Transforaminal epidural steroid injection in lumbar spinal stenosis: an observational study with two-year follow-up

Evaluation of Fluoroscopically Guided Transforaminal Selective Nerve Root Sleeve Injections for Lumbar Spinal Stenosis With Radiculopathy Utilizing Patient Reported Outcome Measurement Information System as an Outcome Measure

OBJECTIVE

To evaluate the therapeutic effect of transforaminal selective nerve root sleeve injections (TFSNRIs) in a specific subset of patients with clinical symptoms and presentation consistent with spinal stenosis.

DESIGN

Retrospective review.

SETTING

Tertiary academic spine center.

PARTICIPANTS

A total of 176 patients with radicular leg pain with or without low back pain as well as ≥3 clinical features of spinal stenosis and corroborative radiographic features of spinal stenosis on lumbar spine magnetic resonance imaging without confounding spinal pathology (N=176).

INTERVENTIONS

Fluoroscopically guided transforaminal selective nerve root sleeve injections.

MAIN OUTCOME MEASURES

Patient Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) v1.2/v2.0, Pain Interference (PI) v1.1, and PROMIS (D) v1.0 were collected at baseline and post-procedure short term (<3-months) and long-term (6-12 month) follow-up. Statistical analysis comparing baseline and postprocedural PROMIS scores was performed. Differences were compared with previously established minimal clinically important differences in the spine population.

RESULTS

For patients with spinal stenosis treated with TFSNRI, no statistically significant improvement was observed short- and long-term follow-up in PROMIS PF (P=.97, .77) and PROMIS Depression (P=.86, .85) scores. At short-term follow-up, PROMIS PI scores did significantly improve (P=.01) but the average difference of pre- and post-procedure scores did not reach clinical significance. No significant difference in PROMIS PI was noted at long-term follow-up (.75).

CONCLUSIONS

Although a statistically significant difference was observed for improvement in pain, in this retrospective study, TFSNRI did not provide clinically significant improvement in patients' function, pain, or depression for lumbar spinal stenosis at short- and long-term follow-up.

The Short-Term Outcome of Transforaminal Epidural Steroid Injection in Patients with Radicular Pain Due to Foraminal Stenosis from Lumbar Isthmic Spondylolisthesis

Purpose

In this study, we evaluated the therapeutic outcomes of transforaminal epidural steroid injection (TFESI) in managing chronic radicular pain due to foraminal stenosis. Furthermore, we evaluated its effectiveness according to isthmic spondylolisthesis (IS) severity.

Patients and Methods

We included 40 patients with radicular pain due to IS-derived foraminal stenosis in our study and treated them with TFESI. Two patients were lost during follow-up. Based on the lateral lumbar radiograph findings, we allocated the recruited patients with < 25% slippage by IS to Group 1 (n = 23) and those having 25-50% slippage to Group 2 (n = 15). The degree of pain was measured using a numeric rating scale (NRS) at pre-treatment and 1 and 2 months after TFESI.

Results

In 38 patients who completed the study, the NRS at pre-treatment was significantly reduced at the 1- and 2-month follow-ups. In the Group analysis, the NRS scores were significantly reduced after TFESI in both Groups 1 and 2, regardless of IS severity. However, the reduction in NRS scores 1 month after TFESI was significantly greater in Group 1 than in Group 2. Moreover, the rate of successful treatment outcomes was significantly higher (65.2%) in Group 1 than in Group 2 (26.7%).

Conclusion

After TFESI, chronic radicular pain was significantly reduced regardless of IS severity, and its effect persisted for at least 2 months. However, its effect was superior when the vertebra slippage by IS was less than 25% compared to patients with 25%-50%.

Does a Positive Response to Transforaminal Epidural Steroid Injection Identify Patients Who Can Avoid Surgery for Two Years?

Background

Transforaminal epidural steroid injection (TFESI) is widely used to manage lumbar radiculopathy. In clinical settings, patients often undergo repeated transforaminal epidural injections with or without steroid administration.

Objectives

To examine whether a positive response to TFESI at the first month, can in clinical settings, identify patients with radiculopathy who can avoid surgery for two years. Study Design/Setting. This prospective observational study was conducted at an academic medical center.

Methods

Individuals aged ≥20 years who had been referred to our pain center by spine surgeons were enrolled. All patients were assessed using the Numerical Rating Scale (NRS) at baseline and 1 month after the first TFESI. Patients were divided into two groups according to the NRS decrement: the positive response (PR) group achieved a ≥2.0 decrease on the NRS 1 month after the first TFESI compared to baseline and the no response (NR) group achieved a <2.0 decrease on the NRS. The incidence rates of surgery over two years were compared between the two groups. In addition, we calculated the hazard ratio of the PR group to the NR group regarding the incidence of surgery over two years using the Cox proportional hazard model, adjusting for baseline NRS.

Results

Seventy-six patients completed the two-year follow-up. In total, 8 and 68 patients had bilateral and unilateral radiculopathy, respectively. The PR and NR groups included 35 and 41 patients, respectively. The rate of surgery avoidance was 85.7% and 73.2% in the PR and NR groups, respectively. This difference was not statistically significant (p=0.26). After adjusting for baseline NRS, the hazard ratio of the PR group to the NR group regarding the incidence of surgery within two years was 0.35 (95% confidence interval: 0.11-1.11, p=0.08).

Conclusion

A positive response to TFESI may not identify patients who can avoid surgery for two years.

A Change in Global Sagittal Alignment after Transforaminal Epidural Steroid Injections in Lumbar Spinal Stenosis

Patients' functional adaptation to pain can affect global sagittal alignment. This study evaluated the short-term spinal sagittal alignment change after transforaminal epidural steroid injection (TFESI) in lumbar spinal stenosis patients. Patients with lumbar spinal stenosis who underwent TFESI were retrospectively examined. Clinical outcomes were assessed using the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). Before and two weeks after the intervention, whole-spine lateral standing view radiographs were taken. Radiographic parameters including the Sagittal Vertical Axis (SVA), C2C7 Cobb, Thoracic Kyphosis (TK), Lumbar Lordosis (LL), Pelvic Incidence (PI), Pelvic Tilt (PT), Sacral Slope (SS), and Lumbopelvic Mismatch (PI-LL) were measured. Ninety-nine patients (mean age 64.3 ± 9.2 years) were included in this study. Both VAS and ODI outcomes were statistically improved after two weeks of intervention. Radiographic parameters showed that SVA, PT, and PI-LL mismatch were significantly decreased, while C2C7 Cobb, TK, SS, and LL were significantly increased after the intervention. SVA was improved by 29.81% (52.76 ± 52.22 mm to 37.03 ± 41.07 mm, p < 0.001). PT also decreased significantly from 28.71° ± 10.22° to 23.84° ± 9.96° (p < 0.001). Transforaminal epidural steroid injection (TFESI) significantly improves VAS, ODI, and global sagittal parameters in lumbar spinal stenosis patients.

Epidural hematoma treated by aspiration after transforaminal epidural steroid injection - A case report

Background

Spinal epidural hematoma is rare condition that can rapidly develop into severe neurologic deficits. The pathophysiology of this development remains unclear. There are several case reports of emergency hematoma evacuations after epidural steroid injection.

Case

We report on two patients who developed acute, large amounts of epidural hematoma without neurological deficits after transforaminal epidural steroid injection. After fluoroscopy guided aspiration for epidural hematoma was performed, neurological defects did not progress and the hematoma was shown to be absorbed on magnetic resonance imaging.

Conclusions

These reports are believed to be the first of treating epidural hematoma occurring after transforaminal epidural steroid injection through non-surgical hematoma aspiration. If large amounts of epidural hematoma are not causing neurological issues, it can be aspirated until it is absorbed.

Diagnosis and Treatment of Transforaminal Epidural Steroid Injection in Lumbar Spinal Stenosis

Objectives:

Transforaminal epidural steroid injection reduces the low back-leg pain and enables daily activities of the patients. In this study, we aim to evaluate the treatment of transforaminal epidural steroid injection for lumbar spinal stenosis, which was mainly performed for lumbar disc herniation and share our diagnostic experience for lumbar spinal stenosis which is treated surgically.

Methods:

In our study, 37 patients were included who were treated by transforaminal epidural steroid injection for Grade B lumbar spinal stenosis in our clinic between June-2014 and June-2018. We evaluated the patients at the second weeks, third/sixth months and one year after the treatment by Oswestry-Disability-Index and Visual-Analogue-Scale and followed up for surgical treatment after one year.

Results:

The mean low back and leg pain Visual Analogue Scale was 5.1±0.3 before the transforaminal epidural steroid injection procedure, and it was 2.7±0.1 after two weeks. It was 2.8±0.2, 3.1±0.1 at three and six months after procedure, respectively. The improvement of low back-leg pain mean Visual-Analogue-Scale is statistically significant at two weeks, three and six months after transforaminal epidural steroid injection procedure, respectively. The mean Oswestry-Disability-Index was 29.6±0.4 before the transforaminal epidural steroid injection procedure, and it was 14.1±0.3 after two weeks. It was 15.3±0.5, 24.4±0.2 at three and six months after procedure, respectively. The improvement of Oswestry-Disability-Index is statistically significant at two weeks, three-six months.

Conclusion:

The transforaminal epidural steroid injection is safe procedure for non-surgical treatment of lumbar spinal stenosis and this procedure may be preferred support to the indication of the surgical treatment of level of lumbar spinal stenosis.

Percutaneous endoscopic unilateral laminotomy and bilateral decompression under 3D real-time image-guided navigation for spinal stenosis in degenerative lumbar kyphoscoliosis patients: an innovative preliminary study

BACKGROUND

The aim of this study is to introduce a new method of percutaneous endoscopic decompression under 3D real-time image-guided navigation for spinal stenosis in degenerative kyphoscoliosis patients without instability or those who with multiple comorbidities. Decompression alone using endoscope for kyphoscoliosis patient is technical demanding and may result in unnecessary bone destruction leading to further instability. The O-arm/StealthStation system is popular for its ability to provide automated registration with intraoperative, postpositioning computed tomography (CT) which results in superior accuracy in spine surgery.

METHODS

In this study, we presented four cases. All patients were over seventy years old female with variable degrees of kyphoscoliosis and multiple comorbidities who could not endure major spine fusion surgery. Percutaneous endoscopic unilateral laminotomy and bilateral decompression under 3D real-time image-guided navigation were successfully performed. Patients' demographics, image study parameters, and outcome measurements including pre- and post-operative serial Visual analog scale (VAS), and Oswestry Disability Index (ODI) were well documented. The follow-up time was 1 year.

RESULTS

Pre- and post-operative MRI showed average dural sac cross sectional area (DSCSA) improved from 81.62 (range 67.34-89.07) to 153.27 (range 127.96-189.73). Preoperative neurological symptoms including radicular leg pain improved postoperatively. The mean ODI (%) were 85 (range 82.5-90) at initial visit, 35.875 (range 25-51) at 1 month post-operatively, 26.875 (range 22.5-35) at 6 months post-operatively and 22.5 (range 17.5-30) at 12 months post-operatively (p < 0.05). The mean VAS score were 9 (range 8-10) at initial visit, 2.25 (range 2-3) at 1 month post-operatively, 1.75 (range 1-2) at 6 months post-operatively and 0.25 (range 0-1) at 12 months post-operatively (p < 0.05). There was no surgery-related complication.

CONCLUSIONS

To the best of our knowledge, this is the first preliminary study of percutaneous endoscopic laminotomy under O-arm navigation with successful outcomes. The innovative technique may serve as a promising solution in treating spinal stenosis patients with lumbar kyphoscoliosis and multiple comorbidities.

Comparison of treatment outcomes in lumbar central stenosis patients treated with epidural steroid injections: interlaminar versus bilateral transforaminal approach

Background

We aimed to compare interlaminar epidural steroid injections (ILESI) and bilateral transforaminal epidural steroid injections (TFESI) on pain intensity, functional status, depression, walking distance, and the neuropathic component in patients with lumbar central spinal stenosis (LCSS).

Methods

The patients were divided into either the ILESI or the bilateral TFESI groups. Prime outcome measures include the numerical rating scale (NRS), Oswestry disability index (ODI), Beck depression inventory (BDI), and pain-free walking distance. The douleur neuropathique en 4 questions score was used as a secondary outcome measure.

Results

A total of 72 patients were finally included. NRS, ODI, and BDI scores showed a significant decline in both groups in all follow-ups. Third-month NRS scores were significantly lower in the ILESI group (P = 0.047). The percentages of decrease in the ODI and BDI scores between the baseline and the third week and third month were significantly higher in the ILESI group (P = 0.017, P = 0.001 and P = 0.048, P = 0.030, respectively). Pain-free walking distance percentages from the baseline to the third week and third month were significantly higher in the ILESI group (P = 0.036, P < 0.001). The proportion of patients with neuropathic pain in the bilateral TFESI group significantly decreased in the third week compared to the baseline (P = 0.020).

Conclusions

Both ILESI and TFESI are reliable treatment options for LCSS. ILESI might be preferred because of easier application and more effectiveness. However, TFESI might be a better option in patients with more prominent neuropathic pain.

At Least 5-Year Follow-up After Transforaminal Epidural Steroid Injection Due to Lumbar Radicular Pain Caused by Spinal Stenosis

OBJECTIVES

Transforaminal epidural steroid injection (TFESI) can be used to control radicular pain following lumber spinal stenosis (LSS). However, limited information is available on the long-term prognosis of TFESI in patients with LSS.

METHODS

Of the 90 patients who underwent TFESI for controlling LSS-induced radicular pain at least 5 years previously, 54 patients completed a phone interview. We inquired about their degree of pain during walking or standing, current oral medication used for radicular pain, current TFESI injections, progression to surgery, and unemployment due to pain at least 5 years after the TFESI for LSS-induced radicular pain.

RESULTS

Five to seven years after the initial TFESI, the numeric rating scale (NRS) score had decreased from 6.7 to 3.7. Of the included patients, approximately 65% of the patients had an NRS score of ≥3, although roughly 15% of patients reported complete resolution of the initial pain. Approximately half of the included patients were currently receiving repetitive TFESIs every 2 to 6 months or were taking oral pain medications. Further, approximately 25% of the patients had undergone a surgical intervention; however, its outcome was poor.

CONCLUSION

The prognosis after TFESI for controlling LSS-induced radicular pain is thought to be relatively poor. However, considering poor long-term outcome and complications after surgery, we believe that TFESI is worth considering as a safe modality for controlling radicular pain following LSS.

Risk factors for sleep quality disturbances in patients with lumbar spinal stenosis before operation

PURPOSE

We aimed to explore the risk factors of preoperative sleep quality in patients with lumbar spinal stenosis (LSS) and the association of sleep-related beliefs with sleep quality in these patients.

METHODS

Sleep quality and related risk factors of sleep quality disturbances in patients with LSS preoperatively were assessed by questionnaires. Pittsburgh Sleep Quality Index (PSQI) for sleep quality, Oswestry Disability Index (ODI) for clinical outcomes, Visual Analog Scale for Pain (VAS Pain), Self-Rating Anxiety Scale (SAS) for anxiety level, and Dysfunctional Beliefs and Attitudes about Sleep (DBAS-16) for sleep-related beliefs were assessed. Bivariate logistic regression analysis was used to assess the risk factors of sleep quality disturbances.

RESULTS

A total of 227 patients were enrolled, mean age 64 years (SD 13.1), 119 women (52%). The incidence of sleep quality disturbances in patients was 37% (83/227). Increased DBAS-16 scores (OR = 0.781; 95% CI, 0.725-0.841; p < 0.001) significantly decreased the probability of developing sleep quality disturbances, while increased anxiety levels (OR = 1.241; 95% CI, 1.152-1.337; p < 0.001) significantly increased the probability of developing sleep quality disturbances in patients. Factors including educational level, increased age, sex, preoperative length of stay, VAS Pain scores, and ODI scores showed no significant association and were therefore excluded from the model.

CONCLUSIONS

High levels of anxiety and mistaken sleep-related beliefs were risk factors of sleep quality disturbances in patients with LSS before surgery. The more mistaken sleep-related beliefs were, the greater the probability of sleep disturbances.

The Effectiveness of Lumbar Transforaminal Injection of Steroid for the Treatment of Radicular Pain: A Comprehensive Review of the Published Data

Objective

To determine the effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain.

Design

Comprehensive systematic review.

Outcome Measures

The primary outcome of interest was the proportion of individuals with reduction of pain by ≥50%. Additional outcomes of interest were a more-than-two-point reduction in pain score, patient satisfaction, functional improvement, decreased use of pain medication, and avoidance of spinal surgery.

Results

For patients with disc herniations, using the criterion of ≥50% reduction in pain, success rates across included studies (range) were 63% (58–68%) at one month, 74% (68–80%) at three months, 64% (59–69%) at six months, and 64% (57–71%) at one year. For patients with lumbar spinal stenosis, success rates across included studies (range) were 49% (43–55%) at one month, 48% (35–61%) at three months, 43% (33–53%) at six months, and 59% (45–73%) at one year, but there was a lack of corroboration from appropriately controlled studies.

Conclusions

There is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. There is a lack of high-quality evidence demonstrating their effectiveness for the treatment of radicular pain due to spinal stenosis, though small studies suggest a possible benefit. Lumbar transforaminal injection of nonparticulate steroids is as effective as injections with particulate steroids.

Effect of needle type on intravascular injection in transforaminal epidural injection: a meta-analysis

Background

Lumbosacral transforaminal epidural injection (TFEI) is an effective treatment for spinal disease. However, TFEI may have several types of complications, some of which can be attributed to intravascular injection. We reviewed studies to compare the intravascular injection rate among different needle types.

Methods

We searched the literature for articles on the intravascular injection rate among different needle types used in TFEI. The search was performed using PubMed, MEDLINE, the Cochrane Library, EMBASE, and Web of Science.

Results

A total of six studies comprising 2359 patients were identified. Compared with the Quincke needle, the Whitacre needle reduced the intravascular injection rate (OR = 0.57, 95% CI = [0.44-0.73], P < 0.001). However, compared with the Quincke needle, the Chiba needle did not reduce the intravascular injection rate (OR = 0.80, 95% CI = [0.44-1.45], P = 0.46). In one study, the intravascular injection rate using a blunt-tip needle was lower than that using a sharp needle. In another study, the Whitacre and the blunt-tip needle have similar intravascular injection rates, while, the catheter-extension needle showed a reduced intravascular injection rate.

Conclusions

This meta-analysis showed that the Whitacre needle reduced the intravascular injection rate as compared with the Quincke needle, but failed to establish that the Chiba needle can decrease the intravascular injection rate in TFEI. Moreover, the blunt-tip needle can reduce the intravascular injection rate compared with the Quincke needle, and the catheter-extension needle can reduce the intravascular injection rate compared with the Whitacre and the blunt-tip needle.