Transforaminal versus interlaminar CT-guided lumbar epidural steroid injections: prospective study of 237 patients with unilateral radicular pain and up to 5 years of follow-up

OBJECTIVE

To compare the efficacy of the transforaminal approach (TFA) versus the interlaminar approach (ILA) for CT-guided epidural steroid injection (CTESI) in the treatment of persistent lumbosacral radicular pain (LRP > 6 weeks) with long-term follow-up.

METHODS

Patients were prospectively assessed for pain by visual analogue scale (VAS) and functional disability (Oswestry Disability Index, (ODI)) before treatment, then 6 weeks (6W), 6 months (6 M), and 5 years (5Y) after CTESI.

RESULTS

Overall, n = 237 patients (TFA, n = 71 and ILA, n = 166) were included, and 96 patients had 5 years of follow-up. Both groups showed a statistically significant improvement in VAS and ODI values at 6W (TFA, n = 60 and ILA, n = 146, P < 0.001 for both), at 6 M (TFA, n = 34 and ILA, n = 96, P < 0.001 for both), and at 5Y (TFA, n = 32 and ILA, n = 64, P < 0.001 for both). No significant differences were observed between the two approaches in VAS or ODI decreases at 6W (P = 0.38 and P = 0.33 respectively), 6 M (P = 0.13 and P = 0.51 respectively), or 5Y (P = 0.15 and P = 0.57 respectively). No major complications were noted.

CONCLUSION

Outcomes after CTESI by ILA approaches are similar to those by TFA for the treatment of persistent LRP.

Variations and management for patients with craniocervical junction arteriovenous fistulas: Comparison of dural, radicular, and epidural arteriovenous fistulas

Background:

Craniocervical junction arteriovenous fistulas (CCJAVFs) are known to be rare, but variations and clinical behaviors remain controversial.

Methods:

A total of 11 CCJAVF patients (M: F=9:2, age 54–77 years) were investigated. Based on the radiological and intraoperative findings, they were categorized into three types: dural AVF (DAVF), radicular AVF (RAVF), and epidural AVF (EDAVF).

Results:

There were four symptomatic patients (subarachnoid hemorrhage in two, myelopathy in one, and tinnitus in one) and seven asymptomatic patients in whom coincidental CCJAVFs were discovered on imaging studies for other vascular diseases (arteriovenous malformation in one, intracranial DAVF in two, ruptured cerebral aneurysm in two, and carotid artery stenosis in two). Of these 11 patients, 2 (18.2%) had multiple CCJAVFs. Of 14 lesions, the diagnoses were DAVF in 5, RAVF in 3, and EDAVF in 6 (C1–C2 level ratio =5:0, 2:1, 3:3). Patients with DAVF/RAVF in four lesions with intradural venous reflux underwent surgery, although an RAVF remained in one lesion after embolization/radiation. Since all six EDAVFs, two DAVFs, and one RAVF had neither feeder aneurysms nor significant symptoms, no treatment was provided; of these nine lesions, one DAVF and one RAVF remained unchanged, whereas six EDAVFs showed spontaneous obliteration within a year. Unfortunately, however, one DAVF bled before elective surgery.

Conclusion:

CCJAVFs have many variations of shunting site, angioarchitecture, and multiplicity, and they were frequently associated with coincidental vascular lesions. For symptomatic DAVF/RAVF lesions with intradural drainage, surgery is preferred, whereas asymptomatic EDAVFs without dangerous drainage may obliterate during their natural course.

Postpartum fever and radicular low back pain

Fever and low back pain with radicular symptoms raise concern for epidural abscess or other neuraxial infection, especially in the context of recent epidural anesthesia. Here we present an unusual case with several confounding factors and an unexpected diagnosis.

The profile of chiropractors managing patients with low back-related leg pain: analyses of 1907 chiropractors from the ACORN practice-based research network

Background

Approximately 60% of people with low back pain also have associated leg pain symptoms. Guidelines for low back pain recommend non-pharmacological approaches, including spinal manipulation - a therapy provided by chiropractors. However, limited empirical data has examined the characteristics of chiropractors managing patients with low back-related leg pain (LBRLP). Our objective is to describe the prevalence, profile and practice characteristics of Australian chiropractors who often treat LBRLP, compared to those who do not often treat LBRLP.

Methods

This is a cross-sectional analysis of a nationally representative sample from the Australian Chiropractic Research Network (ACORN). This study investigated the demographic and practice characteristics as well as clinical management of chiropractors who ‘often’ treated patients with LBRLP compared to those who treated LBRLP ‘never/rarely/sometimes’. Multiple logistic regression models identified independent factors associated with chiropractors who ‘often’ treated patients with LBRLP.

Results

A total of 1907 chiropractors reported treating patients experiencing LBRLP, with 80.9% of them ‘often’ treating LBRLP. Chiropractors who ‘often’ treated LBRLP were more likely to manage patients with multi-site pain including axial low back pain (OR = 21.1), referred/radicular neck pain (OR = 10.8) and referred/radicular thoracic pain (OR = 3.1). While no specific management strategies were identified, chiropractors who ‘often’ treated LBRLP were more likely to discuss medication (OR = 1.8), manage migraine (OR = 1.7) and degenerative spine conditions (OR = 1.5), and treat women during pregnancy (OR = 1.6) and people with work-related injuries (OR = 1.5), compared to those not treating LBRLP frequently.

Conclusions

Australian chiropractors frequently manage LBRLP, although the nature of specific management approaches for this condition remains unclear. Further research on the management of LBRLP can better inform policy makers and educators interested in upskilling chiropractors to deliver safe and effective treatment of LBRLP.

Comparison of three CT-guided epidural steroid injection approaches in 104 patients with cervical radicular pain: transforaminal anterolateral, posterolateral, and transfacet indirect

INTRODUCTION

The treatment of persistent cervical radicular pain (CRP) by CT-guided epidural steroid injections (CTESI) by a transforaminal anterolateral (TFA) approach is associated with rare but serious complications. Two recently described transforaminal posterolateral (TFP) and transfacet indirect (TFT) approaches may be safer options, but have not been extensively evaluated. We compared the efficacy of three CTESI approaches (TFA, TFP, and TFT) in the treatment of persistent CRP (>6 weeks).

METHODS

Patients were prospectively assessed for pain using the visual analog scale (VAS) and for functional disability by the Neck Disability Index (NDI) before treatment, then 6 weeks and 6 months after CTESI.

RESULTS

A total of 104 patients were included (n = 30 TFA, n = 36 TFP, and n = 38 TFT approaches). Each group was found to have a statistically significant improvement at 6 weeks (median VAS values: 7 (2-9) at D0 and 2 (3-6) at 6 weeks p < 0.01; median NDI values: 38 (24-50) at D0 and 29 (18-42) at 6 weeks (p < 0.01)), and at 6 months (median VAS values: 7 (2-9) at D0 and 4 (2-6) at 6 months (p < 0.01); median NDI values: 38 (24-50) at D0 and 28 (13-40) at 6 months (p < 0.01)). No significant difference was observed in the decrease in VAS and NDI scores among the three approaches at 6 weeks (p = 0.635 and p = 0.54 for VAS and NDI respectively) or 6 months (p = 0.704 and p = 0.315 for VAS and NDI respectively). No major complications were noted.

CONCLUSION

The results of CTESI using the TFP or TFT approach are similar to those for TFA in the treatment of persistent CRP and could be a safer option.

Coronal oblique orientation of the neural foramen improves cervical spine MRI: A comparison of the sensitivity of different angulations

OBJECTIVE

Angulated projections are used in radiography to show the cervical neural foramen. Imaging the coronal oblique planes in an MRI of the cervical spine should therefore improve visualization of neural foramen pathology. This has to be demonstrated.

PATIENTS AND METHODS

A multi-center investigation of 40 patients with monoradiculopathy and 10 healthy controls was undertaken. T2-weighted sagittal, coronal oblique and axial slices were individually and separately examined by four readers blinded to the diagnosis. The statistical evaluation compared against the clinical gold standard of the neurological diagnosis of a single nerve root irritation or lesion.

RESULTS

The sensitivity/specificity required to detect the relevant neural foramen pathology was 0.47/0.60 for axial, 0.57/0.90 for sagittal and 0.55/0.70 for coronal oblique scans. The readers felt significantly more confident in attributing the cause of pathology using coronal oblique planes. Interreader reliability was moderate to substantial, with the highest values for the sagittal planes (0.39-0.76) and lower values for the transversal and coronal oblique planes (0.15-0.63). Intrareader reliability was substantial, with values between 0.53 and 0.88. Reading the axial planes was significantly more time consuming than reading the other planes.

CONCLUSION

The use of coronal oblique planes in cervical spine MRIs increases sensitivity and confidence in attributing the cause of neural foramen obstruction. They are easy to interpret and demand less reading time than axial planes, and so the inclusion of coronal oblique planes in the workup of cervical spine MRI is recommended, at least when neural foramen pathology is suspected.

The use of lumbar epidural injection of platelet lysate for treatment of radicular pain

Background

Epidural steroid injections (ESI) are the most common pain management procedure performed in the US, however evidence of efficacy is limited. In addition, there is early evidence that the high dose of corticosteroids used can have systemic side effects. We describe the results of a case series evaluating the use of platelet lysate (PL) epidural injections for the treatment of lumbar radicular pain as an alternative to corticosteroids.

Methods

Registry data was obtained for patients (N = 470) treated with PL epidural injections presenting with symptoms of lumbar radicular pain and MRI findings that were consistent with symptoms. Collected outcomes included numeric pain score (NPS), functional rating index (FRI), and a modified single assessment numeric evaluation (SANE) rating.

Results

Patients treated with PL epidurals reported significantly lower (p < .0001) NPS and FRI change scores at all time points compared to baseline. Post-treatment FRI change score means exceeded the minimal clinically important difference beyond 1 month. Average modified SANE ratings showed 49.7% improvement at 24 months post-treatment. Twenty-nine (6.3%) patients reported mild adverse events related to treatment.

Conclusion

Patients treated with PL epidurals reported significant improvements in pain, exceeded the minimal clinically important difference (MCID) for FRI, and reported subjective improvement through 2-year follow-up. PL may be a promising substitute for corticosteroid.

Screening for neuropathic characteristics in failed back surgery syndromes: challenges for guiding treatment

OBJECTIVE

Neuropathic pain screening tools have shown promise in identifying common neuropathic pain characteristics that derive from diverse etiologies (e.g., diabetic peripheral neuropathy, postherpetic neuralgia). However, no prior studies have specifically assessed whether these tools are capable of discerning the underlying pain mechanisms in the vast, heterogeneous group of patients diagnosed with failed back surgery syndrome (FBSS).

DESIGN

In this clinical observational study, two tests for neuropathic pain characteristics, the Douleur Neuropathique en 4 (DN4) and Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) questionnaires, were performed on 43 subjects with FBSS. Subjects underwent physical or neurosensory exam components of the DN4 and LANSS in the region of most severe pain (e.g., axial low back or lower extremities). DN4 and LANSS scores were correlated with clinical history and neurologic exam, pain-related quality of life questionnaires, and compared to an independent assessment of pain distribution.

RESULTS

The presence of neuropathic characteristics, determined by the DN4 (62% sensitivity, 44% specificity), LANSS (38% sensitivity, 75% specificity; cut-offs of 4 and 12, respectively), or their combination (20% sensitivity, 58% specificity) was associated with higher pain intensity as measured by the visual analog scale (DN4 > 4, P = 0.001; LANSS ≥ 12, P = 0.042), modified Brief Pain Inventory-Short Form (DN4 > 4, P = 0.001; LANSS ≥ 12, P = 0.082), and Neuropathic Pain Symptom Inventory (DN4 > 4, P = 0.001; LANSS ≥ 12, P = 0.001), and greater pain-related functional impairment as measured by the Roland-Morris Disability Questionnaire (DN4 > 4, P = 0.006; LANSS ≥ 12, P = 0.018). The percentage of subjects characterized as neuropathic by the DN4 and LANSS lacked concordance (67.4 vs. 25.6), and the distribution of most severe symptoms (i.e., axial vs radicular) did not correlate with subjects determined to have neuropathic pain.

CONCLUSIONS

Unlike other neuropathic syndromes, the neuropathic component of FBSS is less reliably identified by the LANSS and DN4.

Odontogenic cysts: analysis of 680 cases in Brazil

The purpose of this study was to evaluate the prevalence of 680 odontogenic cysts diagnosed in Porto Alegre, RS, Brazil, and to compare results with findings in the literature. Data of odontogenic cysts diagnosed from 1985 to 2005 were collected from the files of the Oral Pathology Laboratory of Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil, and entered in a standardized form for later comparisons. The most prevalent odontogenic cysts were radicular (72.50%), dentigerous (22.20%) and residual (4.26%) cysts. The mandible of white patients was the anatomic site and ethnic group most frequently affected by this disease. Four of the six types of cysts were more frequent in the second and fourth decades of life, and no significant differences were found between sexes in the diagnosis of odontogenic cysts. In conclusion, the prevalence of odontogenic cysts was similar to that reported in the literature, which shows that inflammatory cysts are the most frequent.