Safety outcomes and improvement in pain scores after radiologist-performed fluoroscopy-guided interlaminar cervical epidural steroid injection

INTRODUCTION

Image-guided spine injections are an important tool in the management of patients with a variety of spinal pathologies. Our practice offers radiologist-performed fluoroscopy-guided interlaminar cervical epidural steroid injection (ESI) routinely performed in the outpatient setting. The purpose of this study was to evaluate clinical outcomes and improvement in pain scores after radiologist-performed cervical ESI.

METHODS

An institutional database was used to retrospectively identify cervical injections performed between October 2016 and October 2022. All injections were performed at the C7-T1 level utilizing 1.0 mL of 10 mg/mL dexamethasone without epidural anesthetic. The Numerical Rating Scale (NRS) was used to assess pain improvement. Cervical MRI was reviewed to assess pre-injection cervical disease severity. Patient charts were reviewed for any post-injection complications.

RESULTS

A total of 251 cervical injections in 186 patients met our inclusion criteria with mean clinical follow up of 28.5 months (range 0.2 - 73.0 months). No patients experienced any major complications after injection. Post-injection pain scores were available for 218 of 251 injections (86.9%) with mean follow-up of 11.8 days (range 6 - 57 days). There was a significant improvement in pain scores from a mean pre-injection NRS score of 5.2/10 to 3.0/10 (p < .0001). 117 patients (53.7%) reported ≥ 50% improvement after injection. Patients who had prior injection were more likely to report ≥ 50% pain improvement after subsequent injection (p = .012).

CONCLUSION

Radiologist-performed fluoroscopy-guided interlaminar cervical ESI at the C7-T1 level is a safe and effective tool in the management of patients with cervical pathology.

Cost-effectiveness of Transforaminal epidural steroid injections for patients with ACUTE sciatica: a randomized controlled trial

BACKGROUND

Transforaminal epidural injections with steroids (TESI) are increasingly being used in patients sciatica. The STAR (steroids against radiculopathy)-trial aimed to evaluate the (cost-) effectiveness of TESI in patients with acute sciatica (< 8 weeks). This article contains the economic evaluation of the STAR-trial.

METHODS

Participants were randomized to one of three study arms: Usual Care (UC), that is oral pain medication with or without physiotherapy, n = 45); intervention group 1: UC and transforaminal epidural steroid injection (TESI) 1 ml of 0.5% Levobupivacaine and 1 ml of 40 mg/ml Methylprednisolone and intervention group 2: UC and transforaminal epidural injection (TEI) with 1 ml of 0,5% Levobupivacaine and 1 ml of 0.9% NaCl (n = 50). The primary effect measure was health-related quality of life. Secondary outcomes were pain, functioning, and recovery. Costs were measured from a societal perspective, meaning that all costs were included, irrespective of who paid or benefited. Missing data were imputed using multiple imputation, and bootstrapping was used to estimate statistical uncertainty.

RESULTS

None of the between-group differences in effects were statistically significant for any of the outcomes (QALY, back pain, leg pain, functioning, and global perceived effect) at the 26-weeks follow-up. The adjusted mean difference in total societal costs was €1718 (95% confidence interval [CI]: - 3020 to 6052) for comparison 1 (intervention group 1 versus usual care), €1640 (95%CI: - 3354 to 6106) for comparison 2 (intervention group 1 versus intervention group 2), and €770 (95%CI: - 3758 to 5702) for comparison 3 (intervention group 2 versus usual care). Except for the intervention costs, none of the aggregate and disaggregate cost differences were statistically significant. The maximum probability of all interventions being cost-effective compared to the control was low (< 0.7) for all effect measures.

CONCLUSION

These results suggest that adding TESI (or TEI) to usual care is not cost-effective compared to usual care in patients with acute sciatica (< 8 weeks) from a societal perspective in a Dutch healthcare setting.

TRIAL REGISTRATION

Dutch National trial register: NTR4457 (March, 6th, 2014).

Efficacy of epidural infiltration in the management of pain and disability due to acute and subacute lumbosacral radiculopathy

BACKGROUND AND OBJECTIVE

Epidural infiltrations are used for treatment of low back pain and sciatica. Linked to lumbar radiculopathy (lumbosacral radicular syndrome). This study evaluates the efficacy of epidural infiltration by different routes to reduce pain intensity, disability and return to work.

METHODS

Is a prospective observational study in one hundred consecutive patients sent to pain unit for severe lumbo-sacral radiculopaty. We analyze the efficacy on pain relief (Visual Analogue Scale) and funcional status at two weeks, one month, and three months after epidural injection of local anesthetics and esteroids with differents approachs (interlaminar, caudal and transforaminal).

RESULTS

Ninety nine patients (46.5% men, 53.5 women) were finally enrrolled in the study. Mean age was 57.47 ± 11.1 years. The caudal approach was used in 58.6% patients, 23.2% transforaminal approach, and 18.2% interlaminar approach. A significant pain relief was found in all times studied (EAV 7.48 ± 1.5 basal; 6.2 ± 0,9 at 15 days; 6.3 ± 1.2 at one month; 6.15 ± 1.3 at 3 months, p < 0.05). Transforaminal approach was superior to caudal or interlaminal. Seventy percent in time off work patients returned to work after epidural inyections.

CONCLUSIONS

Epidural local anesthetics with esteroids injections for lumbo-sacral radiculopathy were effective for low back pain, improved functional status and promoted return to work. Transforaminal approach is superior to others.

Techniques in medicine: ipsilateral transforaminal epidural steroid injection in Bertolotti's syndrome

Bertolotti's syndrome, also known as lumbosacral transitional vertebrae, is a relatively rare spinal condition characterized by an anatomical variation in the lower spine. Conservative approaches such as physical therapy, anti-inflammatory medications and lifestyle modifications may be recommended for mild cases. In more severe cases or when conservative measures fail to provide relief, injections such as may be considered to alleviate pain. This case is unique in that we document a challenging technique of ipsilateral transforaminal epidural steroid injection in a patient with Bertolotti's syndrome.

Pain Reduction and Changes in Serum Cortisol, Adrenocorticotropic Hormone, and Glucose Levels after Epidural Injections With Different Doses of Corticosteroid

BACKGROUND

An epidural steroid injection (ESI) effectively relieves acute lumbar discogenic radicular pain. Corticosteroids, a key ESI component, reduce pain by curbing inflammation and blocking pain signal transmission via C-fibers. While prior research confirms the efficacy of 40 mg and 80 mg methylprednisolone, the effectiveness of lower doses remains uncertain.

OBJECTIVES

This trial aimed to compare the pain-relieving effects of ESI using varying methylprednisolone doses (10 mg, 20 mg, and 40 mg). Additionally, it sought to examine changes in fasting plasma glucose (FPG), serum cortisol, and serum adrenocorticotropic hormone (ACTH) levels across these groups.

STUDY DESIGN

A prospective observational study.

SETTING

Department of Pain Medicine, Affiliated Jinling Hospital, Medical School of Nanjing University, People's Republic of China.

METHODS

Ninety-three patients underwent a single epidural injection of methylprednisolone at different doses: 10 mg (n = 28), 20 mg (n = 32), and 40 mg (n = 33). We evaluated their Numeric Rating Scale (NRS-11) score and Oswestry Disability Index (ODI) score at preinjection and 7 days postinjection. We also measured FPG, serum cortisol, and ACTH levels at baseline and one day postinjection.

RESULTS

Significant differences were observed in the likelihood of achieving substantial pain relief among the 3 groups at 7 days postinjection. Specifically, 10 mg vs 20 mg had an odds ratio (OR) of 6.546 (95% CI, 1.161 - 26.513, P = 0.008), and 10 mg vs 40 mg had an OR of 7.753 (95% CI, 1.98 - 30.353, P = 0.003). However, there was no significant difference between 40 mg and 20 mg, with an OR of 0.844 (95% CI, 0.239 - 2.987, P = 0.793) in Model 3. Additionally, the baseline NRS-11 score significantly predicted substantial pain relief, with an OR of 0.47 (95% CI, 0.287 - 0.768, P = 0.003). Furthermore, at 7 days postinjection, the ODI score was significantly lower in the 20 mg group (P = 0.007) and the 40 mg group (P < 0.001) compared to the 10 mg group. Moreover, the difference in serum cortisol and FPG between the 40 mg and 10 mg groups was more pronounced (P < 0.01), while the difference in ACTH was similar among all 3 groups (P = 0.191).

LIMITATIONS

Potential selection bias and a short follow-up period may have influenced our study, and certain imaging results were omitted from the regression models.

CONCLUSIONS

The effectiveness of ESI in relieving pain was found to be similar for both 20 mg and 40 mg doses, but with fewer changes in FPG and serum cortisol levels for the former (which were not statistically significant). As a result, it may be clinically viable to use a 20 mg dose for achieving short-term pain relief. Moreover, the baseline NRS-11 scores were found to be a reliable predictor of pain relief efficacy, with milder baseline pain intensity being associated with better pain relief outcomes.

Effect of Transforaminal Epidural Corticosteroid Injections in Acute Sciatica: A Randomized Controlled Trial

OBJECTIVE

Transforaminal epidural steroid injections (TESIs) are widely administered for sciatica. The aim of this trial was to evaluate the effectiveness of TESIs in patients with acute sciatica (<8 wk).

METHODS

This study was conducted in 2 Dutch hospitals. Participants (n=141) were randomly assigned to (1) usual care and TESI of 1 ml of 40 mg/ml Methylprednisolone plus 1 ml of 0.5% Levobupivacaine (intervention 1); (2) usual care and transforaminal epidural injection with 1 ml of 0.5% Levobupivacaine and 1 ml NaCl 0.9% (intervention 2); (3) usual care consisting of oral pain medication with or without physiotherapy (control). Co-primary outcomes were back pain and leg pain intensity, physical functioning, and recovery measured during 6-month follow-up.

RESULTS

There were no statistically significant mean differences in co-primary outcomes between groups during follow-up, except for leg pain when comparing intervention group 1 with control (-0.96 95%CI:-1.83 to -0.09). For secondary outcomes, some statistical significant between-group differences were found for treatment satisfaction and surgery, but only when comparing intervention group 2 to control. Post hoc analyses showed a statistically significant difference in response [50% improvement of leg pain (yes/no)] between intervention 1 and the control group at 3 months and that both intervention groups used less opioids.

DISCUSSION

Except for a statistically significant effect of TESI on leg pain for patients with acute sciatica compared with usual care, there were no differences in co-primary outcomes. Nonetheless, transforaminal epidural injections seem to be associated with less opioid use, which warrants further exploration.

Effect of Radiofrequency on Dorsal Root Ganglion Versus Transforaminal Steroids Injection on Tumor Necrosis Factor-Alpha Level in Lumbar Radicular Pain

BACKGROUND

The mechanism of pain control with pulsed radiofrequency (PRF) is unclear.

OBJECTIVES

We aimed to compare the efficacy of combined PRF on dorsal root ganglion (DRG) with transforaminal epidural steroid injection (TFESI) vs TFESI-alone on pain improvement and serum tumor necrosis factor-alpha (TNF-a) level in lumbar disc-related radicular pain.

STUDY DESIGN

Prospective, randomized, controlled trial.

SETTING

Neurology and Pain Management clinics.

METHODS

A total of 80 patients with lumbar disc prolapse were divided into 2 groups: combined PRF on DRG with TFESI group and TFESI-alone group. The Numeric Rating Scale (NRS-11), Oswestry Disability Index (ODI), and Functional Rating Index (FRI) before intervention and at 2 weeks, 1 month, and 3 months after the intervention were observed. Serum TNF-a level was assessed pre- and post-intervention at 3 months.

RESULTS

The scores of NRS-11, ODI, and FRI showed a significant improvement at 2 weeks, 1 month, and 3 months following intervention in both combined PRF & TFESI group and TFESI-alone group (P < 0.001 in all comparisons), with no significant difference between the 2 groups. Serum TNF-a levels showed a statistically significant reduction, 3 months following intervention in the combined PRF & TFESI group (P < 0.001), but not in the TFESI-alone group (P = 0.297) (P between groups < 0.001).

LIMITATIONS

The main limitation of this study is that TNF-a level was not assessed earlier to see how long the steroids might reduce TNF-a. On the other hand, further study with extended follow-up periods is needed to confirm the long-term lowering effect of TNF-a provided by PRF.

CONCLUSIONS

Combined PRF on DRG with TFESI showed similar outcomes to TFESI-alone in relieving pain in patients with lumbar disc prolapse. However, PRF on DRG caused a significant decrease in TNF-a serum levels at 3 months.

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.

The effect of Caudal Epidural Injection on healing in the treatment of chronic anal fissure

BACKGROUND

Chronic anal fissure is called the reaching the muscle layer under the skin by deepening of the fissure in the breech skin. Our purpose is to enable the tissue to heal by relaxing the anal sphincter with caudal epidural injection.

METHODS

One hundred twenty cases were included in this randomized, controlled study. The cases were categorized into 2 groups; Under ultrasound guidance, the first group, caudal epidural injection group (Group CE, n = 60) was treated with 5 cc bupivakain + 5 cc isotonic from a caudal epidural for a total of 3 sessions at the beginning, 1 week and 2 weeks later; the second group, control group (Group C, n = 60) were provided medical treatment (cream, pill etc.) every day for 2 weeks. Wexner's constipation score was used to assess constipation severity and visual analog scale was used to assess pain severity. Short Form-36 was used to determine the patient's quality of life.

RESULTS

This study was conducted with 2 groups of 60 people and a total of 120 patients. There was no statistically significant difference between the groups in terms of demographic characteristics (age, body mass index, gender, American Society of Anesthesiologist, mean blood pressure, heart rate) (P > .05). Out of the detected fissures, 32 (26.7%) were located anteriorly and 88 (73.3%) were located posteriorly. The groups were statistically same in terms of fissure location (P = .423). When groups were compared with pain, Wexner constipation and visual analog scale scores decreased significantly in Group CE compared to Group C after 2.and 3.sessions (P = .001 and P = .002, respectively). In Group CE, the Short Form-36 subscales increased significantly (P = .003).

CONCLUSION

Caudal epidural injection has a potential to be an alternative treatment option for chronic anal fissure.

Epidural Injection of Harpagoside for the Recovery of Rats with Lumbar Spinal Stenosis

Epidural administration is the leading therapeutic option for the management of pain associated with lumbar spinal stenosis (LSS), which is characterized by compression of the nerve root due to narrowing of the spinal canal. Corticosteroids are effective in alleviating LSS-related pain but can lead to complications with long-term use. Recent studies have focused on identifying promising medications administered epidurally to affected spinal regions. In this study, we aimed to investigate the effectiveness of harpagoside (HAS) as an epidural medication in rats with LSS. HAS at various concentrations was effective for neuroprotection against ferrous sulfate damage and consequent promotion of axonal outgrowth in primary spinal cord neurons. When two concentrations of HAS (100 and 200 μg/kg) were administered to the rat LSS model via the epidural space once a day for 4 weeks, the inflammatory responses around the silicone block used for LSS were substantially reduced. Consistently, pain-related factors were significantly suppressed by the epidural administration of HAS. The motor functions of rats with LSS significantly improved. These findings suggest that targeted delivery of HAS directly to the affected area via epidural injection holds promise as a potential treatment option for the recovery of patients with LSS.

Clinical Effectiveness of Single Lumbar Periradicular Infiltration in Patients with Sciatica

Periradicular therapy (PRT) is a minimally invasive radiological procedurein patients with chronic lumbar pain.The aim of the study is to identify clinical and radiological predictive factors for treatment success after a single PRT treatment in patients with sciatica.The study includes a prospective follow-up of 166 patients treated with PRT. The pain intensity is determined according to the VAS scale and the degree of improvement is presented as excellent (over 75%), good (50-70%), moderate (25-49%), and weak (less than 25%). The follow up of the treated patients was done at 2 weeks, 3 and 6 months. In patients with pain duration up to 3 months, the improvement was excellent in n=32 (58.18%) after 2 weeks, after 3 months n=41 (74.55%) and after 6 months n=41 (74.55%). This stands in contrast to patients with pain over 1 year. The percentage of improvement after 6 months, post-intervention, was highest in patients without nerve root compression (86.25±19.2),and the highest improvement after 6 months was in patients with localization of pain at the L4-L5 level (69.69±29.7), the greatest improvement after six months was in patients with extraforaminal hernia (62.82±34.3), and the lowest in patients with central stenosis (40.21±30.7).Our study results suggest that the shorter a pain duration, low-grade root compression, injection level and type of herniation area predictor the more favourable response patients have to transforaminal epidural steroid injection in patients with sciatica.

The Influence of COVID-19 on Utilization of Epidural Procedures in Managing Chronic Spinal Pain in the Medicare Population

STUDY DESIGN

A retrospective cohort study of utilization patterns and variables of epidural injections in the fee-for-service (FFS) Medicare population.

OBJECTIVES

To update the utilization of epidural injections in managing chronic pain in the FFS Medicare population, from 2000 to 2020, and assess the impact of COVID-19.

SUMMARY OF BACKGROUND DATA

The analysis of the utilization of interventional techniques also showed an annual decrease of 2.5% per 100,000 FFS Medicare enrollees from 2009 to 2018, contrasting to an annual increase of 7.3% from 2000 to 2009. The impact of the COVID-19 pandemic has not been assessed.

METHODS

This analysis was performed by utilizing master data from the Centers for Medicare and Medicaid Services, physician/supplier procedure summary from 2000 to 2020. The analysis was performed by the assessment of utilization patterns using guidance from Strengthening the Reporting of Observational Studies in Epidemiology.

RESULTS

Epidural procedures declined at a rate of 19% per 100,000 Medicare enrollees in the FFS Medicare population in the United States from 2019 to 2020, with an annual decline of 3% from 2010 to 2019. From 2000 to 2010, there was an annual increase of 8.3%. This analysis showed a decline in all categories of epidural procedures from 2019 to 2020. The major impact of COVID-19, with closures taking effect from April 1, 2020, through December 31, 2020, will be steeper and rather dramatic compared with April 1 to December 31, 2019. However, monthly data from the Centers for Medicare and Medicaid Services is not available as of now. Overall declines from 2010 to 2019 showed a decrease for cervical and thoracic transforaminal injections with an annual decrease of 5.6%, followed by lumbar interlaminar and caudal epidural injections of 4.9%, followed by 1.8% for lumbar/sacral transforaminal epidurals, and 0.9% for cervical and thoracic interlaminar epidurals.

CONCLUSION

Declining utilization of epidural injections in all categories was exacerbated to a decrease of 19% from 2019 to 2020, related, in part, to the COVID-19 pandemic. This followed declining patterns of epidural procedures of 3% overall annually from 2010 to 2019.

Changes in pain scores and walking distance after transforaminal epidural steroid injection in patients with lumbar foraminal spinal stenosis

Transforaminal epidural steroid injections (TFESI) are widely used in patients with lumbar foraminal spinal stenosis. Previous studies have evaluated the effects of TFESI on lumbar foraminal spinal stenosis using only pain scores. However, no study has evaluated the effect of TFESI on pain scores and walking distance in patients with lumbar foraminal spinal stenosis. This study aimed to assess the effect of TFESI on pain scores and walking distance in patients with lumbar foraminal spinal stenosis stratified according to disease severity. This retrospective study reviewed the medical records of patients who received TFESI for lumbar foraminal spinal stenosis. A total of 128 patients were divided into the moderate and severe groups based on the extent of fat obliteration and the presence of nerve root compression. A significant decrease in the numeric rating scale (NRS) scores was observed in the moderate and severe groups compared with the corresponding baseline values 4 weeks after TFESI; however, the NRS pain scores were lower in the moderate group than those in the severe group. In addition, the proportion of patients who experienced pain reduction (≥50%) was higher in the moderate group than that in the severe group. The moderate and severe groups showed a significant increase in walking distance compared with the baseline values 4 weeks after the treatment. However, the walking distance values did not differ significantly between the moderate and severe groups. Furthermore, the degree of satisfaction was higher in the moderate group than that in the severe group. Lumbar TFESI may reduce pain scores and increase walking distance in patients with moderate or severe lumbar foraminal spinal stenosis. Patients with moderate foraminal stenosis had better pain relief outcomes than those with severe foraminal stenosis.

Treatment With Opioids Is Not Associated With Poor Outcomes Among Older Adults With Lumbar Spinal Stenosis Receiving Epidural Injections

STUDY DESIGN

Secondary analysis of a randomized controlled trial.

OBJECTIVE

To assess how baseline treatment with opioids is associated with pain and function in older adults with lumbar spinal stenosis who receive epidural injections.

SUMMARY OF BACKGROUND DATA

Data were obtained from the Lumbar Epidural Steroid injections for Spinal Stenosis trial, a double-blind, multisite, randomized controlled trial.

METHODS

Baseline treatment with opioids was assessed from electronic medical record prescription pharmacy data or from health utilization records collected from patients. We calculated adjusted changes in back pain numerical rating scale, leg pain numerical rating scale, and back-related disability (Roland Morris Disability Questionnaire scores) from baseline to three weeks and to six weeks among patients treated and not treated with opioids at baseline using generalized linear regression.

RESULTS

Baseline treatment with opioids was not significantly associated with back pain intensity (adjusted difference in means at three weeks of follow-up between patients treated with opioids at baseline versus not [±95% CI, 0.1 (-0.7, 0.7)], leg pain intensity [-0.2 (-0.9, 0.4)], or back-related function [-0.8 (-2.1, 0.4)]. We found similar results at six weeks of follow-up.

CONCLUSIONS

Among older adults with lumbar spinal stenosis who are receiving epidural injections, those treated with opioids at baseline had similar outcomes to those who were not.

The Impact of Contrast Spread Patterns to Clinical Outcomes of Cervical Interlaminar Epidural Steroid Injection: An Observational Study

AIM

To investigate the relationship between epidural contrast spread patterns, and the treatment success of cervical interlaminar epidural steroid injection (CIESI) for cervical radicular pain.

MATERIAL AND METHODS

A total of 76 patients aged between 20 and 60 years who had neck and unilateral upper limb pain due to a single-level disc herniation at C5-C6 or C6-C7 were included. Severity of pain and disability were assessed with Numerical Rating Scale (NRS-11) and Neck Pain Disability Scale (NPDS) at baseline, three weeks, and three months after the treatment. Contrast dispersion prior to injection of the medication was graded in anteroposterior fluoroscopic view. Treatment success was defined as a ≥50% improvement at three months in the NRS-11 scores compared to baseline.

RESULTS

A significant improvement in pain and disability scores was observed at three months compared to baseline (p < 0.001). Treatment success was observed in 57% of the patients. The multivariate binary logistic regression analysis revealed that high initial NPDS scores, severe foraminal and central stenosis, Grade 1 contrast spread pattern were negative predictors of response to CIESI.

CONCLUSION

Lateral contrast spread toward the dorsal root ganglion (DRG) and spinal nerve root of the target level was associated with more favorable clinical responses. Clinicians performing CIESIs should exert effort to administer the injectate around the DRG and spinal nerve root at the target level.

Relationship Between Socioeconomic Status and the Outcome of Lumbar Epidural Steroid Injections for Lumbar Radiculopathy

OBJECTIVE

The aim of the study was to investigate the relationship between socioeconomic status and pain reduction from epidural steroid injections for lumbar radiculopathy.

METHODS

The retrospective cohort consisted of patients undergoing epidural steroid injection for lumbar radiculopathy ( n = 544). Numeric Pain Rating Scale was measured at baseline and 2 wks after epidural steroid injection. Socioeconomic status was estimated using median family income in patients' ZIP code. Linear and mixed models examined demographic and clinical differences in pain before and after injection and whether family income moderated the effect.

RESULTS

Majority of patients were White (72.4%), female (56.4%), engaged in physical activity (68.2%), and underwent unilateral, transforaminal epidural steroid injection (86.0% and 92.1%, respectively). Non-White patients and those who did not engage in physical activity had higher baseline pain ( P < 0.05). Lower socioeconomic status was associated with higher baseline pain (β = 0.06 per $10,000, P = 0.01). Patients with lower socioeconomic status experienced larger improvement in pain after epidural steroid injection: -1.56 units for patients in the 10th percentile of family income versus -0.81 for 90th percentile. Being a current smoker was associated with higher pain (β = 0.76, P = 0.03) and engaging in structured physical activity with less pain (β = -0.07 P < 0.01).

CONCLUSIONS

Lower socioeconomic status was independently associated with higher pain alleviation after controlling for other potentially influential demographics. Modifiable lifestyle factors may be a target of potential intervention.

The Effectiveness of Facet Joint Injection with Steroid and Botulinum Toxin in Severe Lumbar Central Spinal Stenosis: A Randomized Controlled Trial

Lumbar central spinal stenosis (LCSS) is a common disorder that causes disability and pain in the elderly. It causes pain in the radicular leg. Recently, transforaminal epidural steroid injection (TFESI) has been widely used to control radicular leg pain caused by LCSS. However, in cases of severe LCSS, drugs injected using TFESI cannot spread into the spinal canal and would have less therapeutic effects than in mild LCSS. To compensate for this limitation of TFESI, we injected steroids and botulinum toxin type A into the bilateral facet joints, evaluated their effects, and compared them with those of TFESI. One hundred patients with severe LCSS were included in the study and randomly allocated to either the facet injection (FI) or TFESI group. For 50 patients in the FI group, 30 mg (40 mg/mL) of triamcinolone with 50 IU of botulinum toxin type A mixed with a 1 mL solution of 100 mL of 50% dextrose water and 30 mL of 4% lidocaine were administered into the bilateral facet joints under fluoroscopy. For 50 patients in the TFESI group, 30 mg (40 mg/mL) of triamcinolone with 0.8 mL of 2% lidocaine and 2.5 mL of 50% dextrose water was injected bilaterally under fluoroscopy. Radicular leg pain (measured with a numeric rating scale) and pain-related disability (measured with the modified Oswestry Disability Index) due to severe LCSS were significantly reduced after facet joint injection. The therapeutic effects were greater after facet joint injection than after bilateral TFESI. The injection of a mixed solution of steroids and botulinum toxin type A into the bilateral facet joints would be a beneficial therapeutic option in patients with severe LCSS.

Comparison of programmed intermittent epidural bolus injection and continuous epidural injection in controlling nighttime pain and improving sleep quality after thoracotomy

BACKGROUND

Postoperative pain after open thoracotomy is known to be very severe and affects sleep quality. This study aimed to investigate the effects of a programmed intermittent epidural bolus injection versus continuous epidural injection for controlling nighttime pain and improving sleep quality after thoracotomy.

METHODS

Seventy-six patients scheduled for open thoracotomy for lung cancer or other lung diseases were enrolled. The participants were divided into 2 groups. Group A was continuously injected with 0.2% levobupivacaine at 1.1 mL/h, and group B was injected intermittently with 3 mL 0.2% levobupivacaine at 3 hours intervals through a thoracic epidural catheter via a programmed infusion pump. Within 48 hours after surgery, the degree of pain control using visual analog scale and the patients' sleep conditions on postoperative day (POD) 0 and 1 were evaluated, and other adverse events were investigated.

RESULTS

On POD 1 night, the visual analog scale in group B showed lower than group A (P = .009). Comparison of time to fall asleep showed no differences between 2 groups. Total sleep time was no difference on POD 0 but was longer in group B than that in group A on POD 1 (P = .042). Awakening from sleep on POD 0 was lower in group B than that in group A (P = .033), and satisfaction with sleep quality on POD 0 was superior in group B compared to group A (P = .005). Postoperative nausea and vomiting occurred more frequently in group B than in group A (P = .018).

CONCLUSION

The programmed intermittent epidural bolus technique of patient-controlled epidural analgesia reduces postoperative nighttime pain and improves sleep quality in patients undergoing thoracotomy for lung cancer or other lung diseases.

Cascade of decisions meet personal preferences in sciatica treatment decisions

STUDY DESIGN

An in-depth interview study including patients, general practitioners, neurologists and neurosurgeons.

OBJECTIVE

To gain insight in decision-making in sciatica care, by identifying patients' and physicians' preferences for treatment options, and the differences between and within both groups.

SUMMARY OF BACKGROUND DATA

Sciatica is a self-limiting condition, which can be treated both conservatively and surgically. The value of both options has been disputed, and the care pathway is known for a substantial amount of practice variation. Most Dutch patients are taken care of by general practitioners before they are referred to hospital-based neurologists, who might refer to a neurosurgeon, who can perform a surgical intervention. Dutch sciatica care thus follows the principles of stepped care, and a cascade of decisions precedes surgery. Better understanding of the decision-making within this cascade might reveal opportunities to improve shared decision-making and to reduce unwarranted practice variation.

METHODS

Interviews with 10 patients and 22 physicians were analysed thematically.

RESULTS

While physicians were confident of their clinical diagnosis, patients preferred confirmation trough imaging to exclude other possible explanations. Furthermore, many patients showed reluctance towards the use of (strong) opioids, while all physicians favoured this and underlined the benefits of opioids in the management of sciatica complaints, to buy time and to allow patients to recover naturally. Finally, individual physicians differed strongly in their opinion on benefits and optimal timing of surgical treatment and epidural injections.

CONCLUSIONS

Dutch sciatica care is characterised by a cascade of decisions preceding surgery. Preferences differ within and between patients and physicians, which adds to the practice variation. To improve decision-making, physicians and patients should invest not necessarily more in the exchange of options or preferences, but in making sure the other understands the rationale behind them.

Comparing the therapeutic effects of pregabalin and gabapentin after transforaminal epidural nerve block in lumbar radiculopathy

Lumbar radiculopathy can be presented as low back pain and radiating pain. Transforaminal epidural steroid injection (TFESI) has been used to treat radicular pain, and after the injection, additional medications such as gabapentinoids including pregabalin (PGB) and gabapentin (GBP) can be administered to relieve remnant pain. However, little is known about the effectiveness of gabapentinoids in relieving pain after transforaminal epidural steroid injection. This study was conducted to compare the effect of pregabalin and gabapentin in lumbar radiculopathy patients who underwent transforaminal epidural steroid injection. One hundred seven patients who received TFESI and had taken PGB or GBP after the intervention at Daegu Catholic University Medical Center from January 2013 to August 2021 were included in this study. Visual Analogue Scale (VAS) was evaluated in all patients. Among 107 patients, 57 (53.3%) patients took PGB and 50 (46.7%) patients took GBP after TFESI. The PGB and GBP groups showed reduced VAS scores according to visit (P < .001). However, no statistically significant differences in VAS scores according to the types of medication (P = .811) and change aspects according to visit were observed between the PGB and GBP groups (P = .947). The study findings suggest that both pregabalin and gabapentin can be equally used to reduce pain in lumbar radiculopathy patients who underwent TFESI. Further studies with larger sample size are needed to generalize the findings of this study.

Epidural Steroid Injections Acutely Suppress Bone Formation Markers in Postmenopausal Women

CONTEXT

Over 9 million epidural steroid injections (ESIs) are performed annually in the United States. Although these injections effectively treat lumbar radicular pain, they may have adverse consequences, including bone loss.

OBJECTIVE

To investigate acute changes in bone turnover following ESI. We focused on postmenopausal women, who may be at greatest risk for adverse skeletal consequences due to the combined effects of ESIs with aging and estrogen deficiency.

METHODS

Single-center prospective observational study. Postmenopausal women undergoing lumbar ESIs and controls with no steroid exposure were included. Outcomes were serum cortisol, markers of bone formation, osteocalcin, and procollagen type-1 N-terminal propeptide (P1NP), and bone resorption by C-telopeptide (CTX) measured at baseline, 1, 4, 12, 26, and 52 weeks after ESIs.

RESULTS

Among ESI-treated women, serum cortisol declined by ~50% 1 week after injection. Bone formation markers significantly decreased 1 week following ESIs: osteocalcin by 21% and P1NP by 22%. Both markers remained suppressed at 4 and 12 weeks, but returned to baseline levels by 26 weeks. There was no significant change in bone resorption measured by CTX. Among controls, there were no significant changes in cortisol or bone turnover markers.

CONCLUSION

These results provide evidence of an early and substantial reduction in bone formation markers following ESIs. This effect persisted for over 12 weeks, suggesting that ESIs may have lasting skeletal consequences. Given the large population of older adults who receive ESIs, further investigation into the long-term skeletal sequelae of these injections is warranted.

Fluoroscopic lumbar transforaminal epidural steroid injections for recurrent herniated intervertebral disc after discectomy: Effectiveness and outcome predictors

Background

Despite transforaminal epidural steroid injection (ESI) being the first choice in patient with recurrent herniated intervertebral disc (HIVD), efficacy of ESI in those patients are not well established. Herein, we evaluate the effectiveness and outcome predictors of fluoroscopic transforaminal ESI for recurrent HIVD.

Methods

Seventy-seven patients (48 male; mean age, 51.3 years) with recurrent lumbar HIVD were included and divided into three groups according to initial treatment: conservative treatment, transforaminal ESI, and immediate surgery. ESI effectiveness was evaluated by operation rates, injection numbers in 6 months, and pain reduction (visual analog scale (VAS) scores). Clinical and MRI variables were analyzed as possible outcome predictors. Each subject in the transforaminal ESI group was individually matched to two patients with initial HIVD (control group).

Results

In the transforaminal ESI group (n = 37), 20 patients (54.1%) did not undergo reoperation. The initial and follow-up VAS scores were significantly higher in the reoperation group (p = 0.014, p = 0.019, respectively). Patients with either paresthesia or motor weakness (12/19, 63.2%) had a significantly higher reoperation rate than patients with only pain (5/18, 27.8%; p = 0.031). Extruded disc ratios ≥2.0 were significantly higher in the reoperation group (10/17, 58.8%; p = 0.048). The reoperation rate in the transforaminal ESI group (17/37, 45.9%) was higher than the operation rate in the control group (6/73, 8.2%; p<0.001).

Conclusion

Transforaminal ESI was effective in reducing radicular pain in patients with recurrent HIVD. Approximately 54% of patients did not undergo reoperation. An extruded disc ratio ≥2.0 and paresthesia or motor weakness were poor outcome predictors.

Changes in pain scores and walking distance after epidural steroid injection in patients with lumbar central spinal stenosis

Lumbar spinal stenosis is a common degenerative disorder that is characterized by pain and neurogenic claudication. Previous studies have evaluated the effects of an epidural steroid injection (ESI) on spinal stenosis, based on changes to the spinal canal diameter.This study aimed to examine the impact of the ESI on pain scores and walking distance in patients with lumbar central spinal stenosis, stratified based on disease severity, which was graded according to the degree of cauda equina separation.We reviewed the medical records of patients who received the ESI for lumbar spinal central canal stenosis. A total of 128 patients were divided into moderate and severe groups, based on the degree of cauda equina separation.Relative to baseline values, 2 weeks after the ESI, the moderate group showed a significant decrease in the numeric rating scale (NRS) scores and an increase in walking distance. Meanwhile, the severe group showed a significant decrease in the NRS scores and no significant change in walking distance. The moderate group had lower NRS scores and a longer walking distance than did the severe group 2 weeks after the ESI. The proportion of patients with improved levels of satisfaction was higher in the moderate group than in the severe group.Lumbar interlaminar ESI may reduce pain scores and increase walking distance in patients with moderate lumbar spinal central canal stenosis. Patients with moderate spinal stenosis achieved better outcomes than did patients with severe stenosis.

Safety of Interlaminar Cervical Epidural Injections: Experience With 12,168 Procedures in a Single Pain Clinic

BACKGROUND

Cervical epidural steroid injections have long been utilized to treat intraspinal inflammation causing cervicalgia and/or cervical radiculopathy, and much has been written about safety and efficacy. There are published opinions, without evidence basis, that these injections should not be performed above C7-T1 for fear of dural puncture, spinal cord injury, and other complications that might occur more frequently at higher spinal levels. However, many experienced interventional pain physicians believe that epidural injections targeted to the level of spinal inflammation may be more effective. Although medication injected at the lowest cervical level C7-T1 may ascend to higher spinal levels, it often does not since inflammation and swelling at the cervical level of pathology may increase epidural pressure causing the injectate to move caudally down the path of least resistance.

OBJECTIVES

We sought to provide evidence for safety of posterior interlaminar epidural steroid injections at spinal levels at and above C7-T1 and to outline a 'best practices' approach to posterior cervical epidural injection based on experience with over 12,000 injections over 2 decades. We provide a discussion of cervical spinal anatomy, preferred technique for injection, and briefly review published literature to date regarding safety and efficacy of this procedure.

STUDY DESIGN

Retrospective case series.

SETTING

Single center, private practice institution.

METHODS

To document safety of interlaminar cervical epidural injections at levels above C7-T1, we conducted a retrospective study where we queried our electronic medical record database for information regarding 12,168 interlaminar cervical epidural steroid injections performed on 6,158 unique patients during a 14-year period by 5 different board-certified interventional pain physicians using similar technique within a single medical practice. Each injection was performed using fluoroscopic guidance with cervical epidurography routinely performed prior to injection of a therapeutic steroid and local anesthetic mixture. We found 129 minor complications (complications that did not require medical care beyond the post-anesthesia care unit [PACU] and 7 complications which we considered serious (required care beyond PACU stay), although no patients suffered paralysis or death. There was no correlation between spinal level of injection and complication rates.

RESULTS

Our most common spinal level for injection was C5-6, followed closely by C6-7. Hundreds of injections were performed at spinal levels above C5-6 with the most cephalad level C2-3.

LIMITATIONS

Retrospective design.

CONCLUSION

Our article supports the contention that interlaminar cervical epidural injections above C7-T1 are safe. Complication rates were not increased with cervical injections cephalad to C7-T1.

Epidural Steroid Injections for Low Back Pain: A Narrative Review

Low back pain represents a significant socioeconomic burden. Several nonsurgical medical treatments have been proposed for the treatment of this disabling condition. Epidural steroid injections (ESIs) are commonly used to treat lumbosacral radicular pain and to avoid surgery. Even though it is still not clear which type of conservative intervention is superior, several studies have proved that ESIs are able to increase patients' quality of life, relieve lumbosacral radicular pain and finally, reduce or delay more invasive interventions, such as spinal surgery. The aim of this narrative review is to analyze the mechanism of action of ESIs in patients affected by low back pain and investigate their current application in treating this widespread pathology.

Predicting Maternal-Fetal Disposition of Fentanyl Following Intravenous and Epidural Administration Using Physiologically Based Pharmacokinetic Modeling

Fentanyl is an opioid analgesic used to treat obstetrical pain in parturient women through epidural or intravenous route, and unfortunately can also be abused by pregnant women. Fentanyl is known to cross the placental barrier, but how the route of administration and time after dosing affects maternal-fetal disposition kinetics at different stages of pregnancy is not well characterized. To address this knowledge gap, we developed a maternal-fetal physiologically based pharmacokinetic (mf-PBPK) model for fentanyl to evaluate the feasibility to predict the maternal and fetal plasma concentration-time profiles of fentanyl after various dosing regimens. As fentanyl is typically given via the epidural route to control labor pain, an epidural dosing site was developed using alfentanil as a reference drug and extrapolated to fentanyl. Fetal hepatic clearance of fentanyl was predicted from CYP3A7-mediated norfentanyl formation in fetal liver microsomes (intrinsic clearance = 0.20 ± 0.05 µl/min/mg protein). The developed mf-PBPK model successfully captured fentanyl maternal and umbilical cord concentrations after epidural dosing and was used to simulate the concentrations after intravenous dosing (in a drug abuse situation). The distribution kinetics of fentanyl were found to have a considerable impact on the time course of maternal:umbilical cord concentration ratio and on interpretation of observed data. The data show that mf-PBPK modeling can be used successfully to predict maternal disposition, transplacental distribution, and fetal exposure to fentanyl. SIGNIFICANCE STATEMENT: This study establishes the modeling framework for predicting the time course of maternal and fetal exposures of fentanyl opioids from mf-PBPK modeling. The model was validated based on fentanyl exposure data collected during labor and delivery after intravenous or epidural dosing. The results show that mf-PBPK modeling is a useful predictive tool for assessing fetal exposures to fentanyl opioid therapeutic regimens and potentially can be extended to other drugs of abuse.

The effect of spinopelvic parameters on transforaminal epidural steroid injection treatment success in lumbar disc herniation

BACKGROUND

Spinopelvic parameters (SPP) is closely associated with diseases such as lumbar disc herniation (LDH), disc degeneration and spondylolisthesis. Although there exist many known clinical and radiological factors affecting the success of the transforaminal epidural steroid injection (TFESI) treatment, the effect of SPP has not yet been investigated. This study aims to examine the effects of SPP on treatment success in patients who undergo TFESI because of lumbar disc herniation and to investigate the correlation among multifidus cross-sectional area (MFCSA).

METHODS

This was a prospective, observational study. Patients with low back and/or leg pain, unilateral nerve root compression were applied TFESI. Outcome measures included the numerical rating scale (NRS), Oswestry Disability Index (ODI) and Beck Depression Inventory (BDI). The patients were evaluated at the first hour, third week and third month. The SPP and MFCSA measurements were made on direct radiographs and MRIs.

RESULTS

A total of 58 patients, 24 women and 34 men, with an average age of 42.0 ± 9.5 were included. NRS, ODI and BDI scores improved significantly up to three months follow-up (P < .001). Moderately positive correlations were found between leg NRS and PT/PI scores immediately after treatment (r: 0.307 and r: 0.334) and a weak positive correlation was found between BDI and PT at third week (r: 0.269). The MFCSA/vertebral sectional area (VSA) and MFCSA/total multifidus cross-sectional area (TMFCSA) of the affected side was found to be significantly low (P < .001).

CONCLUSIONS

Subjects with high PI and PT reported less improvement in leg pain immediately after treatment and patients with high PT had fewer BDI improvements. MFCSA had no correlations with SPPs in patients who underwent TFESI.

Comparison of Intravascular Injection Incidences and Technical Easiness Between Anteroposterior and Oblique Approaches During S1 Transforaminal Epidural Injection

BACKGROUND

Transforaminal epidural injection (TFEI) is a useful intervention for radicular leg pain. Compared to TFEI in lumbar level, S1 TFEI is reported to have higher incidence rates of intravascular injection as well as technical difficulties.

OBJECTIVE

The purpose of this study is to compare the incidence rates of intravascular injection and foramen passage time between anteroposterior (AP) and oblique (OB) approaches.

STUDY DESIGN

Prospective randomized trial.

SETTING

An interventional pain management practice in South Korea.

METHODS

One hundred forty-seven patients receiving S1 TFEI for radicular leg pain were randomly assigned to one of 2 approach methods (AP view vs OB view). For S1 TFEI in the OB view group, lineup of the L5-S1 endplate was performed by adjusting the cephalad-caudad tilt. Then C-arm was rotated at an ipsilateral oblique angle, approximately 10° to 15°. After final confirmation of intravascular injection with real time fluoroscopy, the foramen passage time and amount of radiation exposure during S1 TFEI were measured.

RESULTS

The incidence rate of intravascular injection in the AP view group was 24.2% (24/99), whereas that of intravascular injection in the OB view group was 10.1% (17/99, P = 0.008). The radiation dose required to pass the S1 foramen was significantly higher in the AP view group than in the OB view group (51.3 ± 27.2 cGy/cm2 vs 41.0 ± 17.0 cGy/cm2, P = 0.002). The foramen passage time during S1 TFEI was significantly higher in the AP view group than in the OB view group (103.5 ± 44.1 second vs 84.9 ± 21.0 second, P = 0.001). The failure rate of S1 TFEI was significantly higher in the AP view group than in the OB view group (13% vs 4%, P = 0.022).

LIMITATION

The physicians involved in the present study were not blinded to the type of approach method (AP view vs OB view) by fluoroscopy.

CONCLUSION

Our study demonstrated reduced incidence rates of intravascular injection and reduced foramen passage time and radiation dosage with the use of OB view method during S1 TFEI.

A New Solution to an Old Problem: Ultrasound-guided Cervical Retrolaminar Injection for Acute Cervical Radicular Pain: Prospective Clinical Pilot Study and Cadaveric Study

STUDY DESIGN

Prospective clinical pilot study and cadaveric study.

OBJECTIVE

The aim of this study was to evaluate the spread of an ultrasound-guided interfascial plane blocks (UGIPBs) and its potential efficacy for cervical radiculopathy.

SUMMARY OF BACKGROUND DATA

Cervical radiculopathy is a common disorder, potentially leading to severe pain and disability. Conservative treatment with cervical epidural steroid injections (ESI) is limited by concerns regarding their safety. UGIPBs are used in cervical surgical procedures as part of the multimodal postoperative analgesia regimen however, were not described for cervical radiculopathy.

METHODS

Twelve patients with acute cervical radicular pain who failed conservative treatment and were candidates for surgery were offered a cervical retrolaminar injection. A solution of 4 mL lidocaine 0.5% and 10 mg dexamethasone was injected, assisted by ultrasound guidance, at the posterior aspect of the cervical lamina corresponding to the compressed nerve root level. Additionally, a cadaver study was carried to evaluate the contrast spread and infiltration into near structures, both anatomically and radiographically.

RESULTS

Twelve patients underwent the procedure, with a mean follow-up time of 14.5 weeks. Average numerical rating scale improved from 7.25 at baseline to 2.83 following the injection (P < 0.001). Three patients received 2 to 3 injections without significant improvement and were eventually operated. No adverse events were reported.In the cadaver study, fluoroscopy demonstrated contrast spread between T1 and T3 caudally, C2 to C5 cranially and facet joints laterally. Anatomically, the dye spread was demonstrated up to C2 cranially, T1 caudally, the articular pillars of C4 to C7, and the neural foramen of C6 laterally.

CONCLUSION

A solution injected into the cervical retrolaminar plane can diffuse in the cranial-caudal axis to C2-T3 and laterally to the facet joints and the cervical neural foramen. Our pilot study confirmed the feasibility of our study protocol. Future studies are needed to support our early results.Level of Evidence: 4.

Does Paramedian Approach Preferentially Secure Optimal Drug Delivery Onto Ventral Epidural Space and Subsequent Superior Clinical Efficacy Over a Dorsal Midline Approach During Cervical Interlaminar Epidural Injection?

BACKGROUND

There is paucity in the literature directly comparing the clinical results between the paramedian and the midline interlaminar cervical epidural injections.

OBJECTIVE

To compare the proportion of ventral epidural spread of injectate and consequent clinical outcome between the paramedian and midline approach during interlaminar epidural injection in patients with axial neck and/or interscapular pain triggered from the underlying cervical spine pathologic condition.

STUDY DESIGN

Retrospective study.

SETTING

Primary pain clinic and spine hospital.

METHODS

Two hundred and twenty-three patients with axial neck and/or interscapular pain due to cervical problem underwent interlaminar epidural injection through either a paramedian approach (PM group, n = 93) or a midline approach (ML group, n = 130). We compared the portion of ventral epidural filling, Numeric Rating Scale (NRS), and McNab criteria between both groups. The NRS and McNab criteria were also separately compared between the ventrally spread (VS) group and non-ventral spread (non-VS) group inside each PM and ML group, respectively, at 2 weeks and 10 weeks post-injection.

RESULTS

The PM group showed a significantly higher proportion of ventral spread, successful NRS reduction, and satisfactory McNab criteria than the ML group at 10 weeks. In the PM group, the VS group showed the same results as above compared to the non-VS group.

LIMITATIONS

A retrospective analysis based on the relatively short-term follow-up period clinical results.

CONCLUSIONS

The paramedian approach showed the better direct injectate transfer over the ventral epidural space and subsequently superior clinical efficacy for the patients suffering from axial neck and/or interscapular pain secondary to cervical spine problems.

Caudal Epidural Steroid Injections in the Setting of Remaining on Antithrombotics: A Retrospective Study

BACKGROUND

The American Society of Regional Anesthesia currently recommends ceasing antithrombotic medications for all spinal epidural steroid injections, however there is a paucity of data on the true risk of spinal epidurals via various approaches versus the risk of cessation of an agent as it relates to the underlying medical condition.

OBJECTIVE

This study evaluated the complication rate of caudal epidural steroid injections in patients who remain on antithrombotic medications.

STUDY DESIGN

Retrospective chart review.

SETTING

Physiatric Spine Clinic in Orthopedic Specialty Office and Surgical Center.

METHODS

A retrospective chart review was performed identifying patients (n = 335) who received a caudal epidural steroid injection (n = 673) from June 2015 through April 2020. Patients were included if they had received the injection while taking an antithrombotic medication. Patients were excluded if they were not taking an antithrombotic. The patient's age, indication for the injection including magnetic resonance imaging or computed tomography findings, antithrombotic medication, the medical condition requiring an antithrombotic, and any complications following the injection were collected via chart review.

RESULTS

Of the 443 injections included in the study, 51 encounters were lost to follow-up. Of the other 392 injections, there were no reported complications, regardless of the patient's imaging findings, age, the antithrombotic medication used, or the underlying medical condition for which an antithrombotic medication was indicated.

LIMITATIONS

This is a retrospective study. Therefore, a prospective study may have yielded fewer encounters lost to follow-up. Patients were not contacted directly after the procedure and chart reviews were utilized to evaluate for complications, which was limited to a patient's reporting of perceived complications without any imaging.

CONCLUSIONS

We conclude that caudal epidural steroid injections can be performed safely in patients while taking antithrombotic medications. Catastrophic events have been observed in patients who have discontinued antithrombotic agents preceding procedures. Thus, discontinuing antithrombotic medications may pose a greater risk than benefit for patients on an antithrombotic medication who have painful lumbar radiculopathy.

Safety of Epidural Steroid Injections for Lumbosacral Radicular Pain: Unmet Medical Need

OBJECTIVE

Epidural steroid injections (ESIs) are a commonly utilized treatment for lumbosacral radicular pain caused by intervertebral disc herniation or stenosis. Although effective in certain patient populations, ESIs have been associated with serious complications, including paralysis and death. In 2014, the US Food and Drug Administration (FDA) issued a safety warning on the risk of injecting corticosteroids into the epidural space. The aims of this article were to review the neurological complications associated with ESIs and to compare the formulations, safety, and effectiveness of commercially available corticosteroids given by transforaminal, interlaminar, or caudal injection.

METHODS

Serious adverse events associated with ESIs were identified by a search of the FDA Adverse Event Reporting System (FAERS) database. A MEDLINE search of the literature was conducted to identify clinical trials comparing the safety and effectiveness of nonparticulate and particulate corticosteroid formulations.

RESULTS

Neurological complications with ESIs were rare and more often associated with the use of particulate corticosteroids administered by transforaminal injection. Among the 10 comparative-effectiveness studies reviewed, 7 found nonparticulate steroids had comparable efficacy to particulate steroids, and 3 studies suggested reduced efficacy or shorter duration of effect for nonparticulate steroids.

DISCUSSION

The risk of complications for transforaminal ESI is greater with particulate corticosteroids. Nonparticulate corticosteroids, which are often recommended as first-line therapy, may have a short duration of effect, and many commercial formulations contain neurotoxic preservatives. The safety profile of ESIs may continue to improve with the development of safer, sterile formulations that reduce the risk of complications while maintaining efficacy.

A Comparative Systematic Review and Meta-Analysis of 3 Routes of Administration of Epidural Injections in Lumbar Disc Herniation

BACKGROUND

The Best Practices in Pain Management from the U.S. Department of Health and Human Services (HHS) describes interventional techniques as part of a continuum. Epidural injections are commonly utilized modalities in managing low back and lower extremity pain. Epidural injections were initially administered in 1901 where the first descriptions of caudal epidural with local anesthetic for low back pain appeared. Since then, multiple developments have occurred. Currently, epidural injections are provided by caudal, interlaminar, and transforaminal approaches. The comparative effectiveness of each modality has been studied. However, comparative assessment has been sparse.

OBJECTIVES

To assess the efficacy of 3 routes of administration of epidural injections for lumbar disc herniation.

STUDY DESIGN

A systematic review and meta-analysis of randomized controlled trials (RCTs) of transforaminal, interlaminar and caudal epidural injections in managing chronic low back and lower extremity pain due to lumbar disc herniation.

METHODS

RCTs with a placebo control or an active control design, performed under fluoroscopic guidance, with at least 6 months of follow-up are included. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Data extraction and methodological quality assessment were performed. Evidence was summarized utilizing principles of best evidence synthesis.

RESULTS

A total of 21 trials were included. Of these, 7 studied caudal epidural injections, whereas transforaminal epidural injections were studied in 12 trials, and lumbar interlaminar epidural injections were studied in 10 trials, which all met inclusion criteria. Based on qualitative and quantitative analysis, which included conventional dual-arm and single-arm analysis for interlaminar epidural injections, and single-arm analysis for caudal and transforaminal epidural injections, and the approach to the epidural space, there is Level I evidence for local anesthetic and steroids, Level II for local anesthetic alone for transforaminal and interlaminar approaches, and Level II for the caudal approach with steroids or local anesthetic alone for short- and long-term relief.

LIMITATIONS

There is a paucity of literature with intermediate or long-term relief of at least 6 months with appropriate outcome parameters. Conventional dual-arm meta-analysis was feasible only for interlaminar epidural injections.

CONCLUSION

Epidural injections with local anesthetic and steroids showed Level I evidence for transforaminal and interlaminar approaches, whereas with local anesthetic alone Level II evidence was demonstrated. In contrast, caudal epidural injections showed Level II evidence with local anesthetic with steroids or local anesthetic alone.

The Impact of Vitamin D Deficiency to Treatment Success of Transforaminal Epidural Steroid Injection

BACKGROUND

Transforaminal epidural steroid injection (TFESI) is an interventional technique used to relieve disc herniation related back and radicular pain. Although few studies have investigated the factors predicting positive outcomes after TFESI, there is no data concerning the possible relationship between pre-procedure serum 25-hydroxyvitamin D (25(OH)D) levels and the response to TFESI.

OBJECTIVES

To investigate the effect of vitamin D deficiency to treatment success of fluoroscopy-guided transforaminal epidural steroid injection.

STUDY DESIGN

A retrospective assessment.

SETTING

A university hospital interventional pain management center.

METHODS

Nine hundred forty-eight patients received lumbosacral TFESI between January 2018 and December 2019 in a university hospital pain management center and were examined retrospectively for eligibility. Clinical and demographic data; magnetic resonance imaging (MRI); pre-procedure laboratory tests, including serum 25(OH)D; pain scores at baseline, third week, and third month follow-ups were collected.

RESULTS

A total of 83 patients were recruited and divided into 2 groups with respect to vitamin D status. The number of patients with serum 25(OH)D level below 20 ng/mL was 57 and the number of patients with serum 25(OH)D level above 20 ng/mL was 26. Treatment success rates were significantly lower in vitamin D deficient group at third week and third month (P: 0.006, P: 0.01).

LIMITATIONS

Retrospective nature and the absence of functional outcomes.

CONCLUSION

Vitamin D deficiency is associated with a lower probability of meaningful pain relief following TFESI. It may worth assessing serum vitamin D level prior to this intervention, although prospective investigation is necessary.

Transforaminal Epidural Steroid Injection for Zoster-Related Pain: The Golden Period for the Best Outcome

BACKGROUND

Zoster-related pain (ZRP) has many negative effects on a patient's quality of life. The transforaminal steroid injection (TFESI), which reduces neural inflammation and pain, has been advocated by pain physicians. Many reports demonstrated that early administration of TFESI showed better efficacy; however, the golden period during which TFESI is most effective remains unclear.

OBJECTIVES

This multicentre retrospective cohort study aimed to identify the golden period by which TFESI yields the best outcome in patients with ZRP.

STUDY DESIGN

Multicenter, retrospective cohort study.

SETTING

University-affiliated hospitals.

METHODS

After performing the TFESI in patients with ZRP, the patients were classified into two groups: the effective group (E) and the not effective group (N) based on the changes in the pain intensity 3 months after the TFESI. The receiver operating characteristic (ROC) curve analysis was used to assess the cut-off time point for predicting TFESI effectiveness. Furthermore, a logistic regression analysis was performed to identify patients' factors associated with a successful treatment outcome.

RESULT

Of the 302 patients, 186 and 116 patients were classified into the E and N group, respectively. ROC curve analysis showed that the best cut-off time point for TFESI was 12 weeks (95% confidence interval [CI]; 10-14 weeks) after the onset of HZ. The only variable associated with a favorable outcome was a symptom duration of ? 12 weeks compared with > 12 weeks (Odd ratio, 0.107; 95% CI, 0.055-0.205; P < 0.001). Other patient variables were not significantly associated with the effectiveness of TFESI. TFESI was most effective when administered within 12 weeks of the onset of herpes zoster.

LIMITATION

This study was not a prospective randomized controlled trial (RCT) and the follow-up period was only 3 months after TFESI.

CONCLUSION

TFESI is more effective when administered within 12 weeks of onset of herpes zoster.

Epidural Injections for Lumbar Radiculopathy or Sciatica: A Comparative Systematic Review and Meta-Analysis of Cochrane Review

BACKGROUND

Epidural injections are one of the commonly performed procedures in managing low back and lower extremity pain. In the past, Pinto et al and Chou et al performed systematic reviews and meta-analyses with a recent update from Oliveira et al showing lack of effectiveness of epidural steroid injections in managing lumbar radiculopathy. In contrast, multiple other systematic reviews and meta-analyses have supported the efficacy and use of epidural injections utilizing fluoroscopic guidance.

STUDY DESIGN

A systematic review and meta-analysis of randomized controlled trials (RCTs) of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy.

OBJECTIVES

To assess the efficacy of 3 categories of epidural injections for lumbar radiculopathy or sciatica performed utilizing saline with steroids, local anesthetic alone, or steroids with local anesthetic.

METHODS

In this systematic review and meta-analysis, RCTs with a placebo control or an active control design, performed under fluoroscopic guidance, with at least 6 months of followed-up were included. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Literature search was performed through January 2021. Methodological quality assessments were performed. Evidence was summarized utilizing principles of best evidence synthesis.

RESULTS

In this analysis, a total of 21 RCTs were utilized with at least 6 months of follow-up and performed under fluoroscopic guidance. However, only 6 of 25 trials from Cochrane review met inclusion criteria for this review. Based on qualitative analysis, of the 21 trials included in the present analysis, there was only one placebo-controlled trial found to be negative. With conventional meta-analysis, there was no significant difference among the studies because all of the studies were active control with local anesthetic or local anesthetic and steroids. Further, with single-arm analysis, of the 5 trials included in that portion of the study, significant improvement was seen with local anesthetic alone compared to local anesthetic and steroids. There was a tendency for better improvement with steroids in terms of both pain relief and functional status. The level of evidence is Level I or strong for local anesthetic with steroids and Level I to II or moderate to strong for local anesthetic as a single agent based on multiple relevant high quality RCTs.

LIMITATIONS

Despite multiple trials available, there is a paucity of true RCTs performed under fluoroscopic guidance with any of the approaches.

CONCLUSION

Epidural injections with or without steroids for radiculopathy showed significant effectiveness with Level I or strong evidence for local anesthetic with steroids and Level II to I or moderate to strong evidence with local anesthetic alone.

Clinical Relevance of Epidural Steroid Injections on Lumbosacral Radicular Syndrome-related Synptoms: Systematic Review and Meta-Analysis

OBJECTIVES

Epidural steroid injections (ESIs) can be used to reduce lumbosacral radicular syndrome (LRS) related pain. The clinical relevance of ESIs are currently unknown. This systematic review and meta-analyses aims to assess whether ESIs are clinically relevant for patients with LRS.

MATERIALS AND METHODS

Comprehensive literature searches for randomized controlled trials regarding steroid injections for LRS were conducted in PudMed, EMBASE, CINAHL, and CENTRAL from their inception to September 2018 (December 2019 for PubMed). For each homogenous comparison, the outcomes function, pain intensity and health-related quality of life at different follow-up intervals were pooled separately. The GRADE approach was used to determine the overall certainty of the evidence.

RESULTS

Seventeen studies were included. Two different homogenous comparisons were identified for which the randomized controlled trials could be pooled. In 36 of the 40 analyses no clinically relevant effect was found. The certainty of evidence varied between very low to high. Four analyses found a clinically relevant effect, all on pain intensity and health-related quality of life, but the certainty of the evidence was either low or very low. Two of the 33 subgroup analyses showed a clinically relevant effect. However, according to the GRADE approach the certainty of these findings are low to very low.

DISCUSSION

On the basis of the analyses we conclude there is insufficient evidence that ESIs for patients with LRS are clinically relevant at any follow-up moment. High-quality studies utilizing a predefined clinical success are necessary to identify potential clinically relevant effects of ESIs. Until the results of these studies are available, there is reason to consider whether the current daily practice of ESIs for patients with LRS should continue.

New Simple Ultrasound-Guided Transforaminal Injection in Patients With Radiculopathy in the Lower Cervical Spine: A Computed Tomography-Controlled Study

OBJECTIVES

To evaluate the feasibility of a new simple ultrasound-guided transforaminal injection in patients with cervical radiculopathy.

METHODS

Ultrasound scans of the neck in a plastic model and in 5 unaffected participants were first performed to identify the intervertebral foramen. Then ultrasound-guided transforaminal injections were performed in 20 patients with radiculopathy in the lower cervical spine, and computed tomography was used to verify the accuracy. Complications, the visual analog score, and the neck disability index were assessed at 1 and 3 months after the injection.

RESULTS

Computed tomography confirmed that the needle tip was correctly placed in the intervertebral foramen in 88.5% (23 of 26) of injections. No immediate or short-term complications were observed in all patients. The visual analog score and neck disability index at 1 and 3 months were significantly lower than those before the injection (both P < .0001).

CONCLUSIONS

Ultrasound may be a feasible and accurate method to guide cervical transforaminal injection.

Radicular Pain After Hip Disarticulation: A Clinical Vignette

ABSTRACT

A 36-yr-old man with a history of industrial accident causing traumatic left hip disarticulation, pubic symphysis, and right sacroiliac joint fractures presented with a 3-yr history of left-sided lower back pain radiating down the amputated limb. Computed tomography lumbar spine showed osteophytes surrounding the sacroiliac joint bilaterally with reduced left L4-L5 foraminal space. A fluoroscopically guided left sacroiliac steroid injection led to mild improvement in low back pain. Magnetic resonance imaging of the lumbar spine without contrast showed transitional type L5 vertebral body with left-sided flowing osteophytes abutting the extraforaminal L4 and L5 nerves. Ultimately, multilevel left fluoroscopically guided transforaminal epidural steroid injection at L4-L5 and L5-S1 significantly improved symptoms. Although phantom radiculopathy is a rare entity, clinical suspicion of degenerative spine disease or other pathology contributing to nerve impingement in patients with amputations should remain; this unique case discusses bony osteophyte complex as the cause for phantom radiculopathy instead of previously described disc herniation. Magnetic resonance imaging remains a key tool in delineating causes of low back pain among patients with lower limb amputations.