Selective Nerve Root Blocks for Low Back Pain and Radiculopathy:

Comparison of the Severity of Zoster-Associated Pain and Incidence of Postherpetic Neuralgia in Patients with and without Pre-Existing Spinal Disorders at the Same Spinal Nerve Level: A Retrospective Multicenter Study

The incidences of herpes zoster (HZ) and postherpetic neuralgia (PHN) are significantly influenced by age. As individuals age, the occurrence of spinal disorders increases, thereby raising the likelihood of HZ and PHN coexistence. Considering this, our study aimed to explore the potential impact of pre-existing spinal disorders at the nerve level where HZ developed, on the severity of zoster-associated pain (ZAP) and the incidence of PHN. For our investigation, we retrospectively analyzed a total of 237 patients who presented with HZ and ZAP at various sensory levels (cervical, thoracic, lumbar, and sacral) with or without pre-existing spinal disorders. The presence or absence of spinal disorders at the sensory level affected by HZ was determined using computed tomography or magnetic resonance imaging. Our study results revealed that the group with spinal disorders at the sensory level where HZ developed did not exhibit an increased incidence of PHN. However, 3-6 months after HZ onset, this same group showed significantly higher ZAP scores compared to the group without spinal disorders. It implies a need for heightened pain management, as the coexistence of these conditions can increase pain severity. This study furnishes an initial standpoint to delve into intricate interactions between two diseases.

The Dorsomedian Ligamentous Strand: An Evaluation In Vivo with Epiduroscopy

Several anatomical studies have described the morphology of the spinal space; however, researchers do not all agree on the presence of the dorsomedian ligamentous strand (DLS), which divides the epidural space. The possible existence of this structure still influences some clinical practice, such as locoregional anesthesia and pain therapy. Since the number of procedures occurring inside the epidural space have increased, this study’s primary objective was to describe the composition of this space through epiduroscopy. We conducted a retrospective analysis of video recorded during epiduroscopy. Two independent doctors performed blind analyses of morphological aspects of peridural space visualized during the procedure in each patient for the maximum possible extension depending on the underlying pathology in the tract from S1 to L1. We enrolled 106 patients who underwent epiduroscopy; 100% of patients presented no medial longitudinal segmentation dividing the epidural channel at any level of the spinal tract investigated, including in the epidural space with pathological fibrotic scars and in those with no adherence. The main finding of our study was the visual absence of any anatomical structure dividing the epidural channel. We report that in vivo, in our experience, with direct epiduroscopy, the DLS is not visible.

Efficacy of transforaminal epidural magnesium administration when combined with a local anaesthetic and steroid in the management of lower limb radicular pain

BACKGROUND

Lower limb radicular pain resulting from a herniated intervertebral disc is a cause of functional disability and could lead to increased consumption of opioids. We evaluated the efficacy of epidural magnesium combined with a local anaesthetic and steroid in the management of this pain.

METHODS

This was a prospective, case-control, randomized, double-blind study. Fifty patients each received 2 ml bupivacaine, 1 ml (40 mg) methylprednisolone and 1 ml saline (0.9%) (group C) or magnesium (200 mg) instead of saline (group M). The primary outcome measure was the improvement in the pain score (assessed using a visual analogue scale (VAS)), and the secondary outcome was the improvement in the functional ability (assessed using the Modified Oswestry Disability Questionnaire (MODQ)). The VAS and MODQ scores were assessed before and at 1 day, 1 week, 1 month and 3 months post-intervention.

RESULTS

The VAS and MODQ scores were significantly better in group M compared to those in group C at all times post-injection (p-value < 0.001). Comparisons within the same group showed that the VAS and MODQ scores were significantly better at all post-injection time points compared to the pre-injection scores in both group C and group M (p-values < 0.0001).

CONCLUSIONS

Adding magnesium to a local anaesthetic and steroid to be injected in the transforaminal epidural space could improve the pain and the quality of life in patients suffering from lower limb radicular pain due to lumbo-sacral disc herniation, and this improvement could last for up to 3 months.

SIGNIFICANCE

Magnesium is efficient when added to local anaesthetics and steroids for management of lower limb radicular pain.

Fluoroscopy-guided approach to the lumbar dorsal root ganglion in dogs: cadaver study in Beagles

OBJECTIVE

To evaluate an approach to the canine lumbar dorsal root ganglion (DRG), a significant contributor to the pain pathway, using new methylene blue staining.

STUDY DESIGN

Prospective randomized study.

ANIMALS

A total of three Beagle dog cadavers weighing 10.4 ± 0.7 kg (mean ± standard deviation).

METHODS

Bilateral third to fifth lumbar DRG approaches were performed in three dog cadavers positioned in sternal recumbency. The mammillary process was palpated, and a 22 gauge spinal needle was inserted through the skin 1 cm lateral to the process and directed towards the median plane at a 45° angle to the dorsal plane. The needle was advanced along the transverse plane until touching bone, or a popping sensation was detected. Under fluoroscopic guidance, the position of the needle tip was adjusted to be in the cranioventral part of the intervertebral foramen. The location of the needle was confirmed by demarcation of the nerve roots after iohexol (0.1 mL) injection. For evaluation of the DRG approach, new methylene blue (0.1 mL) was injected. Subsequently, anatomical dissection of the area was performed. The DRG staining was scored as follows: 0, no staining; 1, partial (<50%); 2, partial (≥50%); and 3, complete staining. Comparisons among the staining scores of the third to fifth DRG were assessed with the Friedman test.

RESULTS

Staining score 3 was achieved in 14 of 18 (77.8%) sites. Staining scores 2, 1 and 0 were identified at two, one and one of the 18 sites, respectively. No significant difference was noted in the staining scores among the third to fifth DRGs (p = 0.78).

CONCLUSIONS AND CLINICAL RELEVANCE

The technique used for DRG injections achieved adequate DRG staining, supporting use of the fluoroscopy-guided approach to the canine lumbar DRG.

Contrast Spread in the Superoposterior Approach of Transforaminal Epidural Steroid Injections for Lumbosacral Radiculopathy

Objective

To observe the contrast spread in superoposterior transforaminal epidural steroid injection (SP TFESI) and investigate the correlation between spread patterns and efficacy.

Methods

Thirty-one patients with lumbosacral radiculopathy underwent single-level TFESI under fluoroscopy. The final needle tip position was targeted toward the SP quadrant of the intervertebral foramen. To observe the spread, 1 mL of contrast material was injected, followed by a steroid injection. The contrast spread was graded anteroposteriorly and vertically in the epidural space. The effect of SP TFESI was evaluated by proportional pain score reduction.

Results

Levels injected were L4-5 (n=20) and L5-S1 (n=11). Seventeen cases were lateral, and 14 were central herniated disc (HD). Baseline mean visual analog scale score was 6.23. Contrast dispersed dorsally in all the cases, and 45.2% cases showed a concurrent ventral spread. The proportion of the pain reduction after 2 weeks showed no difference between the two groups. In vertical spreading analysis, mean cephalic/caudal grades were 1.40/1.55 at L4-5 level and 1.73/1.64 at L5-S1 level. The HD location had no effect on contrast dispersion.

Conclusion

In SP TFESI, ventral contrast spread did not guarantee a better effect; however, the extent of cephalic flow in ventral expansion group correlated with the proportion of pain reduction.

Neuropathic pain in elderly patients with chronic low back painand effects of pregabalin: a preliminary study

STUDY DESIGN

Preliminary study.

PURPOSE

To assess the association of neuropathic pain with chronic low back pain (LBP) and the effect of pregabalin on neuropathic pain in the elderly.

OVERVIEW OF LITERATURE

Of those with chronic LBP, 37% were predominantly presenting with neuropathic pain in young adults. Pregabalin is effective for pain in patients with diabetic neuropathy and peripheral neuralgia. No study has reported on the effects of pregabalin for chronic LBP in elderly patients yet.

METHODS

Pregabalin was administered to 32 patients (age, ≥65 years) with chronic LBP for 4 weeks. Pain and activities of daily living were assessed using the Neuropathic Pain Screening Questionnaire (NePSQ), the pain DETECT questionnaire, visual analog scale, the Japanese Orthopedic Association score, the short form of the McGill Pain Questionnaire and the Roland Morris Disability Questionnaire. Modic change and spinal canal stenosis were investigated using magnetic resonance imaging.

RESULTS

Altogether, 43.3% of patients had neuropathic pain according to the NePSQ and 15.6% patients had pain according to the pain DETECT. The efficacy rate of pregabalin was 73.3%. A significant effect was observed in patients with neuropathic pain after 4 weeks of administration.

CONCLUSIONS

Neuropathic pain was slightly less frequently associated with chronic LBP in the elderly. Pregabalin was effective in reducing pain in patients with chronic LBP accompanied with neuropathic pain. Lumbar spinal stenosis and lower limb symptoms were observed in patients with neuropathic pain. We recommend the use of pregabalin for patients after evaluating a screening score, clinical symptoms and magnetic resonance imaging studies.

Variations in selective nerve root block technique

INTRODUCTION

Much literature reports on selective nerve root blocks (SNRBs) in cases of lumbosacral radiculopathy. Unfortunately, authors only inconsistently reveal the exact needle tip position relative to the causative pathology at the time of injection. Different injection sites may provide different symptomatic benefits. We investigated the variation in injection techniques of practitioners working in the UK.

METHODS

A clinical scenario was devised depicting a patient with radiculopathy secondary to an L4/5 vertebral disc prolapse. Participants were questioned on their chosen management of this patient, focusing particularly on SNRB technique. Questionnaires were sent to spinal surgeons, pain management specialists and musculoskeletal radiologists.

RESULTS

A total of 100 responses were detailed enough for inclusion. The majority (83%) of respondents reported they would inject local anaesthetic and steroids, 4% would inject local anaesthetic alone and 13% would inject a different substance. Over half (53%) would target the L5 nerve root, 26% the L4 nerve root, 12% the prolapsed disc itself and 9% two separate vertebral levels. Variation was also noted in needle tip location relative to the neural sheath.

CONCLUSIONS

When treating lumbar radiculopathy, there are apparent variations in the use and positioning of SNRBs for a given level of disc pathology. Needle tip position may have a direct influence on clinical outcome following SNRBs. Caution is therefore required when considering the validity of previously published studies investigating SNRBs and different injectates.

Factors that affect the efficacy of fluoroscopically guided selective spinal nerve root block in the treatment of radicular pain: a prospective cohort study

AIM

The fluoroscopically guided selective nerve root block (SNRB) is being used increasingly as a therapy for radicular pain as well as a diagnostic tool. However, studies and the literature reviews have yet to reach a definite conclusion on the efficacy in this setting. Our aim was to prospectively investigate factors that may affect the success of this procedure.

MATERIALS AND METHODS

A total of 301 treatment episodes with 283 patients were assessed over 25 months by patient questionnaire over a 7-day period. Changes in analgesic benefit over time, by operating consultant, referring specialty, spinal level, and the presence of periprocedural symptom provocation were evaluated. Statistical analysis was performed by using the χ(2) test, Wilcoxon test, and Kruskal-Wallis rank sum test, and the asymptotic marginal-homogeneity test. P < .05 was considered significant.

RESULTS

There was a statistically significant increase in pain relief over the 7 days after the procedure. Pain provocation during the procedure did not improve analgesic success. Cervical, lumbar, and sacral level procedures were equally efficacious. The specialist who referred the patient and the use of contrast to verify needle position during the procedure also did not affect the analgesic outcome. Overall, 69.1% of patients experienced some pain relief by day 7.

CONCLUSION

Analgesic success rates of selective nerve root blocks did not vary with spinal level, or use of contrast or periprocedural replication of symptoms, when using fluoroscopic guidance. Patients may expect a continued significant improvement in their symptoms for at least a week after the procedure.

Efficacy of therapeutic fluoroscopy-guided lumbar spine interventional procedures

PURPOSE

To evaluate the benefit of fluoroscopy-guided lumbar spine interventional procedures in treatment of low back pain.

METHODS

This prospective descriptive study was performed on 60 patients with back/radicular pain after showing no improvement with conservative treatment.

RESULTS

One hundred and two injection sessions were done (average 1.7 injection per patient). Caudal and lumbar transforaminal injections were effective in 55.9% and 78.5%, respectively. Facet and sacroiliac interventions were effective in 28.3% and 10%, respectively. Complications occurred in 20% of the procedures.

CONCLUSION

Lumbar injections improved pain/disability related to discogenic lumbar spinal diseases. Efficacy of facet and sacroiliac injections is limited.

Adjacent double-nerve root contributions in unilateral lumbar radiculopathy

BACKGROUND AND PURPOSE

Image-guided selective nerve root block/steroid injection is commonly performed for lumbar radiculopathy. The purpose of this study was to evaluate the clinical/imaging characteristics and injection response of adjacent double-root contributions to unilateral lumbar radiculopathy in a typical interventional spine practice.

MATERIALS AND METHODS

In 132 of 350 patients (37.7%) with unilateral radiculopathy, adjacent double-nerve root block/steroid injection was performed on the basis of preprocedural clinical/imaging characteristics. Clinical presentation (pain pattern, VAS), response to injection, and imaging features of potential root compression/irritation (disk protrusion, subarticular/foraminal stenosis) were tabulated.

RESULTS

Clinically, a subset of patients with both L4+L5 and L5+S1 radiculopathy presented with proximal sciatica only in addition to those with typical L4, L5 or S1 radicular patterns. Preprocedural imaging demonstrated evidence of adjacent double-root abnormality in 56 of 79 (71%) patients without prior surgery (single-level disease, 32; 2-level disease, 24) and in all 53 patients with prior lumbar surgery (scar, 42; separate-level root abnormality, 13). Adjacent double-level replication of the patient's familiar pain was present in 82 of 132 (62%) patients, with single-root replication in 37 (28%) and no response in 13 (10%). Typical sciatica was encountered by injection at L4 (15%-33%), likely reflecting furcal nerve lumbar plexus contribution from L5. Sensations from each injected root usually replicated separate recognizable portions of the patient's radiculopathy, with marked or complete pain improvement reported in most patients.

CONCLUSIONS

Adjacent double-level contributions to lumbar radiculopathy are common, and clinical/imaging clues should be assessed to ensure optimum nerve root block/steroid injection treatment response.

Clinical, anatomic, and imaging correlation in spine-related pain: the essential elements

Successful treatment of a patient's spine-related pain depends on accurate targeting of its location and cause. At a basic level, a focused history and physical examination is essential. Understanding of spine anatomy, in particular, spine innervation, is fundamental. Correlation with preprocedure imaging is important to confirm the suspected location(s) of the pain generator and is helpful in planning the approach for image-guided treatment. Understanding the variations in spine anatomy, subtle imaging features, or correlates of root irritation and factors that can affect the patient's presentation at the time of treatment are also critical to accurate targeting and effective treatment. This section reviews the fundamental elements that play a role in accurate diagnosis of the cause of a patient's spine-related pain. Routine application of these basic principles should aid in the approach to the spine-related pain patient and improve both accurate targeting of a patient's pain generator and the outcomes of image-guided treatment.

Infiltrations, blocs et neurolyses en pathologie ostéo-articulaire

Computed Tomography fluoroscopy for blocks and neurolysis provides a minimally-invasive, accurate and rapid alternative to surgery. Spinal and peri-spinal ultrasound-guided procedures, excluding peripheral procedures, will be discussed as well. The imaging-guided procedures discussed are performed using small needles. These percutaneous procedures must be performed with maximum patient comfort and cause as little complications as possible. These procedures should be performed by an experienced radiologist after discussion with the treating clinician.

Transforaminal epidural steroid injection for lumbosacral radiculopathy: preganglionic versus conventional approach

Objective

The present study was undertaken to evaluate the effectiveness of transforaminal epidural steroid injection (TFESI) with using a preganglionic approach for treating lumbar radiculopathy when the nerve root compression was located at the level of the supra-adjacent intervertebral disc.

Materials and Methods

The medical records of the patients who received conventional TFESI at our department from June 2003 to May 2004 were retrospectively reviewed. TFESI was performed in a total of 13 cases at the level of the exiting nerve root, in which the nerve root compression was at the level of the supra-adjacent intervertebral disc (the conventional TFESI group). Since June 2004, we have performed TFESI with using a preganglionic approach at the level of the supra-adjacent intervertebral disc (for example, at the neural foramen of L4-5 for the L5 nerve root) if the nerve root compression was at the level of the supra-adjacent intervertebral disc. Using the inclusion criteria described above, 20 of these patients were also consecutively enrolled in our study (the preganglionic TFESI group). The treatment outcome was assessed using a 5-point patient satisfaction scale and by using a VAS (visual assessment scale). A successful outcome required a patient satisfaction scale score of 3 (very good) or 4 (excellent), and a reduction on the VAS score of > 50% two weeks after performing TFESI. Logistic regression analysis was also performed.

Results

Of the 13 patients in the conventional TFESI group, nine showed satisfactory improvement two weeks after TFESI (69.2%). However, in the preganglionic TFESI group, 18 of the 20 patients (90%) showed satisfactory improvement. The difference between the two approaches in terms of TFESI effectiveness was of borderline significance (p = 0.056; odds ratio: 10.483).

Conclusion

We conclude that preganglionic TFESI has the better therapeutic effect on radiculopathy caused by nerve root compression at the level of the supra-adjacent disc than does conventional TFESI, and the diffence between the two treatments had borderline statistical significance.

The prognosis of conservative treatments for lumbar spinal stenosis: analysis of patients over 70 years of age

STUDY DESIGN

A prospective study.

OBJECTIVES

To identify outcomes of aged patients with lumbar spinal stenosis (LSS) treated conservatively and to examine factors that control the prognosis.

SUMMARY AND BACKGROUND DATA

There have been no reports evaluating the outcomes of conservative treatments for elderly LSS patients.

METHODS

A total of 89 patients, 70 years of age and older, who underwent in-hospital conservative treatment were included. The Japanese Orthopedic Association's score (JOA score) and the disturbance level of activities of daily living (ADL) were used for evaluation. Nerve involvement was classified into radicular, cauda equina, and mixed type. Myelographic findings were classified into central defect with or without block and root defect. Associations between disturbance level of ADL, nerve involvement, and myelographic classifications were investigated.

RESULTS

The mean JOA score increased from 11.1 points at admission to 15.9 points at discharge, with 14.3 points maintained at the follow-up; 48.8% of radicular type showed no obstacle in ADL at the follow-up compared with 33.3% of the other types; 13.3% of central defect with block showed no obstacle in ADL compared with 47.8% of the other types with significant difference.

CONCLUSION

The prognosis of conservative treatment for aged LSS was relatively good. Radicular type may be a candidate for conservative treatment. However, patients with complete block in the myelogram may not respond favorably to conservative treatment.