radiofrequency of cervical nerve root for cervical radicular pain: a prospective randomized controlled trial. Spine J 2023; 23:651-655. [PMID: 36641034 DOI: 10.1016/j.spinee.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/13/2022] [Accepted: 01/03/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND CONTEXT Pulsed radiofrequency (PRF) on cervical dorsal root ganglion (DRG) for pain management in cervical radicular pain is mainly performed via a transforaminal approach under fluoroscopic guidance. Ultrasound-guidance periradicular cervical nerve root intervention raises concern about the neuromodulatory effect. This study aims to evaluate the effectiveness and duration of pain relief between PRF treatment and steroid injection on the cervical nerve roots. PURPOSE To evaluate the efficacy of pulsed radiofrequency for cervical radicular pain. STUDY DESIGN A prospective, double-blinded, randomized controlled clinical trial PATIENT SAMPLE: Patients who underwent ultrasound-guided periradicular cervical nerve root PRF or steroid injection from January 2020 to May 2021 at King Chulalongkorn Memorial Hospital (KCMH), Bangkok, Thailand. OUTCOME MEASURES The primary outcome was the pain score at 3 months postprocedure. The secondary outcomes were the duration of pain relief of at least 50%, pain scores at other time points after pain intervention, the amount of rescue pain medications, procedural time, and complications. METHOD Forty-two patients who presented with chronic cervical radicular pain were prospectively randomized into the PRF and steroid groups. Patients in the PRF group received PRF treatment at 42°C for 4 minutes, followed by the injection of 2% lidocaine 1.5 mL and dexamethasone 10 mg to the targeted cervical nerve root. The steroid group received the same injectate. Patients and pain assessors were blinded. The numerical rating scale (NRS) and the Neck Disability Index (NDI) questionnaires were used for pain intensity and neck functional assessment before and after the procedure. Pain reduction was recorded up to a 9-month follow-up. RESULTS Data analysis was obtained from 20 and 21 patients receiving PRF and steroid treatment, respectively. At 3-month postprocedure, there were 70% of patients in the PRF group reported 50% pain reduction compared with 23.8% of patients in the steroid group (p<.01). Moreover, patients in the PRF group had significantly less pain (NRS 2.8±2.7) compared with patients in the steroid group (NRS 5.5±2.6) (p=.01). The neck disability index demonstrated significant improvement at 3 and 6 months (p<.01) after PRF treatment compared with steroid injection alone. The duration, in which pain relief was at least 50%, was significantly longer in patients who received PRF treatment (6.0±4.1 months) compared with those in the steroid group (2.3±2.1 months) (p<.01). CONCLUSION Ultrasound-guided periradicular cervical nerve root PRF exhibited a neuromodulatory effect and was considered effective for patients with cervical radicular pain. It provided a longer duration of pain relief and improvement of neck function for up to 6 months.
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Affiliation(s)
- Pornpan Chalermkitpanit
- Pain Management Research Unit, Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand; Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Patt Pannangpetch
- Pain Management Research Unit, Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand; Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Yuwarin Kositworakitkun
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Weerasak Singhatanadgige
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand; Center of Excellence in Biomechanics and Innovative Spine Surgery, Department of Orthopedics, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Wicharn Yingsakmongkol
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand; Center of Excellence in Biomechanics and Innovative Spine Surgery, Department of Orthopedics, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Porntipa Pasuhirunnikorn
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Teerachat Tanasansomboon
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Department of Orthopedics, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand; Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA; Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
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Ehsanian R, Schneider BJ, Kennedy DJ, Koshkin E. Ultrasound-guided cervical selective nerve root injections: a narrative review of literature. Reg Anesth Pain Med 2021; 46:416-421. [PMID: 33441430 DOI: 10.1136/rapm-2020-102325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND/IMPORTANCE Ultrasound (US)-guided cervical selective nerve root injections (CSNRI) have been proposed as an alternative to fluoroscopic (FL) -guided injections. When choosing US guidance, the proceduralist should be aware of potential issues confirming vertebral level, be clear regarding terminology, and up to date regarding the advantages and disadvantages of US-guided CSNRI. OBJECTIVE Review the accuracy and effectiveness of US guidance in avoiding vascular puncture (VP) and/or intravascular injection (IVI) during CSNRI. EVIDENCE REVIEW Queries included PubMed, CINAHL and Embase databases from 2005 to 2019. Three authors reviewed references for eligibility, abstracted data, and appraised quality. FINDINGS The literature demonstrates distinct safety considerations and limited evidence of the effectiveness of US guidance in detecting VP and/or IVI. As vascular flow and desired injectate spread cannot be visualized with US, the use of real-time fluoroscopy, and if needed digitial subraction imaging, is indicated in cervical transforaminal epidural injections (CTFEIs). Given the risk of VP and/or IVI, the ability to perform and to retain FL images to document that the procedure was safely conducted is valuable in CTFEIs. CONCLUSION US guidance remains to be proven as a non-inferior alternative to FL guidance or other imaging modalities in the prevention of VP and/or IVI with CTFEIs or cervical selective nerve root blocks. There is a paucity of adequately powered clinical studies evaluating the accuracy and effectiveness of US guidance in avoiding VP and/or IVI. US-guided procedures to treat cervical radicular pain has limitations in visualization of anatomy, and currently with the evidence available is best used in a combined approach with FL guidance.
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Affiliation(s)
- Reza Ehsanian
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedics & Rehabilitation, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Byron J Schneider
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David J Kennedy
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eugene Koshkin
- Department of Anesthesia & Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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Kleimeyer JP, Koltsov JCB, Smuck MW, Wood KB, Cheng I, Hu SS. Cervical epidural steroid injections: incidence and determinants of subsequent surgery. Spine J 2020; 20:1729-1736. [PMID: 32565316 DOI: 10.1016/j.spinee.2020.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Cervical epidural steroid injections (CESIs) are sometimes used in the management of cervical radicular pain in order to delay or avoid surgery. However, the rate and determinants of surgery following CESIs remain uncertain. PURPOSE This study sought to determine: (1) the proportion of patients having surgery following CESI, and (2) the timing of and factors associated with subsequent surgery. STUDY DESIGN Retrospective analysis of a large, national administrative claims database. PATIENT SAMPLE The study included 192,777 CESI patients (age 50.9±11.3 years, 55.2% female) who underwent CESI for imaging-based diagnoses of cervical disc herniation or stenosis, a clinical diagnosis of radiculopathy, or a combination thereof. OUTCOME MEASURES The primary outcome was the time from index CESI to surgery. METHODS Inclusion criteria were CESI for cervical disc herniation, stenosis, or radiculopathy, age ≥18, and active enrollment for 1 year before CESI to screen for exclusions. Patients were followed until they underwent cervical surgery, or their enrollment lapsed. Rates of surgery were assessed with Kaplan-Meier survival curves and 99% confidence intervals. Factors associated with subsequent surgery were assessed with multivariable Cox proportional hazard models. RESULTS Within 6 months of CESI, 11.2% of patients underwent surgery, increasing to 14.5% by 1 year and 22.3% by 5 years. Male patients and those aged 35 to 54 had an increased likelihood of subsequent surgery. Patients with radiculopathy were less likely to undergo surgery following CESI than those with stenosis or herniation, while patients with multiple diagnoses were more likely. Patients with comorbidities including CHF, other cardiac comorbidities or chronic pain were less likely to undergo surgery, as were patients in the northeast US region. Some 33.5% of patients underwent >1 CESI, with 84.6% of these occurring within 1 year. Additional injections were associated with reduced rates of subsequent surgery. CONCLUSIONS Following CESI, over one in five patients underwent surgery within 5 years. Multiple patient-specific risk factors for subsequent surgery were identified, and patients undergoing repeated injections were at lower risk. Determining which patients may progress to surgery can be used to improve resource utilization and to inform shared decision-making.
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Affiliation(s)
- John P Kleimeyer
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway Street MC 6342, Redwood City, CA 94063, USA
| | - Jayme C B Koltsov
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway Street MC 6342, Redwood City, CA 94063, USA
| | - Matthew W Smuck
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway Street MC 6342, Redwood City, CA 94063, USA
| | - Kirkham B Wood
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway Street MC 6342, Redwood City, CA 94063, USA
| | - Ivan Cheng
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway Street MC 6342, Redwood City, CA 94063, USA
| | - Serena S Hu
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway Street MC 6342, Redwood City, CA 94063, USA.
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Hong JY, Park JS, Suh SW, Yang JH, Park SY, Kim BT. Transforaminal epidural steroid injections in cervical spinal disease with moderate to severe disability: Comparative study in patients with or without surgery. Medicine (Baltimore) 2020; 99:e19266. [PMID: 32049868 PMCID: PMC7035037 DOI: 10.1097/md.0000000000019266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Despite many clinical trials on cervical epidural steroid injections, the indications for and long-standing outcomes of this treatment remain controversial. We evaluated the outcomes and indications for transforaminal cervical epidural steroid injection (TCESI) in patients with moderate to severe disability.We prospectively gathered data from patients with 1 or 2-level cervical degenerative disease (herniated disc, foraminal stenosis) with moderate to severe disability (3.5 < initial visual analog scale < 6.5, 15 < Neck Disability Index < 35) and greater than 12 weeks of pain, despite conservative treatment. Patients with persistent disability and those who desired surgical intervention underwent decompression surgery. The clinical and demographic characteristics were compared between groups.Of the 309 patients who underwent TCESI, 221 (72%) did not receive surgical treatment during the 1-year follow-up period. The remaining 88 patients (28%) underwent surgery at a mean of 4.1 months after initial TCESI. Patients who underwent injection alone showed a significant decrease in disability and pain that persisted until the 1-year follow-up visit (P < .05). In patients who underwent surgery, the mean disability and pain scores after injection did not decrease for several months, although the scores significantly decreased up to 1 year after surgery (P < .05).The TCESI significantly decreased pain and disability in the moderate to severe disability group up to 1 year after injection. We recommend cervical TCESI as an initial treatment with moderate to severe disability patients.
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Affiliation(s)
- Jae-Young Hong
- Department of Orthopedics, Korea University Ansan Hospital, Ansan
| | - Jin-Sung Park
- Department of Orthopedics, Korea University Ansan Hospital, Ansan
| | - Seung-Woo Suh
- Department of Orthopedics, Korea University Guro Hospital
| | - Jae-Hyuk Yang
- Department of Orthopedics, Korea University Guro Hospital
| | - Si-Young Park
- Department of Orthopedics, Korea University Anam Hospital, Seoul, South Korea
| | - Bo Taek Kim
- Department of Orthopedics, Korea University Ansan Hospital, Ansan
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Cervical Ultrasound Utilization in Selective Cervical Nerve Root Injection for the Treatment of Cervical Radicular Pain: a Review. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00248-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Hashemi M, Dadkhah P, Taheri M, Ghasemi M, Hosseinpour A, Farjam M. Patient-Reported Outcomes and Satisfaction after Cervical Epidural Steroid Injection for Cervical Radiculopathy. Galen Med J 2019; 8:e1478. [PMID: 34466515 PMCID: PMC8343784 DOI: 10.31661/gmj.v8i0.1478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/10/2019] [Accepted: 03/15/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Cervical radiculopathy caused by disc herniation is a frequent public health issue with economical and socio-professional impacts. The objective of the present study is to evaluate the patient-reported outcomes and satisfaction from cervical epidural steroid injection during a 2-year follow-up. MATERIALS AND METHODS Results based on patients' reports from a previously performed intervention of cervical epidural steroid injection on patients with cervical radiculopathy due to cervical disc herniation are prospectively collected. Outcome measures are Neck Disability Index (NDI), numerical rating scale (NRS) for pain assessment, and 5-scale patient satisfaction questionnaire (PSQ) plus opioid medication for pain relief, additional injections, and progression to surgery. RESULTS Of total 37 cases, 34 were available for follow-up after 2-year postoperatively. The mean preoperative NDI was 21.17 and improved to 17.38, and the mean NRS was 7.7 and improved to 5.00; both were statistically significant. Mean patient satisfaction after 2 years was 3.17 out of 5. 11 cases needed additional injections, and 4 of patients proceeded to surgery. CONCLUSION We showed that transforaminal cervical epidural steroid injection for cervical radiculopathy is an effective non-surgical treatment option, providing significant pain relief and functional improvement during 2-years follow-up along with higher-than-average patient satisfaction in most of our patients.
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Affiliation(s)
- Masoud Hashemi
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Payman Dadkhah
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Taheri
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahshid Ghasemi
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Hosseinpour
- Non-Communicable Disease Research Center, Fasa University of Medical Sciences, Fasa, Fars, Iran
| | - Mojtaba Farjam
- Non-Communicable Disease Research Center, Fasa University of Medical Sciences, Fasa, Fars, Iran
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Conger A, Cushman DM, Speckman RA, Burnham T, Teramoto M, McCormick ZL. The Effectiveness of Fluoroscopically Guided Cervical Transforaminal Epidural Steroid Injection for the Treatment of Radicular Pain; a Systematic Review and Meta-analysis. PAIN MEDICINE 2019; 21:41-54. [DOI: 10.1093/pm/pnz127] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Abstract
Objective
Determine the effectiveness of fluoroscopically guided cervical transforaminal epidural steroid injection (CTFESI) for the treatment of radicular pain.
Design
Systematic review and meta-analysis.
Subjects
Persons aged ≥18 years with cervical radicular pain due to disc herniation or degenerative spondylosis.
Comparison
Sham, placebo procedure, or active standard of care treatment, excluding alternative versions of epidural steroid injection.
Outcomes
The primary outcome measure was patient-reported improvement in pain of at least 50% from baseline, assessed four or more weeks after the treatment intervention. Secondary outcomes included validated functional assessment tools and avoidance of spinal surgery.
Methods
Randomized or nonrandomized comparative studies and nonrandomized studies without internal control were included. Three reviewers independently assessed publications in the Medline, PubMed, and Cochrane databases up to July 2018. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system was used to evaluate risk of bias and overall quality of evidence. A meta-analysis was conducted for comparative measures of effect and for within-group response rates if applicable.
Results
There were no studies with an internal comparison group (control group) meeting the review’s definition of comparison group. Therefore, comparative measures of effect were not calculated. In cohort studies, pooled response rates were 48% (95% confidence interval [CI] = 34–61%) at one month and 55% (95% CI = 45–64%) at three months.
Conclusions
Approximately 50% of patients experience ≥50% pain reduction at short- and intermediate-term follow-up after CTFESI. However, the literature is very low quality according the GRADE criteria, primarily due to a lack of studies with placebo/sham or active standard of care control comparison groups.
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Affiliation(s)
- Aaron Conger
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Daniel M Cushman
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Rebecca A Speckman
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
- Department of Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Taylor Burnham
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Masaru Teramoto
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
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Lukies MW, Teoh WW, Clements W. Safety of CT-guided cervical nerve root corticosteroid injections. J Med Imaging Radiat Oncol 2019; 63:300-306. [PMID: 30859711 DOI: 10.1111/1754-9485.12870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 02/16/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Computed tomography-guided cervical nerve root corticosteroid injections are a commonly performed procedure for cervical radiculopathy. There have been major complications such as spinal cord infarction and posterior circulation stroke reported mostly with X-ray fluoroscopic-guided methods, however, there is relatively little data on the safety of newer CT-guided methods. The purpose of this study was to identify any major complications and evaluate the rate of minor complications from CT-guided cervical nerve root corticosteroid injections performed in a tertiary public hospital. METHODS Four hundred and three CT-guided cervical nerve root injection procedures were identified over a period from July 2015 to January 2018 using the radiology information system (RIS) and data collected about the technique and any immediate complications. Patient follow-up and delayed complications were then reviewed, either via outpatient clinic records or telephone consultation. RESULTS Two hundred and eighty-six procedures were performed by radiology registrars or fellows, and 117 by radiologists, most commonly via an anterolateral approach and injecting 4 mg (in 1 mL) of dexamethasone. Follow-up data were obtained for all 403 procedures and identified 16 minor complications, but no major neurovascular complications. CONCLUSION The overall recorded rate of minor complications with CT-guided nerve root injection was 4.0% with no major neurovascular complications, suggesting that CT-guided transforaminal cervical corticosteroid injection is a safe procedure.
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Affiliation(s)
- Matthew W Lukies
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Wesley Wh Teoh
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
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Kesikburun S, Aras B, Kelle B, Yavuz F, Yaşar E, Taşkaynatan MA. The effectiveness of cervical transforaminal epidural steroid injection for the treatment of neck pain due to cervical disc herniation: long-term results. Pain Manag 2018; 8:321-326. [PMID: 30278822 DOI: 10.2217/pmt-2018-0002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To investigate the long-term effect of fluoroscopy guided cervical transforaminal epidural steroid injection on neck pain radiating to the arm due to cervical disc herniation. MATERIALS & METHODS 64 patients (26 women [40.6%], 38 men [59.4%]; mean age, 44.9 ± 12.1 years) who had received fluoroscopy guided cervical transforaminal epidural steroid injection for neck pain due to cervical disc herniation at least 1 year before were included in the study. The effectiveness of transforaminal epidural steroid injection was assessed using data obtained by medical records and a standardized telephone questionnaire. Multiple linear regression analysis was applied to evaluate the factors affecting the pain reduction after injection and the duration of treatment effect. RESULTS The mean duration of neck pain symptom was 23.3 ± 23.9 months. Most of the patients received a single injection (50 patients, 78.1%). The mean time since injection at the time of interview was 21.4 ± 9.4 months. There was a significant reduction in mean pain visual analog scale (VAS [10 cm]) score, from 8.6 ± 1.4 at baseline to 3.2 ± 2.5 at check visit two weeks after injection (p < 0.001). 52 patients (81.2%) reported pain relief of more than 50%. The mean duration of treatment effect was 13.3 ± 9.44 months. Greater pain on the VAS was found to predict strongly the higher pain reduction and longer treatment effect (p = 0.042 and 0.011, respectively). CONCLUSION The results suggested that cervical transforaminal epidural steroid injections might be an effective treatment for neck back pain radiating to the arm due to cervical disc herniation.
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Affiliation(s)
- Serdar Kesikburun
- Department of Physical Medicine & Rehabilitation, Gulhane School of Medicine, University of Health Science, Ankara 06100, Turkey
| | - Berke Aras
- Kastamonu Rehabilitation Centre, Kastamonu 37100, Turkey
| | - Bayram Kelle
- Çukurova University, Physical Therapy & Rehabilitation Department, Adana 01100, Turkey
| | - Ferdi Yavuz
- Fizyocare Physical Therapy & Rehabilitation Centre, Ankara 01110, Turkey
| | - Evren Yaşar
- Department of Physical Medicine & Rehabilitation, Gulhane School of Medicine, University of Health Science, Ankara 06100, Turkey
| | - Mehmet A Taşkaynatan
- Department of Physical Medicine & Rehabilitation, Gulhane School of Medicine, University of Health Science, Ankara 06100, Turkey
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Joswig H, Neff A, Ruppert C, Hildebrandt G, Stienen MN. Repeat epidural steroid injections for radicular pain due to lumbar or cervical disc herniation. Bone Joint J 2018; 100-B:1364-1371. [DOI: 10.1302/0301-620x.100b10.bjj-2018-0461.r1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to determine the efficacy of repeat epidural steroid injections as a form of treatment for patients with insufficiently controlled or recurrent radicular pain due to a lumbar or cervical disc herniation. Patients and Methods A cohort of 102 patients was prospectively followed, after an epidural steroid injection for radicular symptoms due to lumbar disc herniation, in 57 patients, and cervical disc herniation, in 45 patients. Those patients with persistent pain who requested a second injection were prospectively followed for one year. Radicular and local pain were assessed on a visual analogue scale (VAS), functional outcome with the Oswestry Disability Index (ODI) or the Neck Pain and Disability Index (NPAD), as well as health-related quality of life (HRQoL) using the 12-Item Short-Form Health Survey questionnaire (SF-12). Results A second injection was performed in 17 patients (29.8%) with lumbar herniation and seven (15.6%) with cervical herniation at a mean of 65.3 days (sd 46.5) and 47 days (sd 37.2), respectively, after the initial injection. All but one patient, who underwent lumbar microdiscectomy, responded satisfactorily with a mean VAS for leg pain of 8.8 mm (sd 10.3) and a mean VAS for arm pain of 6.3 mm (sd 9) one year after the second injection, respectively. Similarly, functional outcome and HRQoL were improved significantly from the baseline scores: mean ODI, 12.3 (sd 12.4; p < 0.001); mean NPAD, 19.3 (sd 24.3; p = 0.041); mean SF-12 physical component summary (PCS) in lumbar herniation, 46.8 (sd 7.7; p < 0.001); mean SF-12 PCS in cervical herniation, 43 (sd 6.8; p = 0.103). Conclusion Repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection. Cite this article: Bone Joint J 2018;100-B:1364–71.
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Affiliation(s)
- H. Joswig
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland and Department of Clinical Neurological Sciences, Division of Neurosurgery, London Health Sciences Centre, University Hospital London, Canada
| | - A. Neff
- Department of Radiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - C. Ruppert
- ZHAW School of Applied Psychology, Zurich, Switzerland
| | - G. Hildebrandt
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - M. N. Stienen
- Department of Neurosurgery, University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
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Merrill CA, Ferreira J, Parrino A, Moss IL. Team Approach: Upper-Extremity Numbness. JBJS Rev 2018; 6:e3. [PMID: 29894340 DOI: 10.2106/jbjs.rvw.17.00166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Christian A Merrill
- Departments of Orthopaedic Surgery (C.A.M., J.F., A.P., and I.L.M.) and Neurosurgery (I.L.M.), UConn Health Musculoskeletal Institute, University of Connecticut, Farmington, Connecticut
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The value of short-term pain relief in predicting the long-term outcome of 'indirect' cervical epidural steroid injections. Acta Neurochir (Wien) 2018. [PMID: 29541886 DOI: 10.1007/s00701-018-3511-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The predictive value of short-term arm pain relief after 'indirect' cervical epidural steroid injection (ESI) for the 1-month treatment response has been previously demonstrated. It remained to be answered whether the long-term response could be estimated by the early post-interventional pain course as well. METHODS Prospective observational study, following a cohort of n = 45 patients for a period of 24 months after 'indirect' ESI for radiculopathy secondary to a single-level cervical disk herniation (CDH). Arm and neck pain on the visual analog scale (VAS), health-related quality of life with the Short Form-12 (SF-12), and functional outcome with the Neck Pain and Disability (NPAD) Scale were assessed. Any additional invasive treatment after a single injection (second injection or surgery) defined treatment outcome as 'non-response'. RESULTS At 24 months, n = 30 (66.7%) patients were responders and n = 15 (33.3%) were non-responders. Non-responders exited the follow-up at 1 month (n = 10), at 3 months (n = 4), and at 6 months (n = 1). No patients were injected again or operated on between the 6- and 24-month follow-up. Patients with favorable treatment response at 24 months had significantly lower VAS arm pain (p < 0.05) than non-responders at days 6, 8-11, and at the 3-month follow-up. The previously defined cut-off of > 50% short term pain reduction was not a reliable predictor of the 24-month responder status. SF-12 and NPAD scores were better among treatment responders in the long term. CONCLUSIONS Patients who require a second injection or surgery after 'indirect' cervical ESI for a symptomatic CDH do so within the first 6 months. Short-term pain relief cannot reliably predict the long-term outcome.
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Abstract
Image-guided spinal injection is commonly performed in symptomatic patients to decrease pain severity, confirm the pain generator, and delay or avoid surgery. This article focuses on the radiologist as spine interventionist and addresses the following four topics relevant to the radiologist who performs corticosteroid injections for pain management: (a) the rationale behind corticosteroid injection, (b) the interaction with patients, (c) the role of imaging in procedural selection and planning, and (d) the pearls and pitfalls of fluoroscopically guided injections. Factors that contribute to the success of a pain management service include communication skills and risk mitigation. A critical factor is the correlation of clinical symptoms with magnetic resonance (MR) imaging findings. Radiologists can leverage their training in MR image interpretation to distinguish active pain generators in the spine from incidental abnormalities. Knowledge of fluoroscopic anatomy and patterns of contrast material flow guide the planning and execution of safe and effective needle placement. © RSNA, 2016 Online supplemental material is available for this article.
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Affiliation(s)
- William E Palmer
- From the Department of Musculoskeletal Radiology, Massachusetts General Hospital, 55 Fruit St, YAW 6030, Boston, MA 02114
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17
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Joswig H, Neff A, Ruppert C, Hildebrandt G, Stienen MN. The value of short-term pain relief in predicting the 1-month outcome of 'indirect' cervical epidural steroid injections. Acta Neurochir (Wien) 2017; 159:291-300. [PMID: 27796650 DOI: 10.1007/s00701-016-2997-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/13/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Clinical management after epidural steroid injections (ESI) of patients with radiculopathy secondary to a cervical disc herniation (CDH) is uncertain. This study aims to determine whether short-term arm pain alleviation following computed tomography-guided 'indirect' cervical ESI can predict the 1-month outcome. METHODS We conducted a prospective observation of 45 consecutive patients at a tertiary radiological department. Study components were visual analog scale arm and neck pain at baseline, 15, 30, and 45 min, 1, 2, and 4 h, on days 1-14, 1 month, and at 1 year. Health-related quality of life and functional impairment were assessed using the short form-12 and Neck Pain and Disability Scale. Patients who reported ≥80 % persisting arm pain, as well as patients who underwent a second injection or an operation within 1 month were defined as 'non-responders'. Logistic regression was used to analyze the effect size of the relationship between >50 % pain relief at any given study visit and responder status. RESULTS Patients experiencing a >50 % pain reduction 4 h after the injection were four times as likely to be responders as those experiencing ≤50 % pain reduction (OR 4.04, 95 % CI 1.10-14.87). The effect was strongest on days 5-6 (OR 18.37, 95 % CI 3.39-99.64) and remained significant until day 14. CONCLUSIONS The results of this study can guide physicians in managing patients with CDH: a ≤50 % arm pain relief within 1 week after an 'indirect' cervical ESI predicts an unfavorable 1-month outcome and suggests that other treatment options may be considered at an earlier point in time.
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Affiliation(s)
- Holger Joswig
- Department of Neurosurgery, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007, St. Gallen, Switzerland.
| | - Armin Neff
- Department of Radiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | | | - Gerhard Hildebrandt
- Department of Neurosurgery, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007, St. Gallen, Switzerland
| | - Martin Nikolaus Stienen
- Department of Neurosurgery and Faculty of Medicine, University Hospital of Geneva, Geneva, Switzerland
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Abstract
BACKGROUND AND OBJECTIVE Epidural corticosteroid injections (ESIs) have been used for several decades and now represent the most common intervention performed for the management of back pain with a radicular component. However, several reports have presented devastating complications and adverse effects, which fuelled concerns over the risk versus clinical effectiveness. The authors offer a comprehensive review of the available literature and analyse the data derived from studies and case reports. METHODS Studies were identified by searching PubMed MEDLINE, Ovid MEDLINE, EMBASE, Scopus, Google Scholar and the Cochrane Library to retrieve all available relevant articles. Publications from the last 20 years (September 1994 to September 2014) were considered for further analysis. Studies selected were English-language original articles publishing results on complications related to the technique used for cervical and lumbar ESIs. The studies had to specify the approach used for injection. All studies that did not fulfil these eligibility criteria were excluded from further analysis. RESULTS Overall, the available literature supports the view that serious complications following injections of corticosteroid suspensions into the cervical and lumbar epidural space are uncommon, but if they occur they can be devastating. CONCLUSIONS The true incidence of such complications remains unclear. Direct vascular injury and/or administration of injectates intra-arterially represent a major concern and could account for the vast majority of the adverse events reported. Accurate placement of the needle, use of a non-particulate corticosteroid, live fluoroscopy, digital subtraction angiography, and familiarisation of the operator with contrast patterns on fluoroscopy should minimise these risks. The available literature has several limitations including incomplete documentation, unreported data and inherent bias. Large registries and well-structured observational studies are needed to determine the true incidence of adverse events and address the safety concerns.
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Kressig M, Peterson CK, McChurch K, Schmid C, Leemann S, Anklin B, Humphreys BK. Relationship of Modic Changes, Disk Herniation Morphology, and Axial Location to Outcomes in Symptomatic Cervical Disk Herniation Patients Treated With High-Velocity, Low-Amplitude Spinal Manipulation: A Prospective Study. J Manipulative Physiol Ther 2016; 39:565-575. [DOI: 10.1016/j.jmpt.2016.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 08/12/2016] [Indexed: 12/16/2022]
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Lee DG, Ahn SH, Lee J. Comparative Effectivenesses of Pulsed Radiofrequency and Transforaminal Steroid Injection for Radicular Pain due to Disc Herniation: a Prospective Randomized Trial. J Korean Med Sci 2016; 31:1324-30. [PMID: 27478346 PMCID: PMC4951565 DOI: 10.3346/jkms.2016.31.8.1324] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 06/23/2016] [Indexed: 01/23/2023] Open
Abstract
Transforaminal Epidural steroid injections (TFESI) have been widely adopted to alleviate and control radicular pain in accord with current guidelines. However, sometimes repeated steroid injections have adverse effects, and thus, this prospective randomized trial was undertaken to compare the effectivenesses of pulsed radiofrequency (PRF) administered to a targeted dorsal root ganglion (DRG) and TFESI for the treatment of radicular pain due to disc herniation. Subjects were recruited when first proved unsuccessful (defined as a score of > 4 on a visual analogue scale (VAS; 0-10 mm) and of > 30% according to the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI)). Forty-four patients that met the inclusion criteria were enrolled. The 38 subjects were randomly assigned to receive either PRF (PRF group; n = 19) or additional TFESI (TFESI group; n = 19) and were then followed for 2, 4, 8, and 12 weeks. To evaluate pain intensity were assessed by VAS. ODI and NDI were applied to evaluate functional disability. Mean VAS scores for cervical and lumbar radicular pain were significantly lower 12 weeks after treatment in both study groups. NDI and ODI scores also declined after treatment. However, no statistically significant difference was observed between the PRF and TFESI groups in terms of VAS, ODI, or NDI scores at any time during follow-up. PRF administered to a DRG might be as effective as TFESI in terms of attenuating radicular pain caused by disc herniation, and its use would avoid the adverse effects of steroid.
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Affiliation(s)
- Dong Gyu Lee
- Department of Physical Medicine & Rehabilitation, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Sang-Ho Ahn
- Department of Physical Medicine & Rehabilitation, Yeungnam University School of Medicine, Daegu, Korea
| | - Jungwon Lee
- Department of Physical Medicine & Rehabilitation, Yeungnam University School of Medicine, Daegu, Korea
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Klessinger S. Interventional pain therapy in cervical post-surgery syndrome. World J Anesthesiol 2016; 5:38-43. [DOI: 10.5313/wja.v5.i2.38] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/31/2016] [Accepted: 07/13/2016] [Indexed: 02/07/2023] Open
Abstract
Fifteen percent to forty percent of patients present with persistent disabling neck pain or radicular pain after cervical spine surgery. Persistent pain after cervical surgery is called cervical post-surgery syndrome (CPSS). This review investigates the literature about interventional pain therapy for these patients. Because different interventions with different anatomical targets exist, it is important to find the possible pain source. There has to be a distinction between radicular symptoms (radicular pain or radiculopathy) or axial pain (neck pain) and between persistent pain and a new onset of pain after surgery. In the case of radicular symptoms, inadequate decompression or nerve root adherence because of perineural scarring are possible pain causes. Multiple structures in the cervical spine are able to cause neck pain. Hereby, the type of surgery and also the number of segments treated is relevant. After fusion surgery, the so-called adjacent level syndrome is a possible pain source. After arthroplasty, the load of the facet joints in the index segment increases and can cause pain. Further, degenerative alterations progress. In general, two fundamentally different therapeutic approaches for interventional pain therapy for the cervical spine exist: Treatment of facet joint pain with radiofrequency denervation or facet nerve blocks, and epidural injections either via a transforaminal or via an interlaminar approach. The literature about interventions in CPSS is limited to single studies with a small number of patients. However, some evidence exists for these procedures. Interventional pain therapies are eligible as a target-specific therapy option. However, the risk of theses procedures (especially transforaminal epidural injections) must be weighed against the benefit.
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22
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Oder B, Thurnher S. [Periradicular infiltration therapy : Clinical indications, technique and results]. Radiologe 2016; 55:833-9. [PMID: 26377920 DOI: 10.1007/s00117-015-0017-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Minimally invasive procedures have played an emerging role in pain management during recent years. OBJECTIVES Evaluation of the different types of periradicular infiltration as fundamental procedures in the progressive stepwise concept of pain management. Comparison of the different therapeutic substances. RESULTS In the mid-term and long-term periradicular infiltration is effective in 60-80 % of patients regarding analgesic and functional aspects. Compliance with the guidelines should help to minimize potentially fatal complications. CONCLUSION Periradicular infiltration is of significant importance concerning the treatment of spinal nerve root irritation. Periradicular infiltration is regarded as a safe procedure, especially when supported by computed tomography (CT) scans.
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Affiliation(s)
- B Oder
- Abteilung für Radiologie und Nuklearmedizin, Krankenhaus der Barmherzigen Brüder Wien, Johannes von Gott Platz 1, 1020, Wien, Österreich.
| | - S Thurnher
- Abteilung für Radiologie und Nuklearmedizin, Krankenhaus der Barmherzigen Brüder Wien, Johannes von Gott Platz 1, 1020, Wien, Österreich
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Peterson CK, Pfirrmann CWA, Hodler J, Leemann S, Schmid C, Anklin B, Humphreys BK. Symptomatic, Magnetic Resonance Imaging-Confirmed Cervical Disk Herniation Patients: A Comparative-Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either Imaging-Guided Indirect Cervical Nerve Root Injections or Spinal Manipulative Therapy. J Manipulative Physiol Ther 2016; 39:210-7. [PMID: 27040033 DOI: 10.1016/j.jmpt.2016.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 10/14/2015] [Accepted: 10/14/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the outcomes of overall improvement, pain reduction, and treatment costs in matched patients with symptomatic, magnetic resonance imaging-confirmed cervical disk herniations treated with either spinal manipulative therapy (SMT) or imaging-guided cervical nerve root injection blocks (CNRI). METHODS This prospective cohort comparative-effectiveness study included 104 patients with magnetic resonance imaging-confirmed symptomatic cervical disk herniation. Fifty-two patients treated with CNRI were age and sex matched with 52 patients treated with SMT. Baseline numerical rating scale (NRS) pain data were collected. Three months after treatment, NRS pain levels were recorded and overall "improvement" was assessed using the Patient Global Impression of Change scale. Only responses "much better" or "better" were considered "improved." The proportion of patients "improved" was calculated for each treatment method and compared using the χ(2) test. The NRS and NRS change scores for the 2 groups were compared at baseline and 3 months using the unpaired t test. Acute and subacute/chronic patients in the 2 groups were compared for "improvement" using the χ(2) test. RESULTS "Improvement" was reported in 86.5% of SMT patients and 49.0% of CNRI patients (P = .0001). Significantly more CNRI patients were in the subacute/chronic category (77%) compared with SMT patients (46%). A significant difference between the proportion of subacute/chronic CNRI patients (37.5%) and SMT patients (78.3%) reporting "improvement" was noted (P = .002). CONCLUSION Subacute/chronic patients treated with SMT were significantly more likely to report relevant "improvement" compared with CNRI patients. There was no difference in outcomes when comparing acute patients only.
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Affiliation(s)
- Cynthia K Peterson
- Professor, Radiology Department, Orthopaedic University Hospital Balgrist, University of Zürich, Switzerland; Professor, Chiropractic Medicine Department, Orthopaedic University Hospital Balgrist, University of Zürich, Switzerland.
| | - Christian W A Pfirrmann
- Professor, Head of Radiology Department, Orthopaedic University Hospital Balgrist, University of Zürich, Switzerland
| | - Jürg Hodler
- Professor, Head of Radiology Department, University Hospital, University of Zürich
| | | | | | | | - B Kim Humphreys
- Professor, Department Head, Chiropractic Medicine, Faculty of Medicine, Orthopaedic University Hospital Balgrist, University of Zürich, Switzerland
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Lee JH, Lee SH. Comparison of Clinical Efficacy Between Interlaminar and Transforaminal Epidural Injection in Patients With Axial Pain due to Cervical Disc Herniation. Medicine (Baltimore) 2016; 95:e2568. [PMID: 26825899 PMCID: PMC5291569 DOI: 10.1097/md.0000000000002568] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Transforaminal (TF) approach is preferred by physician to interlaminar (IL) approach because it can deliver injectates directly around nerve root and dorsal root ganglion, which is regarded as main pain sources. Axial neck pain is originated from sinuvertebral nerve located in ventral epidural spaces, which has been described to be related to central or paramedian disc herniation. It is very questionable that TF injection is also more effective than IL injection in the patients with axial neck or interscapular pain. This study was to evaluate clinical efficacy of cervical epidural injection in patients with axial pain due to cervical disc herniation and to compare the clinical outcomes between TF and IL approaches. Fifty-six and 52 patients who underwent IL and TF epidural injections, respectively, for axial neck/interscapular pain due to central or paramedian cervical disc herniation were included. Numeric Rating Scale (NRS) and Neck Disability Index (NDI) were compared between both groups at 2 and 8 weeks after treatment. Successful pain relief was defined if a 50% or more reduction of NRS score was achieved in comparison with pretreatment one. Successful functional improvement was defined if at least a 40% reduction of NDI was obtained. Overall, 79 (73.1%) and 57 (52.8%) among 108 patients showed successful pain relief at 2 and 8 weeks, respectively. Seventy-six (70.4%) and 52 (48.1%) had successful functional improvement at 2 and 8 weeks, respectively. The IL and TF groups showed no significant difference in proportion of successful results of NRS 2 weeks (73.2% vs 67.3%) and 8 weeks (48.2% vs 48.1%). Also, no significant difference was obtained in proportion of successful NDI between 2 groups at 2 weeks (75.0% vs 71.2%) and 8 weeks (53.6% vs 51.9%). Cervical epidural injection showed favorable results in 2 weeks and moderate results in 8 weeks in patients with axial pain due to cervical disc herniation. IL and TF showed no significant difference in clinical efficacy. Considering TF was relevant to more serious side effects, IL was more recommendable in these patients.
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Affiliation(s)
- Jung Hwan Lee
- From the Departments of Physical Medicine and Rehabilitation (JHL) and Neurosurgery (S-HL), Wooridul Spine Hospital, Seoul, Korea
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Hashemi SM, Aryani MR, Momenzadeh S, Razavi SS, Mohseni G, Mohajerani SA, Esmilijah AA. Comparison of Transforaminal and Parasagittal Epidural Steroid Injections in Patients With Radicular Low Back Pain. Anesth Pain Med 2015; 5:e26652. [PMID: 26587400 PMCID: PMC4644318 DOI: 10.5812/aapm.26652v2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/11/2015] [Accepted: 03/18/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Epidural steroid injection (ESI), including transforaminal (TF) epidural injections and interlaminar (IL) epidural steroid injections are commonly performed procedures for the management of lumbosacral radicular pain. Parasagittal interlaminar (PIL) approach could enable higher ventral epidural spread, with fewer complications than TF. OBJECTIVES This study aims to compare the effectiveness of PIL and TF ESI in relieving the pain and disability of patients with lumbosacral pain. PATIENTS AND METHODS This prospective study enrolled 64 patients, aged between 18 to 75 years, with a diagnosis of low back pain and unilateral lumbosacral radicular pain. The patients were randomized to receive fluoroscopically guided epidural injection, through either the PIL or TF approach. Patients were evaluated for effective pain relief [numerical rating scale (NRS) < 3] by 0 - 10 numeric rating scale (NRS) and functional improvement by the Oswestry Disability Index (ODI). RESULTS Effective pain relief [numeric rating scale (NRS) < 3] was observed in 77.3% (95% CI: 67‒90.5%) of patients in PIL group and 74.2% (95% CI: 62.4 - 89.4%) of patients in the TF group (P = 0.34), at 4 weeks. Mean NRS score was not significantly different between the PIL group compared to the TF group, at 4 weeks (P = 0.19). Number of patients with improved disability (measured by ODI < 20%) was not significantly different in PIL group (78% of cases) compared to the TF group (76% of cases), at 4 weeks (P = 0.21). There were no adverse effects observed in any of our patients. CONCLUSIONS The PIL epidural injection is as effective as TF epidural injection in improving pain and functional status, in patients with chronic lumbosacral low back pain, due to disc degeneration.
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Affiliation(s)
- Seyed Masoud Hashemi
- Department of Anesthesiology, Akhtar Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohamad Reza Aryani
- Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding author: Mohamad Reza Aryani, Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel/Fax: +98-2122612252, E-mail:
| | - Sirus Momenzadeh
- Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Sajad Razavi
- Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Gholamreza Mohseni
- Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Amir Mohajerani
- Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Akbar Esmilijah
- Department of Orthopedics Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Xiao L, Li J, Li D, Yan D, Yang J, Wang D, Cheng J. A posterior approach to cervical nerve root block and pulsed radiofrequency treatment for cervical radicular pain: a retrospective study. J Clin Anesth 2015; 27:486-91. [PMID: 26051825 DOI: 10.1016/j.jclinane.2015.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Revised: 02/10/2015] [Accepted: 04/01/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Catastrophic complications have been reported for selective cervical nerve root block (SCNRB) or pulsed radiofrequency (PRF) via an anterolateral transforaminal approach. A posterior approach to these procedures under computed tomography guidance has been reported. Here, we report the clinical outcomes of 42 patients with chronic cervical radicular pain (CCRP) treated with a combination of SCNRB and PRF through a posterior approach under fluoroscopy guidance. METHODS We retrospectively reviewed the clinical outcomes of 42 consecutive patients with CCRP who received a combination of SCNRB and PRF through a posterior approach under fluoroscopy guidance. The thresholds of electrical stimulation and imaging of the nerve roots after contrast injection were used to evaluate the accuracy of needle placement. The numeric rating scale was used to measure the pain and numbness levels as primary clinical outcomes, which were evaluate in scheduled follow-up visits of up to 3 months. RESULTS A total of 53 procedures were performed on 42 patients at the levels of C5-C8. All patients reported concordant paresthesia in response to electrical stimulation. The average sensory and motor thresholds of stimulation were 0.28 ± 0.14 and 0.36 ± 0.14 V, respectively. Injection of nonionic contrast resulted in excellent spread along the target nerve root in large majority of the procedures. The numeric rating scale scores for both pain and numbness improved significantly at 1 day, 1 week, and 1 and 3 months after the treatment. No serious adverse effects were observed in any of the patients. CONCLUSIONS The posterior approach to combined SCNRB and PRF under fluoroscopy guidance appears to be safe and efficacious in the management of CCRP.
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Affiliation(s)
- Lizu Xiao
- Department of Pain Management of Shenzhen Nanshan Hospital, Guangdong Medical College, Shenzhen, China 518052.
| | - Jie Li
- Department of Pain Management of Shenzhen Nanshan Hospital, Guangdong Medical College, Shenzhen, China 518052
| | - Disen Li
- Department of Pain Management of Shenzhen Nanshan Hospital, Guangdong Medical College, Shenzhen, China 518052
| | - Dong Yan
- Department of Pain Management of Shenzhen Nanshan Hospital, Guangdong Medical College, Shenzhen, China 518052
| | - Jun Yang
- Department of Pain Management of Shenzhen Nanshan Hospital, Guangdong Medical College, Shenzhen, China 518052
| | - Daniel Wang
- Department of Pain Management, Cleveland Clinic, Cleveland, OH, USA 44195; Department of Neurosciences, Cleveland Clinic, Cleveland, OH, USA 44195
| | - Jianguo Cheng
- Department of Pain Management, Cleveland Clinic, Cleveland, OH, USA 44195; Department of Neurosciences, Cleveland Clinic, Cleveland, OH, USA 44195
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Bensler S, Sutter R, Pfirrmann CWA, Peterson CK. Long Term Outcomes from CT-guided Indirect Cervical Nerve Root Blocks and their relationship to the MRI findings- A prospective Study. Eur Radiol 2015; 25:3405-13. [DOI: 10.1007/s00330-015-3758-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 02/25/2015] [Accepted: 03/31/2015] [Indexed: 12/22/2022]
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Ideal Cervical Epidural Injection Route: Interlaminar or Transforaminal. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2015. [DOI: 10.1007/s40141-015-0084-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Pneumocephalus during cervical transforaminal epidural steroid injections: a case report. Am J Phys Med Rehabil 2015; 94:63-9. [PMID: 25133619 DOI: 10.1097/phm.0000000000000165] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A cervical transforaminal epidural injection of anesthetic and corticosteroids (CTFESI) is a frequently used procedure for cervical radiculopathy. Most cases of pneumocephalus after an epidural block occur when using an interlaminar approach with the loss-of-resistance technique. The authors present the first case of pneumocephalus after cervical transforaminal epidural injection of anesthetic and corticosteroids. A 64-yr-old woman with left C7 radiculopathy was undergoing C6-7 transforaminal epidural injection of anesthetic and corticosteroids. The epidural spread of contrast was checked by fluoroscope, and 5 mg of dexamethasone in 4 ml of 0.1875% ropivacaine was injected. She lost consciousness 5 mins after the procedure and regained awareness after manual ventilation. She subsequently complained of nausea and headache, and a computed tomography brain scan revealed pneumocephalus. After carefully assessing the fluoroscopic images, the authors believe that the needle may have punctured the dura mater of the nerve root sleeve, allowing air to enter the subdural space. Thus, fluoroscopic images should be carefully examined to reduce dural puncture when performing cervical transforaminal epidural injection of anesthetic and corticosteroids, and air should be completely removed from the needle, extension tube, and syringe.
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Tiric-Campara M, Krupic F, Biscevic M, Spahic E, Maglajlija K, Masic Z, Zunic L, Masic I. Occupational overuse syndrome (technological diseases): carpal tunnel syndrome, a mouse shoulder, cervical pain syndrome. Acta Inform Med 2014; 22:333-40. [PMID: 25568584 PMCID: PMC4272839 DOI: 10.5455/aim.2014.22.333-340] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 10/25/2014] [Indexed: 11/26/2022] Open
Abstract
Technological diseases are diseases of the modern era. Some are caused by occupational exposures, and are marked with direct professional relation, or the action of harmful effects in the workplace. Due to the increasing incidence of these diseases on specific workplaces which may be caused by one or more causal factors present in the workplace today, these diseases are considered as professional diseases. Severity of technological disease usually responds to the level and duration of exposure, and usually occurs after many years of exposure to harmful factor. Technological diseases occur due to excessive work at the computer, or excessive use of keyboards and computer mice, especially the non-ergonomic ones. This paper deals with the diseases of the neck, shoulder, elbow and wrist (cervical radiculopathy, mouse shoulder and carpal tunnel syndrome), as is currently the most common diseases of technology in our country and abroad. These three diseases can be caused by long-term load and physical effort, and are tied to specific occupations, such as occupations associated with prolonged sitting, working at the computer and work related to the fixed telephone communication, as well as certain types of sports (tennis, golf and others).
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Affiliation(s)
- Merita Tiric-Campara
- Neurology Clinic. Clinical Center of Sarajevo University. Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Ferid Krupic
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenbug, Sweden
| | - Mirza Biscevic
- Orthopaedics and Traumatology Clinic. Clinical Center of Sarajevo University. Sarajevo, Bosnia and Herzegovina
| | - Emina Spahic
- Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Kerima Maglajlija
- Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | | | - Lejla Zunic
- Faculty of Health Sciences, University of Zenica, Zenica, Bosnia and Herzegovina
| | - Izet Masic
- Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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Cervical radicular pain: the role of interlaminar and transforaminal epidural injections. Curr Pain Headache Rep 2014; 18:389. [PMID: 24338702 DOI: 10.1007/s11916-013-0389-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic neck pain and cervical radicular pain are relatively common in the adult population. Treatment for chronic radicular pain recalcitrant to conservative management includes surgical management as well as interventional techniques with epidural injections utilizing either an interlaminar approach or transforaminal approach. Although there have been multiple systematic reviews and randomized clinical trials of cervical interlaminar epidural injections, the literature is sparse in reference to cervical transforaminal epidural injections. Overall, there is good evidence for the effectiveness of cervical interlaminar epidural injections in managing cervical disc herniation and fair evidence in managing central spinal stenosis and postsurgery syndrome. The evidence is poor, however, for cervical transforaminal epidural injections. Complications with cervical interlaminar epidural injections are rare, but more commonly occur with transforaminal epidural injections and can be fatal. Emerging concepts in pain include further randomized trials; proper placebo design; focus on control design (either active control or placebo control); and appropriate methodologic quality assessment and evidence synthesis.
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The short- and medium-term effectiveness of CT-guided selective cervical nerve root injection for pain and disability. Skeletal Radiol 2014; 43:973-8. [PMID: 24615407 DOI: 10.1007/s00256-014-1843-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 01/31/2014] [Accepted: 02/04/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION CT-guided cervical nerve root injection with corticosteroid and/or local anesthetic is a recognized technique in the evaluation and treatment of cervical radiculopathy. There are few prospective studies on the efficacy of the various techniques employed in cervical nerve root injection. We present our results from a 1-year prospective series using a CT-guided anterolateral transforaminal approach for cervical nerve root injection of bupivacaine and dexamethasone. METHODS Pain using a numeric rating scale was assessed at pre-injection, 15 min post-injection, 1 month, and 3 months. Disability was assessed using the Oswestry Neck Disability Index (NDI) questionnaire at pre-injection, 1 month post-injection, and 3 months. RESULTS In total, 50 patients were followed for 3 months. The mean reductions in pain were: 15 min (77 %), 1 month (39 %), and 3 months (33 %). The mean reductions in NDI were: 1 month (26 %) and 3 months (also 26 %). Results were statistically significant. CONCLUSIONS CT-guided selective cervical nerve root injection in the treatment of cervical radicular pain and related disability produces statistically significant reductions in pain and disability to at least 3 months post-procedure.
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Abstract
Cervical radiculopathy is the result of irritation and/or compression of nerve root as it exits the cervical spine. Pain is a common presenting symptom and may be accompanied by motor or sensory deficits in areas innervated by the affected nerve root. Diagnosis is suggested by history and corresponding physical examination findings. Confirmation is achieved with MRI. A multimodal approach to treatment helps patients improve. Medications may be used to alleviate symptoms and manage pain. Physical therapy and manipulation may improve neck discomfort. Guided corticosteroid injections and selected nerve blocks may help control nerve root pain. Most patients improve with a conservative, nonoperative treatment course.
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Affiliation(s)
- Deanna Lynn Corey
- Department of Family Medicine, Boston Medical Center, Boston University, 1 BMC Place, Boston, MA 02118, USA.
| | - Douglas Comeau
- Sports Medicine, Ryan Center for Sports Medicine, Boston Medical Center, Boston University, 915 Commonwealth Avenue Rear, Boston, MA 02215, USA; Family Medicine, Boston University School of Medicine, Boston University, 1 BMC Place, Boston, MA 02118, USA; Department of Sports Medicine, Boston College, 140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA
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Klessinger S, Freund W, Karpel-Massler G, Halatsch ME. Response to Transforaminal Injection of Steroids and Correlation to MRI Findings in Patients with Cervical Radicular Pain or Radiculopathy due to Disc Herniation or Spondylosis. PAIN MEDICINE 2014; 15:929-37. [DOI: 10.1111/pme.12415] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Engel A, King W, MacVicar J. The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data. PAIN MEDICINE 2013; 15:386-402. [PMID: 24308846 DOI: 10.1111/pme.12304] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine the effectiveness and risks of fluoroscopically guided cervical transforaminal injection of corticosteroids in the treatment of radicular pain. DESIGN Systematic review of the literature with comprehensive analysis of the published data. INTERVENTIONS Three reviewers with formal training in evidence-based medicine searched the literature on fluoroscopically guided cervical transforaminal injection of steroids (CTFIS). Each reviewer independently assessed the methodology of studies found and appraised the quality of the evidence presented. OUTCOME MEASURES The primary outcome assessed was relief of radicular pain. Other outcomes such as reduction in surgery rate and complications were noted if reported. The evidence on each outcome was appraised in accordance with the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system of evaluating evidence. RESULTS The searches yielded 16 primary publications on effectiveness. Available evidence, derived mainly from observational studies, suggests that approximately 50% of patients experience 50% relief of radicular pain for at least 4 weeks after CTFIS, and the intervention may have surgery-sparing effects. The literature also contains 21 articles with primary reports of serious complications, including 13 deaths and many catastrophic neurological injuries. The evidence of pain-relieving effects, of surgery-sparing effects, and of risks of CTFIS were all rated as of very low quality according to the GRADE system. CONCLUSIONS In patients with cervical radicular pain, fluoroscopically guided CTFIS may be effective in easing pain and reducing need for surgery. However, the evidence of effectiveness is of very low quality, and the benefits of the procedure are compromised by the risks of serious complications.
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Affiliation(s)
- Andrew Engel
- Continental Anesthesia, Oak Brook, Illinois, USA
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Peterson CK, Schmid C, Leemann S, Anklin B, Humphreys BK. Outcomes From Magnetic Resonance Imaging–Confirmed Symptomatic Cervical Disk Herniation Patients Treated With High-Velocity, Low-Amplitude Spinal Manipulative Therapy: A Prospective Cohort Study With 3-Month Follow-Up. J Manipulative Physiol Ther 2013; 36:461-7. [DOI: 10.1016/j.jmpt.2013.07.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 06/24/2013] [Accepted: 06/27/2013] [Indexed: 11/15/2022]
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Maurer MH, Disch AC, Hartwig T, Renz DM, Schreiter N, Hamm B, Streitparth F. Outcome Study of Real-time MR-guided Cervical Periradicular Injection Therapy in an Open 1.0 Tesla MRI System. Cardiovasc Intervent Radiol 2013; 37:756-62. [DOI: 10.1007/s00270-013-0738-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 08/26/2013] [Indexed: 01/10/2023]
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Persson L, Anderberg L. Repetitive transforaminal steroid injections in cervical radiculopathy: a prospective outcome study including 140 patients. EVIDENCE-BASED SPINE-CARE JOURNAL 2013; 3:13-20. [PMID: 23531493 PMCID: PMC3592766 DOI: 10.1055/s-0032-1327805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Study design: Prospective case series. Objective: To evaluate the effect of three repetitive transforaminal steroid injections in a large series of selected patients with cervical radiculopathy caused by spondylosis. Methods: Consecutively, 140 patients with long-lasting medical history, clinical findings, and MRI indicating a cervical nerve root origin based on degenerative disease and a positive selective transforaminal diagnostic nerve root blocks with local anesthetics resulting in at least 50% temporary arm pain reduction were included. Before treatment started, patients underwent a clinical examination by a neurosurgeon. All patients were followed-up and evaluated by one physiotherapist at the neurosurgery outpatient clinic. A designed outcome questionnaire including Neck Disability Index (NDI), Symptoms Frequency Index, and Visual Analog Scale for pain intensity were used. A series of three transforaminal steroid injections, with 3 weeks in between, were performed by a neuroradiologist using image intensifier guidance in an x-ray suite. At 12–14 weeks after the first injection, follow-up was performed. Criteria for positive response to the treatment was >50% radicular arm pain reduction. Except for occasional painkillers, no other treatment was given to the patients. Results: Positive response to the treatment was achieved in 49% (n = 69) with a significant difference in NDI and pain intensity between responders and nonresponders. Conclusions: Repetitive transforaminal steroid injections may reduce symptoms (frequency, intensity, and fewer limitations of daily living activities) of radiculopathy in patients with degenerative disease in the cervical spine at a short time follow-up.
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Affiliation(s)
- Liselotte Persson
- Department of Clinical Science, Neurosurgery, Lund University Hospital, Lund, Sweden
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Park EJ, Park SY, Lee SJ, Kim NS, Koh DY. Clinical outcomes of epidural neuroplasty for cervical disc herniation. J Korean Med Sci 2013; 28:461-5. [PMID: 23487574 PMCID: PMC3594612 DOI: 10.3346/jkms.2013.28.3.461] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 01/11/2013] [Indexed: 11/20/2022] Open
Abstract
Cervical disc herniation is a common disorder characterized by neck pain radiating to the arm and fingers as determined by the affected dermatome. This condition has a favorable prognosis, but pain can have a serious detrimental impact on daily activities. Epidural neuroplasty has been applied as a treatment option for cervical disc herniation; however, no study has addressed the clinical outcomes. This retrospective study evaluated the clinical outcomes of epidural neuroplasty on 128 patients for the treatment of cervical disc herniation. To measure pain-related disabilities over time, the changes of pain scores in neck and arm were evaluated using a numerical rating scale (NRS) and the neck disability index (NDI). Compared with preprocedural values, the pain NRS of neck and arm demonstrated significant improvement at day 1, and 1, 3, 6, and 12 months after the procedure (P < 0.001). Likewise, the NDI was significantly reduced at 3, 6, and 12 months after the procedure (P < 0.001). There were no serious complications. Cervical epidural neuroplasty shows good clinical outcomes in the treatment of cervical disc herniation and can be considered a treatment modality for cervical disc herniation refractory to conservative treatment.
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Affiliation(s)
| | - Sun Young Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Se Jin Lee
- Department of Anesthesiology and Pain Medicine, Soonchunhyang Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Nan Seol Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Do Yle Koh
- Godoil Spine and Pain Hospital, Seoul, Korea
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Wald JT, Maus TP, Geske JR, Diehn FE, Kaufmann TJ, Murthy NS, Thielen KR, Watson S. Immediate pain response does not predict long-term outcome of CT-guided cervical transforaminal epidural steroid injections. AJNR Am J Neuroradiol 2013; 34:1665-8. [PMID: 23449654 DOI: 10.3174/ajnr.a3439] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Imaging-guided cervical transforaminal epidural steroid injections have been shown to decrease verbal numerical pain scores and improve functionality (Roland Morris Disability Index). These injections are often administered in combination with local anesthetic. The purpose of this study was to determine if the immediate postprocedure VNPS predicts the long-term effectiveness of the injection. MATERIALS AND METHODS A quality assurance data base review of 247 patient records was used to document the VNPS and RMDI of patients undergoing a single CT-guided CTESI. Pain scores were recorded before the procedure, immediately after the procedure, at 2 weeks, and at 2 months. The RMDI was recorded before the procedure, at 2 weeks, and at 2 months. Spearman rank correlation analysis and logistic regression models were used to determine if the immediate postprocedure or 2-week VNPS correlated with or predicted the longer-term VNPS and RMDI as measured at 2 weeks and 2 months. RESULTS There was not a strong correlation between the pain score obtained immediately after the procedure and the 2-month outcome of the VNPS or RMDI. The pain scores at 2 weeks did correlate with the 2-month outcomes. The 2-week VNPS also was a significant predictor of patients who would achieve a >50% improvement in VNPS or RMDI at 2 months. CONCLUSIONS Pain scores obtained immediately after completion of a single CT-guided CTESI do not predict the long-term effectiveness of this procedure. However, patient response at 2 weeks does correlate with the long-term effectiveness of these injections as measured by the VNPS and the RMDI.
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Affiliation(s)
- J T Wald
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA.
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Liu Y, Liu X, Zhang X, Zhang H. Extradural injections and manual repositioning of spine in treatment of megalgia caused by cervical spondylotic radiculopathy. J TRADIT CHIN MED 2013; 33:74-7. [DOI: 10.1016/s0254-6272(13)60104-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hoang JK, Massoglia DP, Apostol MA, Lascola CD, Eastwood JD, Kranz PG. CT-guided cervical transforaminal steroid injections: where should the needle tip be located? AJNR Am J Neuroradiol 2012; 34:688-92. [PMID: 22954742 DOI: 10.3174/ajnr.a3266] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The aim of CT-guided CTSI is to inject medication into the foraminal region where the nerve root is inflamed. The optimal location for needle placement and therapeutic delivery, however, remain uncertain. The purpose of this study was to investigate how needle positioning and angle of approach impact the transforaminal distribution of injectate. MATERIALS AND METHODS We retrospectively reviewed fluoroscopic images from 90 CT-guided CTSI procedures for needle-tip location, needle angle, and contrast distribution. Needle-tip position was categorized as either foraminal zone, junctional, or extraforaminal. Distribution of contrast injected immediately before steroid administration was categorized as central epidural, intraforaminal, or extraforaminal in location. Needle-tip location and angle were correlated with contrast distribution. RESULTS The needle tip was most commonly placed in the junctional position (36 cases, 40%), followed by foraminal (30 cases, 33%) and extraforaminal (24 cases, 27%) locations. Intraforaminal contrast distribution was highest when the needle location was foraminal (30/30, 100%) or junctional (35/36, 97%), compared with extraforaminal (7/24, 29%) (P value <.0001). There was no relationship between needle angle and contrast distribution. CONCLUSIONS Needle-tip location at the outer edge of the neural foramen (junctional location) correlated well with intraforaminal distribution of contrast for CT-guided CTSI and compared favorably with injectate distribution following foraminal zone needle positioning. Junctional needle positioning may be preferred over the foraminal zone by some proceduralists. Extraforaminal needle positioning resulted in less favorable contrast distribution, which may significantly diminish the therapeutic efficacy of CTSI.
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Affiliation(s)
- J K Hoang
- Department of Radiology, Division of Neuroradiology, Duke University Medical Center, Durham North Carolina 27710, USA.
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Clinical outcomes of cervical radiculopathy following epidural steroid injection: a prospective study with follow-up for more than 2 years. Spine (Phila Pa 1976) 2012; 37:1041-7. [PMID: 22024908 DOI: 10.1097/brs.0b013e31823b4d1f] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective clinical outcome study. OBJECTIVE To analyze clinical outcome and prognostic factors of the epidural steroid injection (ESI) for cervical radiculopathy (CR) patients who were considered surgical candidates. SUMMARY OF BACKGROUND DATA The clinical outcomes and prognostic factors of ESI for CR have not been consistently reported, and there has been no prospective study with long-term follow-up. METHODS ESI was administered in 98 patients (mean age = 50.1 yr, follow-up = 40.4 mo) with CR without major neurological deficit. A total of 3 or fewer ESIs were administered, using either the interlaminar or transforaminal technique. The patients were divided into 2 groups: those who did not have surgery and those who underwent surgery at the last follow-up. We analyzed statistical difference of relevant clinical (sex, age, duration of symptom, previous episode of CR, visual analogue scale [VAS] of arm pain, etc.), radiological factors (soft disc vs. hard disc, central disc vs. foraminal disc, single segment involvement vs. multiple segment involvement, degree of neural compression and degeneration, etc.) and clinical outcomes (VAS of arm pain, Odom's criteria, and neck disability index) between the 2 groups. RESULTS The patients received mean 1.8 ESI treatments. At the final follow-up, 79 of the patients (80.6%) did not undergo surgery, whereas the other 19 patients (19.4%) underwent surgery. Of the clinical factors, recurred CR (15.2% vs. 42.1%, P = 0.022) and mean VAS score of arm pain before (6.1 vs. 8.2, P = 0.000) and after ESI (2.8 vs. 6.9, P = 0.000) were significantly different between both groups. Radiological factors and outcome parameters showed no significant difference. CONCLUSION In more than 80% of patients with CR who were surgical candidates, surgery was avoided using ESI. The significant factors predisposing failure of ESI were intensity of symptom and a previous episode of CR. ESI is therefore considered a safe and effective treatment to choose before undergoing surgery.
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Wald JT, Maus TP, Geske JR, Carter RE, Diehn FE, Kaufmann TJ, Morris JM, Murthy NS, Thielen KR. Safety and efficacy of CT-guided transforaminal cervical epidural steroid injections using a posterior approach. AJNR Am J Neuroradiol 2011; 33:415-9. [PMID: 22207298 DOI: 10.3174/ajnr.a2835] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Image-guided cervical transforaminal epidural injections play an important role in the management of cervical radicular pain syndromes. The safety and efficacy of these injections via an anterolateral approach has been well-studied. The goal of this retrospective review was to determine the safety and efficacy of CT-guided transforaminal epidural injections by using a posterior approach. MATERIALS AND METHODS Retrospective review of patient records was used to define VNPS and RMDI of patients undergoing CT-guided transforaminal cervical epidural injections between 2006 and 2010. Pain scores were recorded preprocedure, immediately postprocedure, at 2 weeks, and at 2 months. The RMDI was recorded preprocedure, at 2 weeks, and at 2 months. Data analysis of 247 patients was completed. Differences in VNPS scores and the RMDI were then compared on the basis of a CT-guided approach (anterolateral versus posterior). RESULTS There was no statistical difference in the degree of pain relief and improvement in the RMDI between the CT-guided transforaminal anterolateral approach and the posterior approach at 2 weeks and at 2 months. Both groups demonstrated a statistically significant improvement in pain scores and the RMDI. Approximately 35% of patients in both groups demonstrated >50% pain relief at 2 months. There were no serious complications in either group. CONCLUSIONS CT-guided transforaminal cervical epidural injections by using a posterior approach are safe and effective.
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Affiliation(s)
- J T Wald
- Mayo Clinic, Rochester, Minnesota 55905, USA.
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Abstract
Interventional radiology plays a major role in the management of symptomatic intervertebral disc herniations. In the absence of significant pain relief with conservative treatment including oral pain killers and anti-inflammatory drugs, selective image-guided periradicular infiltrations are generally indicated. The precise control of needle positioning allows optimal distribution of steroids along the painful nerve root. After 6 weeks of failure of conservative treatment including periradicular infiltration, treatment aiming to decompress or remove the herniation is considered. Conventional open surgery offers suboptimal results and is associated with significant morbidity. To achieve minimally invasive discal decompression, different percutaneous techniques have been developed. Their principle is to remove a small volume of nucleus, which results in an important reduction of intradiscal pressure and subsequently reduction of pressure inside the disc herniation. However, only contained disc herniations determined by computed tomography or magnetic resonance are indicated for these techniques. Thermal techniques such as radiofrequency or laser nucleotomy seem to be more effective than purely mechanical nucleotomy; indeed, they achieve discal decompression but also thermal destruction of intradiscal nociceptors, which may play a major role in the physiopathology of discal pain. The techniques of image-guided spinal periradicular infiltration and percutaneous nucleotomy with laser and radiofrequency are presented with emphasis on their best indications.
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Affiliation(s)
- Xavier Buy
- Department of Radiology B, University Hospital of Strasbourg, Strasbourg, France
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Wolter T, Knoeller S, Berlis A, Hader C. CT-guided cervical selective nerve root block with a dorsal approach. AJNR Am J Neuroradiol 2010; 31:1831-6. [PMID: 20801765 DOI: 10.3174/ajnr.a2230] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Cervical transforaminal blocks are frequently performed to treat cervical radicular pain. These blocks are performed mostly under fluoroscopy, but a CT-guided technique has also been described. The aim of this study was to review the results of CT-guided CSNRB by using a dorsal approach, to describe the contrast patterns achieved with this injection technique, and to estimate the degree of specificity and sensitivity. MATERIALS AND METHODS We used a CT-guided technique with a dorsal approach leading to a more extra-than transforaminal but a selective nerve root block as well. Of 53 blocks, we performed 38 for diagnostic and 15 for therapeutic indications. Pain relief was measured hourly on a VAS. The distribution of contrast and the angle of the trajectory of the injection needle were analyzed as well as the degree of pain relief. RESULTS Contrast was found in the intraforaminal region in 8 (15%) blocks, extraforaminally in 40 (78%) blocks, and intraspinally in 3 (6%) blocks. The mean angle between the needle and the sagittal plane was 26.6° (range, from 1° to 50°). The mean distance between needle tip and nerve root was 4.43 mm (range, 0-20 mm). Twenty-six (68.4%) of the 38 diagnostic blocks led to a decrease in the pain rating of >50%. There were no complications or unintended side effects, apart from occasional local puncture pain. CONCLUSIONS We conclude that CT-guided CSNRBs using a dorsal approach are feasible and that they are sensitive and specific.
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Affiliation(s)
- T Wolter
- Interdisciplinary Pain Centre, University Hospital Freiburg, Germany.
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