The short and midterm outcomes of lumbar transforaminal epidural injection with preganglionic and postganglionic approach in lumbosacral radiculopathy: a systematic review and meta-analysis

Enhancing contrast distribution with the far lateral approach in lumbar transforaminal epidural steroid injections: A retrospective analysis

BACKGROUND

Herniated intervertebral disc (HIVD) with radiculopathy is a common degenerative spine disorder. Transforaminal epidural steroid injection (TFESI) is one of the pain relief treatments for lumbar radiculopathy recommended by evidence-based guidelines. Adequate contrast distribution is correlated with better pain control, but the best approach has not been confirmed yet.

AIM

To confirm the distribution of contrast medium injected with a new approach of TFESI, that is, far lateral lateral recess approach (FLLR-TFESI).

METHODS

Patients receiving TFESI due to HIVD with radiculopathy between 2010 January and 2020 August were retrospectively enrolled. While the FLLR-TFESI was taken as the experimental group, the conventional approach was viewed as the control group. The baseline characteristics, the pattern of contrast enhancement under fluoroscopic guidance, and the complications of these patients were collected and analyzed.

RESULTS

A total of 380 patients were analyzed (143 in control group and 237 in experimental group). The two groups were balanced in most baseline characteristics, except disc extrusion (p = 0.01) and scoliosis (p = 0.04). The FLLR-TFESI have a better contrast distribution (p < 0.01), even after adjustment (p < 0.001). No intrathecal injection was noted, but higher rate of intra-disc injection was noted in FLLR-TFESI group (10% vs. 3%, p = 0.008).

CONCLUSION

The FLLR-TFESI has a superior contrast enhancement and distribution in comparison to conventional approach. Prospective study to confirm the study result as well as the clinical benefits is suggested in the future.

Contralateral retrodiscal transforaminal approach for percutaneous epidural adhesiolysis: A technical description and retrospective comparative study

OBJECTIVES

Retrodiscal transforaminal (RdTF) epidural steroid injection (ESI) is clinically comparable to conventional transforaminal ESI and can avoid catastrophic complications. However, it poses a risk of inadvertent intradiscal, intravascular, and intrathecal injections. Therefore, we aimed to evaluate the feasibility of percutaneous epidural adhesiolysis (PEA) using the contralateral (Contra)-RdTF approach.

METHODS

The electronic medical records of 332 patients with unilateral lumbar radiculopathy due to foraminal disk pathology were reviewed. Patients were categorized into two groups: Group A (ESI using the RdTF approach) and Group B (PEA using the Contra-RdTF approach). Effective pain relief (EPR; ≥50% pain relief from baseline) in patients was evaluated using the visual analog scale (VAS) at 4 and 12 weeks after the procedure. The presence of unintended fluoroscopic findings and complications was recorded.

RESULTS

A total of 119 patients were enrolled in the final analysis: 81 in Group A and 38 in Group B. Both groups showed lesser VAS scores after 4 and 12 weeks than at baseline (p < 0.05). However, the proportion of patients with EPR was significantly greater in Group B after 12 weeks (p = 0.015). No complications, including intrathecal injection, infectious discitis, and neurologic deterioration, were reported. However, inadvertent intradiscal and intravascular injections were reported to be significantly higher in Group A than in Group B (14.8% and 0%, respectively; p = 0.009).

CONCLUSIONS

Although applications of this study are limited by its retrospective design, the results suggest that PEA using the Contra-RdTF approach is feasible because it can achieve EPR and avoid unintended fluoroscopic findings.

The utility of magnetic resonance imaging results in physician decision-making before initial lumbar spinal injection

BACKGROUND CONTEXT

The need for advanced imaging before spinal intervention is an area of ongoing debate. Many studies have demonstrated the accuracy of magnetic resonance imaging (MRI) results in evaluating structural pathology in the lumbar spine, but few have addressed how frequently MRI findings change clinical management. A randomized controlled trial showed that viewing MRI results did not impact outcomes in patients with radiculopathy undergoing epidural steroid injection (ESI). The results suggested ESIs that correlated with both imaging and clinical findings experienced slightly more benefit than the blinded cohort, although statistically insignificantly.

PURPOSE

Three related studies were conducted to (1) increase understanding of the opinions of interventional spine physicians regarding the utility of viewing imaging before injection and (2) evaluate the impact of viewing MRI results on injection planning (retrospective and prospective analyses).

STUDY DESIGN

Survey, prospective, and retrospective analysis.

PATIENT SAMPLE

Patients presenting to a university-based spine center for initial evaluation of back or leg pain who were candidates for spinal intervention.

OUTCOME MEASURES

Self-reported measures from a clinical practice questionnaire distributed to interventional spine physicians to determine rates and rationale for utilization of MRI before spine injection, physiologic measures including MRI results, functional measures including physician decision-making regarding type and location of injection performed.

METHODS

This study was funded by the University of Colorado Health and Welfare Trust. A survey was sent to interventional spine physicians to assess their utilization of MRI results before spine procedures. A retrospective analysis of patients who were candidates for ESI was conducted to evaluate how initial injection plan compared with the postviewing of MRI results on injection performed. In a prospective analysis, injection plans pre- and post-MRI were compared among patients presenting for initial evaluation of low back or leg pain.

RESULTS

Survey responses showed that specialists order MRI studies to correlate with physical exam (91%) and to detect the presence of synovial cysts (68%), whereas tumor/infection (93%) was most likely to cause a change in their approach. In the retrospective review, the physician's planned approach before viewing the MRI was concordant with the actual procedure 49% of the time. A different type of procedure was performed in 15% of planned injections. In such cases, the initial treatment plan was altered (ie, same procedure at a different or additional level or side) in 35% of planned injections. In the prospective data collection, 43% of injections were different from the initial physician decision. The most common reasons for altering the injection was different level affected (36%), facet pathology (22%), and different nerve root affected (16%).

CONCLUSIONS

In clinical practice, MRI before injection frequently changes management decisions in the planning and delivery of lumbar spine injections.

CT-guided transforaminal epidural steroid injections: do needle position and degree of foraminal stenosis affect the pattern of epidural flow?

OBJECTIVE

To determine the effect of needle position and foraminal stenosis on contrast flow directionality during CT-guided transforaminal epidural steroid injections (TFESI).

MATERIALS AND METHODS

One hundred five consecutive CT-guided injections were performed in 68 patients (mean age, 65.5 years) from January 1 to December 31 2017, all with preceding MRI. Two readers independently reviewed CT images to assess needle position and to determine direction of contrast flow, which was defined as central or peripheral. The MRIs were independently reviewed by the readers to determine the degree of foraminal stenosis. Inter-reader agreement for both was evaluated with the kappa statistic. Analyses were performed to determine effect of needle position, degree of foraminal stenosis, and volume of contrast injected with directionality of contrast flow, and association between contrast flow directionality with immediate post-procedural pain scores.

RESULTS

Central direction of contrast flow was demonstrated in 41/78 (52.6%) of cases with posterolateral needle position, and 20/27 (74.1%) with central or anteromedial needle position (p = 0.07). There was no difference in direction of contrast flow with high-grade versus absence of high-grade neuroforaminal narrowing, or with volume of contrast injected. There was no difference in immediate post-procedure pain scores regardless of contrast flow directionality.

CONCLUSIONS

Needle position is not significantly associated with contrast flow directionality during CT-guided TFESI, although there was a trend towards relatively decreased central flow with posterolateral positioning. Degree of foraminal stenosis and volume of injected contrast did not affect contrast flow directionality. There was no difference in immediate post-procedural pain scores with either direction of contrast flow.