The Impact of Lumbosacral Transitional Vertebrae on Therapeutic Outcomes of Transforaminal Epidural Injection in Patients with Lumbar Disc Herniation

A Whole Spine MRI Based Study of the Prevalence, Associated Disc Degeneration and Anatomical Correlations of Lumbosacral Transitional Vertebra

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Lumbosacral transitional vertebra (LSTV) results in numerical alterations of the lumbar and sacral segments. Literature concerning true prevalence, associated disc degeneration, and variation in numerous anatomical landmarks concerning LSTV is lacking.

METHODS

This is a retrospective cohort study. The prevalence of LSTV was determined in whole spine MRIs of 2011 poly-trauma patients. LSTV was identified as sacralization (LSTV-S) or lumbarization (LSTV-L) and further sub-classified into Castellvi's and O'Driscoll's type respectively. Disc degeneration was evaluated using Pfirmann grading. Variation in important anatomical landmarks was also analysed.

RESULTS

Prevalence of LSTV was 11.6% with 82% having LSTV-S. Castellvi's type 2A and O'Driscoll type 4 were the commonest sub-types. LSTV patients demonstrated considerably advanced disc degeneration. The median termination level of conus medullaris (TLCM) in non- LSTV and LSTV-L groups was at middle L1 (48.1% and 40.2%) while in the LSTV-S group, it was at upper L1 (47.2%). The median level of right renal artery (RRA) in non- LSTV patients was at middle L1 in 40.0% of individuals while in the LSTV-L and LSTV-S groups, it was at upper L1 level in 35.2% and 56.2% respectively. The median level of abdominal aortic bifurcation (AA) in non-LSTV and LSTV-S patients was at middle L4 in 83.3% and 52.04% respectively. However, in the LSTV-L group, the most common level was middle L5 (53.6%).

CONCLUSION

The overall prevalence of LSTV was 11.6%, with sacralization accounting for more than 80%. LSTV is associated with disc degeneration and a variation in the levels of important anatomical landmarks.

Prediction of transforaminal epidural injection success in sciatica (POTEISS): a protocol for the development of a multivariable prediction model for outcome after transforaminal epidural steroid injection in patients with lumbar radicular pain due to disc herniation or stenosis

BACKGROUND

Transforaminal epidural injections (TEI) can alleviate symptoms and help to maintain physical functioning and quality of life in patients with lumbar radicular pain. We aim to develop a prediction model for patient outcome after TEI in patients suffering from unilateral lumbar radicular pain due to lumbar disc herniation (LDH) or single-level spinal stenosis (LSS). The secondary aim is to estimate short-term patient outcome differences between LDH and LSS patients, the association between psychological variables and patient outcome, the rate of additional injections, surgery and complications, and to explore the short-term cost-effectiveness of TEI.

METHODS

This study is designed as a multi-centre, observational, prospective cohort study in two large regional hospitals in the Netherlands. Patients diagnosed with unilateral lumbar radicular pain secondary to LDH or LSS and congruent with MRI findings, who are referred for TEI along usual care pathways, are eligible for study participation. A total of 388 patients with LDH or LSS will be included. A pre-defined set of demographic, clinical and radiological variables will be used as the predictors in the model. The primary outcome measure is the Numerical Rating Scale (NRS) for leg pain. Secondary outcome measures include back pain, physical functioning, perceived recovery, pain coping strategies, anxiety and depression and use of analgesics and physical therapy. Patients will be evaluated at baseline, 2 weeks and 6 weeks after treatment. NRS leg pain and Likert perceived recovery data will be used as the dependent variables in a generalized linear mixed model for prediction of TEI outcome, with internal validation of performance (explained variation) by bootstrap resampling. Cost-effectiveness for a period of 6 weeks prior to and after treatment will be performed with decision-analytic modelling.

DISCUSSION

Patients with severe lumbar radicular pain often request additional treatment when conservative care is insufficient. TEI can offer relief of symptoms. Currently, it is not possible to predict responsiveness to this treatment for individual patients. This study is designed to explore predictors that can differentiate between patients that will and will not have a positive outcome after TEI. This information may support treatment strategies for this patient group.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov database under registry number NCT04540068 on September 1, 2020.

A Whole-Spine Magnetic Resonance Imaging-Based Cross-Sectional Study of the Clinicoradiological Association of Lumbosacral Transitional Vertebra with Degenerative Disc Disease, End Plate Degeneration, Low Back Pain, and Facet Tropism

OBJECTIVE

To understand lumbosacral transitional vertebra (LSTV)-associated degenerative pathologies and their correlation to low back pain and radicular pain.

METHODS

Whole-spine magnetic resonance imaging was evaluated for disc degeneration using Pfirrmann grading, end plate changes using total end plate score (TEPS), and facet tropism in patients with low back pain and radicular pain, and their association with LSTV was analyzed.

RESULTS

In group 1, LSTV was seen in 15% of patients with 83% of these patients having sacralization. Disc degeneration was seen in 58%, 51%, and 63% of patients at levels C, B, and A, respectively; patients with sacralization had significant degeneration at all 3 levels. Similarly, the total end plate score and facet tropism were significantly higher in patients with sacralization. Facet tropism was observed in 31%, 40%, and 35% of patients with no -LSTV, patients with sacralization, and patients with lumbarization, respectively. In group 2, LSTV was seen in 17% of patients with sacralization accounting for 82%. Disc degeneration was seen in 44%, 36%, and 54% patients at levels C, B, and A, respectively. No significant difference was observed in the mean total end plate score between groups. Facet tropism was identified in 89% and 81% of patients with sacralization and patients with lumbarization, respectively, compared with only 19% of patients with no LSTV.

CONCLUSIONS

Patients with low back pain had a higher incidence of sacralization with corresponding disc degeneration, facet tropism ,and end plate changes. In patients with radicular pain, lumbarization was associated only with facet tropism. These findings may aid clinicians in prognostication and patient counseling.

The effect of lumbosacral transitional vertebra on lumbar spine degeneration and spondylolisthesis among patients with low back pain

AIM

To examine the impact of lumbosacral transitional vertebra (LSTV) on lumbar spine degeneration, disc protrusion, and spondylolisthesis among patients with low back pain.

METHODS

The records of the patients who had undergone anterioposterior lumbar radiographs and lumbar magnetic resonance imaging (MRI) for low back pain between November 2014 and September 2021 were extracted retrospectively and assessed for eligibility. Of the remaining patients, those with LSTV were assigned as "case group." Age- and sex-matched patients without LSTV were assigned as "control group." On digitalized lumbar MRIs, Modic degeneration (type I-III) and Pfirrman's disc degeneration (grade I-V) immediately cephalad to the transitional level were evaluated; intervertebral disc height (mm), disc protrusion (mm), and percentage of vertebral slippage (%) were measured.

RESULTS

Of the 501 patients with low back pain, 128 ineligible patients were excluded; 113 patients with LSTV and 117 age- and sex-matched controls were included in the study. LSTV group revealed decreased intervertebral disc height, increased vertebral endplate degeneration, and slippage, as well as increased disc degeneration and protrusion when compared with controls (p < 0.001). Patients with type III LSTV had greater disc protrusion and higher percentage of slippage compared to those with type I LSTV (p = 0.008 and p = 0.009, respectively). Vertebral endplate degeneration, disc height, and disc degeneration did not differ across categories of LSTV type.

CONCLUSION

Lumbosacral transitional vertebra malformation is related to decreased intervertebral disc height, increased disc degeneration, vertebral endplate degeneration, disc protrusion, and slippage above the level of transition. Patients with type III LSTV revealed the highest percentage of slippage and disc protrusion.

Effect of sacralization on the success of lumbar transforaminal epidural steroid injection treatment: prospective clinical trial

OBJECTIVE

The aim of this study was to invastigate the effect of the sacralization on the results of transforaminal epidural steroid injection for radicular low back pain.

MATERIALS AND METHODS

The study included 64 patients diagnosed with radicular low back pain due to unilateral and single-level lumbar disk herniation. Patients were divided into 2 groups: patients with sacralization (Group S) and patients without lumbosacral transitional vertebrae (Group A). Injection was applied to the relevant level. Patients were evaluated with Numeric Rating Scale and Modified Oswestry Disability Index before, at week 3 and month 3 after the procedure. Sacralization presence was determined by MRI. Sacralization was categorized by anteroposterior lumbar radiography using Castellvi classification. Treatment success was considered as ≥ 50% reduction in NRS scores.

RESULTS

Numeric Rating Scale and Modified Oswestry Disability Index scores decreased in both groups on both week 3 and month 3 (p < 0.05). Pain scores of Group S (median value 5 (3-6)) were significantly higher than Group A ((median value 3 (0-5)) in the third month follow-up (p = 0.026), but no significant difference was observed at other time points. There was no significant difference in Modified Oswestry Disability Index scores between the groups at all follow-ups (p > 0.05). Treatment success in the third month was 44.8% in Group S and 65.6% in Group A.

CONCLUSION

Transforaminal epidural steroid injection is an effective and safe method for radicular low back pain. Sacralization presence should be evaluated before treatment considering that it may be a risk factor reducing treatment success.

Role of the Lumbosacral Transition Vertebra and Vertebral Lamina in the Pathogenesis of Lumbar Disc Herniation

OBJECTIVE

To investigate the prevalence of lumbosacral transition vertebrae (LSTVs) in both the normal population and the lumbar disc herniation (LDH) population and to determine the risk factors for LDH.

METHODS

Between January 2019 and September 2020, all patients aged 18-39 years and underwent an anteroposterior (AP) X-ray of the lumbar vertebrae were retrospective reviewed in our institution. Those patients who were diagnosed with LDH were eligible for inclusion in the LDH group. During the same period, those patients admitted to our hospital who underwent an anteroposterior X-ray of the lumbar spine and had not been diagnosed with LDH were included in the control group. Those patients with disease that might affect the lumbar anatomy were excluded from both groups. The type of LSTV was classified according to the Castellvi classification. The height of the lumbar vertebral lamina was evaluated through the h/H index. The inter- and intra-observer reliability was evaluated by one senior radiologist and one senior orthopedist using intraclass correlation coefficient (ICC). The association between the LSTV and the herniation level was also investigated. Binary logistic regression was used to explore the association of different factors between the LDH group and the control group.

RESULTS

Two hundred LDH patients (115 male and 85 female) and 200 individuals (108 male and 92 female) were investigated retrospectively. The prevalence of LSTVs was 71.5% (n = 143) in the LDH group and 34.0% (n = 68) in the control group. The most frequent LSTV types were type Ib and type IIa. The inter- and intra-observer ICCs of the measurement of "h/H" index and the classification of LSTV were all "excellent" (ICC > 0.90). The median h/H index in the control group was significantly higher than that in the LDH group (0.28 (0.26, 0.31) vs 0.34 (0.31, 0.37), P = 0.000). The distribution of the Castellvi classification in the L4/5 and L5/S1 herniation patients was significantly different (P = 0.048). LSTVs, BMI and the h/H index were closely associated with LDH, with odds ratios of 3.06 (95% CI: 2.12-4.43), 1.23 (95% CI: 1.13-1.33) and 0.09 (95% CI: 0.05-0.15), respectively. The incidence of L4/5 disc herniation in patients with an LSTV was significantly more common than that in patients with L5/S1 disc herniation (P = 0.048).

CONCLUSION

The prevalence of LSTVs was 34.0% in the control group and 71.5% in the LDH group; LSTVs and BMI were positively correlated with LDH, and h/H was negatively correlated with LDH.

Acupoint injection versus sacral canal injection in lumbar disc herniation: A protocol of randomized controlled trial

BACKGROUND

Both acupoint injection and sacral canal injection are widely adopted in the treatment of lumbar disc herniation (LDH), but there are still doubts about the effectiveness and safety of the 2 methods. Therefore, the objective of the randomized controlled trial is to evaluate the effectiveness and safety of acupoint injection and sacral canal injection in the treatment of LDH.

METHOD

This is a prospective randomized controlled trial to study the effectiveness and safety of acupoint injection and sacral canal injection in the treatment of LDH. With the approval by the clinical research ethics committee of our hospital, patients were randomly included into 1 of 2 treatment protocols:Patients, doctors, nurses, and research assistants responsible for collecting data were blinded to group allocation. Main outcome observation indicator: visual analogue scale; secondary outcome observation indicator: Oswestry disability index scores; paresthesia score; adverse reactions. Data were analyzed using the statistical software package SPSS version 25.0 (Chicago, IL).

DISCUSSION

The effectiveness and safety of acupoint injection and sacral canal injection in the treatment of LDH were evaluated in this study, and the results of this trial would establish clinical evidence for the adoption of acupoint injection or sacral canal injection to treat LDH.

TRIAL REGISTRATION NUMBER

DOI 10.17605 / OSF.IO / VTFUD.

Efficacy and Safety of Modified Duhuo Jisheng Decoction in the Treatment of Lumbar Disc Herniation: A Systematic Review and Meta-Analysis

Objective

Lumbar disc herniation (LDH) is based on the degenerative changes of the intervertebral disc. Many drugs are used to treat and prevent LDH, including Western medicine and Chinese medicine. Duhuo Jisheng Decoction (DHJSD) is one of the most classic Chinese medicine prescriptions. The purpose of our meta-analysis is to evaluate the efficacy and safety of modified DHJSD in the treatment of LDH.

Methods

We searched multiple databases including PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI) databases, Wanfang Database, and Chinese Scientific Journal Database (VIP) to identify studies that met the inclusion criteria. This meta-analysis was registered at INPLASY with reference number ID: INPLASY202060053.

Results

Fourteen randomized controlled trials (RCTs) were identified, including 1560 patients. This meta-analysis showed that the total effective rate and cure rate of modified DHJSD are higher than those of diclofenac sodium enteric-coated tablets (total effective rate: RR = 1.18, 95% CI: 1.12 to 1.25, P < 0.0001, I² = 0%; cure rate: RR = 1.60, 95% CI: 1.30 to 1.97, P < 0.00001, I² = 2%), diclofenac sodium enteric-coated tablets plus ibuprofen and indomethacin (total effective rate: RR = 1.23, 95% CI: 1.11 to 1.37, P=0.0001, I² = 0%; cure rate: RR = 1.58, 95% CI: 1.22 to 2.04, P=0.0005, I² = 0%), and diclofenac sodium sustained-release capsule (total effective rate: RR = 1.49, 95% CI: 1.27 to 1.74, P < 0.00001, I² = 0%; cure rate: RR = 10.07, 95% CI: 3.29 to 30.88, P < 0.00001, I² = 5%). Modified DHJSD was also better than Western medicine (MD = −1.56, 95% CI: −2.42 to −0.70, P=0.0004, I² = 74%) in terms of visual analogue scale (VAS) scores. Three RCTs showed no adverse events in the modified DHJSD group, but adverse events existed in the Western medicine group.

Conclusion

This meta-analysis showed that modified DHJSD had a more favorable effect on the treatment of LDH than Western medicine, and there were no obvious adverse events. More high-quality RCTs are needed to complement existing conclusions.

Modified technique for thermal radiofrequency ablation of Thoracic dorsal root ganglia under combined fluoroscopy and CT guidance: a randomized clinical trial

Background

This study is comparing thermal radiofrequency ablation (TRFA) of the thoracic dorsal root ganglia (TDRG) guided by Xper CT and fluoroscopy with the standard fluoroscopy.

Methods

This randomized clinical trial included 78 patients suffering from chronic refractory pain due to chest malignancies randomly allocated into one of two groups according to guidance of TRFA of TDRG. In CT guided group (n = 40) TRFA was done under integrated Xper CT-scan and fluoroscopy guidance, while it was done under fluoroscopy guidance only in standard group (n = 38). The primary outcome was pain intensity measured by visual analog scale (VAS) score, functional improvement and consumption of analgesics. The secondary outcome measures were patient global impression of changes (PGIC) and adverse effects.

Results

VAS scores decreased in the two groups compared to baseline values (p < 0.001) and were lower in CT guided group up to 12 weeks. Pregabalin and oxycodone consumption was higher in the standard group at 1, 4 and 12 weeks (p < 0.001). Functional improvement showed near significant difference between the two groups (P = 0.06 at week 1, 0.07 at week 4 respectively) while the difference was statistically significant at week 12 (P = 0.04). PGIC showed near significant difference only at week 1 (P = 0.07) while the per-patient adverse events were lower in CT guided group (p = 0.027).

Conclusions

Integrated modality guidance with Xper CT-scan and fluoroscopy together with suprapedicular inferior transforaminal approach may improve efficacy and safety of TRFA of TDRG for the treatment of intractable chest pain in cancer patients.

Trial registration

The study was retrospectively registered at clinicaltrials.gov on 04/22/2018 (Registration No.: NCT03533413).

The Impact of L5 Sacralization on Fusion Rates and Clinical Outcomes After Single-level Posterior Lumbar Interbody Fusion (PLIF) at L4-L5 Level

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To determine the impact of L5 sacralization on fusion rates and clinical outcomes after single-level posterior lumbar interbody fusion (PLIF) surgery at the L4-L5 level.

SUMMARY OF BACKGROUND DATA

L5 sacralization can produce greater stress concentration at the adjacent segment (L4-L5); therefore, L4-L5 PLIF surgery in patients with L5 sacralization may negatively affect fusion rate and be associated with poor clinical outcomes. However, no study has examined the impact of L5 sacralization on fusion rates and clinical outcomes of patients who undergo L4-L5 PLIF surgery.

MATERIALS AND METHODS

Of 153 patients who underwent L4-L5 PLIF, data of 145 who met the study criteria were retrospectively reviewed. Among them, 31 patients had L5 sacralization (group A), whereas the remaining 114 patients did not (group B). The primary study endpoint was fusion rate evaluated using dynamic radiographs and computed tomographic scans. Secondary endpoints included (1) pain intensity in the lower back and radiating to the lower extremities on the visual analog scale; (2) clinical outcomes assessed using the Oswestry Disability Index and 12-item Short Form Health Survey; (3) surgical outcomes; and (4) complications.

RESULTS

Fusion rate evaluated using dynamic radiographs and computed tomographic scans at 6 months after surgery did not differ significantly between patients with and without sacralization (P=0.70 and 0.81, respectively), whereas fusion rate at 1 year after surgery did (P=0.04 and 0.04, respectively). In particular, patients with type II or III L5 sacralization had significantly lower fusion rates than those with other types of or no L5 sacralization. Pain intensity, clinical and surgical outcomes, and complications did not differ significantly between groups.

CONCLUSIONS

Patients with type II or III L5 sacralization may have worse fusion rates after L4-L5 PLIF surgery than those with type I or no sacralization.