Radiation exposure for fluoroscopy-guided lumbosacral epidural steroid injections: comparison of the transforaminal and caudal approaches

A magnetic resonance conditional robot for lumbar spinal injection: Development and preliminary validation

PURPOSE

This work presents the design and preliminary validation of a Magnetic Resonance (MR) conditional robot for lumbar injection for the treatment of lower back pain.

METHODS

This is a 4-degree-of-freedom (DOF) robot that is 200 × 230 × 130 mm3 in volume and has a mass of 0.8 kg. Its lightweight and compact features allow it to be directly affixed to patient's back, establishing a rigid connection, thus reducing positional errors caused by patient movements during treatment.

RESULTS

To validate the positioning accuracy of the needle by the robot, an electromagnetic (EM) tracking system and a needle with an EM sensor embedded in the tip were used for the free space evaluation with position accuracy of 0.88 ± 0.46 mm and phantom mock insertions using the Loop-X CBCT scanner with target position accuracy of 3.62 ± 0.92 mm.

CONCLUSION

Preliminary experiments demonstrated that the proposed robot showed improvements and benefits in its rotation range, flexible needle adjustment, and sensor protection compared with previous and existing systems, offering broader clinical applications.

Fluoroscopy-Guided Transforaminal versus Caudal Epidural Steroid Injection for Chronic Pain After Spinal Surgery: A Retrospective Mid-Term Comparative Study

Introduction

This study is to compare advantages, safety and mid-term effects of fluoroscopy (FL)-guided transforaminal (TF) to caudal (CA) epidural steroid injection (ESI) for chronic pain after spinal surgery (CPSS) by assessing pain relief and improvement of functionality.

Methods

Patients with radicular pain in CPSS who received FL-guided CA (n = 21) or TF (n = 28) ESI were included in this retrospective study. Complication frequencies, adverse events, treatment effects, and functional improvements for each procedure were compared at 1, 3, and 6 months following the last injection.

Results

Both the Oswestry Disability Index (ODI) and verbal numeric pain scale scores (VNS) demonstrated improvement in both groups at all 1, 3, and 6 months following the last injection, without meaningful difference between groups (p < 0.05). Moreover, no meaningful difference was present between groups in terms of treatment success rate at every time point. The amount of time used for the injection procedure was shorter in CA group than in TF group (410.32 ± 25.73 seconds vs 640.65 ± 18.03 seconds, p < 0.05). Within 2 weeks of the injection treatment, the patient satisfactory scores were evaluated, with excellent being rated 85.7% (n = 18) among CA-ESI patients and 55.7% (n = 16) among TF-ESI patients (p < 0.05). Logistic regression analysis revealed that variables such as method of injection (CA or TF approach), sex, use of analgesics, pain duration, number of injections, and age were not significant variables for successful treatment results. There were no adverse complications after the procedure in both groups.

Conclusion

The outcomes of FL-guided CA-ESI and TF-ESI for CPSS are similar in terms of pain reduction and functional improvements. CA-ESI is associated with lesser procedure time. In addition, compared with the TF-ESI, the patient experiences less discomfort during the injection, and the satisfaction with the injection treatment is confirmed to be better. Accordingly, both methods are effective; however, in the CA approach, patient satisfaction is higher and the procedure time is shorter.

A study on legal and medical dimensions of radiation exposure in neurosurgery clinics in Turkish practice

Background:

In the present study, the first aim was to address the detrimental effects of the fluoroscopy procedure performed by physicians and other health-care professionals in neurosurgery clinics, then to examine precautions that should be taken to avoid harmful effects of radiation and radioactive substances during this process. The second aim was to handle the rights provided for health-care professionals exposed to the radiation in workplaces.

Methods:

A standardized questionnaire was used for a multicenter survey. Volunteer, intellectual, and cooperative participants (n = 41) were randomly chosen. The survey was prepared considering reports drawn up by the International Atomic Energy Agency. The questions concerning safe and effective fluoroscopy procedure were asked to the participants. The answers received were statistically evaluated. The alpha significance value was accepted as 0.05.

Results:

Two neurosurgeons only knew the legal rights that they might possess due to the exposure to the radiation or radioactive substances.

Conclusion:

The survey conducted among the health-care professionals revealed the insufficiency of knowledge about the protection from the radiation exposure or radioactive substances in workplaces. Furthermore, both health-care professionals working in radiology clinics, and those in neurosurgery and other clinics who are likely to be exposed to the radiation or radioactive substances have the rights afforded by the law.

Sacral hiatus corticosteroid injection in the management of radicular pain in adults

Radicular pain is a common reason for patients to consult at back pain clinics. While epidural steroid injections are widely done, some aspects are still controversial. The epidural space can be accessed via a transforaminal approach, an interlaminar route or by passing through the sacral hiatus. The aim of this article is to describe the epidural injection technique through the sacral hiatus that our team uses and to report our experience with it. Beyond the treatment effect, sacral hiatus corticosteroid injection can be useful as a diagnostic test or as an interim solution. Image-guided injection is recommended to ensure optimal positioning of the needle below S3. Sacral hiatus corticosteroid injection is a relevant alternative for treating lumbar radiculopathy in adults.

Role of transforaminal epidural injections or selective nerve root blocks in the management of lumbar radicular syndrome - A narrative, evidence-based review

OBJECTIVE

Lumbar radicular Syndrome (LRS) is a common spinal pathology and is attributed to complex interplay of mechanical, inflammatory and immunological processes. Epidural injection of steroids has a significant therapeutic role in mitigating the inflammatory component of LRS. Trans-foraminal approach under image guidance enables a targeted drug delivery. The current narrative review discusses the various aspects related to lumbar trans-foraminal epidural injection of steroid (LTFIS).

METHODS

An elaborate search on PubMed, Google and Medline databases was made using keywords "lumbar selective nerve root block", "lumbar trans-foraminal epidural steroid injection", "selective nerve root block in lumbar disc prolapse", "trans-foraminal epidural steroid injection in lumbar prolapse", "selective nerve root block in lumbar radiculopathy", and "trans-foraminal epidural steroid injection in lumbar radiculopathy" The articles were selected based on specific inclusion criteria.

RESULTS

Our search identified 539 articles. All articles discussing alternate procedures, LTFIS in other pathologies, diagnostic roles of LTFIS, not pertaining to concerned questions, in non-English language and duplicate articles were excluded. Review articles, randomised controlled trials or level 1 studies were given preference. Overall, 108 articles were included. Being a focussed narrative review, further screening [Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) or Methodological Index for non-randomized studies (MINORS) criteria] was not performed to select articles. Based on the evidence, LTFIS is an effective and useful treatment modality. It is offered to patients with lumbar disc herniation (LDH) presenting with persistent, unilateral, radiculopathy after a course of conservative measures for around 6 weeks' duration. It has been reported to yield better results than caudal or inter-laminar epidural injections. The anti-inflammatory and nociceptive signal stabilization actions of steroids, as well as mechanical effects of washout of inflammatory mediators and neural lysis contribute to its efficacy. The three different approaches include sub-pedicular, retro-neural and retro-discal. The procedure is performed under image guidance using a water-soluble contrast under fluoroscopy. The four described radiculogram patterns include "arm", "arrow", "linear" and "splash". Computerised tomography, ultrasonography and magnetic resonance imaging are other modalities, which may be helpful in performing LTFIS. The use of particulate versus non-particulate steroids is controversial.

CONCLUSION

The overall success rate of SNRB is reported to be 76-88%. The majority of benefits are observed during immediate and early post-injection period. Clinical factors including duration and severity of symptoms, and radiological factors like presence of osteophytes, location, size and type of disc prolapse influence outcomes. The radiculogram "splash" pattern is associated with poor outcomes.

Examining the association of body mass index and the depth of epidural space, radiation dose exposure and fluoroscopic screening time during transforaminal nerve block injection: a retrospective cohort study

OBJECTIVE

The primary objective of this study was to examine the association between body mass index (BMI) and the depth of tissue overlying the epidural space. Secondary objectives examined the association between BMI and (1) radiation dose exposure and (2) fluoroscopic screening time during transforaminal nerve block (TFNB) injections.

METHODOLOGY

This is a retrospective cohort study including patients aged ≥ 16 years who underwent unilateral single-level TFNB in a single centre over a 28-month period, by a single spinal orthopaedic surgeon. Demographic data, BMI (kg/m²), fluoroscopic screening time (seconds) and radiation dose exposure (centi-gray per square centimetre squared (cGy-cm²)) were recorded. Exposure of interest: BMI.

PRIMARY OUTCOME

depth of epidural space.

SECONDARY OUTCOMES

(1) radiation dose exposure, (2) fluoroscopic screening time. Descriptive statistics for study participants' demographics are presented. Spearman's rank (r) coefficient and linear regression analysis was performed examining the association between BMI and the outcome measures.

RESULTS

A total of 362 patients met inclusion criteria; n = 45 patients were excluded due to incomplete data, final analysis included 317 patients. Mean age was 62.6 years (IQR 53-74). Male:female ratio was 37.9% (n = 120):62.1%(n = 197). Mean BMI was 26.9 kg/m² (IQR 24.4-28.9 kg/m²). Following adjustment for age, gender and spinal comorbidities there is a statistically significant association between BMI and the depth of tissue overlying the epidural space (adjusted coefficient 2.41, (95% CI (2.14, 2.68), p < 0.001)). We also found a significant association between BMI and both secondary outcomes, radiation dose exposure (adjusted coefficient 1.45, (95% CI (0.84, 2.06), p < 0.001)) and fluoroscopic screening time (adjusted coefficient 0.11, (95% CI (0.02, 0.20), p = 0.02)).

CONCLUSION

This study has demonstrated a significant association between increasing BMI and increased depth of the epidural space. Furthermore, significant associations between increasing BMI, radiation dose exposure and fluoroscopy screening time have been identified. BMI may represent a modifiable risk factor with a view to decreasing patient exposure to medical ionised radiation.

Comparison of lumbosacral transforaminal epidural steroid injection techniques in terms of radiation safety

Aim: To investigate the difference in radiation exposure to the patients between oblique and posteroanterior view, initial approach techniques in fluoroscopy-guided lumbosacral transforaminal epidural steroid injections. Patients & methods: Total amount of Kerma area product, elapsed time of the procedure and fluoroscopy time were obtained from medical records retrospectively. Results: 28 patients were included in each group. Fluoroscopy time was significantly lower in group 1, but there was no statistically significant difference in terms of procedure time and Kerma area product. Conclusion: Radiation risk does not change between these approaches.

The Effect of Skin Pressure on Needle Entry Point Accuracy During Fluoroscopically Guided Lumbar Transforaminal Epidural Injections: A Randomized Clinical Trial

OBJECTIVE

The aim of this study was to investigate the effect of skin pressure on needle entry point accuracy during fluoroscopically guided lumbar transforaminal epidural injection.

DESIGN

This study is a prospective randomized clinical trial; 64 patients with a body mass index of 25 kg/m or greater were enrolled. For patients in the pressing group, the operator marked the needle entry point on the patient's back while pressing the patient's skin with the tip of an indicator. For patients in the nonpressing group, the tip of the indicator was gently positioned on the patient's skin. The data related to technical performance and radiation exposure during the procedure were compared.

RESULTS

Sixty patients (nonpressing group, n = 30; pressing group, n = 30) were analyzed. There were more attempts to reposition the needle (n) and increased procedure time (in seconds) in the pressing group (median, 5 vs. 4 [P = 0.019]; 400.0 vs. 358.5 [P = 0.033]). The fluoroscopy time (in seconds) and the kerma-area product (in cGy cm) were also significantly longer and greater in the pressing group, respectively (median, 63.5 vs. 50.5 [P = 0.038]; 416.3 vs. 318.6 [P = 0.014]).

CONCLUSIONS

This study shows that practitioners should not press the skin with a radiopaque indicator when determining the needle entry point by fluoroscopy during lumbar transforaminal epidural injection.

The effect of body mass index on fluoroscopic time and radiation dose during lumbar transforaminal epidural steroid injections

OBJECTIVE

Transforaminal epidural steroid injections (TFESIs) are a commonly used, effective treatment for radicular pain. Accurate delivery of the injected medication helps to ensure maximum therapeutic efficacy and to decrease possible adverse events, and fluoroscopy is the preferred and most common image-guidance modality used to ensure accurate needle placement during lumbar TFESIs. However, fluoroscopic-guided lumbar TFESIs put patients at risk because of radiation exposure. The purpose of this study was to determine the relationship between body mass index (BMI) and fluoroscopy time and radiation dose during lumbar TFESIs.

DESIGN

A retrospective study design was used.

SETTING

The study was conducted at an academic orthopedic center. All procedures were performed by physicians board-certified in Physical Medicine and Rehabilitation (PM&R) and with subspecialty certification in sports medicine, or by a trainee under close supervision from an attending physician.

PARTICIPANTS

Participants were patients who underwent fluoroscopic-guided lumbar TFESIs between February 2013 and March 2015 with a documented height/weight, fluoroscopy time, and radiation dose.

INTERVENTIONS

All patients received unilateral or bilateral lumbar TFESIs with fluoroscopic guidance. Fluoroscopy time and dose were recorded.

MAIN OUTCOME MEASURES

The main outcome measures were fluoroscopy time and radiation dose. A Bonferroni correction was implemented for multiple comparisons, defining statistical significance at p<.01.

RESULTS

A total of 2,443 injections were performed on 1,548 patients. There were 419 normal, 572 overweight, and 557 obese patients, respectively. There were 1,426 first-time injections and 1,017 repeat injections. Sixty-nine percent (1,681) were unilateral injections, and 26.4% (645) were single level injections. A trainee was involved in 1,361 (55.7%) of the injections performed. The mean fluoroscopy time for all injections was 30.0±17.5 seconds, and the mean radiation dose was 2,164±1,484 mGy-cm(2). The mean fluoroscopy time was 27.7±15.2 seconds for normal weight patients, 30.0±21.0 seconds for overweight patients, and 32.2±15.1 seconds for obese patients, showing a significant difference between groups (p<.001). The mean radiation doses for each group were 1,376±450, 1,911±653, and 3,029±640 mGy-cm(2), respectively, with a significant increase in radiation dose with increasing BMI (p<.001).

CONCLUSIONS

The findings of this study demonstrate that fluoroscopy radiation dose and fluoroscopy time during lumbar TFESIs are increased in patients with an elevated BMI, and in patients of greater age, but the presence of a trainee had no effect on fluoroscopy time.